This week’s conversation is with Dr. Anna Lembke, a professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. 

A clinician scholar, she has published more than a hundred peer-reviewed papers, book chapters, and commentaries. 

Anna sits on the board of several state and national addiction-focused organizations.

In 2016, she published Drug Dealer, MD – How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, which was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic. 

Anna appeared on the Netflix documentary The Social Dilemma, an unvarnished look at the impact of social media on our lives.

She’s also the author of the recently published, Dopamine Nation: Finding Balance in the Age of Indulgence, which explores how to moderate compulsive overconsumption in a world where feeling good is the highest good.

“If we’re constantly scrolling or otherwise distracting ourselves, are we really giving ourselves an opportunity to consolidate our experiences, grow, change and create the new neural networks that we need in order to move forward?”

In This Episode:

Her experience writing her book, “Dopamine Nation”

It was terrifying. I think I was in a constant state of panic in the two months just before the book came out. I didn’t really want to share myself in that way, but I felt almost obligated to, because I had asked my patients to share their stories. And I felt that I would be hypocritical if I didn’t also share my own. So I did share in small ways here and there, but it was really scary for me.

The relationship between thoughts and emotions

To me it’s just a constant interplay between them. I mean, I would say emotions really matter to me, and I think they should matter. And I think they should inform thoughts. And one of the things that I try to live out and also teach is that emotions are good, because I see so many patients who come in and are ashamed of their emotions and think it should all be very cut and dried and logical. And of course, that’s absurd. So I want to champion emotions. But if I were to talk about how it is for me, it’s the constant interplay between those two things. Probably not weighting one more than another.

Why she followed the path of psychiatry

I was a chronically unhappy kid, and I don’t blame my family situation on that. My parents were very unhappily married and did ultimately divorce after 20 years. And their unhappy marriage permeated our household. But I think even if they had been blissfully married, I probably would’ve been an unhappy kid… [also] my sister had a psychotic manic episode when I was in medical school. And that was when I got to see forms of fused, mental illness, like, oh, wow. The brain can get really messed up even without drugs on board. And so that was a very powerful moment, which originally made me run far away from psychiatry, because I thought, can’t handle it. Then ultimately brought me back to psychiatry in service to wanting to help other people with severe mental illness.

The pain-pleasure balancing act

One of the most exciting findings in neuroscience in the past half century or so, is that pain and pleasure are co-located, which means the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance. So if you were to imagine that in your brain, there’s a little teeter-totter like in a kid’s playground. And that when we experience something pleasurable that teeter-totter tips to the side of pleasure and something painful it tips to the side of pain.

Dopamine-deficit states

The central sort of takeaway from the way that our brains restore homeostasis, which is not just to bring dopamine back to level baseline – because we’re always secreting a tonic baseline level of dopamine – but actually to bring it below baseline. So, that’s really the key neurobiological concept that I want people to grasp. It’s not just like you use up the dopamine you have and then you’ve run out and you’re even again. The way that the brain restores homeostasis is to go below baseline and put us in this dopamine deficit state, which is essentially akin to depression.

“Nature’s cruel joke”

It seems like nature’s cruel joke to require that for every pleasurable experience, we will experience pain. But if you, again, think about the way that humans have survived on this planet over most of human existence, it’s absolutely genius, because no sooner have we found some kind of rewarding substance or behavior than our brain plummets us into this dopamine deficit state, which has got us going, looking for that next thing.

The fundamental problem that we have now is…

We’re no longer living in that world of scarcity and ever-present danger. We’re now living in a world of overwhelming abundance, where all of our basic survival needs are met. And then on top of that, we have almost universal access to these highly potent rewards and behaviors, which means that the people that had that sort of drive to seek out rewards, i.e. people vulnerable to addiction, are now incredibly vulnerable. But even beyond that, people who maybe are relatively immune to that problem are also vulnerable because there are so many drugs and they’re so potent and access is so easy.

The thesis of her book, “Dopamine Nation”

Well, it’s this idea that our primitive brains are mismatched for our modern ecosystem. And if you reframe addiction to think about, well, “What is the addicted person?” That’s a person who’s got incredible tenacity and perseverance, right? Once they decide what their drug of choice is, they’re willing to go to the end of the earth to get it. I like that reframe, and I think it’s important because I think it speaks to a truism across the board when we’re thinking about psychopathology and how we diagnose it. It’s not really in the person, it’s not something wrong necessarily with their brain. It’s very often a mismatch between their unique characteristics and their environment.

A root cause of modern day human suffering

If we’ve been conditioned to believe that after a reminder, we’re going to get the reward, and then we don’t actually get that reward that we were expecting, dopamine levels go way below baseline. So not just a little bit, but way below. So, I think this speaks to a lot of aspects of modern human suffering. The fact that we’re constantly ingesting these high-dopamine rewards and behaviors, we’re bombarding our reward pathway. This is not what our primitive brains were designed for.

There’s a price to pay

Even if those accomplishments are really fulfilling and rewarding and they get that big hit of dopamine, there’s a come-down. So, there’s a price to pay. You’re out and you’re performing and it’s all wonderful and you’re getting that rush. But then you come home, and you go into a dopamine deficit state, you experience anxiety, you’re worrying about, “Will I ever be able to replicate that?” Feeling depressed, again, just that come-down. So, I think it’s really important to notice these fluctuations, to appreciate that they’re essentially normal because they’re driven by this pleasure-pain balance, which again is evolutionarily designed to keep us seeking in a world of scarcity, but which is now made much more complex by this sort of hyper-convenient world that we live in now.

Reorient your relationship with dopamine

I think the orientation that has to shift around this is, like, the dopamine for its own sake is sort of the problem. So, just the reward is not really ultimately going to pan out. And really, what we need to do is look for meaning and purpose pretty much independent of that reward. But it’s very hard to get away from, because we do have a culture that is steeped in this idea of bookending our days through rewarding ourselves. And rewarding ourselves has really almost become the primary way we organize time. And so, it’s a huge shift to think about doing it any differently.

Gedanken experiments

I suggest a Gedankenexperiment, which I sometimes do on myself, which I think is really interesting. Go through an entire day without doing anything that gives you pleasure, beyond eating the food that you need to get through the day, but not anything really tasty or good. So, no listening to music, no eating sweets, no Netflix binges, absolutely nothing, just the whole day without any reward. First of all, I think it’s noteworthy that that would be really different for most of us, because usually we’re thinking, “Okay, I’m going to do my work. And then, when I get home, I’m going to have a cocktail, or I’m going to smoke a joint, or I’m going to watch a movie, or I’m going to read a book,” or whatever it is. So, if you take that away, what I find happens, which I think is really interesting, is it totally changes the shape of the day because when I stop looking forward to the reward that I’m going to get at a later moment in time, all I can do then is be here in the moment now. And it really, it just changes the experience of time.

Social media, as a drug

It’s important to define what social media is. When I think about social media as a drug, I am not talking about all of the ways in which people exchange images, texts, and ideas online, and much of that can be really good and foster amazing, true, and intimate and adaptive connections. I’m really talking about the ways in which the media portion of social media has turned human connection into performance and into posturing, and has engineered it to follow people around, and essentially constantly amend what they’re already looking at for increased novelty, which then triggers dopamine. Because again, if we look at the four aspects that make a drug more addictive, it’s access, quantity, potency and novelty, and when social media conspires to increase all of those four functions, you really do end up with a drug.

Resting states, and what happens to our brains during them

We do have what are called resting neural states. And these were discovered sort of by accident when people were put in fMRI machines to look at their brain activity engaging in certain, specific tasks. And originally, researchers were very interested in what nuclei were stimulated during these specific tasks and ignored what the brain was doing in between tasks. But at some point somebody realized, well actually there’s some really interesting stuff occurring in this resting state, that mental resting network, because what they found was that specific activities that required focus concentration lit up specific nuclei. But these resting mental networks were a cross dialogue of a diffuse set of nuclei all across the brain integrating together in a symphony, which is really fascinating, because it suggests that this is the brain’s heartbeat or a resting consolidation integration period.

Boredom and it’s value

The truth is that being bored is not just boring, it’s also scary because when we are bored, it brings up all those questions like, “What am I supposed to do right now? What am I supposed to do in the big picture? Why am I here? What am I ever supposed to do?” But being bored is fundamental to having an original idea. You cannot have an original idea unless you have a period of being bored.

Reclaiming joy

If you can get through it, what you’ll notice is that it’s like a window opens. Here’s a really important key piece about addiction, it narrows our focus. Other things become less salient, things we used to enjoy are no longer enjoyable. We start to blame those other activities as being inherently unenjoyable or those people being, not the right people or not the right job or not the right major in college. When in fact it’s actually our drug of choice, which is depleting the hedonic valence from those substances and behaviors, and when we take a period of abstinence, we can get that joy back because we are starting to regenerate our own dopamine and endogenous cannabinoids, et cetera.

Shame

Shame is an incredibly powerful emotion and I believe that shame is probably the most powerful pro-social emotion that we have because it’s what brings us back into the tribe. We feel shame naturally when we do something that deviates from social norms and then shame is what, again, brings us back in. We have this kind of vicious cycle in our culture where we’re encouraged to seek out this narcissistic achievement and we do, and we do get a Dopamine hit from it, but then the come down is shame and that shame is the price that we pay. Often that’s the lingering feeling, a kind of lingering shameful self-loathing, which is the cost of this external accolades.

Take yourself out of it

I do believe it’s possible to seek out excellence and achieve without narcissistic self-aggrandizement, and to do that, we have to take ourselves out of that achievement and just think about what it is we are trying to accomplish. What’s the meaning? What’s the purpose? What’s the message? It’s not so much what I did. It’s what is being put into the world through me, and I think through that, we can pursue excellence without getting into this terrible sort of seesaw between the high of narcissism and the come down of self-loathing and shame.

The dopamine cycle in sports

I think that in many ways, the way that that sports has become commodified, the way that the media really encourages this narcissistic self-aggrandizement, instead of the beauty of the human body and what it can accomplish, I think this has made it really difficult for athletes to take joy in their sports and find themselves. Even my children, who are quite good athletes, they get interviewed by the intrepid reporter after they win a race, and then they’re watching that interview afterwards. I just think it sets it up. This terrible dopamine cycle where it’s not about the joy of the sport, but about chasing those accolades and so for athletes, I would just really get them to be thinking about that.

 

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Chief of the Stanford Addiction Medicine Dual Diagnosis at |

Anna Lembke is an American psychiatrist who is Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic at Stanford University. She is a specialist in the opioid epidemic in the United States, and the author of Drug Dealer, MD, How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.