Dopamine Nation: Finding Balance in the Age of Indulgence with Anna Lembke

I'm going to cover the three following topics I'm going to talk about how our brains process Pleasure and Pain by using the extended metaphor of a balance I'm going to talk about the Plenty Paradox which in essence is how our ancient wiring is mismatched for our modern ecosystem and then finally I'm going to talk about what we can do about it so first the pleasure pain balance very exciting findings in Neuroscience in the past 75 years and one of those important scientific findings is the discovery of a dedicated pleasure circuit in our brain called the

reward pathway as well as the discovery of dopamine as a human brain neurotransmitter now dopamine is not the only neurotransmitter involved in the experience of pleasure reward and motivation but it is the final common pathway for all reinforcing substances and behaviors the more reinforcing something is the more dopamine it's released it releases in the pleasure or reward pathway and the faster that dopamine is released this slide represents a conglomeration of many different studies done over the years showing how rodents respond to different types of rewards so we all are releasing dopamine at a tonic Baseline

level kind of like the heartbeat of our brain now when a rodent ingests chocolate that firing increases 55 percent above Baseline sex 100 uh nicotine 150 cocaine 200 and amphetamine a thousand percent above Baseline that doesn't necessarily mean that amphetamines are more addictive than chocolate because it depends on the individual what releases a lot of dopamine in your reward pathway may not release as much in my reward pathway and vice versa so how do we process Pleasure and Pain we reflexively approach pleasure and avoid pain we don't need to think about it in in fact

we need to think about the opposite and one of the really exciting findings in Neuroscience to me anyway is that Pleasure and Pain are co-located in the brain so the same parts of the brain that process pleasure also process pain and they work like opposite sides of a balance imagine that in your reward pathway there's a teeter-totter like in a kid's playground when you do something pleasurable it tips one way and when you do something painful it tips the other but there are certain rules governing this balance and I'm going to tell you three of

them the first and most important rule is that the balance wants to remain level or what neuroscientists call homeostasis so that with any deviation from neutrality our brains will work very hard to restore a level balance how do they do that first by tilting an equal and opposite amount to whatever the initial stimulus is that's called neuroadaptation I like to think of that as these neuroadaptation Gremlins hopping on the pain side of the balance to bring us level again but those Gremlins like it on the balance so they don't get off as soon as we're

level they stay on until we're tilted and equal and opposite amount to the side of pain that's that moment of wanting a second piece of chocolate or wanting to watch one more Tick Tock video now if we wait long enough those Gremlins hop off and homeostasis is restored but what if we don't wait what if we continue to ingest our drug of choice over days to weeks to months to years those Gremlins start to multiply and pretty soon we have enough Gremlins on the pain side of the balance to fill this whole room and then

we are entering addicted brain and this is what addicted brain looks like those Gremlins are now camped out on the pain side of our balance tents and barbecues and toe now we need our drug of choice not to feel pleasure but just to the left just to level the balance and stop feeling pain to illustrate this graphically what we see is that with the initial exposure to a high dopamine reward we get a huge increase in dopamine followed by precipitous fall and dopamine levels not just to Baseline but actually below Baseline to that dopamine deficit

State that's that moment of craving that can happen even while we're eating the piece of chocolate right we're already thinking about the next one but if we resist those Gremlins hop off and dopamine levels go back up to our Baseline level position but if we continue to ingest what we find is that with repeated exposure to the same or similar reinforcing stimulus that initial Spike upwards gets shorter and weaker but that after response gets stronger and longer and eventually we can end up in a chronic dopamine deficit state that is addiction this is an image

from a very famous study by neuroscientist Nora volkoff who's the head of Nida and her colleagues and what you see here is the brains of healthy control subjects on the left hand side red represents dopamine transmission and you see in their nucleus accumbens or the reward pathway there's plenty of red there right good healthy dopamine transmission now you have on the right hand side the brains of individuals who have been using addictive substances for very long periods of time and stopped two weeks prior to this image and you see very little dopamine transmission they are

in a chronic dopamine deficit State and two weeks is importantly not enough to reverse that state what is long enough what we find in clinical care is that on average it takes about four weeks after we've stopped using our drug of choice whether it's heroin or meth or Tick Tock or chocolate or in my case romance novels Twilight was my gateway drug anyone else in here before we can restore those Baseline levels of firing okay so you've got the first two rules the first rule is the opponent process mechanism the way that we restore the

balances first by tilting an equal and opposite amount to the side of paint that means for every pleasure we pay a price the second rule of the balance is that with repeated exposure to the same or similar drug that initial deviation upward gets weaker and shorter and that after response or the dopamine deficit state gets stronger and longer the third rule of the balance our brains remember they remember forever which means even those Gremlins once they've hopped off they're lurking in the wings eager to hop on again which is why people with severe addiction can

relapse with a single exposure to their drug of choice even if they have abstained for years and years it also means that we can be triggered not just by the drug but by reminders of the drug so what you see here is a rat that's been trained to know that if it sees a light it can go to a lever press it and get intravenous cocaine and you can see dopamine levels through that process let's just switch to the right hand side of this graph and you see a huge dopamine spike in response to cocaine

but what I want you to focus on is that response to the light itself what happens when we're just reminded of our drug we get a little bit high right a little spike in dopamine and then right after a little mini dopamine deficit state that is craving which is why we need to insulate ourselves not just from our drug of choice but even things that run remind us of our drug of choice some of my patients can be triggered even by euphoric recall of their drug here's what happens when we anticipate a certain reward and

it doesn't come that dopamine level goes way below Baseline right we all know that a reward that you were expecting that doesn't come as much worse than a reward you were never expecting at all so that speaks to some of our more modern digital drugs where we go on WE Post our kids post something online they get a ton of likes the next time they do it they don't get any likes or maybe they get a bunch of hate they're just not in neutral they're going in a dopamine deficit state for somebody who's vulnerable to

addiction to that particular drug that will drive them to do more work to get the levels up up it won't encourage them to stop doing that behavior okay which gives us which brings us now to the Plenty paradox what I want to argue is that the reason that we're all so miserable is because we're working so hard to avoid being miserable and in fact and in fact over abundance itself is the one of the most important modern day stressors we were not physiologically wired for this world of overwhelming overabundance which we have created I have

seen in the past 25 years of being of being in psychiatric practice more and more people coming with severe anxiety depression chronic pain in some cases suicidality who have very wonderful lives everything you would associate with what we think of as the good life loving parents of a robust social network access to Elite Education otherwise good physical health and yet they can barely get out of bed in the morning what is going on here I believe that what's happening is that we as both individuals and nations are exposed to so many high reward substances from

our coffee in the morning to that first text that we read to our Netflix binge at night that we're all in a chronic dopamine deficit State barely able to enjoy the modest rewards of life and experiencing more and more anxiety and depression and bearing this out if you look at World happiness surveys it turns out in the last 20 years people all over the world including the United States are less happy than they used to be with people in the richest Nations being the most unhappy rates of anxiety depression chronic pain are going up all

over the world with people in Rich Nations having the highest rates of increase this incredible Paradox can be explained by the notion of all of us being in some kind of dopamine deficit state so what to do about it it's easy to remember because it Rhymes abstain maintain and seek out pain I'm glad you guys are humorous group that's great so okay so first what's the first obvious thing that we have to do we have to abstain from our drug for long enough for those neuro adaptation Gremlins to hop off the pain inside of the

balance so that homeostasis can be restored why is that important because it allows us again to take pleasure in more modest rewards but importantly it also gives us Insight when we're chasing dopamine we do not see true cause and effect we need distance from our drug of choice in order to see the true impact that it's having on our lives our relationships also our mood depression anxiety so it's very important first we abstain how long four weeks again on average is the amount of time it takes to reset reward Pathways but if you can't do

four weeks do two weeks if you can't do two weeks do a week if you can't do a week do a single 24-hour period And even if it's not long enough to reset reward Pathways it is long enough to experience the withdrawal symptoms and the universal symptoms of withdrawal from any addictive substance or anxiety irritability insomnia depression and craving the next thing we need to do is after our dopamine fast we need to figure out how to maintain those gains and re-enter into a healthy relationship with our drug of choice or we need to figure

out how to continue abstinence depending upon what we decide and the way to do that importantly is to create both literal and metacognitive barriers between ourselves and our drug of choice so that we can press the pause button between desire and consumption and aren't relying entirely on Willpower and that comes in geographical forms get the potato chips out of the house turn off your phone chronological this is something like intermittent fasting I'm only going to be on my device between 9 A.M and 5 PM and otherwise I'm going to give my brain a break categorical

that's where my patients who are addicted to video games say okay I can't play League of Legends but it's okay if I play this other video game with my friends and then finally we have chemical there are a lot of exciting medications that are coming out that can now help with this repetitive control many of you may have heard of ozempic which is now being used for people to lose weight but first thing interestingly there are some preliminary studies suggesting it might also help people abstain from alcohol and then finally we can seek out pain

because those Gremlins are agnostic to whatever the initial stimulus was so if we intentionally press on the pain side of the balance they will hop on the pleasure side of the bounce and they won't get off the level position they'll stay on until we're tilted and equal and opposite amount to the side of pain that's the science of hormesis hormesis is Greek for to set in motion what are we setting in motion our body's own upregulating mechanisms to increase our feel good neurotransmitters like dopamine serotonin norepinephrine yay things like exercise ice cold water baths fasting

prayer meditation this is a healthy way to get our dopamine indirectly by paying for it up front you can see here graphically what happens when we initiate the painful activity let's say exercise we slowly increase dopamine over the latter half and then once we stop exercising dopamine levels actually remain elevated for hours afterwards before going back down to the level position so we never have to go into that dopamine deficit State thank you for listening and I would just my final challenge to all of you is to think of that thing that you use compulsively

once you start you have trouble stopping it and give it up for just 24 hours plan it in advance do it with a friend and see how you do look at observe yourself in that withdrawal but make it through and then you might think about a different relationship you want to have with that substance going forward including your phones [Applause]