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Dr. Anna Lembke: How to reset your dopamine in 30 days

Stanford addiction psychiatrist on the pleasure-pain seesaw behind cravings; why 30-day fasts and deliberate discomfort restore your dopamine balance.

Dr. Anna LembkeguestSteven Bartletthost
Jan 2, 20252h 11mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 3:44

    Intro

    1. AL

      There is a very famous experiment in which rats were engineered to have no dopamine, and the scientists discovered that if they put food in the rat's mouth, the rat would eat. But if you put the food even a body length away, the rat will starve to death, which tells us that dopamine is fundamental to get the things that we need for our basic survival. Now, every time we're doing something that's pleasurable, from sugar, to video games, work, pornography, social media, that will affect dopamine. And the more dopamine that's released, the more likely that drug or behavior is to be addictive. But also, the genetic risk of addiction is about 50 to 60%. So if you have a biological parent or grandparent with addiction, you are more likely to develop that addiction. We have to keep it in balance in order to stay healthy.

    2. SB

      Dr. Anna Lembke is Professor of Psychiatry at Stanford, Chief of the Stanford Addiction Clinic...

    3. NA

      ... and a world-leading expert on the subject of dopamine. She will tell you how this one powerful chemical is controlling your life and what to do about it.

    4. AL

      One of the most important findings in neuroscience in the past 75 years is that the same parts of the brain that process pleasure also process pain, and the balance wants to remain level. The problem is that we automatically seek out pleasure and avoid pain, and we're exposed to all kinds of pleasures that we have in the modern world. And our brains are reeling in response to try to compensate. Now I need more of my drug in more potent forms to get the same effect, which then leads to addiction. And that's what happened to me when I got addicted to romance novels.

    5. SB

      Take me into that phase of your life.

    6. AL

      I was out of control and I needed to restore a level balance and take the advice I give my patients.

    7. SB

      And what is that advice?

    8. NA

      The Diary of a CEO is independently fact-checked. For any studies or science mentioned in this episode, please check the show notes.

    9. SB

      This has always blown my mind a little bit. 53% of you that listen to this show regularly haven't yet subscribed to this show. So could I ask you for a favor before we start? If you like this show and you like what we do here and you wanna support us, the free simple way that you can do just that is by hitting the subscribe button. And my commitment to you is, if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback, we'll find the guests that you want me to speak to, and we'll continue to do what we do. Thank you so much. (upbeat music) I've sat here for the last 20 minutes trying to figure out how to say this to you, so I'm just gonna say it how it comes out my mouth, and I apologize if this is messy. But if there was ever an episode this year that you should listen to, it is this one. I've li- since this episode was recorded about a month ago, all I've been thinking about is how on earth I get you to watch this. And I don't say this often. The last time I said this was the first time Mo Gawdat came on this podcast. This is the second time I've said this in almost four years of recording this podcast on YouTube. And the reason for that is, so many of the things that I know you're struggling with in your life that stand in the way of the person you wanna become, that relationship you have with your phone, the procrastination, the cycles of behavior that make you feel embarrassed and full of shame that you've just never been able to crack, all of them, all of them, I genuinely believe, for many of you, are going to be understood today if you listen to this episode. It has changed my life and it has changed much of the lives of my team. If, if I'm wrong here, you have the right to message me and tell me that I was wrong. Please listen to this episode. Really, really, I mean that from the bottom of my heart. And just to make sure you do, throughout this episode there's gonna be these pop-ups. If you collect eight of these codes that are gonna pop up on the screen and put them in the document link below, you'll unlock something very special, some additional content. Please listen to this episode. Dr. Anna Lembke, you wrote one of the most iconic well-known books about dopamine, which propelled the subject

  2. 3:44 – 4:08

    Why Does Dopamine Matter?

    1. SB

      matter of dopamine into the public consciousness. But I guess the most important question I should ask you is, why does dopamine matter?

    2. AL

      Ah, good question. Good, good place to start. I mean, dopamine matters because it's fundamental to our survival, right? So it's the chemical that we make in our brain that tells us this is something we should

  3. 4:08 – 5:35

    What Is Dopamine?

    1. AL

      approach, explore, investigate. So it's, it's really almost the survival chemical.

    2. SB

      So what is dopamine? If you had to explain it to a 10-year-old, how would you go about explaining it?

    3. AL

      (laughs) So dopamine is a chemical that we make in our brain. Um, it has many different functions, but one of its most important functions is that it helps us experience pleasure, reward, and motivation. Um, it may be even more important for the motivation to do things than it is for the pleasure itself. So for example, there's a very famous experiment in which rats were engineered to have no dopamine in the brain's reward pathway. And the scientists discovered that if they put food in the rat's mouth, the rat would eat the food, would seem to get some pleasure from the food, if you can determine that from watching a rat eat, which I think they felt like they could. Uh, but if you put the food even a body length away, the rat will starve to death. The idea being that without dopamine, we're not motivated to seek out the things that we need for our basic survival.

    4. SB

      That's crazy.

    5. AL

      Mm-hmm.

    6. SB

      So you get a rat, you put the food an inch from its mouth, and it will starve to death because it doesn't have dopamine, the dopamine required to just reach out and eat.

    7. AL

      Yeah, essentially. Maybe it's not an inch, maybe it's a little more than an inch. But the idea being that dopamine is necessary

  4. 5:35 – 6:09

    How Understanding Dopamine Can Improve Your Life

    1. AL

      to be motivated to do the work to get the thing that we need.

    2. SB

      And having an understanding of dopamine, how might that improve my life?

    3. AL

      Having a basic understanding of how dopamine works, how we process pleasure and pain, and also what happens with dopamine as we go from adaptive recreational use to maladaptive addictive use is something that is really useful, especially for those of us living in the modern world where now we're exposed to so many reinforcing

  5. 6:09 – 7:30

    Biggest Misconceptions About Dopamine

    1. AL

      substances and behaviors that...... we've all become vulnerable to the problem of addiction.

    2. SB

      And what are the biggest misconceptions of, on the subject of dopamine? Because it's kind of thrown around in society. I see it in my group chats, people saying, "I need more dopamine," or whatever, or you know, "That person just craves dopamine." Wh- what are the biggest misconceptions you've come across?

    3. AL

      The main misconception is that s- somehow we can get addicted to dopamine. W- we're not getting addicted to dopamine itself. Dopamine is neither good nor bad. It's a signal to tell us whether or not something that we're doing is potentially useful for our survival, and also it's related to what we predicted about how rewarding or pleasurable something would be. And so it's really, um, you know, I sort of, sometimes I joke, it's like the, um, reward theory of relativity, dopamine is, in the sense that pleasure and pain really are truly relative to one another, and so dopamine gives us information about where we are in that relativity scale between pleasure and pain.

    4. SB

      And when you say relative, you mean ... I mean, it's, it's quite fitting for anyone that can't see, we have a s- a set of scales on the table, and scales are relative to each other because if you pour in one end-

    5. AL

      Yes.

    6. SB

      ... the other end goes up, and if you pour in the other end, the other end goes up-

    7. AL

      (laughs)

    8. SB

      ... and this end goes down. And when you s- say

  6. 7:30 – 9:36

    Everyday Activities That Impact Dopamine

    1. SB

      relative, that's what you're describing, right?

    2. AL

      Yes.

    3. SB

      The ... Okay.

    4. AL

      That's what, that's what I'm describing, yes.

    5. SB

      Okay. And what activities that I do every day have an impact on my dopamine?

    6. AL

      Well, probably almost everything, you know, in some ways. Um, I mean, every time we are doing something that's pleasurable, reinforcing, rewarding, that will affect dopamine. It's, it's really the primary signal that lets us know that this thing is potentially important for our survival, as I mentioned. Um, but you know, even, um, aversive stimuli can, uh, trigger dopamine.

    7. SB

      What's aversive mean?

    8. AL

      Um, oh, something that's painful or not pleasurable, dopamine gets involved in, in that, um, equation. Anything that's novel or new is something that triggers our, uh, dopamine in, in our reward pathway. Dopamine is fundamental for movement, so not just pleasure and reward, but also movement. So for example, Parkinson's disease, which is a disease related to stiffness and tremor, is caused by a depletion of dopamine in a part of the brain called the substantia nigra. And as dopamine gets depleted in that part of the brain, people lose the ability to move their bodies. And it's probably no coincidence that the same neurotransmitter that is so important for pleasure, reward, motivation is also really important for movement, because most organisms have to locomote toward the object of their desire. If we want that thing, we have to exert effort, right? We have to put in the work to go get it. But in the world today, we really don't have to do that, right? We can swipe right, we can swipe left, and all of a sudden it magically appears at the touch of a finger, and that's very confusing for our brains because that's not how we evolved. We really evolved for h- for having to do quite a bit of upfront work for a tiny little bit of reward.

    9. SB

      I just wanna, m- before we move on, talk about this point you said, because I think it's quite foundational to everything we're gonna talk about, about

  7. 9:36 – 18:26

    Dopamine and Its Relationship to Pleasure and Pain

    1. SB

      dopamine being relative to pain.

    2. AL

      Mm-hmm.

    3. SB

      And I have this set of scales in front of me, and here I have some chemicals that are likely to produce dopamine in my brain, I believe.

    4. AL

      Mm-hmm. Yes.

    5. SB

      Right? So alcohol.

    6. AL

      (laughs) Yeah.

    7. SB

      I have some rum, I have some whiskey-

    8. AL

      Mm-hmm.

    9. SB

      ... I have some vodka.

    10. AL

      Mm-hmm.

    11. SB

      And can you explain to me using this rum, whiskey, and vodka how dopamine is relative to pain and h- what's going on in my brain?

    12. AL

      Sure.

    13. SB

      Okay, I'll slide this over to you.

    14. AL

      Oh, okay. (instrumental music plays) Okay. So one of the most exciting findings in neuroscience in the past 75 years 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 in a very simple, reductionist kind of way, they work like opposite sides of a balance. So imagine that deep in your brain's reward pathway, which is another exciting discovery, right, that there's this dedicated reward pathway of the brain that consists, broadly speaking, of the prefrontal cortex, which is this large gray matter area right behind our foreheads that's so important for future planning, for delayed gratification, for appreciating future consequences. You might think of it as like the brakes on the car, if we're going to s- analogize to, to a, to an engine. And then deep, you know, in the brain, we've got what we call the limbic areas or the emotion brain, and there you have the nucleus accumbens and the ventral tegmental area that are rich in dopamine-releasing neurons, right? And they act like the accelerator on the car. So when you've got a healthy functioning brain, you've got enough accelerator, but not too much, right? So enough dopamine being released, but not too much, and you've got a healthy prefrontal cortex putting the brakes on that dopamine release. When people, um, become addicted, there's either a problem with the brakes, the prefrontal cortex, or the accelerator, the nucleus accumbens and ventral tegmental area, or both, right? What we're finding is that there's actually a disconnect, so there are large neuronal circuits and pathways between those deep limbic structures and the prefrontal cortex that literally get severed or disconnected when people become addicted. As we think about pleasure and pain being co-located in the same parts of the brain, working like opposite sides of the balance...In order to understand what happens in the addicted brain is to appreciate that there are fundamental rules governing this balance, and one of the most important rules is, is that the balance (instrumental music plays) wants to remain level. It does not want to be tilted very long to the side of either pleasure or pain. And in fact, what our brain does is first tilt an equal and opposite amount to whatever the initial stimulus is. So I'm gonna try to illustrate that here. So let's say our initial stimulus is alcohol.

    15. SB

      Mm-hmm.

    16. AL

      Now, alcohol works through its own chemical pathway, it works on our endogenous opioid system, the opioids that we make, we have receptors for opioids in our brains, it works on our endogenous GABA system, which is our calming neurotransmitter, and at the end of the day, it releases dopamine in the reward pathway. So any potentially addictive substance will release dopamine in the reward pathway. The more that's released and the faster that's released in a given individual, the more likely that substance is to be addictive. Now, another important concept here is what we call drug of choice, which is to say what reli- re- releases a lot of dopamine in your brain may not release a lot of dopamine in my brain and vice versa, right? Which is this idea that people have predilections to different kinds of drugs. And by the way, people can get addicted to behaviors too. I should emphasize that.

    17. SB

      When you say drug of choice, you mean the brain has a particular sensitivity to that drug in terms of dopamine?

    18. AL

      Yes.

    19. SB

      Okay.

    20. AL

      The more dopamine that's released, the faster that it's released, the more likely that drug is to be addictive for a given individual.

    21. SB

      So you're holding some whiskey there.

    22. AL

      I'm holding some whiskey.

    23. SB

      There could be a brain that is very sensitive to whiskey, and there could be a different brain that you could pour all the whiskey in you like and the dopamine response is sort of limited.

    24. AL

      Exactly.

    25. SB

      Okay.

    26. AL

      And for many of my patients who become addicted to alcohol, they will tell you that from the first moment they had alcohol, they knew they were either in trouble or had met their best friend or some combination. It was a very potent experience for them. All right, so let's, let's go ahead and put this on the pleasure side of the balance. Dopamine's being released, but no sooner has that happened than my brain will work very hard to restore a level balance. And by the way, a level balance is what neuroscientists call homeostasis, okay? And one of the overarching physiologic drives for all living organisms is to return to homeostasis. Homeostasis is that parameter of what's often called off- called affordances, or states of being that are adaptive and healthy for the organism. For example, like, we have a certain homeostasis of body temperature, and if we go much too, much beyond that, either too high or too low, we will disintegrate and die, right? So homeostasis is that, that states of being that are compatible with existence and, and potentially advantageous too.

    27. SB

      Sort of baseline level-

    28. AL

      That's right.

    29. SB

      ... okay, balance.

    30. AL

      Yeah, baseline level. And by the way, we're always releasing dopamine at a kind of tonic baseline level in our brains. I sometimes think of it as the heartbeat of the brain.

  8. 18:26 – 20:31

    Why Do Our Brains Overshoot?

    1. AL

      smaller scale, just that moment of craving, right? That moment of wanting to have one more shot, right?

    2. SB

      Why does it overshoot? Why can't it just perfectly hit homeostasis?

    3. AL

      Such a great question.

    4. SB

      'Cause then we'd feel fine.

    5. AL

      Yeah, why did Mother Nature do that to us? So cruel, right?

    6. SB

      Yeah.

    7. AL

      Okay. I'm gonna tell you an evolutionary just-so story. What we mean by that is we don't really know why, you know, this mechanism exists, but from an evolutionary perspective, if you're living in a world of scarcity and ever-present danger, this is the perfect mechanism to make sure that we're never satisfied with what we have, that we're always wanting more. It's made us the ultimate seekers.

    8. SB

      Okay, because immediately after getting something, I'm now feeling a lack of pleasure, and I'm at a deficit, you know, on the pain side of the scale, which means that I'm gonna go seeking out more dopamine. And in a world where everything is quite scarce, that could mean going on another four-hour hunt the next day to go kill a gazelle or something.

    9. AL

      Perfect. You've got-

    10. SB

      Okay.

    11. AL

      Yeah. You've got it perfectly.

    12. SB

      So you... Okay, interesting.

    13. AL

      Yeah.

    14. SB

      Okay, so that's gonna motivate me because the sca- so but, but wait... Jesus, people that have hangovers don't seem very motivated.

    15. AL

      (laughs) Right, so now that's a... So w- why is that, right? It's because alcohol is a product of human engineering that releases so much dopamine all at once in the reward pathway that our brains are reeling to compensate, right? We, we really weren't evolved for this much pleasure with this much easy access. As you said yourself, we were really evolved for... To have to do quite a lot of work upfront and to be hungry and to be lonely and to be tired and then get a little bit of reward that would then bring us back up to homeostasis. So really, we were evolved to be pressing on the pain side of the balance in our effort to find pleasure, and then when we find it,

  9. 20:31 – 25:22

    How Our Brains Are Wired for Addiction

    1. AL

      that little bit of food or clothing or shelter or a mate would bring us back to the level position. Does that make sense?

    2. SB

      Yeah, so you're, you're telling me essentially that we're all wired to be addicted because if this is how our brain works in a world... It's designed to seek out more dopamine. But the problem we have now is we have all this synthetic dopamine, effectively, like this... Synthetic chemicals and s- synthetic things, and, you know, an internet that is wiring us to give us so much dopamine so easily, that, that means that our brains are effectively, like, mismatched to the world that we live in and therefore wired to be addicted. Yeah, I think you actually said that, I, I found a quote you said in an interview where you said, "We are all wired to be addicted, and if you're not addicted yet, it's right around the corner."

    3. AL

      Right, coming to a website near you. Yes. I, I guess I would f- th- I would qualify that a little bit b- by saying we're wired for survival in a world of scarcity. That's not the world we live in now. We live in a world of overwhelming overabundance, and so there is a mismatch between this ancient wiring that has us relentlessly pursuing pleasure in order to survive and a world that's so infused with pleasure and so many rewarding stimuli that now we're overwhelming our reward system, and our brains are reeling in response to try to compensate.

    4. SB

      So what happens to this scale, then, in such a world where I can get a big hit of dopamine all the time using some of these synthetic things or the internet or pornography or whatever else? What's going on with this scale over and over again?

    5. AL

      Okay, great. So l- let me get there. Let me first say, though, that remember, a- after we do something that's highly pleasurable, our brain compensates with neuroadaptation, tilting an equal and opposite amount to the side of pain, and then restoring our balance back to the level position, right? Or what we call homeostasis. So this doesn't last forever, right? It's to pleasure, then it's to pain, then it's back to the level position. But if we continue to consume our drug of choice over days to weeks to months to years and we add in a whole bunch of other drugs and now we're consuming, you know, pornography and smoking pot and eating, um, donuts and, you know, you name it, all at the same time, then essentially what happens is those gremlins on the pain side of the balance end up camped out there.

    6. SB

      For anyone that can't see, she put all of the rocks into the pain side-

    7. AL

      Right.

    8. SB

      ... to represent all of the addictive behaviors that this individual has now taken on.

    9. AL

      Right. And now, we've entered addicted brain, by which I mean that we've changed our hedonic or joy set point to the side of pain. Now we need more and more of our drug in more potent forms not to get high and feel good, but just to level the balance and feel normal, and this is not going to be enough. To level the balance, I would have to, like, keep filling this m- much more than this container can hold, and that would be in pursuit really of just trying to level that balance so that we can feel normal. And when we're not using, we're walking around with a balance tilted toward the side of pain, experiencing the universal symptoms of withdrawal from any addictive substance or behavior, which are anxiety, irritability, insomnia, depression, and craving.

    10. SB

      So if I manage to get enough vodka, whiskey, rum and pour it into the pleasure side of the scale, now that all the rocks are in the pain side of the scale, I manage to outweigh it, it would, it would... What would then happen?

    11. AL

      More rocks.

    12. SB

      More rocks would be added.

    13. AL

      The, the re- Yes.

    14. SB

      Okay.

    15. AL

      More, more rocks.

    16. SB

      So, so momentarily-

    17. AL

      Yeah.

    18. SB

      ... I would maybe be a- in a little bit of pleasure.

    19. AL

      Yes.

    20. SB

      But then my brain would remove those docking stations again, remove more of them, and more rocks would go in, and I'd slam down...... on, on the pain side again-

    21. AL

      Yes.

    22. SB

      ... which means I need more alcohol-

    23. AL

      Yes.

    24. SB

      ... to try and get up to pleasure, and it's that, and, and, okay. So really, you wanna, you wanna, like, dopamine fast, or you need, you, you need to just balance this. And this is so difficult because of the world we live in.

    25. AL

      Yes.

    26. SB

      It's almost, I, I, it's, it's funnily enough, 'cause this little scales experiment, um, e- analogy here has given me a huge amount of empathy for people that are addicts.

    27. AL

      Oh, gosh, I'm so glad you said that because I think that is the key to empathy for the disease of addiction, as well as for people with the disease. Having empathy for themselves is recognizing that on some level, it, it's, it's out of their control, right? Because when we are tilted to the side of pain, the overwhelming drive to restore a level balance or restore homeostasis as quickly as possible overwhelms any other rational thought about the consequences of my drug use, right? It's just like,

  10. 25:22 – 31:51

    Finding Ways to Deal With Pain

    1. AL

      get back to the level position, because if I do that, I'll at least feel temporarily better.

    2. SB

      One of the things this analogy also highlights for me is that people who are addicted aren't trying to self-harm.

    3. AL

      Right.

    4. SB

      And this is kind of the prevailing narrative, that if you're, like, "Why would you do that to yourself?"

    5. AL

      Right.

    6. SB

      Whereas when I look at this analogy, I go, "Actually, what they're trying to do is to deal with pain," and we're all trying to find ways to deal with our pain. And it, it, but in this analogy, what ultimately happens, and I guess is what's happening with addicts is, the way they're choosing to deal with their pain is becoming self-destructive, and that's creating more pain.

    7. AL

      Right.

    8. SB

      And it's this vicious downward cycle.

    9. AL

      Yes.

    10. SB

      And I think that sort of reframing of what's going on there is really critical 'cause again, it begets more empathy.

    11. AL

      Absolutely. I agree with you. And, and I think, you know, we, this, this metaphor, it makes an assumption that we all start with a pleasure-pain balance that's level with the ground. But actually, that's probably not true.

    12. SB

      Mm-hmm.

    13. AL

      Right? Some people at baseline may actually be more depressed or more anxious or may have had life experiences that sets them up for a kind of chronic stress reaction. And we know that people with co-occurring psychiatric disorders, for example, are at increased risk of developing addiction, probably because they're reaching for that substance to self-medicate their psychiatric problem. The, the issue with that is that it's not medicinal, right? It's not healing, although in the short term, substances can help with those kinds of feelings of psychological and physical pain. Over time, because of the way the brain adapts, as we've discussed, substances and other addictive behaviors just make psychiatric problems worse, right? As we drive ourselves further into the, the kind of, uh, you know, the pain side of the balance.

    14. SB

      So is this why trauma often leads to addictive behaviors, because the trauma has caused a, a pain, a stress, and we're searching for ways to medicate that pain or stress?

    15. AL

      Yeah, to numb ourselves, to not be present in our reality and have to deal with what's going on there.

    16. SB

      Is dopami- what role is dopamine playing in all this?

    17. AL

      It's all the same.

    18. SB

      Okay.

    19. AL

      Dopamine originally was to help us find those things that we need to survive: food, clothing, shelter, a mate. We call those natural rewards. But today, that same reward pathway that relies on dopamine has been hijacked by all of these artificial rewards that our brain confuses as necessary for survival, which is why people with severe addiction will be willing to lose, you know, not consciously, but unconsciously, their loved ones, their homes, their jobs, everything they have in pursuit of their drug of choice. It's because their brain has been hijacked and they now confuse the drug as necessary for survival. The other thing about drugs is that they're incredibly potent. They release a lot of dopamine all at once, which again is confusing for our brain. Natural rewards require upfront effort where we do a lot of work, and then we get a little bit of dopamine, and that's what our brains evolved for.

    20. SB

      I mean, I can, that makes sense in my own life when I'm most stressed or most challenged by something professionally is when I, I immediately notice that my diet goes out the window.

    21. AL

      Right.

    22. SB

      I start eating things that are bad. I actually stop going to the gym as much. Um, and it's, it can form a bit of a downward spiral, can't it? And I guess as we've kind of seen from the dopamine scale, um...

    23. AL

      Can I, can I get back to that, your-

    24. SB

      Please, yeah, yeah.

    25. AL

      ... question though about trauma and stress? So, um, there's a very series, there's a very interesting series of experiments in rodents, mice and rats, where they... First of all, rodents very easily get addicted to cocaine. They will press a lever for cocaine until exhaustion or death. But if that cocaine is then taken away, that behavior will extinguish, which means that the mice will eventually just stop pressing the lever, right? 'Cause they're not getting any cocaine. Totally makes sense, and then they'll go off and do something else in the cage. But if they're then exposed to a very painful foot shock, right? So a very extreme physical pain, which you could equate to a serious life stressor, the first thing the rat will do is run over to the lever and start pressing for cocaine.

    26. SB

      Hmm.

    27. AL

      Which tells us that once our brain has discovered a drug that releases a lot of dopamine in our reward pathway, even after we stop using that drug, if we are exposed to a- an extreme stressor, our brain will tell us immediately, "Go and do that thing that gives us a lot of dopamine, because you are under stress and I need to be relieved of stress." Does that make sense?

    28. SB

      Makes perfect sense.

    29. AL

      Yeah.

    30. SB

      Yeah, so if you, especially, so if you discover your drug of choice when you're younger and it's food or it's pornography or if it's, I don't know, anything that really made you feel good for a moment, a moment of pleasure, that will always become...In the case of these rodent experiments, the thing you run back to when life gets hard.

  11. 31:51 – 34:52

    Stories of Addiction

    1. SB

      shift that cycle that they might be going through, especially when they're HALTING, hungry, angry, lonely, or tired.

    2. AL

      Right.

    3. SB

      How often have you worked with addicts? Have you spent much time working with addicts directly?

    4. AL

      Oh my gosh, yeah. So that's the bulk of my career, is working, uh, with people with all different kinds of addictions to-

    5. SB

      Give me an example of the most obscure.

    6. AL

      The most... I had a patient who was addicted to water. I know, ha- hard to imagine. You have to, though, understand her narrative. So she had a very severe alcohol addiction. She got into recovery from that addiction and gave up alcohol, but she discovered that by drinking copious amounts of water, she could become hyponatremic, meaning that she could lower the sodium levels in her bloodstream, which would then lead her to become delirious. And so in her desire to just be checked out, she would do that, she would, she would drink, uh, large amounts of water.

    7. SB

      She's doing okay?

    8. AL

      No, sadly, she's not. Um, she, she ended up taking her own life. So that was very sad.

    9. SB

      Gosh. In that situation, was there, was there a root cause of that behavior pattern further upstream? Some kind of trauma or experience that had set this sort of cascade, cascading set of issues off?

    10. AL

      Yeah, you know, I'm just speaking broadly, um, for, for some patients with severe addiction, trauma is a huge factor, um, especially severe early childhood trauma. But there are also many folks we see who have kind of great parents and have had happy childhoods and have great social networks and, and work that they enjoy, and yet they still become addicted. And that's because we, again, we are wired to consume as much as possible of whatever releases dopamine in our brains to have survived evolution to this date. And yet we're living in this world where we have access to so many drug-ified substances and behaviors that we've all become vulnerable to this problem. And the reason I highlight this is because one of the things that I think has happened in the field of addiction medicine that maybe isn't the best is that oftentimes patients themselves, as well as their providers, are digging really deep to find the trauma or the reason that someone has become addicted. And I think that that's important to do in some cases, but in, in other cases, it can lead to kind of manufacturing trauma where there really isn't any. Furthermore, I would say that when a person is in the throes of their addiction, they're not going to be able to really do the complex emotional processing of their trauma while they're still using their drug of choice. That they really need to get out of that vortex of addiction and get into some degree of recovery

  12. 34:52 – 40:14

    How Many People Have Addiction Disorders?

    1. AL

      before you would even wanna go tackle some of those early traumatic experiences.

    2. SB

      How many people do you think are struggling with some form of addiction?

    3. AL

      Well, if you think of addiction as a spectrum disorder, right? There's mild, moderate, and severe. Um, and there's, I would even say a kind of a pre-addiction state where we're all sort of dabbling in compulsive overconsumption. I would say the vast majority of us, like 90, probably 95%, have some degree of compulsive overconsumption. And you know, if and when it tips over into what we would call addiction, there's not a brain scan or a blood test to assess that. It's not like, you know, switching a light, a light switch, and it's like, "Oh yeah, now you have addiction." Um, it's not like that. It's, you know, it's a gradual, often a gradual and insidious thing, and we don't in fact have a biological measurement of addiction. We base it on what we call phenomenology, which is patterns of behavior that re- repeat themselves across time. And broadly speaking, the definition of addiction is the continued compulsive use of a substance or a behavior despite harm to self and/or others. And so, you know, that harm can be very subtle, um, or not, right? And it can be a judgment call.

    4. SB

      Interesting 'cause we do throw the word addiction around a lot in society, but, but really the most important part of that is to understand if it's harming yourself or someone else, the behavior pattern.

    5. AL

      Yes, that's right, and to also recognize that we're not very good judges of that when we're chasing dopamine.

    6. SB

      Okay. So we sometimes justify behaviors we have as being not harmful, and it's fine, and it's not impacting me at all, and what do you mean?

    7. AL

      Exactly. And we don't... We're not very good at seeing true cause and effect, honestly, when it comes to these behaviors, which is why oftentimes people won't really see the harm until they've stopped using for a period of time.

    8. SB

      In your book, Dopamine Nation, you talk about an addiction that you had.

    9. AL

      Yes.

    10. SB

      And it was really surprising to me because I would never have thought that being obsessed with erotic novels-... could be classified as an addiction. What happened? What was the behavior? Take me into that, that phase of your life.

    11. AL

      So I was in my early 40s. Um, uh, my kids were no longer little. Um, I, I got a lot of my self-worth and identity from being a mom, and my kids were sort of entering adolescence. They were doing fine, but they didn't need me as much. Um, so I had kind of a grief reaction, you know, in response to that, was trying to figure out, you know, how to navigate this next phase of my life. I'd always been a reader, and an, and in particular, a reader of novels. Um, in my own way, that was how as a child I self-soothed, was to escape into, uh, the fantasy life of novels. Um, but I never had what I, what I would call a problem with it. And then one day, I heard another mother at school said that she was reading this great book. It was called Twilight. It was about these vampires, and she was going on and on about it. And I read it, and I, I can't tell you what it was, but it was just like the, the, the key in my particular lock. It was completely transporting. It just released a lot of dopamine is all I can imagine in my brain's reward pathway, and so I read the whole series, and then I read the series again, and I read it again. And of course, by the third or fourth time, it wasn't as, you know, reinforcing, and I thought to myself, "I wonder if there are any more vampire romance novels." And then for me, the real tipping point was I got an eReader. I got a Kindle. Because what happened was, I, I, even before I got the Kindle, I started reading, you know, novels that I would say I would be slightly embarrassed to admit that I was reading, like kind of bodice ripper novels. As time went on, I, I needed more and more, like, graphic kinds of descriptions in order to find it pleasurable. And, and by the way, that's classic for the addiction narrative, right, where you start out with a little bit and it goes a long way, and then over time, you build up tolerance. That's neuro-adaptation, the gremlin's pressing down on the pain side of the balance. Now I need more of my drug in more potent forms to get the same effect. Gradually over time, I started, um, reading, you know, more and more sort of, uh, graphic, erotic, sexualized versions of this novel, and I would ... I was embarrassed, so I would hide that I was reading them. And that gets into the whole double life of addiction where now we're lying about our use. We're, we're using our drug over here but pretending like we're not. So my kids or my husband would walk in the room and I would be, you know, hiding behind another book, uh, one book behind another book so it looked like I was (laughs) reading something, you know, I don't know, more sophisticated. And then the tipping point for me came really when I got a Kindle or an eReader, and then my reading was totally anonymous. I could read these books anywhere anytime. No one knew what I was reading, and as soon as I finished one, um, I could read another one. And I almost overnight became a chain reader. Like literally, when I wasn't doing something else that I had to do, I was reading romance novels, one after another after another. Um, which meant I was, you know, less present for my kids, less present for my husband. I would often stay up 'til 2:00, 3:00, 4:00 in the morning on a weeknight reading romance novels,

  13. 40:14 – 41:21

    Hiding Away From Friends and Family

    1. AL

      have to get up two hours later, go to work exhausted, not able to be present for my patients, not enjoying my work, gradually getting more depressed, more irritable, more anxious, more insomnia. We went on a, a family vacation with an- uh, f- family friends of ours, everybody together at this beach house, all the kids playing. I was, like, hiding in a room reading romance novels. So i- i- and this is exactly what happens with addiction is that our focus narrows and the things that we used to enjoy are no longer pleasurable. Only this one thing has salience for us. We plan our whole, whole day around getting it, using it, hiding our use. Um, and that's what happened to me.

    2. SB

      It's so interesting 'cause I was, as you were talking about that, I was thinking about all the behaviors that I have that are maybe isolating me or, you know-

    3. AL

      Yeah.

    4. SB

      ... just even things like spending a lot of time on the internet, just watching video after video after video on YouTube or, um, those kinds of things, or just, like, spending tons of time in my WhatsApp group chat

  14. 41:21 – 45:50

    Distinguishing Between Good and Bad Behaviors

    1. SB

      talking, like, roasting my friends about nothing.

    2. AL

      Right.

    3. SB

      How do you know if, like, this is, it's 'cause on one end of the spectrum, I could say, "Okay, well, that's harming my relationship with people in the real world, but it's helping making me feel good and it's, you know, maybe helping me in another department 'cause I'm learning more about vampires."

    4. AL

      (laughs)

    5. SB

      Or, you know, like ... So, like, uh, you know, 'cause there's, there might be net harm somewhere else, but then an upside over here, which and then I start rationalizing this behavior. Like, how do you dis- distinguish between these behaviors and know what's bad and what's good?

    6. AL

      You know what? It's really hard. Um, y- these digital devices are powerful tools, but also very potent drugs. There's no doubt that digital media lights up the same reward pathway as drugs and alcohol. These devices and platforms were designed to be addictive, that is to keep us scrolling and tapping long beyond what we planned for or what we want or even what's pleasurable. I think we can all relate to using this medium to a point where we don't even like it anymore and yet have difficulty getting ourselves off of it. That really speaks to the inherently reinforcing and cognitively adherent nature of this medium. It is a drug, and so, you know, if and when and how we're crossing into addictive use, I think we need to be very vigilant about whether that's happened in our lives. And one of the ways to do that is actually to try cutting out that particular digital medium, that website or that behavior for a period of time long enough-... to experience withdrawal, potentially reset reward pathways, and then re-evaluate, because when we're in the behavior, as you yourself noted, it's very easy to rationalize. "Oh, I need to do this for work. Oh, I need to do this to stay in touch with my friends. Oh, I'm learning so much from this," right? And all of that may have been true initially, but may not be that true anymore. And what I often point to is the subtler signs of addiction, which are things like depression, anxiety, inattention, insomnia, restlessness. These can be early signals for our consumption entering into that addiction range, but us not realizing it because again, we don't see cause and effect, which is why doing an experiment like I did with my romance novels, you know, following in the footsteps of my patients and taking the advice I give them, and I gave my romance novels up for 30 days, right? Just to see, like, okay, I think this is a problematic behavior. Can I give it up? How will I feel? And the very first day that I, the very first 24 hours that I did not read any romance novel, any novel at all, I was astounded at my level of anxiety, restlessness, and utter insomnia. I had completely unlearned the art of putting myself to sleep without this digital narrative, and that lasted a good 10 to 14 days, completely mapping on with the amount of time it takes typically to get out of acute withdrawal, that is to say for those neuro adaptation gremlins to hop off the pain side of the balance and for homeostasis to, to begin to be resto- restored. Um, but by the time I got to weeks three and four, I felt not just better than I had in the first two weeks, but actually better than I had felt in a really long time. I enjoyed my kids more. I was more present for them. I enjoyed my husband more. My work seemed salient again. I had started to think, "Well, maybe I should do something else." You know, maybe, maybe I, you know, this work I've been doing it a long time. I don't, it's not that interesting anymore. All of a sudden it was interesting again, right? So you see the relativity of that hedonic pathway and how when we're doing that behavior or substance that's so reinforcing that everything else loses its salience, we can really misidentify what is causing our irritability, anxiety, insomnia,

  15. 45:50 – 47:50

    How Addiction Makes You Feel

    1. AL

      until we stop that substance for long enough to see its impact on our lives.

    2. SB

      How is it making you feel? Because I think a lot of, a lot of people can't understand how you could get addicted to a book. I mean, I'm sure some people understand that, but, but for me, it's not something I've ever become addicted to. So h- how, how did it feel? Was it like exciting? Is it arousing? Is it somewhere in between?

    3. AL

      I mean, I think that romance novels are essentially socially sanctioned pornography for women.

    4. SB

      Okay.

    5. AL

      A- and the medium is narrative. And if you're a person for whom narrative is a powerful drug, as it is for me, a story, a narrative, a fiction, um, very potent since I was a child, then, you know, it was a natural that, that that would be the thing that I would get addicted to. And basically just like we've hacked and bio-engineered everything to make it more potent, I mean people, there's a formula for writing romance novels. Like if you take a physical copy, if you go to a store and you pick up a romance novel and you literally physically open it to two thirds of the way through, you will get to the climactic scene, pun intended, right? It's, it's like it's engineered. I mean, I got to a point where I wouldn't even read it, read after. I wouldn't finish the book. I would go on to the next book.

    6. SB

      Just to get to the climax part, and then you'd move on.

    7. AL

      Yeah, and I wouldn't even read the denouement or like what happens to the characters. I didn't care.

    8. SB

      You didn't care about...

    9. AL

      Nope.

    10. SB

      ... their, their future?

    11. AL

      And also I didn't, I got to a point where I didn't care about the quality of the writing or the depth of the charac- it didn't matter. It was, it was the drug. It was that moment I was looking for. And you know, there are a lot of free books on Amazon, some, some of which are high quality and some of which are not, but like, you know, any good drug dealer knows free samples, that's the way you hook people. I would search for these free samples, and that's part of it too, like the searching for the drug.

    12. SB

      Mm-hmm.

    13. AL

      So the working, the wor- upfront work you do for the drug is part of the drug, right? It's all that, you know, the machinations and the hiding and the this and the

  16. 47:50 – 54:18

    Is Work an Addiction?

    1. AL

      that that gets to be part of like all of the rituals surrounding it.

    2. SB

      Uh, as you were talking as well, I thought about work and work addiction.

    3. AL

      Yes.

    4. SB

      Because you, you earlier used the term excessive consumption.

    5. AL

      Right.

    6. SB

      And when I think about work, even my work, I think, Jesus, I, I excessively consume work.

    7. AL

      Right.

    8. SB

      I start so many bloody businesses and invest in so many things, and if you look to that behavior objectively, if you're like an alien looking down at me, you'd go, "This guy's got a fucking problem."

    9. AL

      (laughs)

    10. SB

      Do you know what I mean? You, you think, you think that's funny? (laughs)

    11. AL

      No, I-

    12. SB

      I'm joking. (laughs)

    13. AL

      You know... (laughs) I feel for you.

    14. SB

      Do you know? And it's funny 'cause in society we then, those people are reinforced. We clap.

    15. AL

      Oh, that's right. That's right.

    16. SB

      We clap. We go, this guy's not sleeping-

    17. AL

      Right.

    18. SB

      ... he's working 18 hours a day.

    19. AL

      Right.

    20. SB

      Clap, clap, clap.

    21. AL

      Right.

    22. SB

      Give him a trophy, an award.

    23. AL

      Right.

    24. SB

      Name a thing after him or her or-

    25. AL

      Right. Right.

    26. SB

      ... you know? Um, and it's just really interesting that, that, that addiction of work, and you tell me if it is, it can be an addiction. Certainly on the scale of one end being sort of consumption, excessive consumption, the other hand being addiction. It's on there somewhere.

    27. AL

      People can get addicted to work, and part of the reason is that we've drugified work, right? When, when I say drugified, what do I mean? We've made it more potent, and this is true for all, all these drugs. We've made them more potent, more novel, more bountiful, meaning there's more of it, and more accessible. So if we, if we break that down with work, how is work more potent?Well, certain types of work are more reinforcing, not all types of work. So for example, works, uh, wor- w- white-collar work is often now associated with stock options and bonuses, right? Um, there's often, like, a social media aspect to it or maybe even a fame aspect, or as you pointed out, those are our cultural heroes, right? So you get all this, you know, adulation for being a workaholic. And that also, because we're such social creatures, right? And human connection stimulates dopamine, that, that also makes work a, a... more of a potent drug.

    28. SB

      A personal brand, right?

    29. AL

      R- Right.

    30. SB

      So your LinkedIn, "Oh my God, this person got a promotion," we'll all clap-

  17. 54:18 – 58:59

    What Activities Provide the Biggest Dopamine Hits?

    1. AL

      It's stressful to have to restore the balance from those extremes of pleasure and pain.

    2. SB

      I read in, um, your book, you were talking about how different behaviors and sort of chemicals and substances have different impacts, and it was on page 50 of Dopamine Nation. In a study of mice, sex increases the release of dopamine by 100% and amphetamines, which is like drugs, right? Hardcore drugs-

    3. AL

      Yeah.

    4. SB

      ... increases it by 1,000%. By this accounting, one hit of a meth pipe is equal to 10 orgasms.

    5. AL

      Yes.

    6. SB

      It's interesting to think about that... the different behaviors we have and how they'll have a bigger impact on our dopamine. Is there, like, any... in an, in a, in a typical order of things that are, like, extremely dopamine-inducing and things that aren't, w- what's at, like, the top and bottom of the list, in your view?

    7. AL

      You know, I really think that it depends on the person, and we've got to look at drug of choice, right? I mean, potent drugs like methamphetamine, like opioids, like alcohol, like nicotine, like cannabis, um, are, are going to be very reinforcing for many people, but not for all people. And most people do have their one drug that they sort of prefer above all others. So-Although generally speaking, intoxicants release a lot of dopamine in the reward pathway, um, I think every person is going to be different. A- and also we, we don't really have good ways of measuring absolute values of dopamine in human beings, right? We can do that in rats, but we can't really do that in humans. It's r- it's relative values.

    8. SB

      I've got this, um, picture here which shows what looks like brain scans in a n- normal person, but then in someone who's addicted to- to different substances. I'll put this on the screen, and I'll link it below in the description for anyone that needs it and wants to see it. But it effectively shows the impact that, like, cocaine has on the brain, meth, um, alcohol, and heroin. What is, what is going on here?

    9. AL

      So, the red in this image represents dopamine transmission.

    10. SB

      Okay.

    11. AL

      So how much dopamine is being released from the presynaptic neuron, crossing that synapse, binding to receptors on the postsynaptic neuron. How much dopamine is kind of swirling around in the reward pathway part of the brain. And what this image shows is that on the left-hand side, in healthy control subjects who do not have addiction-

    12. SB

      Mm-hmm.

    13. AL

      ... there's plenty of red, right? So there's plenty of dopamine transmission in the reward pathway, specifically here in the nucleus accumbens. But if you look at the right-hand column, you'll see that in these individuals who have been using cocaine, methamphetamine, alcohol, and heroin in addictive ways, there's almost no red, which means there's decreased or below normal levels of dopamine transmission. They are in a chronic dopamine-deficit state. This is evidence of the brain trying to compensate for too much dopamine being triggered by downregulating its own dopamine production and transmission, not just to baseline, but below baseline. And importantly, these individuals who are addicted to these substances, these brain scans were done two weeks after they stopped using.

    14. SB

      Oh, wow.

    15. AL

      Yeah. Which tells us that this dop- dopamine-deficit state persists for some period of time. It-

    16. SB

      For how long?

    17. AL

      Well, it depends on the person, but we know at least from this experiment that the first two weeks are this persistent dopamine-deficit state, which is consistent with acute withdrawal, right? People feel... When they first stop their drug of choice, they feel terrible, right? They experience all of the symptoms of physical withdrawal that correspond with that particular drug they were using, usually the opposite of what the drug did, plus the universal symptoms of withdrawal from any addictive substance or behavior: anxiety, irritability, insomnia, depression, and craving. Now, if they can get through the first 10 to 14 days, what we see clinically is those acute withdrawal symptoms slowly start to get better, and we think that that is mapping onto regenerating dopamine transmission in the reward pathway. And if they can make it to a month, that's usually the point for, for, on average, incl- based on clinical experience, when people really can start to get out of that constant state of craving for their drug of choice and begin to see some light at the end

  18. 58:59 – 1:01:00

    Can We Inject or Drink Dopamine?

    1. AL

      of the tunnel for what their lives might look like if they can maintain abstinence from their drug.

    2. SB

      And we can't just inject or drink dopamine. I mean, I guess that would be like drinking alcohol. We can't just artificially mess with the, the balances to try and restore the dopamine levels in an addict, can we? Can't just add a little bit of dopamine.

    3. AL

      Yeah, it's a, it's a great question, because, uh, we have some natural experiments that suggest what, what might happen if we do that. So as I mentioned before, people with Parkinson's have depletion of dopamine in the substantia nigra. That's what causes that, that motor disease. The treatment for it is to give L-DOPA, which is a dopamine precursor. If I were to give you a spoonful of dopamine, it would do absolutely nothing because it doesn't cross into the bri- the brain, it doesn't cross the blood-brain barrier. But I could give you L-DOPA, which is a precursor chemical that would cross your blood-brain barrier and get turned into dopamine, and then diffusely bind dopamine receptors in your brain, in the reward pathway, but also in the movement pathways. When we give patients with Parkinson's dopamine in this form, that can temporarily improve their movements, but in about one in four Parkinson's patients, they will develop a de novo addictive disorder. Shopping addiction, sex addiction, other types of addiction. Because we have the same problem. We are stimulating the reward pathway with dopamine that is ingested exogenously from the outside, and our brain reads that as, "Oh, boy! Gotta compensate by downregulating dopamine transmission to below baseline," which then puts us in that addiction vortex. Does that make sense?

    4. SB

      It does. So we have to... (sighs) I mean, it tells me that we have to live lives in a certain sense of... We have to live our lives in a certain sort of homeostasis, and it's so easy not to in the world we live in. It's like in- it's like impossible

  19. 1:01:00 – 1:02:37

    Why We Must Do Hard Things

    1. SB

      to live in a perfect homeostasis balance in the world we live in.

    2. AL

      Right. Even more than having to try to live within this sort of narrow range of homeostasis, in the world we live in today, we probably have to intentionally do things that are painful, do things that are hard. Pleasure-pain balance?

    3. SB

      Yeah.

    4. AL

      Right? We learn that when we press on the pleasure side of the balance, like with alcohol, or pornography-

    5. SB

      (slurping)

    6. AL

      ... or romance novels, or cannabis, whatever it is, right? No sooner does that happen than our brain adapts-... by those neuro-adaptation gremlins hopping on the pain side of the balance to bring it level again, but they like it on the balance-

    7. SB

      (instrumental music)

    8. AL

      ... so they don't get off right when it's level. They stay on until we're tilted an equal and opposite amount to the side of pain. That's to come down the hangover, et cetera. But it turns out the opposite is also true. If we intentionally press on the pain side of the balance, for example, with exercise or an ice-cold water bath or intermittent fasting, those gremlins will hop on the pleasure side of the balance, and we will get our dopamine indirectly by paying for it upfront. And there are studies in humans showing that when humans expose themselves to exercise, for example, dopamine levels gradually rise over the latter half of the exercise, and then when the exercise stops, dopamine levels will remain elevated for hours afterwards before going back down to the baseline level position without ever going into that dopamine deficit state. So it's a great way to get our dopamine indirectly,

  20. 1:02:37 – 1:04:19

    Can You Get an Exercise Comedown?

    1. AL

      because it's much less vulnerable to that compulsive craving phenomenon of overuse.

    2. SB

      So you're not gonna get an exercise come-down?

    3. AL

      You can, but becau- and people can get addicted to exercise, right? But typically, it's, it's very unusual, because the upfront cost to, to do the work and endure the pain of exercise in the first place mitigates our vulnerability to an exercise addiction. And in general-

    4. SB

      Ah, okay, 'cause it's so hard-

    5. AL

      Yeah. Yes.

    6. SB

      ... to do that it's gonna be hard. You know, it's sort of like-

    7. AL

      Yes.

    8. SB

      ... pulling a lever on a slot machine-

    9. AL

      Yes.

    10. SB

      ... or clicking on a porn website.

    11. AL

      Yes, exactly. Yes.

    12. SB

      It's difficult. Okay. So fighting for the dopamine is... insulates us against the chance of an addiction, having to really fight hard for it. Okay.

    13. AL

      Yeah.

    14. SB

      And this kind of explains, I guess, in part, why... I- I pulled out some stats a- ahead of our conversation today, that from 1996 to 2008, participation in ultra-marathons has increased by 1,676%. The ice bath market is expected to rise from 350 million in 2024 to, to nearly half a billion by 2030. The number of people taking part in obstacle course races like Tough Mudder or Hyrox, et cetera, et cetera, has increased by almost 7X from 2010 to 2017. It seems like in society, there's this counter-movement towards people seeking out hard dopamine, chasing pain.

    15. AL

      Yeah, those are amaz- I didn't know that. Those are amazing numbers. Um, you know, i- in general, there's a part of me that wants to say, "Well, that's a good thing?" Um, but there, there's another part of me that's wary also, because we're so good at

  21. 1:04:19 – 1:05:17

    How to Optimize for a Better Life

    1. AL

      drugifying everything that we do that there's a way in which these types of behaviors can also be drugified, right? Made more potent with all of the technology, the way that we count ourselves, the leaderboards, the social comparisons. All of that takes this thing which is really in its natural state kind of impervious to addiction. Like, you just typically wouldn't get addicted to these types of painful physical activities. You would do what you needed to do for survival. But we've managed to make them addictive in all these different ways. I still think it's a better way to get your dopamine. Like, I really encourage exercise. We always talk about movement as medicine. And in general, our, our life is so convenient, so easy, so passive, so sedentary, that I'm telling patients all the time, you know, "Get up off the couch. Move your body. Walk around the block." I think that's the bigger obstacle right now, is just getting people to move. But I do think we

  22. 1:05:17 – 1:09:29

    How Should We Be Living?

    1. AL

      need to be wary of not going too far in the direction of, like, the ultra, ultra, ultra whatever it is.

    2. SB

      So what is a better way to live? If we're trying to optimize for happiness and to keep our dopamine in balance and not have the crashes, et cetera, and come-downs and hangover, what is a optimal way to live our lives? Do we have to look back at our caveman ancestors and live like them?

    3. AL

      I think that part of the problem is that we've organized our lives now around rewards. Almost everything that we do is predicated on the feelgood moment we'll have at the end of it, and because of that, we are missing out on the process. We're projecting our psyche forward into the future toward the reward and not able to really be here in the moment. Okay, this is gonna be, sound weird. I'm gonna give you a weird example. So driving over here today, I found I was nervous for this interview, and in a way, looking forward to it, but in a way, wanting it to be over, right? And, and in seeing that in myself, I thought, "That's so sad." Like, that's, that's so sad that we live our lives that way, myself included, always this weird blend of wanting whatever we're doing to be over, so then in a way, we can just go hide and do whatever that self-stim thing is that we do where we're safe and we're, like, you know, stimulating ourselves in some way. And then I thought, "Well, what if I knew that I was gonna die right after..." (laughs) This is making me... I'm gonna come off really weird now. But what if I knew that I was actually gonna die right after our conversation today? That totally changes my perspective, doesn't it? 'Cause this time you and I have, that's all I got. It's over for me when this... So this, this conversation is it. I really better be right here, right now, and really taking joy in whatever you and I can find together. And, and I think the more we can do that, the better.

    4. SB

      What's happening there? You're removing the thought of the outcome, the reward, the potential, you know, failure or whatever, and you're focusing on just being present, and in doing so, what is happening?

    5. AL

      It's a great question, and I- I've actually given this quite a lot of thought, because I remember when I was in college, and I, you know, met some, like...... Zen people, and they were like, "Be here now, be here now." And I thought, "Well, whenever I'm here now, I'm miserable. Like, I, I, I don't like me and I don't like being in the world. I, I don't wanna be here now. (laughs) I wanna be somewhere else." So I didn't really understand what they were getting at. It really took me, you know, till I had lived quite a lot of life and had some, you know, some significant experiences and given it some thought that I realized, "Oh, be here now means be here now and be uncomfortable and be okay with being uncomfortable and being okay with not being able to control my pleasure or my pain or my comfort level, but just being open to whatever comes." And I think that's a really, a key shift that I'm not trying to control my experience in the moment and that it's okay to be unhappy or restless or uncomfortable, and not trying to run away from that, but just really turn and face it and embrace the discomfort, which I also think is quite universal. I don't think I'm, I'm alone in that. And then the key piece about not, not anticipating the reward is helps me be in the moment, right? Because I'm not just waiting for the good thing to come after. I'm saying to myself, "Imagine there's nothing good coming after, nothing at all," right? There's just, there aren't rewards. This is it. And then also being able to say, "And it's okay if in the moment, like, it's not great." Like, I, I can embrace that, you know. I can be unhappy or restless or anxious or whatever it is. And then when I do that, you know, I feel like there's a funny, funny thing that happens and all of a sudden, I, I'm not as anxious, right? And

  23. 1:09:29 – 1:10:34

    Being Comfortable With the Uncomfortable

    1. AL

      I am present and i- there is some joy there.

    2. SB

      Interesting. So when you allow yourself to deal with being uncomfortable in the moment, it turns out you're n- it removes the thing that was making you uncomfortable in the moment, which is, like, the avoidance or the worry or overthinking, whatever else.

    3. AL

      Yeah. I, I think we have this f- and it's fed by modern culture, this kind of expectancy that really we should be happy all the time and that if, you know, if we've arranged things appropriately for our lives and we've done our work and, you know, aimed true, then we should just be like, "Life is great." And I don't believe that anymore. I think that, you know, I mean, like Buddha said, "Life is suffering," but I really think that fundamentally, like, it's uncomfortable to be alive and that it's a kind of a constant state of restlessness and discomfort. If we're being really honest and, and tuning in, when I really let myself see that and feel that, all of a sudden, I'm, I'm freed

  24. 1:10:34 – 1:12:43

    Causes of Anxiety Throughout Life

    1. AL

      from, from some of that.

    2. SB

      What has caused your anxiety throughout your life in the moment? You s- you referenced earlier that some things have happened that has, have led you to understand this better and understand yourself better. What is, what am I missing from this jigsaw puzzle?

    3. AL

      Yeah. No, you're, you're good. You could've been a psychiatrist. (laughs)

    4. SB

      Oh, really? Yeah. There's always time. This doesn't work out...

    5. AL

      There's still time, right? It's not too late.

    6. SB

      Yeah. (laughs)

    7. AL

      Get a new profession. Yay. Um, I think, you know, for me, the, the big turning point, um, was that we lost our, we lost a child. And, um, in the immediate aftermath of our child's death, I was just determined to, like, sort of undo the experience and, um, you know, get enough psychotherapy and enough whatever, uh, whatever it took to sort of not feel that pain. And it wasn't until I really just said, "Oh, like, I'm gonna feel this pain for the rest of my life. It's never going away," that suddenly I felt some relief from that pain. And that was a real window for me.

    8. SB

      So interesting that the, it's acceptance.

    9. AL

      Yeah. And, and, you know, and, and I think, you know, one of the reasons I love treating patients with addiction is because I really relate to that hitting bottom moment, you know, that moment when it's like you just have the feeling that, like, everything I try to do to manage this behavior or to make my life better only makes it worse. I felt like I had a very similar experience. Um, and that it was only when I kind of realized, "Oh, I, yeah, I, I can't run from th- I can't outrun this pain," uh, that I, I began to have some the beginnings of relief from that experience.

    10. SB

      "I can't outrun this pain."

    11. AL

      Mm-hmm.

    12. SB

      It's our natural sort of disposition to try and outrun pain, isn't it?

    13. AL

      That's the irony, right? We're really wired to outrun the pain. We are. Like, we reflexively

  25. 1:12:43 – 1:13:09

    Living in a World Where It's Easy to Outrun Pain

    1. AL

      seek out pleasure and avoid pain, and yet that's the very thing, thing that doesn't get us to where we wanna go.

    2. SB

      But we do now live in a world where it's very easy to outrun the pain.

    3. AL

      Yes.

    4. SB

      This is not a lion that's chasing me.

    5. AL

      Yeah.

    6. SB

      This could be a bad email, and then I open up a tab and start doom scrolling or open up a tab and start watching video, playing video games or pornography or whatever.

    7. AL

      Yeah. That's exactly right. There are so many ways

  26. 1:13:09 – 1:14:43

    Where Are You Now in Your Grieving Journey?

    1. AL

      that we can now distract ourselves from, you know, our own suffering or our own awareness.

    2. SB

      And where do you find yourself now with dealing with that grief and the pain as we sit here?

    3. AL

      Yeah. I mean, I, I feel like i- in many ways, it's been a real gift in my life. You know, it's really informed my life in, in ways that, um... I mean, I, I've learned things from that experience that I think it would've been almost impossible for me to learn otherwise.

    4. SB

      You deal with a lot of people that are in a state of suffering.

    5. AL

      Mm-hmm.

    6. SB

      I...... imagine that's a weight, because I, um, even hearing the story of the lady that passed away after that water addiction-

    7. AL

      Mm-hmm.

    8. SB

      ... it, it was like a, it was like a weight on my shoulders just to hear it.

    9. AL

      Yeah.

    10. SB

      So if your profession puts you right at the heart of this type of suffering, how do you manage that, to, to hold that weight?

    11. AL

      A couple things. Um, first of all, a lot of people get better, and when people with addiction get better, it's so much better that it's incredibly rewarding to see. And they're amazing people, absolute- like, some- the most tenacious, talented people you'll ever meet. And when they get better, it impacts so many other people, right? Their friends, their family, the people they work with. So it's very rewarding work and, and not at all burdensome. Of course, you know, for patients who don't, don't get better or patients who die, it's

  27. 1:14:43 – 1:15:37

    Youngest Child Seen With Addictions

    1. AL

      a terrible feeling, and there is a sense of, um, responsibility and, and guilt. Even when I feel like there was nothing that I could have done otherwise, um, you know, I carry those losses with me, so it's hard.

    2. SB

      Is there any particular cases that have stayed with you the most?

    3. AL

      I mean, every patient I've had who's died, uh, while under my care, those are incredibly painful, um, and I will never... You know, tho- those are sort of a, those people will be with me as a part of me for all of my life.

    4. SB

      Young and old?

    5. AL

      Yeah. Young and old. Yeah. It's especially tragic to y- to lose young people, and it always feels like they're second-guessing, like, "Oh, if only I had done that," or, "If only we had intervened here." But I just think that's the nature of death. We, we can't get away from the feelings of guilt around it, no matter who we are and no matter the circumstances.

  28. 1:15:37 – 1:16:50

    Youngest Age When Addiction Can Have an Effect

    1. AL

    2. SB

      How young can a- addiction and the consequences of addiction ruin someone's life? Like, how young can someone be when their life is ruined from, from the work you've done and the ex- the patients you've worked with, and what are those addictions typically that seem to be most, um, susceptible to those that are young?

    3. AL

      Well, I mean, you know, some, some kids start with drugs and alcohol, you know, in five, six, seven, eight, and-

    4. SB

      Really? Five, six, seven?

    5. AL

      Oh, yeah. I mean, it's, you know, some, some pe- some kids use with their parents or their caregivers. They're exposed very early. If we seriously conceptualize digital media as a drug, I mean, then we've got, you know, even younger cohorts starting with that. And we do know that kids can get a- addicted to digital media, and as a result, um, die from that. I mean, there was just this tragic case of a young man who essentially got addicted to a chat box. I think he was 14. Not my patient. It was written up, um, in the New York Times and The Wall Street Journal. And he fell in love with this chat box, started to isolate, wasn't spending time with his family or friends, and then eventually took his own life, purportedly

  29. 1:16:50 – 1:18:40

    Youngest Patient With Addiction

    1. AL

      so he could join this imaginary person.

    2. SB

      What's the youngest patient you've ever seen?

    3. AL

      The youngest I've seen is probably around 15, 14.

    4. SB

      15?

    5. AL

      15.

    6. SB

      And they had an addiction?

    7. AL

      Yeah. Usually cannabis, alcohol, nicotine.

    8. SB

      Can you get addicted to cannabis?

    9. AL

      Oh, yeah. Oh my gosh. Cannabis is very addictive.

    10. SB

      Really?

    11. AL

      Oh, yeah. Yeah.

    12. SB

      Harmful?

    13. AL

      Very harmful. The target organ that it damages the most is the brain. Um, it's harmful in many ways. I mean, i- it, uh, number one, it demotivates people often, and so they can have the feeling that they're getting stuff done or that they're creative when in fact they're not doing anything. Um, it... Most people smoke it, and so it can be damaging to the lungs and, and other, other organs. Um, a lot of people say that, "Well, cannabis isn't addictive because I don't have the standard withdrawal phenomenon when I stop. Like, I don't have the shakes or anything like that." But keep in mind, the universal symptoms of addiction are psychological symptoms, anxiety, irritability, depression, insomnia, craving, and people have that in spades when they try to stop using cannabis. Plus we often see something called the hyperemesis syndrome. So cannabis can help with nausea and vomiting. It can help decrease the feeling of wanting to vomit, but again, as the brain continues to be exposed to it, there's this process of neuroadaptation. It stops working, and it can even turn on them and do the opposite. So eventually people can actually have a cyclical vomiting syndrome as a result of cannabis. So they'll show up in the emergency room and say, "I can't stop... You know, I can't stop vomiting." And the reason is because of the cannabis

  30. 1:18:40 – 1:21:05

    Has Society Gone Soft?

    1. AL

      that they maybe initially started, uh, to stop feelings of nausea.

    2. SB

      On page 40 of Dopamine Nation, you say, "We've lost the ability to tolerate even minor forms of discomfort."

    3. AL

      Yeah.

    4. SB

      And as I was reading through this section of your book, I was thinking it sounds like we've gone a little bit soft-

    5. AL

      (laughs)

    6. SB

      ... in society. Um, we've reset our pleasure-pain threshold to the side of pain, that even the slightest thing feels like trauma to us. Even things that, objectively speaking, a generation or two ago would not have been considered traumatic are now trauma. We live in a bit of a trauma society. Uh, one that doesn't appear to be very resilient, and the only measure of that that I have is if I think about the work that my grandfather had to do-

    7. AL

      Mm-hmm.

    8. SB

      ... versus the work that, you know, people maybe in my generation do and complain about and seem to be, like, objectively suffering over and stressed about.

    9. AL

      Yeah.

    10. SB

      It seems like there's been a, a shift in our threshold or our tolerance levels. Can this be explained through dopamine? What's going on here, and do you believe that's true? Have we gone a bit soft?

    11. AL

      I would say, succinctly, yes, I do believe we have gone a bit soft, but I don't think it's a moral problem or a character problem. I actually think it's a physiological problem, based on the fact that we're insulated from pain and we're exposed to all kinds of pleasures. So I really think that we have, individually and collectively, reset our reward pathways to the side of pain, meaning that the gremlins have now accumulated on the pain side. We've tipped ourselves to the side of pain-

    12. SB

      Because we've had so much pleasure.

    13. AL

      ... because we've had so much pleasure, yes. Thanks for having me clarify. So that, you know, now we need more and more pleasure to feel any pleasure at all, and the slightest little pain, and we're e- you know, experiencing excruciating pain. You add to that the fact that we have a culture that tells us we should never be in pain, and that if we are, something's wrong with our life, or something's wrong with our wife, or something's wrong with our job. And so now you've got, you know, a whole generation of folks who feels like they're experiencing more pain because they're, literally don't, do not have the mental callouses to tolerate pain, and now they're being told, "And if you have any pain at all, you must have, you know, something wrong with your brain. Go see a doctor. Go take a pill." And I think this is really a, this is not a direction we wanna keep going in.

    14. SB

      We have a mental health culture, where we assume most things are a mental health illness. Um, in page 186 of your book, you say, "I've become convinced

  31. 1:21:05 – 1:25:02

    Victimhood and Responsibility

    1. SB

      that the way we tell our personal stories is a marker and predictor of mental health." Now, if you live in a society where everything has a label, and it's a, it's a disease or an illness, or, you know, "I, I don't feel good today so I've got this disorder, and therefore I need this medication," i- i- I guess there's two questions. Is my assessment of the situation correct, and B, is this a bad place to be i- in as a society, where we think everything, every feeling we have, every, you know, d- we think everything that makes us different is a deficiency?

    2. AL

      Let me, let me start... Let me, let me answer this by talking a little bit about the role of language and narrative, because I, I think this is very fascinating. And, you know, as a psychiatrist and a therapist, that is my bread and butter, right, is, is narrative, how people tell their stories.

    3. SB

      Mm-hmm.

    4. AL

      By, by giving language to our experience, we gain awareness of our conceptual models of the world.

    5. SB

      Okay.

    6. AL

      Okay? And what I have learned over time is that the way people tell their stories is a window into their model of the world, and that there are healthy narratives and not-so-healthy narratives. And in general, in my clinical experience, when people come into the room and they tell their life story in such a way that they're always the victim of other people and circumstance in the world, those are people who are, number one, not doing well, and number two, not going to do well going forward unless they change that narrative to acknowledge what they've contributed to the problem. And the reason for that is because the way that we narrate our lives is not just a way to understand our past. It actually is our roadmap for the future. So if I see myself as a victim, and that's my narrative, I will literally create victimhood for myself going forward. I will literally change my sensed experience, so that whatever happens, I'll make sure I end up as a victim. When people with severe addiction get into recovery, one of the most palpable changes that I see is the way that they narrate their lives. They go from, in addiction, talking about their lives as if it's always everybody else's fault, to, in recovery, talking about their lives in a way that says, "Oh, you know what? I coulda done better here," or, "You know what? That's something that I keep doing that really messes with my life that I wanna change, and I'm gonna figure out how to change that."

    7. SB

      Why is it so hard to take responsibility in such a way?

    8. AL

      Great question. We just hate to do it, because when we do it, we feel shame, and shame is an incredibly painful emotion. It's like a gut punch of an emotion that is associated with fear of abandonment, fear of being shunned by our tribe. We'd much rather paper that shame over with anger and resentment toward others.

    9. SB

      It's, it's interesting 'cause there'll be, uh, different groups of people listening to this now. There'll be the high-responsibility group that just love and revel in taking responsibility 'cause they think taking responsibility means that they are strong.

    10. AL

      Uh-huh.

    11. SB

      It means that, "I'm so strong, I can take the blame and withstand it." And it's funny 'cause the more I've learnt to take res- responsibility for things in certain areas of my life, the more I've become proud of myself and the more I think I'm strong, and I'm like, "Oh, look at me, I can take responsibility for anything, and it d-" And then, if you go down this spectrum, you'll eventually get to the end of the spectrum where you've got people who, even as they heard you say that, will feel cognitive disson- they'll feel a sense, uh, like a little... It'll irritate them, it'll piss them off, and they will be the what-about-ery gang. They'll be saying, "Yes, but what about Dave? He did this to me," and you know, they'll immed-

Episode duration: 2:11:39

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