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Dr Rangan ChatterjeeDr Rangan Chatterjee

How To Use DOPAMINE As A Superpower To TREAT ADDICTION! | Anna Lembke

Do you think you have an addiction, or perhaps an unhealthy relationship with a certain behaviour? It may be a behaviour that you have tried to stop in the past that you keep returning back to despite your best intentions.

Anna LembkeguestDr. Rangan Chatterjeehost
Dec 1, 20211h 31mWatch on YouTube

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Transcript

  1. 0:00 – 3:15

    What Dopamine Is and What It Does

    1. AL

      70% of the global deaths today are caused by modifiable risk factors in nations where people have access to all of this abundance. We really have reached a tipping point when we are dying because of our behaviors.

    2. RC

      [Instrumental music] The term dopamine gets spoken about a lot these days in the context of addiction, social media, foods, and I wonder if sometimes we misinterpret what it is and what its function is. So I thought we could start perhaps by you explaining what is dopamine, when does it get released, and why is it so important for us?

    3. AL

      Great. I love starting there. So dopamine is a chemical that our brain makes, and it's essential to informing us about changes in our environment and in our body state, and we need it in particular to tell us when we are getting a signal from the environment about something that we should approach or do more of or work for or pay attention to. Dopamine is also the molecule that's really fundamental to the process of getting addicted to something because dopamine is released when we do something that's highly pleasurable, highly reinforcing. And remember, our brains have evolved over millions of years to approach pleasure and avoid pain. It's what's kept us alive and thriving on this planet for so long. But one of the, I think, common misunderstandings about dopamine is that it's only released in response to pleasure, and that's not true. It actually can be released in response to aversive stimuli that are somehow important for our brain to pay attention to, and we can get, get into that more later. But I mean, as a fundamental sort of function of dopamine, it's really about motivation and the approach signal. You know, interestingly, dopamine's also related to movement, right? It's the, it's the chemical that gets depleted in the disease of Parkinsonism, where people become rigid-

    4. RC

      Yeah

    5. AL

      ... and can't move anymore, um, because they don't have enough d- dopamine in a part of the brain called the substantia nigra. So dopamine is essential for pleasure, motivation, reward, moving toward an object.

    6. RC

      Given how important dopamine is then in our... Well, one of its functions, as you say, is it is our pursuit of pleasure. You say it's intimately linked with addiction. So where is that sweet spot where we can use it to gain pleasure, you know, gain those rewards that, that we, we all want without it sort of tipping over into addiction, you know? And I think that's, that really, I think, underpins a lot of your book, doesn't it? This kind of-

    7. AL

      Yeah

    8. RC

      ... this balance a- and this sweet spot because we f- we find it hard.

  2. 3:15 – 7:53

    The Pleasure-Pain Balance and the Dopamine Deficit State

    1. AL

      Yeah. Yeah. No, you're right, and it's hard not just because we're wired to approach pleasure and avoid pain. It's hard because we're living in a dopamine overloaded world where everything has become drugified, everything has been made more accessible, more abundant, more potent, more reinforcing, more novel. And so we're really living in a world that has turned us all into addicts essentially, um, plus our primitive wiring that's not really evolved for that ecosystem. And to understand sort of how we get out of that adaptive healthy seeking of dopamine and fall into that maladaptive addictive seeking of dopamine, it's really important to understand that pleasure and pain work like a balance in the brain, and that the same parts of the brain that process pleasure also process pain. And if you like, I can, I can describe sort of that relationship.

    2. RC

      Yeah. Yeah, please do. I'd love to hear about it.

    3. AL

      Okay, so i- if you imagine that in your brain there's a balance like a teeter-totter in a kid's playground, okay? And when we experience pleasure, it tips one way, and when we experience pain, it tips the opposite way. And one of the overarching rules governing that 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. So when we do something pleasurable, okay, so in my, in my case that might be reading a romance novel or eating a piece of chocolate or, um, my morning cup of coffee, what happens is that I, I, I get a little release of dopamine in a part of our brain called the reward pathway and my balance tips to the side of pleasure. But no sooner has it done that than my brain will try to restore a level balance by down-regulating dopamine production and dopamine transmission, not just to baseline levels but below baseline levels. So, and I imagine that as these little gremlins hopping on the pain side of the balance that bring it level again, but they like it on the balance, so they stay on until it's tipped an equal and opposite amount to the side of pain. That's the come down, the after effect, the hangover, or that moment of wanting, you know, one more cup of coffee or, you know, wanting that novel not to end or wanting to watch one more episode. Now, if we wait long enough, those neuroadaptation gremlins hop off and baseline dopamine levels are restored. But if we don't wait, if we continue to consume our drug of choice repeatedly over days to weeks to months to years- We end up with enough gremlins on the pain side of the balance to fill this whole room. In other words, we end up with a pleasure-pain balance that has a new hedonic or joy set point. It's now chronically tilted to the side of pain because those gremlins are camped out there, and we are in a dopamine deficit state. In other words, to compensate for the increase in dopamine in our brain's reward pathway beyond what our brain has evolved to deal with, we essentially go into this chronic dopamine deficit state. And once we're in that state, we are struggling with the addicted brain. And then we need our drug not to feel good, but just to restore a level balance and feel normal. And when we're not using, we're experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and intrusive thoughts of wanting to use.

    4. RC

      Yeah, that, that sort of, um, idea of a seesaw, and we move to the side. We, we, we have our drug of choice. And, you know, a- as we're gonna talk about, this doesn't necessarily need to be alcohol or, you know, cocaine. This can be [laughs] sugar, this can be-

    5. AL

      Right

    6. RC

      ... coffee, this can be Instagram.

    7. AL

      Right.

    8. RC

      And so we, we, we press on pleasure on the seesaw, and you're saying that actually the body then responds by the seesaw goes in the other direction to move us to, to try and recreate balance. But if we keep doing this day in, day out, the seesaw gets stuck, and actually we're just left craving all the time. We want... We, we, we, we take any dopamine hit just to get back to normal.

    9. AL

      That's right.

  3. 7:53 – 10:51

    How the Internet and Smartphones Drugified Our World

    1. RC

      So in the world in which we live, you know, if I, if I think back to me as a child, the internet did not exist, and we would hear about addiction, we would hear about drug addicts and alcohol addicts, right? So clearly back then, without, as you so beautifully [laughs] call it, what is it? The smartphone is the modern-day hypodermic needle. Just such a beautifully evocative way of looking at the modern-day smartphone. Addiction was still a problem back then. What has happened with the internet? What has happened with smartphones to our, I guess, our propensity for seeking pleasure, our propensity for addiction? What has the internet done?

    2. AL

      So the internet has really turned us all into people [laughs] struggling with compulsive overconsumption on a number of different levels. First of all, the device itself is quite reinforcing. Screens are like primitive fires that we are drawn toward and, and gather around. The kind of tapping and swiping I think really taps into, no pun intended, um, our sort of primitive desire to use our hands in repetitive ways. Um, the phone itself is, you know, indeed a portal to drugs that have been r- around forever. Like, I can use this phone to order cocaine to my doorstep like ordering a pizza, right?

    3. RC

      Yeah.

    4. AL

      But it's also made drugs that have been around for a long time but were harder to get, like pornography, much, much more accessible. So starting, you know, in the early 2000s, I started to see more and more men in particular come in with debilitating pornography addiction. And almost universally they said it was the internet-

    5. RC

      Yeah

    6. AL

      ... the advent of the internet and the phone that made these graphic images, and then ultimately live people so accessible that really then conspired to make what had been a manageable use of pornography or masturbation into a compulsive, you know, debilitating-

    7. RC

      Yeah

    8. AL

      ... life-threatening problem. And then finally, the internet has created drugs that literally did not exist before, things like video games. And yes, games have been a- around forever but, you know, the internet and the, the screen and the software have allowed for these incredibly vivid experiences that are really unlike, you know, anything that you would find in, in real life. Social media too. So human connection is healthy and adaptive, but social media manages to take the healthy aspects of human connection-

    9. RC

      Yeah

    10. AL

      ... and potentially drugify them with, you know, the bright lights, the curated profiles, the beautiful images-

    11. RC

      Mm-hmm

    12. AL

      ... the bottomless bowls, the likes, the rankings. When we enumerate things, uh, we make them more potent. They release more dopamine. So for all these reasons, a very exciting, wonderful technology really does have this dark underbelly.

  4. 10:51 – 18:58

    Pornography Addiction, Stigma and Opening the Book with It

    1. RC

      You start your book with a very striking case of sex addiction. You are an addiction specialist. People are coming to you, you know, presumably when they've exhausted [laughs] all other options and they really, really need help. Whereas for me, often it's, like, their first portal. It's like, "Okay, I need to go talk to my doctor about this." And I can remember vividly this young man in his early 20s. He came in. He was sort of-- wouldn't make eye contact with me. And, you know, he started... You know, once I'd sort of gained his trust and really tried hard to connect with him, softened my tone so he would open up, you know, he, he couldn't look at me as he was telling me how much-

    2. AL

      Mm

    3. RC

      ... he was using pornography and how it was, um, frankly destroying his life, his social life-

    4. AL

      Right

    5. RC

      ... his life with his family.

    6. AL

      Mm-hmm.

    7. RC

      And I kind of feel we, we really need to talk about this because not enough people are talking about this. We're talking about other addictions. We talk about social media-

    8. AL

      Yes

    9. RC

      ... addictions, about alcohol, about sugar. We-- all these things-

    10. AL

      Mm-hmm

    11. RC

      ... they're okay. But sex and pornography, this is going on. This is a massive problem, and I think in that secrecy, in the shame that builds up in these people- This addiction thrives, yet no one's really talking about it. So I'm fascinated that you had the courage, I would say, to open up your book with this story. So I wonder if you could talk through why you decided to start with this story. 'Cause on one hand, it could put people off. People might go-

    12. AL

      Hmm. Mm-hmm

    13. RC

      ... "You know what? I don't wanna, I don't wanna read about this."

    14. AL

      Yeah. Yeah

    15. RC

      But as you so beautifully say, these things, instead of putting us off, they really show us what we're all capable of.

    16. AL

      Right. That's right.

    17. RC

      What, what, what, what exactly did you mean by that?

    18. AL

      Well, first let me say thank you for acknowledging that it did take some courage to open with that story. And I also, also want to just express my deep and enduring gratitude to all of my patients who were willing to-

    19. RC

      Yeah

    20. AL

      ... allow me to share their stories, um, you know, anonymously. 'Cause that, that, that was a tremendous act of courage on, on their part. And I did get feedback from my editors saying, "Well, you know, maybe you should hide this sort of more in the middle of the book. Do you really wanna open with this?" But I, I agree with you. This is a huge problem. And although there's a lot of stigma and shame with all kinds of addictions, I think there's more stigma and shame with sex addiction than with any other. And more misconceptions, where people think that people, you know, can just stop, that it's not that big a deal, or that people who are looking, it's a lifestyle choice. And, and you know from your clinical work, and I know from my clinical work, that for some people it is a devastating, compulsive, life-threatening condition that is very, very difficult to manage in a world where they're constantly being not just reminded of sex, but literally chased down. I mean, even I in my professional Stanford email inbox get solicitations for pornography. Insane, right?

    21. RC

      Yeah.

    22. AL

      I mean, I don't know where they come from or how they get my email, but you know, if I had a very severe sex addiction, that right there might be a trigger that, you know, in my efforts to maintain recovery would, would send me down that road. So, um, you know, I think this is a growing problem, especially among men, growing numbers of young men. Um, it's also, you know, normalized. So por- pornography use, I think, has really become very normalized. And so the compulsive, the insidious compulsive nature or the, the, the, the point to which people can get, I think is really not appreciated because it's become sort of so normalized. And as I talk about in my book, you know, this patient who developed a severe sex addiction, wonderful man.

    23. RC

      Yeah.

    24. AL

      A scientist. A brilliant, you know, Stanford scientist, a very kind man. A father, a loving father, you know, a, a, a loving spouse, um, committed to his wife. So you know, this is the way that addiction can just take hold of us and, and drive us to engage in behaviors that are not consistent with our goals or values or any of it. And the other thing, as you know, that I talk about in my book, is that I saw parallels between my patient with this very severe sex addiction and my own compulsive reading of romance novels. Romance is in many ways sort of socially sanctioned pornography for women. And I started out with the Twilight saga, which was a vampire romance novel written for teenagers. I was in my early 40s. I just heard some mothers talking about it. I thought, "Oh, that sounds fun." They liked it. I read it. I was completely transported by it. And by that, I mean I was egoless. I was out of my body. I did not experience myself. I achieved non-being, which is what we crave so much in this modern world of hyperstimulation. We want to forget ourselves, essentially. And this provided that for me, and then also led to about a two-year trajectory of me reading more and more graphic, essentially pornography novels, um, that I had to acknowledge at some point had become a problem. So when I saw this patient, I did not see him as other than I. I saw him as somebody who could have been me had my trajectory just been a little bit different.

    25. RC

      Yeah. There's something really powerful, I think, about what you just said. You are a respected neuroscientist, medical doctor, you've written books. Uh, you are considered a world-leading expert, and you were able to engage in a societally sanctioned version of pornography or, you know, romance. And that's okay, you know? You, you're a, you know, it's... I- this kind of speaks to this wider point and problem of addiction, isn't it? And what is okay-

    26. AL

      Right

    27. RC

      ... and what is deemed as, well, at an extreme, what is deemed as criminal. Um, which is, you know, that's another point altogether. Should people in real need of help, who are in so much pain that they're using whatever they can to numb that pain, you know, at what point do we bring criminal charges against them? As a society, I feel-

    28. AL

      Hmm

    29. RC

      ... is a, is a conversation that needs to be had. But you know, that, that view of a man who might be addicted to sex, you know, they're, they're sort of shunned, aren't they? There's sort of that, um-

    30. AL

      Right

  5. 18:58 – 28:35

    Tolerance and Defining Addiction with the Four Cs

    1. AL

      Yeah. So that-- so, you know, getting back to sort of the rules of the balance. The first rule, remember, is that the balance wants to stay level, and it will work hard to restore a level balance, and it does that in this really interesting way, which is to tip an equal and opposite amount to the initial stimulus. So if the initial stimulus is pleasure, there's a price to pay for that, which is this transient experience of pain before the, the balance, uh, goes back to baseline. Another important rule governing this balance is that with repeated exposure to the same or similar stimulus, that initial response to the side of pleasure gets shorter and weaker, but the after response to the side of pain gets stronger and longer. So if we use the same drug over and over again, after a period of time, we will get less pleasure from it, but the price that we pay, the, the after effect, the come-down, gets longer and stronger. And this is why repeated exposure ultimately kind of drives us into this chronic dopamine deficit state where nothing else is enjoyable, where our focus narrows to our drug of choice, and that's the only thing that we look forward to. And then importantly, tolerance develops, meaning that we need more of that drug quantity-wise or more potent forms of that drug in order to get the same effect or in order for it to just work at all. One of the things I commonly see, for example, in cannabis users, is that, you know, cannabis is this miracle drug for them. It helps them sleep. It relaxes them. It makes them, you know, more creative. Although, I must say, they feel more creative. Whether they're actually creating i- is in question. And then over time, what they'll report is that it stops working as well. They need more and more to get the same effect, and then ultimately it turns on them. And this is really fascinating because what it means is that the brain has thoroughly learned and adapted to that drug such that after a while, it doesn't tip the balance at all to the side of pleasure. But as soon as it's introduced, slam, the balance will go down to the side of pain. Those neuroadaptation gremlins that our brain creates to restore balance don't go away, right? They're, like, waiting in the wings, ready to hop on, and as soon as we use, they tilt us. So that's why people will report, "You know, now when I use cannabis, I get paranoid. I get anxious. It does the opposite. Uh, it makes me vomit, the opposite of what it used to do." And that, you know, you can find for a lot of different drugs. Opioids used chronically can actually make physical pain worse. We're seeing this here, especially with chronic pain patients. Um, you know, uh, any of our drugs of choice, if we really think about them, we can ask ourselves, "Are we-- Am I really even enjoying doing this anymore? I'm, like, caught in it. It's hard to stop, but I, I'm not sure I even like it anymore." Which is why, again, dopamine is so, so essential to this, like, wanting something even when we don't necessarily like that thing.

    2. RC

      The way you describe that, I think many if not most people listening or watching to this right now could probably find something in their life that fit that description. Uh, yes, it-- of course, it could be social media. It could be sugar. It could be caffeine. Um, you know, what do you see-- What w- I guess, what-- how would you define addiction, first of all? And then from that, I think it would be useful to go into, what are some of the things that you find people are probably addicted to? But because they're normalized in society, often people don't actually think of them as addictions. Uh, the one at the top of my head is I think a lot of the world is addicted to caffeine in a big, big way.

    3. AL

      Mm.

    4. RC

      Um, so yeah, could you maybe sort of unpack some of that and sort of start off maybe with how do you view and define addiction?

    5. AL

      Sure. So very broadly speaking, addiction is the continued compulsive use of a substance or behavior despite harm to self and/or others. And if we're gonna break it down further, we can talk about the four Cs: control, compulsion, craving, and consequences. Control means using more than I plan to use. Compulsion is a lot of my mental real estate focused on using, a sort of narrowing of my attention as well as the level of automaticity to my use. Craving is a physiologic or psychological overwhelming urge to use despite my intention not to use. And then consequences is health consequences, relationship consequences, work consequences, you name it, spiritual consequences, as a result of my using, especially when I can see that there are consequences and continue to use. You'll notice, Rangan, that none of those behavioral descriptions or psychological descriptions has anything to do with the physiologic tolerance, dependence, and withdrawal. That is also part of addiction, right? Needing more and more to get the same effect. When I stop using, I go into physical withdrawal or, more commonly, psych- psychological symptoms of withdrawal, which again are anxiety, irritability, insomnia, depression, intrusive thoughts of using. But sometimes I'll have patients come to me and they'll say, "Well, you know, I'm not addicted to cannabis," or, "I'm not addicted to alcohol because I can stop using, and when I stop, I don't have any withdrawal." But you don't need to have that physical dependence in order to be addicted because the addiction is happening in the reward centers of the brain where we go into that dopamine deficit state, which might only manifest as psychological symptoms of withdrawal and dependence, not necessarily physical symptoms of withdrawal, withdrawal and dependence. So yeah, getting to the second part of your question, so what are the things that many of us are addicted to that we don't even acknowledge? C- caffeine is certainly way up there. Um, alcohol is so ubiquitous a- and so normalized, and I think many, many people use in ways that are not healthy but are able to tell themselves that their use is okay. I would also put really high up on that list, um, a lot of digital d- products and devices, and I would put up there work, you know, addiction to work. It's so socially, um, rewarded, right? That sort of 24/7, I'm on it, you know, I'm reachable wherever you wanna find me, high stress. And you know, when we add a shot of adrenaline to something, that also releases dopamine. It makes it even more reinforcing. There's a fascinating study looking at rats. If you inject a rat with cocaine, slice open its brain, what you'll see is this incredible arborization of dopamine-releasing neurons in the reward pathway. If you take a rat and subject it to an intense painful foot shock, you will see the identical arborization of dopamine-releasing neurons in the reward pathway. In other words, we can actually probably get addicted to highly painful stimulus too in the form of work or, you know, news. That's why doom scrolling [laughs] kind of comes in. So there are lots of, of, of things that I think are socially sanctioned, um, you know, again, I think work is probably I would put at the top of the list-

    6. RC

      Yeah

    7. AL

      ... uh, that, that we kind of don't acknowledge. Even my own attachment to my email, so I'm not on social media. I do have a phone, but I mostly keep it turned off in my bag for emergency reasons. Um, but I'm, I'm... I have to really watch myself with my email, which is sort of my work-sanctioned social media. Um, you know, and I try to take a digital Sabbath once a week, and it's really hard.

    8. RC

      Yeah.

    9. AL

      But by the end of that day, I don't even wanna go back to using-

    10. RC

      Yeah

    11. AL

      ... because what, what I'll notice when I go back to my email is I'll answer the emails that need answering, and then I'll linger. I don't wanna leave it. I'm sort of waiting for something good or, or reinforcing to come in. Or I'm continue to scroll through and read the things I've read before, you know, as a way of kind of making myself feel like, "Okay, I still need to be here in this space." But really I don't.

    12. RC

      Yeah.

    13. AL

      I should just get out of my email and move on [laughs] to the next thing, and I've developed some tricks for coping with that, but it's really hard.

    14. RC

      Yeah. I mean, what you're speaking to as well is ease of access, and how easy it is to access clearly makes a huge difference. And I guess work, again, going back 20, 30 years ago when we didn't have email or the ability to have email in our pockets, you know, when you left the office, you were probably, barring an emergency where someone phoned your landline, you were probably kind of done, right? You would-

    15. AL

      Right

    16. RC

      ... you would naturally be able to switch off.

    17. AL

      Mm-hmm.

    18. RC

      And I think there's been this insidious creep. We, we, we've not really... I think with technology, for me it's about intentional, it's about intentionality. We've not really asked ourselves, or many of us, what do we want this smartphone for? We, we take it-

    19. AL

      Right

    20. RC

      ... with like it's the sweet shop with all the goodies on it.

    21. AL

      Mm.

    22. RC

      And it's kind of like, well, why don't you think about what do you want from it? Okay, I, I-

    23. AL

      Mm

    24. RC

      ... wanna be able to make calls. Okay, great. You wanna be able to make text messages. Okay, great, right? What else?

    25. AL

      Mm-hmm.

    26. RC

      You might wanna listen to music. Okay. You know, and, and actually-

    27. AL

      Mm

    28. RC

      ... introduce the apps that you want-

    29. AL

      Right

    30. RC

      ... that are gonna enhance your life rather than make you a slave.

  6. 28:35 – 34:32

    Self-Binding and Cheap Versus Expensive Dopamine

    1. RC

      And I guess that email piece is if you don't have email on your phone, it's just a hell of a lot easier to not be checking your [laughs] work emails-

    2. AL

      Right

    3. RC

      ... at the weekend.

    4. AL

      Right. Yeah. Which gets to one of the... You know, so Dopamine Nation is not just about the problem. It's also about what we can do about it.

    5. RC

      Yeah.

    6. AL

      And one of the recommendations in addition to the dopamine fast is these self-binding strategies, which is essentially creating, creating literal and metacognitive barriers between ourselves and our drug of choice, exactly what you describe, that if we make it harder to access, to access our drug of choice, i- that little bit of a pause is often just enough to make us, to allow us to decide not to use in that moment, and that's really, really important.

    7. RC

      Is there something about cheap dopamine versus expensive dopamine? And the reason I ask that question is my son really loves to play snooker, um, so pool, billiards. He, he really enjoys that. And last year, there's a local coach. I got him a couple of lessons. He went and really enjoyed it. And I asked the coach, "Are you getting many kids coming these days?" He said, "No, we used to get so many kids coming," but he says-

    8. AL

      Mm

    9. RC

      ... "We hardly get anyone anymore." And his theory was because people can get dopamine hits so quickly and easily on their phones these days, to come and actually learn a difficult game that requires patience, practice, discipline before you get to that sort of position where you actually gain the pleasure from it, he's saying, "Look, I just don't think people have got the desire anymore to work that hard for their dopamine." Now, I don't know- He's not a neuroscientist. So-

    10. AL

      Mm

    11. RC

      ... is any part of that accurate? Like, are we, are we sort of bringing up a generation of kids now who are so used to getting their rewards quick and easy that they're going to be unwilling to do those harder, more challenging things?

    12. AL

      I mean, absolutely. I mean, this is essentially what I have seen over the last 25 years in my practice. Growing numbers of kids raised in loving homes with incredible privilege and access to the best education, sports, um, you know, friends, you name it, who are increasingly narrowing their world to themselves in their rooms with their devices. And I mean, it's just, it's, it's terrifying because-

    13. RC

      Yeah

    14. AL

      ... the result is that progressively they are shifting their joy set point to the side of pain. They're ending up in this dopamine deficit state with the gremlins camped out on the pain side of their balance such that they need greater and greater rewards to feel anything at all, and they have more and more pain. Any little kind of, you know, injury, no matter how, how slight, is truly injurious to them because they have no resilience. They don't have, uh, you know, their dopamine levels are not at healthy baselines. They're inundated with dopamine and, um, just living essentially in their lizard brain, which is that, you know, limbic part of the brain where the reward pathway is, uh, mostly located. So I, I do think this is, you know, this is of great concern. And many of these young people will come in, uh, you know, endorsing anxiety and depression and thinking that I'm gonna prescribe them a pill or that we're gonna do some kind of talk therapy, or we're gonna find out their trauma, you know, what led to it. I'm like, "No, you know, I think what led to it is that you're playing video games all day, and if you would stop that for a reasonable enough length of time for those neuroadaptation gremlins to hop off and for your, your, you know, your own brain to start to regenerate its own dopamine, you would feel better. Even further, if you go and press on the pain side of your balance and get off the couch and turn off, you know, all of the devices and go outside and go for a walk," something that's really challenging for a lot of, uh-

    15. RC

      Yeah

    16. AL

      ... people today, you know, you will actually, by pressing on the pain side of the balance, you will tell your body, "Oh, I need to start to upregulate my own dopamine production," right? 'Cause then the gremlins hop on the pleasure side. It works both ways. Um, and that, that will create a more resilient, happier brain. But super hard to get people to realize that because in the moment they feel like, oh, no, you know, being online and social media and video games, that, that relieves my anxiety and depression. What they can't see is that in an iterative process over time, that's actually what's causing the anxiety and depression.

    17. RC

      I mean, this is something that really worries me, if I'm honest. I, you know, as a doctor looking out at society, but as a father of two young children, this has been something that has really occupied a lot of my brain space for the past few years.

    18. AL

      Yeah.

    19. RC

      Maybe over a year ago, a patient of mine, a young adolescent girl who had tried to harm herself, and I won't sort of recount the entire story now, but essentially the way I managed to help her was primarily by helping her to not use her phone and social media as much. And it was a-

    20. AL

      That's right

    21. RC

      ... a ripple effect started in her life-

    22. AL

      Yeah

    23. RC

      ... where six months later-

    24. AL

      Mm-hmm

    25. RC

      ... she was unrecognizable. Completely-

    26. AL

      Yeah

    27. RC

      ... a happy, grounded-

    28. AL

      Mm-hmm

    29. RC

      ... connected kid. And that was probably intervention number one was-

    30. AL

      Mm-hmm

  7. 34:32 – 38:57

    The Dopamine Fast: A One-Month Experiment

    1. AL

      Oh, absolutely. So that, that's the prescription from Dopamine Nation, and it's something that I've used repeatedly in my clinical work. The first intervention when I have patients come in with depre- depression, anxiety, insomnia, inattention, I say, "Let's eliminate your drug of choice, whatever it is, whether it's social media, video games, cannabis, alcohol."

    2. RC

      Yeah.

    3. AL

      "We're gonna take it away for a whole month." Why a month? Because a month is typically the minimum amount of time it takes for the brain to restore dopamine levels back to healthy baseline. I also warn them that in the first two weeks of abstention or the dopamine fast, they're gonna feel worse before they feel better. Why? Because those gremlins are camped out on the side of pain, and they're in a dopamine deficit state, which means when they're not using their drug, they're in withdrawal. So I tell them, "You're gonna be more anxious, more depressed, restless. You're gonna have intrusive thoughts of wanting to use your phone, play video games, use cannabis, drink alcohol. But if you can just get through those first two weeks, by weeks three and four the light really does come out, and you will notice yourself feeling better." And almost universally, that is what happens, and I've been doing this for 25 years, so I really, [laughs] I really believe that this works 'cause I have a huge sample. And exactly what you describe with your, you know, young, young patient on social media, you know, patients will say it's hard, but they definitely have reduced anxiety, depression-

    4. RC

      Yeah

    5. AL

      ... insomnia, all of it at a month. Not only that, they have insight because now they're able to really look back and see the true impact of their use on their lives, which is really hard to do when we're in it.

    6. RC

      Yeah.

    7. AL

      It's only by changing something in that biological system, forcing our brains to start to regenerate our own dopamine, that we can look back and say, "Oh, my goodness, that's surreal. I can't believe-

    8. RC

      Yeah

    9. AL

      ... I was so invested in that."

    10. RC

      A- a- and that, that I think is, is a second critical point because- That's empowering for an individual, isn't it? That gives them-

    11. AL

      Yes

    12. RC

      ... a sense of control, a sense of agency that, "Oh, I get it. When I engage in these behaviors, my mood goes down."

    13. AL

      Right.

    14. RC

      "I get depressed."

    15. AL

      Right.

    16. RC

      "I get anxious. When I restart again, or when I, when I come off it, I feel better. When I restart again, I get worse." And it doesn't mean you're gonna get... And certainly through, through what I've seen, it doesn't mean the first time you're gonna get it right, you're gonna stop and then you're all good. No, but it's a, it's a process of education each time, and every time you go back-

    17. AL

      Right

    18. RC

      ... you keep reminding yourself, "Oh, do you know what? I feel better when I'm actually not on this stuff."

    19. AL

      That's right. And I always frame it to patients as an experiment.

    20. RC

      Yeah.

    21. AL

      I said, "You know what? You're the scientist. This is the experiment called your life. Let's gather data. The best way to know how to syst- how a system is working is to change something in that system and see what happens. So the experiment that we're gonna do is you're gonna eliminate this drug for a period of time and see what happens, and my hypothesis is that you will feel initially much worse because you will be in withdrawal and craving, but if you can make it a long enough period to restore homeostasis, you will feel better." And when patients see that for themselves and experience that for themselves, I no longer have to convince-

    22. RC

      Yeah

    23. AL

      ... them that it's a worthy project. One of the most common questions I'll get asked from family members, "What can I do to get my loved one into treatment or to get them to see that they have a problem?" I said, "You know, the dopamine fast is almost the best thing that they can do."

    24. RC

      Yeah.

    25. AL

      "Because once they do that themselves, they'll be able to connect the dots, and then they will be motivated to make the change in their life." Now, Rangan, you know that, you know, abruptly stopping your drug of choice is not something you would recommend in somebody who's-

    26. RC

      Yeah

    27. AL

      ... at life- at, at risk for life-threatening alcohol withdrawal, benzodiazepine withdrawal, or opioid withdrawal. Those, those in- individuals may indeed need medically monitored detoxification in order to get into a dopamine fast, which means that they might need a slow taper or another medicine to prevent life-threatening withdrawal. But for the vast majority of us, especially those of us who are addicted to our devices, stopping cold turkey is perfectly fine.

  8. 38:57 – 45:07

    The Range of Addictions and Asceticism in an Age of Abundance

    1. RC

      You use the term drug of choice. So whichever that patient's drug of choice is, they would try and go on this four-week dopamine fast.

    2. AL

      Right.

    3. RC

      I would love you, with your 25-year clinical experience, to paint a picture of what variety of drugs have you applied this dopamine fast to.

    4. AL

      Hmm.

    5. RC

      Because I suspect it's not just the, the, the kind of classic ones that we think in our brains.

    6. AL

      Right. Well, I'll just start with alcohol, nicotine, cannabis, cocaine, methamphetamine and other stimulants, uh, opioids, benzodiazepines. Although again, with opioids and benzodiazepines, some of those people need a medically managed taper, and stopping abruptly would not be appropriate. Um, but then there's the whole raft of behavioral addictions. So these are, uh, you know, uh, processes, and often food is put in this category, but food would include sugar, processed foods, empty carbohydrates. Um, along with processed food, or we commonly refer to as, you know, junk foods.

    7. RC

      Mm-hmm.

    8. AL

      Um, gambling, which comes in many different forms now, including kind of high-class investments in cryptocurrency, which is looked at as sort of really cool and, you know, sort of that's not gambling because, you know, that's... I don't know, that's what stockbrokers do or something [laughs] . You know, Stanford, St- Stanford undergraduates, that's what they do. But, you know, frankly, that's obviously a form of gamb- gamblinghood. Interfaces like the Robinhood interface are, you know, know how to make that addictive, right? Um, with, you know, flashing lights and congratulations and graphs and cr-

    9. RC

      But what, what is the Robinhood-

    10. AL

      Oh, it's-

    11. RC

      What, what is the Robinhood interface?

    12. AL

      So, you know, typically if you wanted to... And again, this is not my ar- uh, w- money is not my area of expertise, but if you wanted to buy shares in something, you needed a broker. But now there are apps that-

    13. RC

      Right

    14. AL

      ... sort of take that away, and you, you can just do it yourself. So in a way, it's w- like, sort of like a democratization in a way of, you know, investment, which i- is a good thing in many ways, I can see, but it also means that the average person with limited education and the potential for addiction is on there, you know, you know, gambling away, you know, the, the, the family home for cryptocurrency, right?

    15. RC

      Yeah.

    16. AL

      So potentially super dangerous. Um, all of this stuff, pornography, anything related to sex, much of it now happening online. Games, gamification, video games, YouTube, um, pretty much anything online, um, has the potential for addiction.

    17. RC

      Ba- ba- basically what you're saying is pretty much anything that people now-

    18. AL

      [laughs]

    19. RC

      ... use to distract themselves from their lives, to get a bit of relief, to get some pleasure.

    20. AL

      Yeah.

    21. RC

      It sounds like, again, going back to what you said at the start, right? It's about that balance piece where there is, you know, you get, you wanna get that dopamine hit, but you don't wanna do it so much that you start to-

    22. AL

      Yes

    23. RC

      ... tip the seesaw where it gets locked, and then you're in this dopamine deficit states. Yeah.

    24. AL

      That's right. That's right. And, and, and what I'm arguing for in a way is sort of a new form of sy- of asceticism, you know, asceticism being the practice of, um, eschewing or avoiding intense pleasures and actually inviting painful practices into your life. But, you know, the asceticism that would be considered painful in the modern age is literally for some people just getting up off the couch and going outside of their homes for 30 minutes a day and walking around. I mean, that's... And unplugged. Unplugged, walking around in their neighborhood. That is- Painful for some people because of the extent to which we are sedentary, the extent to which we are plugged in, the extent to which we are overstimulated.

    25. RC

      Yeah.

    26. AL

      Um, so but I really do believe that, that, you know, it's a major cause of our unhappiness, and the epidemiologic data would bear that out. Over the last 30 years we've seen massive increases in depression, anxiety, suicide in rich nations more than in poor nations, in nations where people have access to all of this abundance. Um, a world survey happiness report that was done in 2018 surveyed 128 countries and found that people were across the board more unhappy in 2018 than they were in 2008, with people living in rich nations being the most unhappy, right?

    27. RC

      Yeah.

    28. AL

      So it's a paradox, but it's because we've reached this dopamine tipping point.

    29. RC

      Yeah. It's this apparent contradiction that the more money-

    30. AL

      Right

  9. 45:07 – 49:41

    Resetting Reward to Enjoy Simple Pleasures Again

    1. AL

      Well, again, I think that the most important initial intervention is a period of abstinence-

    2. RC

      Right

    3. AL

      ... from the drug of choice. So if it is a smartphone addiction, the intervention, the treatment, will be to put that phone away for a month. And the two reasons to do that, just to highlight them again, are to restore healthy dopamine pathways, right? To allow the gremlins to hop off so that homeostasis can be restored. Why is that so important? Because when we're in that dopamine deficit state, more modest pleasures are no longer rewarding. So I wanna get back to something that you-

    4. RC

      Yeah

    5. AL

      ... said earlier about, you know, how those pleasures of camping or just being with family. The truth is that those things are not pleasurable when we're hooked on dopaminergic substances and behaviors, because they can't compete, as you just said. So in order to make those more modest rewards rewarding again, we need to abstain from the highly dopaminergic substances and behaviors that have essentially hijacked our reward pathway. So again, the first step is to abstain, um, in order to reset reward pathways, but also to be able to look back and see true cause and effect. And that's really gotta be the first intervention. And, and it's not about desire being bad, or even about intoxicants being bad across the board.

    6. RC

      Yeah.

    7. AL

      It's about how we use them, with what frequency-

    8. RC

      Yeah

    9. AL

      ... you know, with what potency, so that after we have a level pl- pleasure/pain balance, if we go back to using, we have to make sure to leave enough time in between for the gremlins to hop off the pain side and for homeostasis to be restored. And we want to inv- avoid intoxicants that press our pleasure/pain balance too hard and too fast-

    10. RC

      Yeah

    11. AL

      ... to the side of pain. Because once we're doing that, we're accumulating these great big Arnold Schwarzenegger gremlins on the pain side to bring us level again. And then we're essentially at war with our gremlins. So the trick is to restore homeostasis with a dopamine fast, and then to stay in a subtle, dynamic relationship with our pleasure/pain balance so that we are ingesting rewarding things in modest doses infrequently, at the same time that we're inviting painful activities into our lives in order to get those gremlins to hop on the pleasure side, right?

    12. RC

      Yeah.

    13. AL

      Which is essentially, um, telling our bodies, "Oh, there's a painful stimulus here. I now need to make my own dopamine and serotonin and norepinephrine and endocannabinoids and endoopioids in order to counteract that painful stimulus." And that's good, because that keeps us in this place where, you know, we are not just shutting down our dopamine factories. We've got our own dopamine factories running, you know, making that feel-good hormone.

    14. RC

      As you describe there that compared to what is on our smartphone, a walk [laughs] in nature with a loved one or going camping actually does feel a bit boring and dry compared to all the-

    15. AL

      Yes

    16. RC

      ... excitement and colors-

    17. AL

      Yes

    18. RC

      ... and vibrancy we can get on this phone. I thought of sugar as well, in the sense that-

    19. AL

      Mm-hmm

    20. RC

      ... the way that the food industry has hijacked our taste buds.

    21. AL

      Right.

    22. RC

      If our kids and us as adults are constantly having highly processed foods, if we're having all these super sweet, um, you know, uh, f- food-like products I guess that are being-

    23. AL

      Mm

    24. RC

      ... made by the food industry, then suddenly a beautiful ripe peach on a summer's-

    25. AL

      Yes. Mm-hmm

    26. RC

      ... day is bland.

    27. AL

      Right

    28. RC

      Right? Because-

    29. AL

      Very well put, yeah

    30. RC

      ... you know, it's, it's, it's very similar, isn't it?

  10. 49:41 – 58:54

    Parenting in a Dopamine-Overloaded World

    1. RC

      You are a parent, like me. Um, I think your kids might be a bit older than mine, from what I can tell.

    2. AL

      Mm-hmm. Yeah.

    3. RC

      Um, my current approach, I, I know, and, you know, I'm, I'm interested as to your view on this.

    4. AL

      Yes.

    5. RC

      Of course, I'm always thinking about what I can do to help my patients. I'm also thinking about what I can do to help my kids.

    6. AL

      Of course.

    7. RC

      And having seen the problems with phones in a lot of my teenage patients, hearing from my friends who tell me that the biggest source of their arguments with their teenagers is always to do with their smartphone usage, I have been very reluctant to, uh, embrace technology with my children. So my son is 11. He has just started secondary school, or high school, and he did not have a phone at all until this summer. And I felt strongly that, you know, at 9, 10, I just thought, I, I just don't really see how this is gonna benefit him. He did want one. He said all his friends had one. And for me as a parent, as I'm sure you may have faced this, it's very difficult because you don't want your children to be social outcasts-

    8. AL

      Right

    9. RC

      ... yet at the same time, you are cautious over what they... Or certainly I was very cautious about what he's been introduced to. Now, I ended up caving in the summer in the sense-- I say caving. Now, it was an intentional decision.

    10. AL

      Mm-hmm.

    11. RC

      You know, the high school's a, you know, it's a bit further away. All of his peers have a smartphone. Every single one. Um, that's how they communicate. And I thought, you know-

    12. AL

      Yeah

    13. RC

      ... it's not really not fair of me to not allow him to, you know, be with his tribe in that way.

    14. AL

      Yeah.

    15. RC

      But we have set some, uh, ground rules. I've gotta say, he has been exquisite at following them so far, so I touch wood-

    16. AL

      Great

    17. RC

      ... that that continues.

    18. AL

      Yeah.

    19. RC

      But simple things like the phone is not allowed in his room.

    20. AL

      Mm-hmm.

    21. RC

      It always has to be used, uh, in the kitchen area where other people are around. He can't take it somewhere to go off.

    22. AL

      Mm-hmm.

    23. RC

      This may sound quite draconian, but we, we're doing what works for us as a family, and I would-

    24. AL

      Right

    25. RC

      ... never cast judgment on how someone else decides to, um, parent their kids.

    26. AL

      Mm-hmm.

    27. RC

      Um, and actually, so far so good. But what I've decided to do, be- beyond phones is... Because my wife and I were talking about, uh, gaming. Again, a lot of his friends play video games, and they play online together.

    28. AL

      Mm-hmm.

    29. RC

      Now, we've not gone down that route because-

    30. AL

      Mm-hmm

  11. 58:54 – 1:10:39

    Recovery, Humility and Addiction as Modern Plague

    1. RC

      Actually coming back to your book, and I, and I, I did say this at the start, but it is one of the favorite books of mine that I've read recently. It is-

    2. AL

      Oh, thank you

    3. RC

      ... fantastically, uh, written. And I, I'll tell you, Anna, what I love about it the most, you know, I love science, but this is so much more than science. This to me speaks of a human being with incredible life experience, a clinician with a lot of practical clinical experience. And you sort of blend in science with, you know, real-life human experience, 'cause it doesn't always connect. I found as a clinician that scientific studies don't always help me one-on-one with my patients, and I-

    4. AL

      Mm

    5. RC

      ... I love the way you've blended it all together. And if I may say, I kind of feel that there's quite a philosophical component to this book as well. There's lots of really good kind of lessons for life.

    6. AL

      Mm.

    7. RC

      So I just wanna appreciate you and acknowledge you for that. I think it really is fabulous.

    8. AL

      Thank you. I am very touched by that. It means a lot. Thank you.

    9. RC

      No, not at all. I, I, I really... I, I hope everyone goes out to get it. It's, it's, it's a brilliant read. Um, I wanna move on to something you, you wrote right at the start of the book in, I think it's the introduction. You put a quote there from Kent Dunnington.

    10. AL

      Mm.

    11. RC

      "Persons with severe addictions are among those contemporary prophets that we ignore to our own demise, for they show us who we truly are."

    12. AL

      Mm.

    13. RC

      I read it, I underlined it, and I was immediately drawn to two conversations I've had on this podcast before, one with Rich Roll, who I know you've been-

    14. AL

      Mm-hmm

    15. RC

      ... on Rich's show.

    16. AL

      Yeah.

    17. RC

      Um, Rich is obviously, um... I say obviously, if people are familiar with Rich, he in the past suffered with addiction to alcohol. I also had a conversation with a singer-songwriter called Benjamin Francis Leftwich. Again, he had real problems with addiction. He's been sober for, I think, three or four years now. And I find in the conversations I had with Rich and Benjamin- I find a real authenticity and truth that you don't often get.

    18. AL

      Mm-hmm.

    19. RC

      And, and I feel that there's something about these people and the walls that they've come against, come up against in their life that's really forced them to confront what it truly means to live a happy, peaceful, content life.

    20. AL

      Mm-hmm.

    21. RC

      And I think that quote kind of sums it up beautifully.

    22. AL

      Mm-hmm. Yeah. I mean, I, I agree with you. And, you know, I, I came into treating people with addiction reluctantly. It's not something I set out to do. But, um, really, they've become sort of my spiritual heroes, people in recovery, because of the tremendous courage and fortitude and tenacity that it takes to get into recovery, especially in this dopamine overloaded world, and to maintain that recovery. And what's striking beyond all else to me is the incredible humility, um, that people in recovery bring to their own lives, uh, to, to other people. This kind of acknowledgement of, of suffering and struggling, which I think is so often, um, you know, hidden in our everyday discourse. I'll never forget, early on when I went to a medical meeting, um, of the California Society of Addiction Medicine, which was, um, composed of doctors treating addiction medicine, and t- I did not realize that many of those individuals were themselves in recovery from addiction. And I had been to so many medical meetings, and I actually didn't really care for medical meetings. It's a lot of doctors standing around, talking about how great they are and how much, you know, how much they know. And I would always leave those [laughs] meetings sort of feeling like, "God, what have I done today?" You know, what a, what a schlep I am, you know, compared to all these brilliant people. And then I went to this meeting of addiction medicine doctors and, um, there was a lunch, you know, thing to go to. And I went there, and the first doc gets up and he just starts talking about his cocaine addiction and how he would steal. And I'm, I, I, I about fell off my chair. I was like, "Is this really a doctor who's talking about his addiction and what he did in the past, you know, in the service of his... " I mean, I was astounded. And yet it was so incredibly beautiful because it was like, wow, this is a space where we can all be our messed up selves. Like, we don't have to pretend anymore that our lives are perfect. And it was just, it was so attractive and compelling to me that I just had this feeling, yeah, this is, these are the, these are my wounded warriors, right?

    23. RC

      Yeah.

    24. AL

      These are, these are the f- people that I, I want to affiliate with. And, and, and that's been, you know, a continual sort of draw for me in the treatment of people with addiction, is the other wonderful people who do this work, many of whom are in recovery themselves. And just, you know, the incredible wisdom and humility that, you know, having an addiction and getting into recovery, you know, gives people access to. And also the spiritual aspect, which is, you would think spirituality would be a big part of the practice of medicine, but actually it's not. Um, you know, we're sort of not even allowed to say, you know, God or religion or ask people about that. But in addiction medicine you can still talk about that. It's a, you know, it's a, it's an important piece. And so that's been a real draw for me too, a kind of... Yeah, you know, science is so important-

    25. RC

      Yeah

    26. AL

      ... but there's a lot that science can't answer. And it's great to have a, a space and a way of talking about the things that science can't solve. Um, and so, you know, I'm grateful for, for that too in the field of addiction medicine.

    27. RC

      I imagine that doctor who shared his cocaine addiction with you and other colleagues, I would imagine that him being able to do that, him going through that, and hopefully coming out the other side of that, there's no doubt in my mind that that would absolutely enhance his ability to not only connect with his patients, but also help them afterwards.

    28. AL

      Right.

    29. RC

      You know? And it's, I think that's, that stuff's important, what you said about spirituality there. Um, you know, in addiction medicine, uh, you say in addiction medicine, but, like, I think to me as a primary care practitioner, addiction plays a role, low-grade addiction actually plays a role in so many of my patients.

    30. AL

      Mm-hmm. Yeah.

  12. 1:10:39 – 1:22:20

    Radical Honesty and the Prefrontal Cortex

    1. RC

      On one, one of the... I loved all the chapters in the book, but one I really enjoyed was towards the end, was this one on honesty, radical honesty. And that's something I think when Benjamin Francis Leftwich came to the studio a few months ago, and this is the singer-songwriter who had struggled for much of his life with addiction. One thing I was struck with was the kind of raw, brutal honesty.

    2. AL

      Mm.

    3. RC

      I got the sense that I'm not going to say anything that is not completely aligned with who I am.

    4. AL

      Mm-hmm.

    5. RC

      And that chapter was brilliant. Can you talk a little bit about honesty and why did you write that? Why is it so important, and how can even people who consider ourselves to be non-addicts, how can we, uh, benefit from more honesty in our lives?

    6. AL

      One of the recurring themes I have seen in my patients in recovery from addiction is how important honesty, telling the truth is to their recovery. And I've seen it again and again and again. Even in patients who haven't gotten into recovery through Alcoholics Anonymous or another 12-step group, and those groups really, um, emphasize the importance of honesty to recovery. And so people who are in, in those organizations, they know that's part of, um, the philosophy. But even people who have gotten into recovery on their own, um, almost universally they will say, "Oh, yeah, I can't, I can't lie. I, I can't lie about anything." And I became really fascinated by that because I thought, what, what is it about telling the truth? Obviously there's the thing about not lying about drug use, right?

    7. RC

      Yeah.

    8. AL

      Which would be important, but it, it's not even that. It's beyond that. It's not lying about anything at all. I had this one patient who said, "Oh, yeah, when I was using, I would lie about stuff that didn't even matter. Like, if I was getting lunch at McDonald's and somebody would call me, I would say I was at Burger King. If I was at Burger King, I would say I was at McDonald's." He said, "It didn't even make any sense. I was just in the lying habit." So part of recovery, and I would contend part of living a good life, is embracing radical honesty.

    9. RC

      Yeah.

    10. AL

      Telling the truth about not just important things or big things, but even about little things in the course of our every day. And, and I have, you know, different theories that I sort of explicate in the book to why that is. You know, one of them is, um, that I think that kind of radical honesty creates true intimacy. You know, we talk so much about relationships being the antidote to addiction, but we don't ever talk about how to get into those-

    11. RC

      Yeah

    12. AL

      ... um, intimate relationships, and one of the ways to do it is to be truthful, you know, with the people who we care about, even when being truthful means disclosing shameful things that we've done-

    13. RC

      Yeah

    14. AL

      ... or aspects of ourselves that, um, that we would rather not people know. And intimacy, true intimacy releases dopamine, right? So there you have a, a, a natural source of dopamine that can fight with these unhealthy sources of dopamine. The other thing that's true also about telling the truth about everything, r- or what I call radical honesty, is that it allows us to develop a truthful autobiographical narrative of our lives. And the stories of our lives are really the only way that we have to document lived time. And if we are not telling true stories about ourselves, then we're liable to perpetuate the same mistakes going forward, and we also then don't have access to truthful, objective data to make informed future decisions. So for example, when I have a patient who comes in, who tells what I would call the victim narrative, everything is always somebody else's fault. I know those people are not in recovery, and they're not gonna get into recovery unless they start acknowledging their contribution to the problem. So being able to tell a story that hews as closely as possible to what is actually true in the world is really, really important for being able to actually see that truth, to own our part, and to make informed decisions going forward.

    15. RC

      Yeah.

    16. AL

      And then another piece of it is that I really do think that intentionally and mindfully telling the truth up regulates the prefrontal cortex, which is that gray matter part of our brain right behind our foreheads involved in storytelling, future planning, and delayed gratification. We know that the prefrontal cortex interacts with the reward pathways in the lower brain regions, and that when those two parts of the brain are talking to each other, we are better able to control overconsumption, to delay gratification, and to avoid the pitfalls of addiction. And I... There's a fascinating experiment, um, that I detail in the book where, um, scientists use transcranial magnetic stimulation to up regulate function of the prefrontal cortex in order to decrease lying in their subjects who were engaged in a dice rolling game-

    17. RC

      Yeah

    18. AL

      ... where they could lie to get more money. And it was fascinating because by, just by stimulating the prefrontal cortex, they could get people to lie less. And by the way, we're all natural liars. People just lie. They tend to lie a little bit most of the time. [laughs] And they tell themselves it doesn't matter. It's little things, you know? But what happens when they pr- when they stimulate the prefrontal cortex was people lied less. So I went to the, the researchers and I said, "Well, you know, if stimulating the prefrontal cortex causes people to lie less, could lying less conversely stimulate the prefrontal cortex?" And he thought, sure, you know, that's perfectly possible. And I think that may be what's happening when we are intentionally, proactively monitoring our lie-o-meter or our truth-o-meter and trying not to lie. What we're doing is we're strengthening our prefrontal cortex, and we're strengthening the connections between our prefrontal cortex and our dopamine reward pathway, and then enabling ourselves to be more resilient in the face of temptations that we're all confronted with every day.

    19. RC

      Yeah. No, I know, I, I, I, I love the way you look at that. I think radical honesty, all of us trying to be more honest. As you say, you know, humans are lying machines. Like we [laughs]

    20. AL

      Yeah

    21. RC

      ... um, we... And it becomes a habit before you know it.

    22. AL

      Yes.

    23. RC

      Like, I don't know if you've had much experience with this. Um, of course, it's not exclusive to people from immigrant families at all, but you know, I, my parents grew up in India. They, you know, emigrated to the UK for all kinds of reasons. And I, like many, uh, of my peers in that situation, you know, often have a conflict of identity where we have a kind of traditional Indian Asian upbringing at home, and at school, we have our sort of Western friends who have got, let's say, a slightly different set of values to the values you have at home. And so by the time you're a teenager, you get pretty good at-

    24. AL

      [laughs]

    25. RC

      ... lying. And you are doing it so often. I'm not saying everyone does this, right, to be really clear.

    26. AL

      Mm-hmm.

    27. RC

      But I know from other people in my boat, um, other people who also are kids of immigrant parents, there's a big problem with these double lives that people lead. And I feel, the way, the way I look at it is that you're whole when you're born. You're, you, you... You know who you are is who you are. And then bit by bit, and I think this often starts at school, we start being someone who we're not in order to fit in. So a fault line starts to show up in who you are. So there's a fracture now.

    28. AL

      Mm.

    29. RC

      And that keeps going. And then you start lying as a teenager, and that fracture becomes bigger and bigger. And then I, I feel, and I certainly felt it in my own life, that a lot of these kind of compulsive behaviors are just, are an attempt to repair that fault line and get back to equilibrium.

    30. AL

      Mm-hmm. Mm-hmm.

  13. 1:22:20 – 1:31:47

    Vulnerability in Writing and Closing Reflections

    1. RC

      How hard was it for you to be this open and vulnerable? Because you've revealed a lot about yourself in Dopamine Nation. Uh, I think it completely adds to the book, uh, hugely. It connects the reader to you and your work hugely. But what was that like for you? Was there ever, was there any part of you that was like, "Ah, should I put this in? Should I keep this out?"

    2. AL

      [laughs] Oh my God. Pretty much the whole book. I would say in the two, two months before it was about to come out, I think I was in a constant state of panic. I also talk in the book about, you know, my struggles with, you know, my relationship with my mother, which has been-

    3. RC

      Yeah

    4. AL

      ... a source of both shame and pain for me in my life. And my mother hadn't read the book and didn't know what I was putting in it, and, um, yeah, I was, I was just really, really scared and anxious and, um, it was hard. It was really hard. But, you know, I felt that my patients had been so brave in sharing their stories that it wouldn't be right for me not to disclose the way that my own refracted lens on this topic had impacted my views. I just felt like that would be disingenuous. Um, and thankfully, really universally, people have responded well to my self-disclosure, including my mom, um, who, you know, read the book and said, "Yeah, that, you got it about right. That's, that's... I would agree with that," which was nice. You know, it wasn't like, "Yay, our relationship is repaired." Nothing like that. But it was like, okay, the way that I sort of saw reality after much reflection was validated by this-

    5. RC

      Yeah

    6. AL

      ... this other person who, who could say that I, I saw the same. And that, that's a good feeling, you know, that like, okay, yeah, I, I'm seeing it clearly. I don't... I, I'm sad about what is the truth, but at least I know what the truth is, and, and this person who is involved in my truth corroborated it.

    7. RC

      Yeah, it's fascinating hearing that. Um, do you think you could have been that open five years ago, 10 years ago? Is this something that as you learn, I guess... This, this is the feeling I get throughout the book, Anna. There's not only you as the expert, but also you as someone who really listens and pays attention to your patients and has actually learned so much about what it means to live a good and proper and calm and peaceful and content life from them. You know, and I guess there's a real personal reason why I'm asking this, because I have-- my book's about to go to print. I am revealing-

    8. AL

      [laughs]

    9. RC

      ... so much more about myself than I ever have done. In fact, my wife-

    10. AL

      Mm

    11. RC

      ... proofread it last week. She's like, "Baby, you sure you wanna put this in?"

    12. AL

      [laughs]

    13. RC

      So I guess I'm feeling, uh, I'm looking for reassurance, and I'm-

    14. AL

      Yes

    15. RC

      ... I'm, and I'm getting it.

    16. AL

      Yeah.

    17. RC

      But I, I feel confident now, but I wouldn't have done a few years ago because-

    18. AL

      Yeah

    19. RC

      ... I would've felt too scared of being judged.

    20. AL

      Mm-hmm.

    21. RC

      And I just wonder if there's anything that resonates with you about that. Is this something you can do now at this stage in your life and your career? Would you have been able to do that, do you think, a few years back?

    22. AL

      I think you're right. I think there's something about getting older, getting more comfortable maybe with ourselves-

    23. RC

      Yeah

    24. AL

      ... and our choices, um, feeling that we, we've actually gained, you know, some modicum of wisdom that we want other people to benefit from. So I do think that when we make ourselves truly vulnerable, right? Not in a manipulative sense, but in a-

    25. RC

      Yeah

    26. AL

      ... in a really it hurts to share kind of way, you know, we're giving people a gift, just as our patients give us a gift every time they tell us what's really going on with them. It's a great gift. Um, and it's a po- it's probably the most powerful gift because you can tell people the lessons that you w- that, you know, to live by or whatever, but until you tell them how you're broken and the way that you came through, it will never have the same kind of power or impact. But, I mean, and also, you know, you're somebody who's, like, from the outside, my gosh. I mean, people look at you like, "Oh, you know, he's so famous, and he's a doctor, and he has all... His world must be perfect." And so, you know, when, when we reveal ourselves, like, "I, I, you know, actually every day is kind of a struggle, you know, and I, I, I suffer with the same kinds-

    27. RC

      Yeah

    28. AL

      ... of problems as..." I think, I think it really, it really helps people.

    29. RC

      Yeah.

    30. AL

      That's been my experience. That's been my experience.

Episode duration: 1:31:47

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