Anna Lembke is a professor of psychiatry and program director for the Stanford Addiction Medicine Fellowship. Her latest book is “Dopamine Nation”.
Dopamine is an important neurotransmitter when it comes to motivation, pleasure and reward. What makes it so special?
It’s the final common pathway for all reinforcing substances and behaviours. So, for example, the use of alcohol, and other stimulants, lead directly to the release of dopamine. The more dopamine that’s released, and the faster it’s released, in this specific circuit [in the brain] called the reward pathway, means it can lead to more addictive behaviour, when it comes to certain substances or activities.
But we need it, don’t we? Isn’t it also involved in memory, attention and the regulation of our body movements?
Yes. It’s no coincidence that over many years of evolution the same neurotransmitter that’s important for motivation, pleasure and reward is also important for movement, because for most organisms, this has always been linked. In order to get your reward, you have to do the physical work to get there. Even the most primitive worm will release dopamine in response to food in its environment, which allows it to move toward that food. Part of the problem today in modern society is that we humans don’t really have to do any work to get our rewards.
You write about the “dopamine economy” and “limbic capitalism”. Can you explain these terms?
I’m talking here about how the natural end result of successful capitalism is to turn us all into good consumers and addicts. The ultimate consumer, after all, invests all their energy, creativity and resources into getting and consuming their drug of choice.
Has the internet made us addicted to information?
Yes. In fact, digital media itself is a drug. The smartphone is a modern-day hypodermic syringe. Take, for example, a 10-second TikTok video. As soon as you view it, you’re already craving the next clip, because as soon as it ends, you’re feeling that comedown. And that drive to want to restore that physiological state is overwhelming.
How can we achieve a healthy balance of pleasure and pain?
The best way to stay in balance is to use intoxicants in extreme moderation. And to avoid intoxicants that are super potent. It’s also helpful to leave sufficient time in between intoxicants to allow the pleasure-pain balance to restore equilibrium. Exposing our bodies and minds to things that are painful and difficult is also a useful way to regulate our own dopamine production and tilt the balance toward the side of pleasure. Because for every pleasure, we pay a price, and that price is the comedown. Getting our dopamine indirectly, through painful effortful engagement, like, say, taking a cold shower, is helpful, because we pay for our dopamine up front – as opposed to getting a quick fix of it.
You define addiction as “the continued and compulsive consumption of a substance or behaviour, despite its harm to self and/or others”. How would I know if I’m addicted to something?
Addiction is very hard to define because it’s a bio-psychosocial disease that is very contextualised, depending upon the time, the place and the culture. It’s also a spectrum disorder. It’s not a single moment in time, where you cross the line, and now you’re addicted. It’s a gradual process, characterised by these brain changes, where, over time, the drug essentially stops working. This means the user needs more of it, and more potent forms to get the same effect.
Is there any way to end this spiral of addiction?
What I recommend is a dopamine fast. This involves abstinence from the particular substance or behaviour. This helps reset reward pathways in the brain. I wouldn’t recommend this for somebody who was at risk of life-threatening alcohol, benzo or opioid withdrawal. Or for someone who had tried repeatedly to stop activities related to addiction on their own, but were unable to because the compulsions were so overwhelming. But for most individuals I treat, it’s a good first pass. Typically, during the first 10 to 14 days, they feel worse, because they’re experiencing withdrawal when they are in that dopamine-deficit state. But if they can just go long enough, and get over that hump, they find their pleasure-pain balance starts to reregulate itself, and they start to upregulate dopamine and other endogenous feel-good neurotransmitters that have been suppressed. Then by week three or four, they’ll report feeling better than they have in a very long time.
What do you make of Gabor Mate’s theory that all addiction stems from trauma?
I don’t agree. Trauma can certainly be one of many gateways into addiction. But another reason is simple exposure to the drug, which changes our brain. We can get addicted to things when our lives seem to be perfect. The main point of Dopamine Nation is to show that we’re now living in a world that’s so saturated with pleasure goods that we’re all more vulnerable to the problem of compulsive overuse.
But you note that the poor and undereducated, especially those living in rich nations, are more susceptible?
People living in poverty don’t have access to the healthier forms of dopamine, which wealthy people do. For example, exposure to being in nature, or gyms, where you can get your dopamine indirectly. People who are unemployed, for instance, have enormous amounts of unstructured time.
You argue that we have created “oversanitised children”. Would tough love from parents better serve their mental health in the long run?
Yes. What I have seen over two decades of clinical work is parents who have assiduously insulated their children not just from painful experiences, but really any kind of challenging experiences. This means that children haven’t had the opportunity to build up the mental strength they need to live in the real world. A more effective strategy is to set limits, and boundaries, and give our children real feedback about their strengths and weaknesses, which in the long term will enforce real consequences for transgression.
Might these “sanitised children” become more predisposed to addiction?
Definitely. If you’re not having the experience of your own self efficacy, and your ability to rely on your own fortitude to overcome challenges, that really undermines a sense of competence, and fosters an avoidant coping style, which is really at the heart of many addictions.
The use of antidepressants is rising all over the world. Is this a problem?
We are definitely insulating ourselves from challenging, painful experiences that we need in order to be resilient in the world. One way we are doing that is by overprescribing psychotropics, antidepressants, anxiolytics and hypnotics. That said, I’m a psychiatrist. And I regularly prescribe these medicines. In many instances, they are life-saving for people with severe mental illness. But I’m concerned about the indiscriminate prescribing of [drugs] like Xanax, which is a highly potent and addictive benzodiazepine. When we take a pill to manage anxiety, we deprive ourselves of the opportunity to learn from that experience, or to conceptualise anxiety as a form of energy. If the anxiety is so overwhelming that it’s paralysing, well, that’s different. But in many instances, anxiety is energy. And we need to figure out how to manage it.
This piece is from the New Humanist spring 2023 edition. Subscribe here.
