Too much pleasure can lead to addiction. How to break the cycle and find balance
ELISE HU, HOST:
This is NPR's LIFE KIT. I'm Elise Hu. Dopamine - you've probably heard of it.
ANNA LEMBKE: Dopamine is a chemical that we make in our brain, and it's essential for the experience of reward, pleasure and motivation.
HU: That's Dr. Anna Lembke. She's a psychiatrist and on faculty at the Stanford University School of Medicine, where she runs the addiction center.
LEMBKE: I occupy the classic three-legged stool of academic medicine, which is I see patients, I teach and I do research.
HU: You forgot to mention you're also an author.
LEMBKE: Oh, yes. And I always forget that, by the way.
LEMBKE: I always forget that.
HU: Dr. Lembke wrote a book called "Dopamine Nation: Finding Balance In The Age Of Indulgence." In it, she helps us better understand pleasure, feeling good. But as it turns out, pleasure needs its counterweight - pain.
LEMBKE: So one of the most interesting findings in neuroscience in the past 75 years is that pleasure and pain are co-located in the brain. So that means that the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance. So if you imagine that in your brain, there's a teeter-totter, like in a kid's playground - and when it's at rest, it's level with the ground. When we experience pleasure, it tips one way; when we experience pain, it tips the other. But one of the overarching rules governing this balance is that it wants to remain level. It doesn't want to be tipped for very long to the side of pleasure or pain, and our brains will work very hard to restore a level balance, or what neuroscientists call homeostasis.
HU: So let's take a stimulus that many of our brains find pleasurable - chocolate.
LEMBKE: When I eat a piece of chocolate, I get a little release of dopamine in my brain's reward pathway, and my pleasure-pain balance tips to the side of pleasure.
LEMBKE: But no sooner has that happened than my brain adapts to that increased dopamine by downregulating dopamine transmission, not just to baseline but below baseline. And I like to imagine this as these little neuroadaptation gremlins hopping on the pain side of the balance to bring it level again.
LEMBKE: But they like it on the balance, so they don't get off.
HU: When you enjoy chocolate or sex or drugs, even gaming or scrolling on Instagram, you end up with increased levels of dopamine. But - and this is crucial - your brain also needs that stimuli even more next time.
LEMBKE: It seems like some kind of, you know, cruel joke. But the fact of the matter is that it's a very ingenious way of making sure that we are always seeking something more. And so if you think about, you know, the world that most of humanity evolved in, which is this world of incredible scarcity where we had to walk tens of kilometers every day just to get subsistence, food and water and shelter, it's really an ingenious method to make sure that no matter what we do that's pleasurable, it doesn't last very long. And it's followed by pain so that immediately, we're searching again.
HU: Over millions of years of evolution, approaching pleasure and avoiding pain made instinctive sense, kept us alive.
LEMBKE: The problem is that we no longer live in a world of scarcity. We now live in a world of overwhelming abundance, and these ancient neural pathways that have been so helpful for so long have now become difficult to handle.
HU: In modern life, how do we not lose ourselves in the chase for the next dopamine hit? On this LIFE KIT - finding balance in a time of abundance.
So is the thesis of your book, then, that we're kind of just not evolved for this, right? We're in a time where it's way easier to get the things that we find pleasurable, but...
LEMBKE: That's right.
HU: ...Our bodies are not evolved to balance that out.
LEMBKE: Exactly. So the fundamental thesis of the book is that we're living with this fire hose of dopamine. So essentially, we're constantly now bombarding our reward pathway with very high levels of dopamine sort of all throughout the day, starting with checking our smartphones the moment we wake up, to our, you know, highly caffeinated beverage, to our highly sugared, salted and fattened Danish that we eat for breakfast.
LEMBKE: ...All the way to the end of the day when we're bingeing on Netflix. And the result is that - and getting back to this balance...
LEMBKE: ...What happens with repeated exposure to highly rewarding drugs and behaviors is that those neuroadaptation gremlins - they start to accumulate on the pain side of the balance, right? We essentially go to war with our own brains, and we end up with enough gremlins to fill a whole room or a whole football stadium as we're desperately trying to restore homeostasis. And that's essentially a dopamine deficit state.
HU: Right. So even if I'm not explicitly struggling with, say, a substance abuse disorder, you could make a case that, in some way, there could be something I'm addicted to or that we're all addicted to in terms of dopamine rewards because we live in modern life.
LEMBKE: That's exactly right, that - kind of the general despair and what I might call this sort of great lassitude that I see so often in my clinic, a kind of inability to take action and also the loss of sort of even wanting to bother - I really think that that is about dopamine. And when we're not using, we're experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, dysphoria and craving. And we're so insulated from really our bodies and the kinds of painful experiences that our bodies were designed to tolerate that we've ended up in this dopamine deficit state where we feel incredibly depressed and nihilistic and unhappy and we don't know why. And so what do we do? We reach for more of those things that give us pleasure in the short term. And yet those are the very things that are creating the despair in the first place.
HU: How do we get out of this cycle? What should we do about it?
LEMBKE: Yeah, so it's actually really simple but not easy to do. And it starts with abstaining from pleasure. So, for example, I will have patients come in who are coming to see me for depression and anxiety, expecting that I will prescribe an antidepressant. But instead what I say is, hey, can you eliminate cannabis from your life for a month? Hey, can you stop playing video games for a month? Can you cut out alcohol for a month? Can you not watch any Netflix shows for a month?
LEMBKE: What I explain to them when I explain how the brain works is that what feels like it's alleviating the problem in the short term may actually just be creating the problem in the long term. And the science supports this hypothesis, but more importantly, my clinical experience does. So when I ask patients to abstain from their drug of choice and they're able to do it for a month, they feel horrible in the first two weeks.
HU: (Laughter) Yeah.
LEMBKE: And I warn them that they are going to feel worse before they feel better. Because what's going to happen - as soon as they take their pleasure away, those gremlins who have been now accumulating and camped out on the pain side are going to tilt that balance to the side of pain. But if they can just hang in there and wait long enough without using, those neuroadaptation gremlins, we'll start to slowly hop off the pain side, homeostasis will be restored and they'll be able to again take pleasure in more modest rewards. And the majority of my patients, if they're able to do this intervention, will come back endorsing a significant improvement in depression, anxiety and motivation.
HU: And they don't necessarily have to go cold turkey forever, but this first month is crucial, right?
LEMBKE: Exactly. So a lot of times, patients will say, well, why can't I just cut back? And the reason they can't just cut back is because it doesn't tend to work. It's much harder in real life to go from using a lot to using less than it is to go from using a lot to using none...
LEMBKE: ...Restoring reward pathways so that you remember what it feels like to enjoy more modest rewards, and then slowly reintegrate your drug of choice back into your life.
Now, obviously, there are some serious caveats with this approach. I would never do this in somebody who is at risk for life-threatening withdrawal from alcohol or benzos or opioids. I would never recommend this in someone with a very severe addiction who had repeatedly tried to abstain on their own and was unable to. So, you know, there are clearly, you know, limits to this intervention. But in my experience, this is a very, very helpful intervention and kind of an aha moment for a lot of people who have sort of been wondering, why is it, you know, that I'm kind of generally unhappy?
HU: Yeah, social media seems like an obvious one...
HU: ...Because so many of us can't imagine not logging on to Twitter or Instagram or TikTok for even a day. So (laughter)...
LEMBKE: Right. Right. You know, social media is a great example because social media is essentially a way in which our modern world has drugified something that used to be a very healthy endeavor - making human connections. Which isn't to say that all social media is bad, but it's certainly - there are platforms that are inherently addictive.
LEMBKE: We get sucked into it. And we're staying engaged, not because we're making real and meaningful and positive human connections, but because we're responding to the dopamine and, in particular, the gremlins and the dopamine deficit state that has us clicking and swiping long after it's ceased being fun.
HU: That's why Dr. Lembke's is key advice for addictions is to abstain from the behavior or substance cold turkey for a month. Willpower alone won't cut it.
LEMBKE: Because the physiologic drive to consume once we're in that dopamine deficit state and those gremlins are hopping up and down on the pain side of our balance - it's almost impossible to withstand that. So what we need to do is make sure that we have distance, both literal distance and sort of metaphorical and cognitive distance, between ourselves and our drug.
HU: Got it. Anna, you also talk about other ways that we can bind ourselves from our addictions - self-binding, time-binding or categorically binding. Can you just real quickly talk me through those options and give an example of each?
LEMBKE: Sure. So self-binding is essentially the literal and metacognitive barriers we put between ourselves and our drug of choice so that we can press the pause button between the desire to consume and actually consuming. So examples of, like, a literal, physical, self-binding - I have patients who, when they're traveling, they will call the hotel in advance and say, please remove the minibar and the television set, because they know that once they're in the hotel room and they've got access to, you know, pornography or Netflix or whatever it is they're trying to avoid.
HU: Or mini bottles. Yeah.
LEMBKE: Or mini bottles. Right. They won't be able to do it, especially in the isolation of a hotel room, which is kind of like a rat Skinner box. There's nothing there to do.
HU: Then there's chronological self-binding, where you set a limit on the amount of time you're going to abstain from something. Dr. Lembke says the 30-day dopamine fast is a good example of this method.
LEMBKE: And then after that 30 days, if people decide they want to go back to using in moderation, they can use time as a self-binding strategy to moderate. Like, say, well, I'm only going to use my drug on Fridays and Saturdays...
LEMBKE: ...Or I'm only going to use my drug two hours a day or I'm only going to use my drug after I finish my exams or after I apply for and get a new job or whatever it is.
And then there's categorical self-binding, where you set limits for yourself within a certain category. You group things into things you can and cannot do.
LEMBKE: For example, I had a patient with a video game problem. And he abstained and felt a whole lot better. He actually dropped out of college, he was so depressed and anxious. He was convinced the video games were the only thing alleviating his depression. But in fact they were driving the depression. When he abstained for 30 days, he felt better than he had in years. So when he went back to using video games, he wanted to use differently, he wanted to use less and he wanted to have a different kind of attachment to the video games. And he accomplished that in part with categorical self-binding, where he only let himself play certain video games. For example, he did not let himself play League of Legends because he found that was just too addictive, and he only let himself play with friends and not strangers.
LEMBKE: And that way, he was able to bracket off his video game playing in a way that helped him limit it.
HU: OK. Got it. This is pretty layered, and you discuss this further in the book. But the endless pursuit of pleasure, if I'm understanding this correctly, leads to pain. And it's the kind of pain that could derail our lives and create so much depression and anxiety that we can't go forward or live a flourishing life. And that's the kind of pain that should be avoided. But there's also the kind of pain that you write about that's for a purpose. How do we strike the right balance? I guess I just need help distinguishing between pain that's for a purpose and then the pain that comes from overly hedonistic behavior.
LEMBKE: Right. So if you think again about the balance, you've got the initial stimulus, which is the intoxicant, and then you've got the pain that comes from the gremlins, which is the brain's attempt to compensate for the intoxicant. That's a distinct type of pain, right? That's the pain of withdrawal or the pain of the comedown. But it turns out that the gremlins are agnostic to which side of the balance they jump on. If the initial stimulus is painful, like if we go for a run or some form of exercise...
HU: Yes, very painful (laughter).
LEMBKE: ...Which - yeah. Which is - yeah, very painful for me, too, right? And exercise is well-known to actually be noxious to cells. It's a form of a mild to moderate noxious stimulus.
LEMBKE: But when we expose ourselves to exercise, that is to say we press on the pain side of the balance, those gremlins hop on the pleasure side of the balance in order to bring us level again, and stay on until they're tilted in equal and opposite amount to the side of pleasure. In other words, by doing that exercise, we are moving our pleasure-pain set point closer to pleasure. So that can be a very healthy and adaptive way to get our dopamine, and it's less vulnerable to this problem of tolerance and addiction because we have to work for it initially, right? The initial piece of it is hard. It takes activation energy. It takes motivation.
Can people get addicted to pain? They certainly can if you press too hard and too fast on the pain side of the balance. For example, self-cutting is a very maladaptive and unhealthy way to use pain to get dopamine, but it does work in the short term. But it very quickly leads to tolerance and dependence and withdrawal and all those things that we don't want.
I feel like your question, though, was also getting at a deeper level, which is sort of meaning and purpose in life, right?
HU: Yeah. Yeah. I - I'd love for you to extend this to emotional pain - right? - being able to tolerate some difficult feelings. Because I understand that could bring us something, even though (laughter)...
LEMBKE: Right. Yeah, so...
HU: ...We want to avoid sitting in our own grief or we want to...
LEMBKE: Yeah. Yeah. Right.
HU: ...Avoid sitting in sadness.
LEMBKE: Well, first of all, just avoiding pleasure forces us to tolerate pain in the ways that we've talked about because we're not distracting ourselves from the suffering of life by checking out with a drug or a behavior. So that alone requires this kind of ability to tolerate pain. And from a physiologic perspective, that is a good thing to do because it's in service of restoring our hedonic set point or our pleasure-pain balance neutrality.
LEMBKE: And also then intentionally inviting pain into our lives - right? - with exercise or ice cold water baths or doing other things that are emotionally or cognitively challenging, like going and having a conversation with somebody even though it makes us anxious...
LEMBKE: ...Or, you know, forcing ourselves to focus on a task without reaching for our phones for a whole - full half hour, you know, which is hard and which we've kind of unlearned in the modern age.
HU: I feel called out.
LEMBKE: Right. Oh, me too. Trust me. I'm right there with you. But even bigger than that, I feel like what your question is getting at is, wow, but if I do something painful in the service of some greater good, does that change the pain or the experience somehow? And I think absolutely the answer is yes. It's very clear that we can tolerate much more pain or even experience pain differently if it's contextualized to be not just about us, but about doing some good in the world or helping other individuals. And in fact, we see this all the time, that the experience of even extreme pain from extreme, obvious physical injuries will be different if it has a different meaning.
HU: So if we're all kind of overloaded with dopamine and we're trying to find this balance, you write about a free yet surprisingly difficult way to get in balance and change our behavior - radical honesty. Can you break that down for us?
LEMBKE: Sure. So it turns out that the average adult tells one to two lies per day. These are not huge lies. They're things like, you know, oh, sorry I was late for the meeting. The traffic was bad.
LEMBKE: No, it wasn't. You know, you're late for the meeting because you wanted five more minutes to read the paper. And if we try very hard to go through a whole day cycle without telling a single lie, it turns out it's really hard to do. But the hypothesis is that it's a worthy project, and here's the reason why. I have seen countless patients now over two-plus decades, and the ones with the severest addiction who are in the best recovery are the ones who have taught me they can't lie about anything at all. I got really curious about that. Like, why - what's the connection between being in recovery from addiction and not telling a lie from a neuroscience point of view?
HU: Right. Right. What is that connection?
LEMBKE: Right. So I think it's operating on a couple different levels.
HU: One level involves being radically honest with others. When we're that real with other people, we're often terrified they'll go running. But Dr. Lembke says the opposite actually happens. Radical honesty tends to draw people closer, which promotes intimacy.
LEMBKE: And intimacy is an incredibly valuable and potent source of dopamine. We know that when we make intimate human connections, oxytocin binds dopamine-releasing neurons in the reward pathway, and dopamine is released. And it feels really good.
HU: Another level involves being radically honest with ourselves. If we tell ourselves stories that aren't true, it's very likely we'll repeat our mistakes.
LEMBKE: There's a fascinating experiment where individuals were asked to engage in a die-rolling task where they could win money.
LEMBKE: And, you know, most of them lied a little bit to win more money. Then they were subjected to transcranial magnetic stimulation of the prefrontal cortex. So electricity was used to stimulate that part of the brain.
LEMBKE: And then they did the task again, and they lied less, which is really fascinating. It means that stimulating the prefrontal cortex makes people more likely to tell the truth. Which raises the question, if stimulating that part of the brain makes people tell the truth, does telling the truth stimulate that part of the brain?
LEMBKE: And, you know, there's this famous saying in neuroscience - what fires together, wires together.
HU: Wires together.
LEMBKE: So it's probably true that if we actively and purposely try to tell the truth, that we're stimulating the prefrontal cortex, which in turn keeps our gremlins in check.
HU: Anna, you are an expert. You are a doctor in addiction treatment, and much of your book details treatment protocols that can be applied to all of us. And so I just want to ask you to zoom out and explain how the treatment for overconsumption that you know so well is really a universal process to understand. It's something that all of us should kind of get.
LEMBKE: Yeah. I mean, whether or not you're struggling with the bona fide disease of addiction or just struggling, like all of us, with daily compulsive overconsumption - maybe it's food, maybe it's tech, maybe it's sex - you know, this is a universal problem today. We are all struggling with this. And so in order to restore our sanity, we really need to rethink how we are going to navigate this dopamine-overloaded world. And I think that people with addiction in recovery are modern-day prophets for how to do this. They've had to figure it out for life and death reasons. They have an enormous amount of wisdom to give to the rest of us. And really what it comes down to is we have to start to intentionally avoid pleasure and seek out pain. And by doing that, we will reset reward pathways and ultimately be a lot happier. Again, it's simple but not easy. But it's well worth doing.
HU: All right, Dr. Anna Lembke, author of "Dopamine Nation: Finding Balance In The Age Of Indulgence." Anna, thank you.
LEMBKE: You're welcome. Thank you.
HU: For more LIFE KIT, check out our other episodes. I hosted one about how to deal with regret and another one on skin care. You can find those at npr.org/lifekit. And if you love LIFE KIT and want more, subscribe to our newsletter at npr.org/lifekitnewsletter. And now a completely random tip, this time from listener Caitlin Poole (ph).
CAITLIN POOLE: So I make spaghetti a lot, and I use jarred marinara sauce. So when I pour the sauce into the pan with my veggies or whatever I'm cooking, I then fill up the pasta jar that's now emptied with about two inches of hot water. And then I put the lid back on, and I shake it up and pour it into the pan with the rest of the sauce. That way, it gets every last bit of the sauce that's been left behind and it stretches my sauce a little bit more. But also, it takes away some of the rinsing that I have to do before I put it in the recycling. So it saves water.
HU: Love that one. If you've got a good tip, leave us a voicemail at 202-216-9823 or email us a voice memo at firstname.lastname@example.org.
This episode of LIFE KIT was produced by Audrey Nguyen. Meghan Keane is the managing producer. Beth Donovan is the senior editor. Our production team also includes Andee Tagle, Clare Marie Schneider and Janet Woojeong Lee. Our digital and visuals editor is Beck Harlan. Our editor is Dalia Mortada. I'm Elise Hu. Thanks for listening.
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