Dopamine Nation.
By Dr. Anna Lembke.
Finding Balance in the Age of Indulgence.
I first heard Dr. Anna Lembke talk about her book on the Rich Roll podcast (episode 623) and again on the Andrew Huberman podcast (episode 33) a few months later. She is calm and factual as a speaker, and passionate about her area of expertise. Addiction is a fascinating subject to me, and I think many of us know someone who has struggled with this in some form or other. Furthermore, if we are honest with ourselves, we all feel the pull of addiction in one or more areas of our lives.
This book has two working subtitles on the cover. The physical copy that I bought says, “Why our addiction to pleasure is causing us pain” and on the online version I looked at it says, “Finding balance in the age of indulgence.” Both are apt descriptions for the content of this book. We certainly are living in an age of an abundance of distractions, which we use with varying levels of compulsivity, to remove ourselves from being fully present in our daily lives. Whether we intend for this to be the result or not, the fact is that our attention has never been more distracted and divided by devices of our own choosing. This is a fascinating and unnerving read, and I found myself finishing it with a strong resolve to be more aware, more honest, more tolerant of embracing pain and discomfort, and more empathetic to others who may be struggling and would value my support.
Introduction
Understanding the relationship between pleasure and pain has become essential for a life well lived. We are drowning in dopamine as a result of a multitude of highly rewarding stimuli: drugs, food, drink, news, gambling, shopping, gaming, texting, sexting, vaping, Facebooking, Instagraming, YouTubing, TikToking etc.
Scientists used dopamine to measure the addictive potential of an experience: the more dopamine in the brain’s reward pathway, the more addictive the experience. The brain processes pleasure and pain in the same place, and they work like opposite sides of a balance. The moment of “wanting” is the brains pleasure balance tipped to the side of pain. Dr Lembke’s book aims to enable us to find a healthier balance between pleasure and pain through understanding the neuroscience, and reading the true stories of addicts who suffer from compulsive over consumption. The stories that she includes are riveting and harrowing, as well as inspiring and uplifting. I have excluded them from this summary, but the triumphs and the struggles experienced by her patients as they navigate their recovery make this book well worth reading from cover to cover.
Part 1: The Pursuit of Pleasure
Addiction is defined as the “continued and compulsive consumption of a substance or behaviour despite its harm to self and/or others.”
The act of consumption itself can become a drug i.e. gambling, or online shopping.
The most important (often unavoidable) risk factor for addiction is accessibility and availability. Supply has created demand.
Other risks:
o Biological parents or grandparent with addiction.
o Mental illness (although it is clear as to whether the illness is a cause or a result of the addiction)
o Trauma, upheaval, poverty (coping)
A growing number of patients with supportive families, quality education, financial stability and good health still develop debilitating anxiety, depression and physical pain.
70% of world global deaths are attributable to modifiable behavioural risk factors like smoking, drinking, physical inactivity and diet.
Global deaths from addiction have risen in all age groups between 1990 and 2017, with more than half the deaths occurring in people younger than 50 years of age.
There seems to be a growing culture of pursuing happiness and avoiding pain. We strive for a pain-free world, but some degree of pain can be healthy. We’re losing the ability to tolerate even minor forms of discomfort.
Our efforts to insulate our children from adverse psychological experiences does not help.
We all run from pain and will do almost anything to distract ourselves from ourselves… and yet this makes our discomfort worse.
Dopamine is a neurotransmitter – a chemical between functional cells of the brain involved in reward processing. It can play a bigger role in the motivation to get a reward then the reward itself i.e. “wanting” more than “liking”. Dopamine is used to measure the addictive potential of a behaviour or drug. Highly addictive substances trigger the release of dopamine in our brain’s reward pathway. According to research, chocolate increases the basal output of dopamine in the brain by 55%; sex by 100%; nicotine by 150%; cocaine by 225% and amphetamines by 1000%.
Pleasure and pain operate in a balancing system: what goes up, must come down. The “after reaction” is equal and opposite in value to the stimulus (i.e. the craving in the aftermath of pleasure). Neuro- adaptation means that the pleasure gets weaker and shorter, and after response of the pain side gets stronger and longer. With prolonged, heavy drug use, the pleasure balance gets waited to the side of pain, and we crave the drug just to feel normal.
Our capacity to experience pleasure goes down and our vulnerability to pain goes up.
Heavy, prolonged consumption of high dopamine substances eventually lead to a dopamine deficit state, or a decreased sensitivity of reward circuits stimulation by natural rewards. Nothing feels good anymore.
The universal symptoms of withdrawal are anxiety, irritability, insomnia and dysphoria. The good news is that if we wait long enough by abstaining, our brains can react to the absence of the drug and re-establish a level balance. We can start to take pleasure in every day, simple rewards i.e. going for a walk, watching the sunrise, enjoying a meal with friends or reading. The pleasure pain balance is triggered by exposure to cues: after a cue, dopamine decreases, which drives craving, and results in purposeful activity to obtain the reward. If we don’t get the reward, we experience an even bigger plunge. Dopamine spikes with anticipation, but is followed immediately by a drop in the aftermath of the cue. So dopamine gets released both in reward anticipation and in reward response but drops in between (= the craving). People who struggle with severe addiction slip right back into compulsive use with a single exposure due to sensitization to the drug of choice. Science teaches us that every pleasure exacts a price, and the pain that follows becomes longer lasting and more intense than the pleasure that gave rise to it.
The brain changes that occur In response to stimulating and novel environment are similar to those seen with high dopamine (addictive) drugs. Learning and newness increases dopamine firing in the brain. Research shows that new synoptic pathways that support healthy behaviours can be created with leaning and practice.
Part 2: Self Binding
Dr Lembke has a framework for talking with addicts that I found interesting and helpful:
D = Data: The simple facts of consumption (Tell me about your addiction?)
O = Objectives: Understanding the personal logic for using (What does it do for you?)
P = problems: Related to use (What are the downsides and unintended consequences of your addiction?)
A = Abstinence: For at least 4 weeks is necessary to restore homeostasis, and the ability to get pleasure from less potent rewards; and to see the cause/effect between our substance use and the way we are feeling. 80% of patients feel better after the dopamine fast. What feels like the addictive substance treating a symptom may just be the substance relieving withdrawal, which means it becomes the cause of our symptom rather than the cure. (Can you abstain for one month?)
M = Mindfulness: An opportunity to observe yourself as separate from your thoughts, emotions and sensations - without judgement. Staying in the observer position is essential to getting to know ourselves in a new way. We use addictive substances and behaviours to distract ourselves from our thoughts. If we learn to allow ourselves to tolerate them, we can live in the moment and handle it. (Can you prepare yourself for feeling worse before you will feel better?)
I = Insight: An angle of understanding of our behaviours that is not possible whilst we continue to use. (Tell me what happened when you abstained?)
N = Next steps: What approach to take after the month of abstinence. (Do you want to continue to abstain, or try to manage in a controlled way?)
E = Experiment: Armed with a new pleasure pain balance, a plan for how to maintain it and strategies on how to achieve the goal.
The goal of a dopamine fast is to restore a level of balance, and renew our capacity to experience pleasure in its many different forms.
Self-binding is “the way we intentionally and willingly create barriers between ourselves and our drug of choice in order to mitigate compulsive over consumption.” Self-binding recognizes limitations of will and acknowledges the loss of voluntariness we experience when under the spell of a powerful compulsion. So, we create tangible barriers which act as the pause button between desire and action. We overvalue short-term rewards. Deciding moments for recovery are often linked to recognition of the long-term cost.
“Binding ourselves a way to be free.”
Three self-binding strategies:
1. Physical (space) i.e. lockboxes for phones, removing alcohol or processed foods from the home, unplugging the TV and putting it in a cupboard.
2. Chronological (time) i.e. time limits or time windows to moderate use (screen time)
3. Categorical (meaning) i.e. what we allow and what we don’t (including circumstances)
Patients with pain who take opioids for more than a month are at increased risk for both opioid addiction and increased pain. Even antidepressants may lead to a tolerance and dependence. Psychiatric medications offer short-term relief from painful emotions but also can limit our ability to experience the full range of emotions, like grief and awe. Perhaps the lows are worth it to feel more human?
These medications can be life-saving tools, but there is a cost to medicating away every type of human suffering. The alternative path of embracing pain might work better. Should any of us whittle ourselves down with medication to better fit the world, or to feel like we are better adapted? Lembke writes that, after coming off Prozac she found herself to be a permanently “somewhat anxious, slightly depressed sceptic”, and admits to being “okay with that”.
Part 3: The Pursuit of Pain
Pain can give way to pleasure e.g. an improved mood after being ill or the “runners high” after exercise. Lembke says: “Exercise has more profound and sustained positive effects on mood, anxiety, cognition, energy and sleep then any pill I can prescribe.”
Pursuing pain goes against our reflex to avoid pain and pursue pleasure. Nietzsche said: “What doesn’t kill me makes me stronger” but people who lean too hard and too long on the pan side of the balance can also end up in a persistent dopamine deficit state. If we consume just the right amount of pain we discover the path to healing and even the occasional “fit of joy”.
Radical honesty is telling the truth about things large and small. Truth telling is critical for sustained mental and physical health. Committing not to tell lies, even small ones, is to decide to live life in a different and better way. Radical honesty promotes awareness of our actions. Recounting our experiences gives us mastery. Our disclosure (whether to an AA sponsor, a priest, a counsellor, a friend or in a journal) brings our behaviour into the open so that we can see it properly. Truth telling allows us to be more aware of what drives our compulsive over consumption, and therefore helps us to change our behaviour.
Sharing honestly fosters intimate human connections, and promotes human attachment.
It leads to a truthful autobiography, which holds us accountable to our present and our future selves. It’s a way to get closer to your authentic self, as opposed to your false self. The way we tell our stories is a marker/ predictor of mental health (i.e. victim narrative). Seeking the truth affords the opportunity of real insight and understanding, which enables us to make informed choices. Empathy (as healthcare providers) without accountability is a shortsighted attempt to relieve suffering. We help the patient take responsibility, for the event and how they react here and now, and the patient is empowered to move forward.
Prosocial Shame: If others respond by holding us and providing clear guidance for redemption and recovery, it helps support our decision to stop or reduce the shameful behaviour.
Shame can be an enabler of behaviour as well as a vehicle of prevention. Shame makes us feel bad about ourselves as people, and guilt makes us feel bad about our actions.
Destructive shame is: over consumption resulting in shame, resulting in lies, resulting in isolation, resulting in over consumption again; and so on.
Prosocial shame is: over consumption resulting in shame, resulting in radical honesty, resulting in acceptance, resulting in belonging and decreased consumption.
Due to social media, we are now comparing ourselves to the whole world, and convincing ourselves that we should’ve done more, or gotten more, or just lived differently. (LJ: It strikes me that despite this we can convince ourselves that going forward we can do less, but qualitatively; give more; and live intentionally, instead.)
Conclusion:
It is natural that we seek a reprieve from our own relentless ruminations. What if, instead of turning away from the world and leaving it behind, we return towards it and immerse ourselves in it? Stop, turn and face whatever it is that you are trying to escape from. Walk towards it with curiosity and openness. Finding and maintaining balance requires patience and persistence. Healthy practices happen day by day, not all at once.
Practice the lessons of balance, so that you can look back at the path of your own progress:
1. The relentless pursuit of pleasure (and avoidance of pain) leads to pain.
2. Recovery begins with abstinence.
3. Abstinence resets the brains reward pathway and with it our capacity to find joy in simple pleasures.
4. Self-binding creates spaces between desire and consumption; a modern necessity in our dopamine-overloaded world.
5. Medication can restore homeostasis, but consider what we lose by medicating away our pain.
6. Pressing on the pain side resets our balance to the side of pleasure.
7. Beware of getting addicted to pain.
8. Radical honesty promotes awareness, enhances intimacy and fosters a “plenty” mindset.
9. Prosocial shame affirms that we belong to the human tribe.
10. Instead of running away from the world we can find escape by immersing ourselves in it.
These 10 steps (and this book) are powerful indeed. After reading this book I am resolved to:
Become more aware of what causes me pain, and to get better at feeling it, and finding positive ways to address it. (Unique to me, of course)
Abstaining in the areas that I need to in order to create distance and gain perspective.
Rediscover more simple pleasures. (Again, unique to me)
To practice observing my various cravings with detachment, and resolve not to engage, with the help if self-binding interventions that I create for myself.
Being more honest in general – with myself and with others.
Leaning into the world more – both the fun bits and the scary ones.
Photo by Myriam Zilles on Unsplash