The Path to Enough

This week, we bring you the second part of our 2023 conversation on the perils of too much pleasure. Psychiatrist Anna Lembke explains the neuroscience behind compulsive consumption. She also shares techniques she’s learned from her patients to overcome the lure of addictive substances and behaviors. Then, Anna responds to your questions and comments on everything from dopamine fasts to kids' use of cell phones in our segment "Your Questions Answered."

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam. It seems like the simplest choice in the world. Given the option between pain and pleasure, we ought to choose pleasure.

• 0:13Shankar Vedantam?

  Is it better to be hungry or full? Better to be tired or alert? Better to watch another episode of our favorite TV show? Or do the dishes?

• 0:24Shankar Vedantam?

  It isn't just our own minds that tell us to choose the path of enjoyment and indulgence. Our friends remind us that life is short.

• 0:34Shankar Vedantam?

  Say no to dessert or another round of drinks, and someone might call you a spoilsport.

• 0:41Shankar Vedantam?

  At Stanford University, psychiatrist Anna Lembke has heard the same messages. But as a scientist, she's also studied the way our brains balance pain and pleasure. The two sit on opposite ends of a neural seesaw, and the brain constantly attempts to bring them into equilibrium, or what is known as homeostasis. When we press down hard and often on the pleasure side of the seesaw, triggering bursts of the neurotransmitter dopamine, Anna says the brain automatically compensates by pressing down on the other side, producing a dopamine deficit.

• 1:19Shankar Vedantam?

  Over time, as people press down too much or too often on the pleasure side of the equation, the brain compensates so forcefully that we start to walk around with a chronic dopamine deficit. This can manifest as anxiety, irritability, and depression.

• 1:39Shankar Vedantam?

  There is complex neurochemistry behind the process of homeostasis, but Anna has come up with a simple way to visualize this. When you press down on one side of the seesaw, imagine a bunch of gremlins inside your head jumping on the other side of the seesaw.

• 1:58Shankar Vedantam?

  We explored how this mechanism works and why it exists in our previous episode. If you missed it, I strongly suggest you listen to it first.

• 2:08Shankar Vedantam?

  Today, we continue with the second part of our story about the paradoxical effects of pleasure. And we ask what it means to live a life of balance and harmony.

• 2:23Shankar Vedantam?

  How to Work With The Brain Rather Than Against It. This Week on Hidden Brain.

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• 3:08Shankar Vedantam?

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• 4:13Shankar Vedantam?

  Anna Lembke is a psychiatrist at Stanford University. She has worked with many patients who have addictions, not just to drugs like cocaine and heroin, but to everyday activities taken to excess. She has treated patients with a range of out-of-control indulgences, from eating and drinking to online shopping and sports betting. Around the time she turned 40, Anna found herself in the grip of an addiction. She was consumed with romance novels and erotica. And a note that this next part of the discussion involves references to sex. At one point, she found herself swept up in the novel Fifty Shades of Grey. The story, later made into a movie, revolves around a sadomasochistic relationship

• 4:57Shankar Vedantam?

  between a college student and a business tycoon.

• 5:01Speaker 02

  There's some people who say that I don't have a heart at all.

• 5:04Speaker 03

  Why would they say that?

• 5:06Speaker 02

  Because they know me well.

• 5:10Speaker 03

  Do you have any interests outside of work?

• 5:14Speaker 02

  I enjoy various physical pursuits.

• 5:17Shankar Vedantam?

  I asked Anna what drew her to the book.

• 5:20Speaker 04

  I'm honestly not even sure I know because it didn't really matter when I was reading it. That is to say, like, the plot and the characters mattered not at all. I was reading it for the sex scenes. You know, embarrassing to admit that, but it's true. But I remember rationalizing it to myself as a modern-day Pride and Prejudice.

• 5:48Speaker 04

  But, you know, not really.

• 5:51Shankar Vedantam?

  Yeah, you don't think Jane Austen would have written Fifty Shades of Grey?

• 5:54Speaker 04

  Don't think so. No, don't think so.

• 5:57Shankar Vedantam?

  So at a certain point, Anna, you started to see that your enjoyment of romance novels and fantasy had tipped over from entertainment to something more potent. When did you have this realization as you were reading Fifty Shades of Grey?

• 6:11Speaker 04

  I remember it vividly. It was about three in the morning on a weeknight, well past the hour I should have been sleeping so that I could be prepared for the next day to come. And I got to a scene where, you know, the characters were using sadomasochistic sex toys. And I just thought to myself, how did I get here? What am I doing? That's not anything that I'm into or even interested in. It was a sort of like, where am I? And how did this happen? And I decided, that's it. This is something has gone seriously right here. I need to look at this problem.

• 6:54Shankar Vedantam?

  Anna eventually came to realize that her own engagement with romance novels and erotica had something in common with the addictions she was treating in her patients. When she was reading, she would become so engrossed that it felt like she was in a trance. You can see this among people who have addictions to sports betting or pornography. You can see it among heavy users of YouTube or social media platforms like TikTok. And of course, you can see it in the way people disappear into their phones. Anna said she would lose track of time, lose track of herself.

• 7:32Speaker 04

  And, you know, we want to be in a trance. I mean, I think that's something we have to admit to ourselves. We want to escape ourselves. And I think part of that is a function of this incredibly narcissistic society that we live in, where we're so preoccupied with ourselves and our problems and our achievements. Like, we're desperate to get away from ourselves. Plus, you know, you have all these amazing drugs that make that possible.

• 8:04Shankar Vedantam?

  So a turning point in your life came in 2011 during an encounter you had with a young resident who was training to be a psychiatrist. Tell me what happened and how it came about.

• 8:14Speaker 04

  Yeah, so this was a lovely young student of mine, doctor in his residency for psychiatry. And I was teaching a small group of residents how to do something called motivational interviewing, which is a way of harnessing the patient's own motivation to change their behavior. So we got into these pairs so that one could role play the psychiatrist and the other could role play the patient. And the patient could talk about a behavior that they want to change and the psychiatrist could do this motivational interviewing to try to explore how to help them do that. And we had an odd number, so that means that I had to pair with the student in order to do the role play. So he said, well, I'll be the psychiatrist.

• 8:58Speaker 04

  I said, OK, I'll be the patient. And he said, is there a behavior you'd like to change? And I just sort of said without even thinking about it, yeah, I do some late night reading that I'd like to change. And in usual motivational interviewing style, I said, well, why is it that you want to change that behavior? Right, you're trying to explore with the patient what their reasons are. And I said, well, I just think it's gotten into a bad habit. It's interfering with my sleep. It's interfering with my ability to be present. You know, just sort of vague generalities. I did not tell him what specific genre of book I was struggling with. So then he asked me, what would you be giving up if you stopped that behavior? And I said, I would be giving up the intense pleasure and feeling of escape that I get

• 9:43Speaker 04

  from reading. But then, when I said that, I realized, yeah, but those things are not as important to me as being present for my husband and for my children, for being invested in and good at the work that I do.

• 9:59Shankar Vedantam?

  So I find it so striking and also so revealing, Anna, that it took an actual conversation where someone asked you a simple question and you had to answer aloud for you to see something about yourself. I mean, you're the trained psychiatrist. You're supposed to have insight. And I think it just shows how difficult it is for all of us to see ourselves clearly.

• 10:19Speaker 04

  Yeah, isn't that amazing? And it is striking and a bit of a mystery, frankly, as to why putting into words what we're doing, especially telling another live human, has this remarkable ability to penetrate our lack of awareness and make us aware in a way that also then greatly enables our ability to change that behavior.

• 10:43Shankar Vedantam?

  So did the conversation end there? Or did the two of you come up with a plan for what you could do to change your behavior?

• 10:49Speaker 04

  The conversation, as I'm recalling it, went on a little bit longer, but not much longer, frankly. So then he asked a very simple question. He said, well, what's one thing you could do to take a step toward changing that behavior? And I thought, well, I could get rid of my Kindle because my Kindle gives me such incredible easy access to these downloadable reads, including free reads from Amazon, that if I got rid of it, it would create a barrier between me and the romance novel so that I'd have to do more work to get it. So that's what I decided to do.

• 11:24Shankar Vedantam?

  So how did that go? Did you just quit cold turkey?

• 11:27Speaker 04

  Once I had had that conversation with him and I thought about it the next day, I had a moment where I realized, oh, wow, I think I've developed a minor addiction to romance novels and erotica. And so then I simply made a decision to do what I recommend my patients do, which is abstain for four weeks, got rid of the Kindle and just, you know, made a strong commitment to not reading romance novels and erotica. But what shocked me was that very night, which was the first 24-hour period of my not engaging in romance novel reading as a way to put myself to sleep, I was gripped by anxiety and restlessness and agitation.

• 12:14Speaker 04

  And I was surprised, right? Because I, first of all, didn't think there would be a huge physiologic or even psychological response. But I experienced withdrawal, the same kind of withdrawal that my patients described.

• 12:28Shankar Vedantam?

  Wow.

• 12:29Speaker 04

  I had a very difficult time putting myself to sleep. And so it was extremely difficult. I lay awake for several hours and finally was able to, you know, put myself to sleep. And that went on for about 10 to 14 days. So in fact, it was the process of trying to give it up that really brought home to me how addicted I had become.

• 12:52Shankar Vedantam?

  What happened at the end of the month, Anna?

• 12:54Speaker 04

  I felt much better. And I thought to myself, I'm good. Now I'm going to go back to reading romance novels now and then in a very rational and tempered way, and we're all going to be fine here. And so I went and, you know, I got some book and I completely binged. I spent the whole weekend, reading all day, every day. And late into the night on Sunday, went to work bleary eyed on Monday. And I realized, wow, that was a complete mess. And it's clear that whatever those circuits are that have been kindled in my brain, they're still kindled and that a month is not sufficient. And I need to recommit to a longer period of abstinence. And that's what I did.

• 13:34Speaker 04

  I recommitted to a year of abstinence from romance novels, erotica of any sort.

• 13:47Shankar Vedantam?

  One of the things that's hardest about problems involving the mind is that we need our minds to battle the problems we have with our minds. Imagine trying to fix a broken toaster and the only tool you have is the very same broken toaster. When we come back, how to reset our relationship to pain and pleasure in a way that produces enduring satisfaction. You're listening to Hidden Brain. I'm Shankar Vedantam.

• 14:18Shankar Vedantam?

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• 15:42Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam. In our previous episode, which I highly recommend you listen to if you haven't heard it yet, Stanford University psychiatrist Anna Lembke explained how our minds come with an internal seesaw. It's designed to keep things in balance to achieve what is called homeostasis. When you bite into a delicious dessert or bet on a sports game and wait excitedly for the result, you're pressing on the pleasure side of the seesaw. You trigger a burst of dopamine. To return to balance, the brain compensates by pressing down on the other side of the seesaw. Over time, if we press too hard or too often on the pleasure side, the brain starts to compensate more and more forcefully,

• 16:25Shankar Vedantam?

  leaving us with a dopamine deficit. This can leave us feeling down and miserable and prompt us to go find our next jolt of pleasure. You can see how this quickly can become a vicious cycle.

• 16:41Shankar Vedantam?

  Anna, it's clear that simply seeking out more pleasure and more intense pleasure or more constant pleasure is not the answer. And you often recommend something that you call a dopamine fast to your patients. How does it work?

• 16:55Speaker 04

  Well, the dopamine fast is a little bit of a misnomer in the sense that we're not actually ingesting dopamine. In fact, what we're doing is using substances and behaviors that trigger the release or increase in firing in dopamine that we make in our brain. What the dopamine fast refers to is to abstain from the substance or behavior for long enough for our brain to get the memo, oh, wait a minute, I'm not getting this external source anymore. It's time for me to start to make more of my own endogenous or innate dopamine to upregulate our own dopamine receptors and increase dopamine transmission.

• 17:39Speaker 04

  Because in response to substances and behaviors that release a lot of dopamine in our brain, this fire hose of dopamine, what our brains essentially do is down-regulate dopamine transmission, not just to baseline, but below baseline, which is this state that's really akin to a clinical depression.

• 17:57Shankar Vedantam?

  There is an important caveat to this recommendation. The more severe the addiction, the more a dopamine fast will produce painful symptoms known as withdrawal. In some cases, withdrawal can be so severe that it can pose medical risks of its own.

• 18:13Speaker 04

  Anybody with a severe addiction is going to need medical supervision and support, and especially if they're physiologically dependent to a chemical like alcohol or benzodiazepines or opioids, such that they would be at risk for life-threatening withdrawal. Because essentially, what happens in withdrawal is that we experience the opposite of whatever that drug does for us. And with sedatives like alcohol, opioids and benzos, we can experience a physiologic storm, including life-threatening seizures. So individuals who are struggling with that kind of severe chemical dependency should not just quit cold turkey.

• 18:52Speaker 04

  They need medically monitored detoxification or tapering in order to get off of their drug of choice. But the principle is still the same, you know, that they need to get off of that chemical in order to allow their brain to heal.

• 19:09Shankar Vedantam?

  So you once treated a patient whom you called Delilah, a young woman who was a heavy user of cannabis. So you broached the idea of a dopamine fast to her. And what was her reaction?

• 19:22Speaker 04

  Well, first of all, she came to me seeking help for anxiety and depression, not seeking help for cannabis. In fact, she identified cannabis as the only thing that helped with her anxiety. And she wanted me to prescribe a pill or offer some kind of psychotherapy that would help with her anxiety and depression. But what I said to her, which is what I say to many people who now come to me wanting help with anxiety and depression, other psychiatric symptoms, whom I discover are using high dopamine rewards excessively, is that instead of prescribing them a pill or recommending any kind of psychotherapy, what I invite them to do is to engage in an experiment,

• 20:07Speaker 04

  which is the dopamine fast for four weeks in order to reset reward pathways. Because there's a possibility, I tell them, that just by doing that alone, their anxiety and depression may get substantially better without our having to do any other intervention. So that's what I suggested to Delilah.

• 20:28Shankar Vedantam?

  So you say that four weeks of abstention are also necessary to begin to see one's life more clearly, to accurately perceive cause and effect when it comes to our moods and the things that are bringing us up and down. What do you mean by that? And how did that work out with Delilah?

• 20:44Speaker 04

  When we're chasing dopamine, it's very difficult to see the true impact of our drug of choice, whether a substance or behavior, on our lives. All we see is the immediate relief that we get from it. We're not able to see that, you know, over time, what's happening is that we're changing our brains in a way that's probably exacerbating the problem we're trying to solve. So I suggested to Delilah, you know, that she try giving up cannabis for a month in order to reset her reward pathways. And what she said to me is... You know, why would I do that? You know, cannabis is the only thing that helps with my anxiety. And I said to her, I hear you that in the moment you get relief from the cannabis.

• 21:29Speaker 04

  But what I suggest to you is that what you're really doing is medicating withdrawal from the last dose, rather than treating your underlying anxiety disorder. And that, in fact, what the cannabis is doing over time is changing your hedonic or joy set point, such that now you need more and more cannabis to feel any pleasure at all. And in fact, what I see is that people who use cannabis that the pot can actually start to do the opposite and make them more anxious and even paranoid over time. And still, she was not interested in stopping. She said, you know, maybe someday, but not now. And then I do something that I often do with patients, and I try to get them to look at the larger timeline of their lives.

• 22:13Speaker 04

  So I said to her, well, I hear you that you're not interested in stopping now. When do you think you do want to change the way you're using cannabis? Do you think you want to be smoking the way you are now in 10 years? She immediately responded, no, I definitely won't be smoking this way in 10 years. You know, implying that there was something about her current use that she could admit was not healthy. So I said to her, okay, well, you don't want to be smoking this way in 10 years. How about five years? She says, no, I don't want to be smoking this way in five years. And I said, okay, how about in a year? And then she stopped and kind of thought about it. She said, okay, I get where you're going with this, doc. You're basically telling me if I don't want to be doing it in 10 years or five years

• 22:58Speaker 04

  or a year from now, why not try stopping now? And I said, exactly. And then she agreed to do it.

• 23:04Shankar Vedantam?

  And how did it turn out?

• 23:07Speaker 04

  Really interesting. She came back four weeks later and she said, Dr. Lemke, you wouldn't believe it. And this is what's so funny. Patients will always say, you wouldn't believe it, as if I'm going to be shocked. I said, tell me. She goes, well, first of all, stopping pot made me realize that I had been addicted to pot, something I really didn't realize before. And I said, well, how? Did you realize that? And she said, well, first of all, the first week I was vomiting violently. So remember that withdrawal is the opposite, both psychologically and physiologically from whatever the drug was doing for us. And we know that cannabis can be an antiemetic or, you know, an anti-nausea kind of effect. So when she stopped using it, she started vomiting.

• 23:49Speaker 04

  And that was the signal to her that her body had been changed by her chronic heavy use. More even in her case than the increased, temporarily increased anxiety and insomnia, which I had warned her about. And then she said, and you wouldn't believe it, but I feel so much better now after four weeks of stopping than I have in a really long time. I feel less anxious. I feel less depressed. I'm more able to enjoy things. I can breathe better. You know, I feel physically better. I'm sleeping better. And this happens again and again and again. We see this so often in clinical care and people are so surprised because they, when we're in it, we don't see the harm, right? All we know is that, oh, smoking this joint makes me feel better

• 24:32Speaker 04

  after a long, hard day. We can't see the ways in which the cumulative effects actually are making us feel worse.

• 24:41Shankar Vedantam?

  So this is not the only client who discovered that the symptoms she thought she was treating with the drug might actually have been caused by the drug. I understand that there has been research on this front, not just looking at individual patients, but a classic study conducted with a group of alcoholic men who also had clinical depression. Tell me about that study and what it found, Anna.

• 25:05Speaker 04

  Yeah, so this is a famous study by Brown and Shuckett where they took a group of adult men who met clinical criteria for alcoholism and also met clinical criteria for major depressive episodes. They put them in the hospital for four weeks, during which time they had no access to alcohol. You know, they made sure they didn't have life-threatening withdrawal, but also during which time they gave them no specific or general treatment for major depression. And what they found is that at the end of those four weeks, eighty percent of those individuals no longer met criteria for major depressive episode. In other words, just stopping drinking resolved their depression.

• 25:48Speaker 04

  And that is very consistent with what we see clinically. People who have anxiety, depression, insomnia, and attention, just by stopping their substance or behavior of choice for four weeks largely resolves many of those symptoms in about eighty percent of patients who come in.

• 26:07Shankar Vedantam?

  I mean, and this is consistent with your larger hypothesis that this is the Plante paradox at work, that the overabundance of things that trigger dopamine in our heads is causing those gremlins in our brain to sort of lean so hard on the other side of the teeter totter, that now, you know, we are walking around feeling depressed and anxious. And if we try and just get back to equilibrium, we're going to feel much better, you know, and when we're not chasing sort of those highs anymore to get rid of our feelings of depression.

• 26:36Speaker 04

  Yeah, exactly. I mean, we're clearly in the midst of a severe mental health crisis, especially affecting our youth. And there's lots of speculation for why that is. And a hypothesis that I would, you know, I've put forward is this idea that the source of our unhappiness is, in fact, our relentless pursuit of pleasure, the many drugified things in our world today that make that possible, and the ways that our brains are trying to compensate for that by actually going into this dopamine deficit state, which is very similar to clinical depression or anxiety, insomnia, et cetera.

• 27:21Shankar Vedantam?

  So, one of the most important claims that you're making here is that the sea of plenty in which many of us find ourselves in nowadays is causally responsible for the fact that many of us actually might be more unhappy than we were 30 years ago, 50 years ago, 100 years ago. Are we sure that there is a causal connection between those two things? And if so, how are we sure of that, Anna?

• 27:44Speaker 04

  It's a hypothesis based on inference, but let me tell you what the data points are. First of all, when you look at happiness surveys, about 50 years ago, you could track that people who were living in wealthier nations were more happy than people living in poor nations, and that they were getting happier over time. Starting about 20 years ago, people in the richest countries in the world started to be less and less happy. Now, what the cause of that is, we don't know for sure, but you could make the inference,

• 28:28Speaker 04

  as I have done, that we reached some kind of tipping point in terms of abundance, where what started out as a good thing became an overabundance, and is actually contributing now to our suffering. And by the way, that holds true also for increasing rates of depression, anxiety, and suicide all over the world, which are going up all over the world, but which are rising fastest in the wealthiest nations. So again, this kind of plenty paradox. You have even, you know, here in the United States, rising rates of anxiety, depression, and suicidal thinking among teenagers, corresponding specifically with the past 20 years, and

• 29:09Speaker 04

  the increasing amounts of time that people are spending on the internet and consuming digital media. And then you have a much smaller data point, which is what we see clinically when we intervene and ask people to stop ingesting these high-reward substances and behaviors. People who come in seeking help for anxiety, depression, suicidal thinking. And what we find is that their anxiety, depression, and suicidal thoughts, in the vast majority, get better without having to do anything else other than cut out for a period of time their high dopamine substances and behaviors.

• 29:56Shankar Vedantam?

  When we come back, techniques to get addictive behaviors under control, and the crucial role that relationships and community can play in helping us to reset our brains. You're listening to Hidden Brain. I'm Shankar Vedantam.

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• 31:20Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam. Psychiatrist Anna Lembke is the author of Dopamine Nation: Finding Balance in the Age of Indulgence.

• 31:32Shankar Vedantam?

  She argues that when we seek out pleasures on a nonstop basis, whether those pleasures are legal indulgences or illegal substances, we mess with the neurochemistry of the brain.

• 31:46Shankar Vedantam?

  Paradoxically, the more we chase pleasure, the more the brain tries to compensate, leaving us in a dopamine-depleted state.

• 31:57Shankar Vedantam?

  Anna recommends multiple techniques to help get indulgences under control. She calls these "self-binding techniques."

• 32:05Speaker 04

  Self-binding techniques create both literal and metacognitive barriers between ourselves and our substance or behavior of choice so that we can press the pause button between desire and consumption. And there are many different ways to do that. I sort of organize it into time-space and meaning to give us a fighting chance to be able to abstain.

• 32:29Shankar Vedantam?

  So what would some of these look like? You know, for example, the physical or spatial self-binding that you talk about, what does that look like?

• 32:37Speaker 04

  That looks like, for example, not having the substance in the house. If it's alcohol, or potato chips, or cookies, or whatever it is, not having it in the house is a really simple one. My patients talk about when they travel, calling the hotel in advance and having the hotel remove the minibar from the room. In some cases, remove the minibar and the television set so there's not access to the kind of cable channels that make people vulnerable. I've had patients use things like the kitchen safe, you know, so that they lock their device in there. They can't get it out for a certain period of time.

• 33:16Shankar Vedantam?

  It could also sometimes help to decide when you are going to engage in an activity.

• 33:21Speaker 04

  So this is the way to use time as a self-binding construct. What I think is really interesting is the way that we essentially organize our time around rewards in the modern world in a way that I think is unprecedented. You know, we sort of look forward to our coffee in the morning and then we can't wait to get home at night and watch our shows. And so what I ask patients to do is to be aware of that and then use time to their advantage. For example, if they've done the dopamine fast and now they want to go back to using their substance or behavior, but they want to use in moderation, they could commit to, for example, only playing video games two days a week, two hours a day, and specify when that is.

• 34:04Speaker 04

  Or if they want to have some mindless scrolling on social media, they can say, okay, I'm going to dedicate a half hour a day and this is when it's going to be. And then I know I'm going to do mindless scrolling or YouTube watching, but outside of that, I'm not going to do that. Or I'm going to wait till I, you know, finish this exam or turn in my paper or get this job promotion. And then to use that as a way to bind themselves.

• 34:27Shankar Vedantam?

  I understand you had a patient Mitch who was addicted to sports gambling and he had to take some pretty extreme measures to bind himself, to keep himself from using his drug of choice.

• 34:39Speaker 04

  Yeah, so he had to do something called self-banning, where he basically went to the casinos and put him on a, himself on a banned list, which is very common among pathological gamblers, pathological sports bettors. It's really hard with the new online apps, but you can also ban yourself on an online app. The other thing that he did was he avoided what I call the stepping stone effect, where certain behaviors are not necessarily our substance or behavior of choice, but they're a stepping stone to it. So he realized that he couldn't really watch sports in any capacity. He couldn't read about sports in the paper. He couldn't listen to sports radio. He couldn't watch sports on television or on the computer.

• 35:24Speaker 04

  Because as soon as he did that, the cravings to bet were just overwhelming.

• 35:31Shankar Vedantam?

  I mean, this is like people who have, let's say, an alcohol dependence problem. And you're taught, don't walk by the bar on your way home from work. Take a different route. So in other words, the things that you put in your environment end up shaping the choices that you make.

• 35:47Speaker 04

  Oh, absolutely. Such a key point. To expect ourselves to be able to change without changing our environment in a dopamine overloaded world is just expecting us to not be human. I deal with a lot of families where the kids are addicted to video games or social media. And the parent's like, I don't know why, he just won't stop, or she just won't stop. Meanwhile, their house is like fiber optic, high-speed internet. They've got a screen in every room, in every bedroom. Everybody's got 12 devices. I mean, no, right? No. And also at school, it's a huge problem. The kids are allowed to have their phones during class. How can a teacher possibly compete with YouTube?

• 36:32Speaker 04

  There's no way.

• 36:33Shankar Vedantam?

  So one of the most radical suggestions that you have, and radical in the sense that I think it would appear to many people to be very counterintuitive and hard to digest, is that one way to deal with compulsive overconsumption is to actively seek out its opposite. You say that we should deliberately seek out experiences of pain and hardship. Now, most of us try our best to avoid pain. Why would we choose to deliberately invite pain into our lives?

• 36:59Speaker 04

  Yeah, I know this sounds really wackadoodle, but there's actually science behind it. It's the science of hormesis. And hormesis is Greek for "to set in motion." And what we're talking about is very mild to moderate doses of adaptive or healthy pain as tolerated. And if you don't like the word "pain," maybe use the word "discomfort" or "challenge" or something along those lines. Although often it does involve some physical duress. At the right doses to up-regulate our own healing mechanisms, but not so much that it causes irreversible harm.

• 37:41Speaker 04

  And what the science of hormesis shows in humans and in animals is that if you expose an organism to mild to moderate doses of painful, toxic, or noxious stimuli, you will actually make that organism healthier, more resilient, more robust.

• 38:00Speaker 04

  And we have evidence for that, overwhelming evidence for that through exercise, but also some emerging evidence for ice cold water plunges. There's also some evidence showing that prayer and meditation, which, you know, are not necessarily painful, but do require effortful engagement and a certain kind of concentration, which is not immediately necessarily pleasurable. That all, that those behaviors also release dopamine. Things like exposure therapy, forcing ourselves to do things that make us psychologically uncomfortable. These are all things that are hard in the initial experience, but essentially trigger our body to sense injury.

• 38:43Speaker 04

  And in sensing injury, our bodies start to upregulate our protective hormones, like, again, our endogenous opioids, all ultimately leading to the release of dopamine. So it's a really great way to overall reset our hedonic or joy threshold to the side of pleasure, which means that we're more resilient in the face of pain and we're generally happier.

• 39:12Shankar Vedantam?

  Let me summarize what you're saying and make sure I'm understanding this correctly. You're basically saying your essential argument here is that there is a system in the brain that tries to maintain homeostasis. When we press down on the pleasure side of the balance, the brain gremlins get on the pain side of the balance to try and compensate it in recovery equilibrium. But if we were to press down on the pain side of the balance, now homeostasis starts to work in some ways in our favor because the gremlins hop onto the pleasure side of the balance and they basically get us to a state where we're feeling better on average than we were doing before?

• 39:46Speaker 04

  That's exactly right. And there is overwhelming evidence to support this. So, for example, we know that if you track dopamine levels, as well as other feel-good neurotransmitters like endogenous serotonin, norepinephrine, endogenous opioids, endogenous cannabinoids, what you find is that initially, when people engage in exercise, those neurotransmitters are low, but over the latter half of exercise, they slowly start to rise. And then when the exercise is stopped, those neurotransmitter levels remain elevated for hours afterwards. And of course, this is our runner's high. And then eventually, those elevated levels of dopamine will go back down to baseline

• 40:30Speaker 04

  levels homeostasis, but without ever going into that dopamine deficit state. In other words, by paying for our dopamine upfront, we get those feel-good experiences, which we need, right? We're humans. We can't just like hang out in homeostasis, but we can get those good feelings without ever having to go into our cash dopamine reserves, so to speak.

• 40:51Shankar Vedantam?

  You made an interesting analogy a second ago, and I want to just draw attention to it, which is that there is an analogy here between the way we engage with our brains and the way we engage with money. You can buy things on credit, and that is sometimes valuable and smart to do, but it does mean that you're getting the good stuff first and then paying for it later. So that's what we do when we intentionally trigger dopamine in our heads. We're getting the good feelings now, but have to deal with it later. You're arguing that focusing on the pain side of the equation in some ways is, as you say, paying for the dopamine upfront. You're doing the difficult thing now in exchange for the reward down the road.

• 41:29Speaker 04

  Exactly. And you can see the ways in which actually the way we pay for things makes us all more vulnerable to addiction, because now they have these credit cards where you don't even have to pay for them in real time. You can pay for them later, which is just terrible.

• 41:47Shankar Vedantam?

  I'm wondering if it will sound to many people that you're almost recommending a life of asceticism here. Are you recommending that people become ascetic, Anna?

• 41:58Speaker 04

  I'm recommending a new form of asceticism for the modern age. And what I mean by that is, we are living in an unprecedented time of overwhelming access to highly reinforcing drugs and behaviors, such that I think that our existence is going to be reliant upon figuring out how to navigate this world of overabundance. And so, in fact, in order to be healthy, we actually have to intentionally veer slightly to the side of pain and insulate ourselves from pleasure in order to preserve balance.

• 42:34Shankar Vedantam?

  Have you done this yourself?

• 42:37Speaker 04

  Oh, yeah. I do this on a regular basis.

• 42:40Shankar Vedantam?

  What do you do?

• 42:44Speaker 04

  Well, I like to start my day with pain, namely doing some kind of exercise, mainly walking or swimming, because I'm in my 50s now. But I, every morning, you know, when I wake up, trust me, I do not want to get out of bed, but I absolutely force myself to do it most of the time, because I know I'll feel so much better afterwards. And it's just a great angioslytic and mood stabilizer for me. And then we've raised our family with a lot of, you know, forced marches and outdoor wilderness experiences, which were challenging and difficult. We've insulated ourselves from digital media in the sense that we didn't have any devices or Wi-Fi, even Wi-Fi to the home, until our eldest went to high school.

• 43:29Speaker 04

  And then she came back and said, and she essentially couldn't function as a high school student without Wi-Fi in the home.

• 43:37Speaker 04

  They change the schedule every day. You have to log on everything just to know what class you're supposed to go to. It's crazy. So I'm really sad because now we have, you know, Wi-Fi and fiber optic. And it makes it a lot harder for me personally to manage my consumption, because like I'll get into these bad YouTube-watching habits in the evenings. You know, you can just imagine. But anyway, that's something that we did. We bike a lot of places instead of driving. In fact, we have one 25-year-old minivan, which has 75,000 miles on it. And when my husband tried to re-register for the insurance, they didn't believe us that it only had 75,000 miles. They made us like get an affidavit.

• 44:15Shankar Vedantam?

  Yeah. So what is the reward for living this way, Anna? What do you see in your life? Do you think you're seeing effects in your mind, on your brain?

• 44:23Speaker 04

  Oh, yeah. You know, I used to think that my life was really hard and that that was the source of my unhappiness. But now I actually think that all along, my life was actually too easy. And that's why I was unhappy.

• 44:42Shankar Vedantam?

  One of the most striking things about stories of addiction is that they often involve increasing levels of social isolation. Think of the person who is up playing endless first-person shooter video games in an apartment by himself at 4 o'clock in the morning, or the furtive, heavy consumer of pornography, the young woman addicted to pot.

• 45:02Shankar Vedantam?

  Anna, I feel like we may have painted an overly negative picture of dopamine in this conversation. Yes, you can have an unhealthy relationship with dopamine, but the problem is not with dopamine, per se, but the ways we go about triggering it. You say that relationships are a powerful way to trigger dopamine in a healthy fashion. Can you talk about that idea?

• 45:23Speaker 04

  Yeah, so my colleague, Rob Malenka, here at Stanford, is a neuroscientist. He and his colleagues have shown that oxytocin, which is our love hormone, binds to dopamine-releasing neurons in the reward pathway. So that makes a lot of sense, because we know when we fall in love, we feel high, right? That's a great feeling. And from a survival point of view or an evolutionary point of view, our brains want us to make connections to other people because we're more likely to find mates, more likely to be able to protect ourselves from predators, more likely to be able to steward scarce resources. So our brains get us to make those connections by releasing dopamine and making sure that it feels good.

• 46:07Speaker 04

  The problem with addiction is that essentially, our substance or behavior of choice comes to replace those human connections, and so we move further and further into isolation. And we meet those basic needs through our drug rather than through making deep human connections. And so part of getting into recovery from addiction means moving out of isolation and trying to make deep and rewarding intimate connections with other people, because essentially, that's what we're really looking for. But we get fooled by these kinds of, you know, false stand-ins for human connection.

• 46:51Shankar Vedantam?

  I'm wondering if you can tell me a little bit about the role of community here. There are many groups that have sprung up to try and fight addictions, you know, groups like AA or NA or Gambler's Anonymous, for example. Tell me about the role that they play. And in some ways, is it part of the same equation that we're looking at here? The role of human relationships in battling addiction?

• 47:10Speaker 04

  Yeah, so, you know, AA, Alcoholics Anonymous and Narcotics Anonymous, in my opinion, are among the most remarkable social movements of the last 100 years. These are amazing grassroots organizations composed of people with addiction, trying to help other people with addiction. And it's remarkably successful for those who actively participate. So you'll read a lot in the media now about how AA and other 12-step organizations don't work, but that's not really a faithful representation of the evidence. There are many people who will not participate or get anything out of it, but for those who actively participate, engagement in AA and other 12-step groups is as effective

• 47:54Speaker 04

  and possibly even more effective than professional treatment.

• 48:02Speaker 04

  So what is the secret of these 12-step groups? Well, first of all, they provide a sober social network. They provide a specific path for recovery, but importantly, they're also really de-shaming because you realize, oh, wow, I'm not the only one. And like, I have this thing that happened to my brain because I'm human and I have this particular vulnerability and other people have experienced and done similar things that I have done in pursuit of their drug. And that is an incredible burst of intimacy and, yes, dopamine, right, that we get then from being taken into the fold of like-minded individuals who understand us and accept us in all our brokenness.

• 48:52Shankar Vedantam?

  One important idea that Anna has adopted in her own life powerfully resonates with the message of groups such as AA and NA. Change begins with telling the truth.

• 49:04Speaker 04

  Yeah, so this was really something that I learned from my patients. Over many years of seeing patients get into recovery from severe addictions, what I noticed was that those who seemed to get into the best recovery and be able to maintain recovery the longest were those who were committed to telling the truth. That was a central value for them, which they saw as just pivotal for maintaining sobriety and recovery. And I thought that was really interesting. Like, what is it about truth telling that enables recovery and enables people to stay in recovery? Because it just was such a consistent theme. Whether they got into recovery through 12 steps, like AA or NA,

• 49:48Speaker 04

  or just through their own, you know, journey, it was inevitable that they would be like, oh, yeah, no, I can't lie. And when they said that, they weren't just talking about, I can't lie about my addictive behaviors. They meant they couldn't lie about anything. That the lying itself was sort of the first breach in the dam for them and that they had to be truthful in all things in order to maintain recovery. So that was really interesting to me. And I began to explore that, both, you know, from a scientific perspective as well as try to employ it in my own life.

• 50:25Shankar Vedantam?

  One of the things I find so striking about this conversation, Anna, is that you're someone who spends her day helping patients. But I'm not getting the sense that you see yourself as better or even different from the people you're trying to help. I understand that you're a fan of the philosopher Martin Buber, who has talked about what it's like to truly engage with another person.

• 50:45Speaker 04

  He talks about this I and thou moment, which he believed can occur between any two individuals who just make the effort to be fully present with each other. And it's a divine moment, right? Where everything else falls away. It's not sexualized love. It's something akin to love. But what's so interesting about this I and thou concept is that it can be achieved in a nanosecond with anybody. You could achieve it with a stranger. This idea being that when we kind of come to the encounter fully open and vulnerable in our shared humanity, and we see each other. That's a really special and remarkable experience.

• 51:30Speaker 04

  And I try to create that in my work with patients because that alone is healing.

• 51:40Speaker 04

  I've probably learned more from my patients than I think I've given them in return. I really see people in recovery from severe addictions as modern day prophets. Because these are folks who have had to figure out pleasure and pain and consumption in a dopamine overloaded world. And they've had to do it as a matter of life and death. And they've been able to do it. And so they really provide this roadmap of deep wisdom for, you know, the rest of us.

• 52:13Shankar Vedantam?

  When we come back, your questions answered. We revisit listener questions about Anna Lembke's research. You're listening to Hidden Brain. I'm Shankar Vedantam.

• 52:33Speaker 06

  Cheers to fall savings at Whole Foods Market, home of higher ingredient standards. This Halloween, share chocolates and candies made without that spooky high fructose corn syrup. Throwing a party? Make it easy with a berry chantilly cake. Ready to cook pizza? No antibiotics ever chicken wings. And sushi made fresh daily. Fall gatherings never tasted better. Save through November 3rd at Whole Foods Market.

• 53:01Speaker 07

  Don't you wish everything was more rewarding? With Rakuten, almost everything is. You can earn cash back on those shoes you've been wanting. You can save on the next trip you book. You can cash in on groceries. Just shop your favorite brands and save. It's that easy. And there are several ways to get paid, including PayPal, check, points, and gift cards. So go ahead, take a trip, fill that cart. Join a world of rewards. Go to rakuten.com or get the app.

• 53:35Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam.

• 53:39Shankar Vedantam?

  In today's episode, we heard part of our 2023 conversation with psychiatrist Anna Lembke. She's author of the book Dopamine Nation: Finding Balance in the Age of Indulgence.

• 53:52Shankar Vedantam?

  We talked about the balance between pain and pleasure in our brains and how our modern lives may be throwing off that balance. We received a flood of listener questions and comments when our episodes with Anna first aired. We're going to turn now to your questions answered, the segment that we released not long after those episodes came out.

• 54:15Shankar Vedantam?

  I started by asking Anna if she was surprised at the widespread public interest in the topic.

• 54:21Speaker 04

  Very surprised. So I was talking with a colleague just before it came out. And he said, well, what's it about? And I said, well, basically, it's a book about how pain is good for us. And he started laughing and he said, oh, that'll be a New York Times bestseller.

• 54:42Speaker 04

  And I said, right, exactly. And to, you know, my surprise, it was. So I think, though, that, you know, this is a very old idea, really. It's thousands of years old. And it's also an idea that many other people have been putting out there. But somehow, it's an idea that I think is right for our times.

• 55:04Shankar Vedantam?

  And I think many people are seeing that they live in a sea of plenty, and yet there are rising rates of anxiety and depression. People see this, people see the paradox.

• 55:13Speaker 04

  Yeah.

• 55:13Shankar Vedantam?

  And in some ways, I think you are giving them a way to resolve that paradox.

• 55:17Speaker 04

  Yeah, to resolve it, to name it, to, at least to some extent, to understand it, and also some actionable items in terms of what to do about it.

• 55:28Shankar Vedantam?

  So as I said, we received a number of questions about the nature of addiction. Let me start with this one from a listener named Michelle.

• 55:37Speaker 06

  What I would love to know is, why is it that one person can engage in certain addictive activities with impunity, but become addicted to others? For example, I've been able to take or leave nicotine throughout my life. You know, even if I smoked it regularly, I would not crave it. Yet a day doesn't go by that I don't drink coffee and I have to completely abstain from alcohol. And I know others who used perhaps hard drugs recreationally and could take it or leave it, but they may have had shopping addictions or sex and love addictions. So what is it that draws one person to a certain type of addiction as opposed to another?

• 56:19Shankar Vedantam?

  What do you think, Anna? Is there a reason why some people are drawn to some sources of addiction and not to others?

• 56:27Speaker 04

  This is a great question, and it's a question about which there's remarkably little science. And there needs to be a lot more. We call this the concept of drug of choice, which is to say, what is highly reinforcing for one person's brain may not be so for another and vice versa. And when I think about this from an evolutionary perspective, I think, well, this is actually Mother Nature ensuring that the tribe gets everything it needs to survive on a population level. If we were all going for the same berry bush, then we would end up with a lot of berries, but not enough meat, not enough shelter, not enough partners, or whatever it is that we need to survive.

• 57:08Speaker 04

  But by ensuring that we're all wired just a little bit differently, what Mother Nature has done is made sure that in a world of scarcity, we are collectively getting everything that we need. And by the way, I do reframe people with severe addiction in today's world as people who would have been absolutely crucial for survival of the group in a world of scarcity. I mean, in a world where we have to work very hard to get even the merest of rewards, you would want people who were very, very tenacious about getting a particular substance.

• 57:44Speaker 04

  But this whole concept of drug of choice is also really relevant for what is unique about the time that we live in now. I mean, I'll just use myself as an example. I used to think that the addiction gene skipped me in my family because alcohol never really gave me any kind of euphoria, wasn't an anxiolytic. Even caffeine doesn't wake me up. I thought, well, whatever this addiction thing is, I must not have inherited it. But the truth was, I just hadn't yet met my drug of choice. And it wasn't until midlife when I discovered, you know, this kind of drugified novel, the romance novel, when I got a Kindle, so that there could be this immediate access and delivery.

• 58:26Speaker 04

  And then I was off and running, completely caught up in it unawares, which is important because what it says is that those of us who previously have been immune to the problem of addiction are now vulnerable because of the ways in which our world has taken even seemingly innocuous behaviors and made them highly reinforcing and highly accessible. All of this being said, it's still important to acknowledge that we do come into this world with different degrees of vulnerability to addiction. So there are some of us who are much more vulnerable in general to the problem of addiction than others. And those individuals will struggle with almost every substance and behavior.

• 59:10Speaker 04

  In other words, the kind of tendency to compulsively overconsume despite harmful consequences is something that some individuals really do struggle with, no matter what the drug is. And those are individuals who, you know, will go on to develop very severe addictions potentially. And that's probably about 10 to 15% of the population. But again, I think the segment of the population struggling with addiction is growing because of our modern ecosystem.

• 59:39Shankar Vedantam?

  In some ways, I think, Anna, you just anticipated the next question, which comes from listener Ron, who is asking the question, are some people more vulnerable to addictions in general? Here he is. Why is it that some people seem to be more of the addictive personality type, while other people seem to be able to eat or drink and never develop the addictive psyche? Never become addicts. How is that? And is there any way we can explain why some people are simply hardwired one way and some people the other way? Thank you so much. I really enjoy the show. So what do you think the reason is, Anna, that some of us seem to have a greater tendency towards addiction and others have much less?

• 1:00:24Speaker 04

  It's true that different people have different vulnerabilities to the problem of addiction. We used to call this the addictive personality. Now we use the language of the disease of addiction. And some people are more vulnerable to the disease of addiction than others. Addiction is a complex biopsychosocial illness, meaning that there are biological contributors, psychological contributors, and social contextual contributors. So when we look at the biological or inherited aspect of addiction, we do know that individuals who have a biological parent or grandparent addicted to alcohol in particular are more vulnerable than the general population of becoming addicted

• 1:01:06Speaker 04

  to alcohol themselves, even if raised out of that alcohol-using home. So that's important because the psychological piece is that if we are raised in a home where our caregivers are either explicitly or implicitly condoning substance use or other addictive behaviors, we are more likely to get addicted ourselves. So then you have this kind of psychological or nurture aspect, which is also biological in the sense that of epigenetics and how our experiences will turn on and off certain genes, making certain proteins, which also can potentially be passed on to the next generation. This is why things like multi-generational trauma, for example, also increase the risk of addiction.

• 1:01:51Speaker 04

  And then finally, you have the social or contextual factors, which is, for example, simple access. If you live in an environment where drugs are readily available, you're more likely to try them and hence more likely to get addicted to them. And of course, that's what Dopamine Nation is all about.

• 1:02:16Shankar Vedantam?

  When we come back, where's the line between a healthy passion and an unhealthy addiction? You're listening to Hidden Brain. I'm Shankar Vedantam.

• 1:02:39Speaker 06

  Cheers to fall savings at Whole Foods Market, home of higher ingredient standards. This Halloween, share chocolates and candies made without that spooky high fructose corn syrup. Throwing a party? Make it easy with a Berry Chantilly cake. Ready to cook pizza? No antibiotics ever chicken wings. And sushi made fresh daily. Fall gatherings never tasted better. Save through November 3rd at Whole Foods Market.

• 1:03:06Speaker 07

  Don't you wish everything was more rewarding? With Rakuten, almost everything is. You can earn cash back on those shoes you've been wanting. You can save on the next trip you book. You can cash in on groceries. Just shop your favorite brands and save. It's that easy. And there are several ways to get paid, including PayPal, check, points, and gift cards. So go ahead, take a trip. Fill that cart. Join a world of rewards. Go to rakuten.com or get the app.

• 1:03:39Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam. Psychiatrist Anna Lembke argues that pleasure and pain exist on opposite ends of a seesaw in our minds. Many of us are pressing down too hard and too often on the pleasure side of the seesaw. We give ourselves little jolts of pleasure through shopping, gaming, and gambling. That can force our brains to compensate by pressing down on the pain side of the seesaw, leading to higher rates of addiction, self-harm, and anxiety. Now Anna Lembke is answering your questions about how to balance that seesaw. Anna, one of the things that jumped out at me in our initial conversation is that it can be very hard to recognize

• 1:04:23Shankar Vedantam?

  that you're in the grip of an addiction when you are in fact addicted. Here's a message we received from a listener named Hannah.

• 1:04:31Speaker 03

  My first question is, what is the difference between passion and too much dopamine? For example, if you're passionate about surfing or skiing, or you're passionate about rising the ranks of your career, at what point does it become like an unhealthy dopamine response?

• 1:04:54Speaker 06

  How do you distinguish between the two, especially if you are trying to be an expert at something? So what's the line between the time that you invest in in all of these different activities and something that might be considered unhealthy? My second question is, how do you avoid being a Luddite? If you're avoiding dopamine triggers, but you don't want to fall behind in society?

• 1:05:21Shankar Vedantam?

  So two questions here, Anna. The first is, what's the difference between passion and addiction? And the second idea here is, you know, if you see all the people around you, you know, working 90-hour weeks to get ahead in their careers, how do you try and get ahead in your career without it becoming an obsession?

• 1:05:38Speaker 04

  Right. So addiction, when I use that word, is intended to denote a form of psychopathology or mental illness. And it's always important to clarify that there is no brain scan or a blood test or other objective measure of addiction. We base the diagnosis on phenomenology, that is to say, patterns of behavior of continued compulsive use despite harm to self or others. So the question of when a passion gives way to an addiction is really the question of whether or not it's harmful to self and/or others. And that could include harm that the individual, him or herself, doesn't recognize, but that others recognize.

• 1:06:21Speaker 04

  Having said that, the question of when we cross that rubicon is very complex because of the cultural aspects in terms of who defines what is dysfunctional or harmful. You know, the caller referred to work, which implies a question, well, when are you a workaholic and when are you just really invested in your career? And our, you know, our modern-day heroes are people who work a lot of hours and sacrifice almost everything to career, and in some instances, to money, and in some instances, to fame. And those are our heroes, so we don't recognize those individuals as engaging in pathological behaviors. So now we have the issue of the societal overlay.

• 1:07:05Speaker 04

  What society says is, okay, this is an illegal drug. This is a legal drug. This is a healthy behavior. This is an unhealthy behavior. I think when taken to the extremes, I think many people would be able to say, oh yeah, that person is addicted to X, Y, or Z because they keep surfing or skiing or working beyond the point where it's good for their bodies, beyond the point where they're able to foster healthy relationships, take care of themselves and the others that they love, live according to their values. Implicit in all of these are ideas we have about values and what makes for the good life.

• 1:07:46Speaker 04

  I'd say in terms of the Luddite question and not wanting to fall behind and the extent to which digital media is interwoven into every aspect of our lives. When we're thinking about overconsumption of digital media and digital drugs, you know, how on earth do we define that? How do we get away from it? And these are really important questions that I think we should all be asking now and I wouldn't presume to have the answers to. I think we're, you know, at the forefront of a grand social human experiment. And I've made certain assumptions about digital media in our lives, namely that for all the good that it's done, there are harms.

• 1:08:31Speaker 04

  So I'm suggesting that disconnecting from digital media and from our devices for a period of time every day or maybe a day, a week, or what have you. There's, you know, there's no data on this amount of time is too much. And if you limit it to that amount of time, you're okay. Except to say that we do have information that shows that as we progressively spend more and more time online, we are more likely to manifest symptoms of anxiety, depression, insomnia, inattention. So there's clearly a correlation between these two things.

• 1:09:07Speaker 04

  And as I hypothesize, I think there is also causation, that it is the enormous amount of time that we're spending online that's contributing to our unhappiness. And I base that in part on the interventions that we do clinically, where we see people who come with anxiety, depression, what have you, consuming enormous amounts of digital media. We ask them to abstain for a period of time. And what we find is that many of them feel better without our doing any other intervention. And so I make this analogy to drugs and alcohol and the same kinds of benefits that we see in our patients when they can abstain from drugs and alcohol for long enough.

• 1:09:51Speaker 04

  And that's kind of where I'm coming from with that.

• 1:09:56Shankar Vedantam?

  You know, given the fact that the term addiction has a negative connotation on it, I'm worried that in some ways people may use the term really as a way of marking people whose behavior that they don't agree with. So for example, I am not a triathlete. And so I can look at someone running triathlons and say, look, this person is obsessed, it borders on an addiction. They really should be scaling back and exercising much more moderately. How do we come up with definitions of addiction that don't just devolve into name-calling, especially when it comes to people who are our opponents or people who we might disagree with?

• 1:10:36Speaker 04

  I agree with you. I think there's a real danger here of overgeneralizing, of labeling, of in fact trivializing the disease of addiction by using it in instances where it doesn't really apply. You know, when we diagnose addiction clinically, we don't do that casually. We talk to patients at length. We talk to their family members. We try to get a full 360-degree view. We get the subjective encounter. But we also try to get non-subjective data that might help inform us whether or not this behavior Is really harmful because I I agree with you, you know, you're absolutely right

• 1:11:20Speaker 04

  that the level of intensity that some people will engage in activities may be for them really healthy, right? People have, I mean, just temperamentally different needs for intensity and engagement. And I I would hate to send the message that any kind of intense engagement is an addiction. That's it's not at all what I'm saying. And I think it trivializes the disease of addiction, which can be not just debilitating, but also life threatening.

• 1:11:52Shankar Vedantam?

  Is it the case that we can say if the person with the problem recognizes they have a problem, that makes it a good candidate for it to be an addiction? And although as I'm saying this, I'm realizing, of course, one of the things that addiction does is rob us of insight.

• 1:12:05Speaker 04

  That's right. Exactly. Oh, I wish that it were that we could use that as a criteria, but that would be incredibly misleading because it's very easy to lose sight of true cause and effect when we are engaging in these types of highly reinforcing behaviors. And in fact, it's so well known in the field of addiction that there's a term for it denial. And it's a powerful, powerful thing denial. It's it's profoundly true that even people with very severe addictions can have very limited awareness of the harm that their behavior is causing, even though it's patently obvious to everyone around them, even if

• 1:12:49Speaker 04

  they've gotten to the point where they've incurred serious health consequences, relationship consequences, legal consequences. So, you know, that's and that's not true for everybody with addiction, obviously. But it's true for enough people that it's a common trope in the field. In fact, I had a patient say to me that denial is actually an acronym for don't even know I am lying.

• 1:13:13Shankar Vedantam?

  Hmm. We received a large number of responses from listeners who wanted to know about the relationship between ADHD and addiction. This question comes from Stacy in Zurich, Switzerland.

• 1:13:27Speaker 06

  My question regarding addiction is regarding neurodiversities because

• 1:13:34Speaker 06

  I feel like a lot of the time, we're just dealing with neurotypical people and how they respond to dopamine. However, when you have something like ADHD, like myself or my children, the urge to have a dopamine hit is so much stronger. And I've noticed that since I've begun taking medication to treat my ADHD, I find myself less addicted to dopamine-producing things like YouTube or Facebook or Instagram. And I just wonder if neurodiversity is playing a larger role in this than people are really realizing and whether we should have more

• 1:14:19Speaker 06

  training or more information available about the way that neurodiversities affect us in regards to addiction. Thank you.

• 1:14:29Shankar Vedantam?

  Fascinating. What's the connection between ADHD and addiction, Anna?

• 1:14:34Speaker 04

  So there's fairly reliable evidence, epidemiologic evidence, to show that children who are diagnosed with ADHD are at increased risk of developing addiction later in life. And it's not clear why that is, but one of the enduring character traits that you can test for that is also associated with the development of addiction is impulsivity. And impulsivity is the tendency to have difficulty putting a pause between the thought of doing something and actually doing it. So if ADHD is indeed a difference in prefrontal cortex wiring

• 1:15:16Speaker 04

  that limits a person's ability to, let's say, control their impulses or appreciate delayed consequences, then it makes sense that those individuals might be more vulnerable to the problem of addiction getting older. There's also, I believe, although I'm not really familiar with this literature, a literature suggesting that when it comes to dopamine firing, that people with ADHD might at baseline actually have lower levels of dopamine firing in the reward pathway. And by that, I mean, might be, to some degree, reward insensitive. So might at baseline need more potent rewards to feel the rewarding effects.

• 1:16:02Speaker 04

  One of the things that I think is important, though, to get out into public awareness is this idea that was promulgated in the field about 20 years ago, based on, you know, some early analyses, that suggested that if you take a group of kids with ADHD and you give half of them stimulants to treat the ADHD and the other half you don't give those stimulants, the idea was that the kids that you give stimulants to will have a decreased risk of developing addiction in adulthood, the idea being that somehow the stimulants would protect them from that problem. That has essentially been debunked.

• 1:16:45Speaker 04

  So, you know, a more recent meta-analysis does not give credence to that idea. So medications to treat ADHD looks like it's not protective in terms of later life development of addiction. And in my practice, and of course, my practice is an addiction practice, so, you know, it comes with some inherent bias there, but in my practice, what I see is individuals who are exposed to stimulants to treat their ADHD and then become addicted to those stimulants. So that's obviously not going to be, you know, everybody who gets stimulants for ADHD. But again, if you're exposed to a drug, if that drug then changes your brain, it may

• 1:17:29Speaker 04

  change your brain in a way that actually makes you more vulnerable.

• 1:17:31Shankar Vedantam?

  Many listeners voiced concerns about kids and the amount of time they spend on cell phones and other devices. We received this question from Giselle in Chicago, Illinois.

• 1:17:43Speaker 04

  I work at a high school, and it's by far the biggest challenge I encounter. Kids cannot stay off their phone for more than five minutes at a time, despite all the rules and policies we have about putting phones away and constant reminders. Kids just cannot get off it, and the addiction is real. And I worry that we're not, as an institution, not addressing it as the serious addiction it is. I worry about kids' mental health, and I worry about them also not learning, because they can't focus for more than

• 1:18:16Shankar Vedantam?

  Five, 10 minutes at a time. What do you recommend or what solution should we do at the high school level to keep kids off their phones? Thanks. What do you think, Anna?

• 1:18:26Speaker 04

  Well, this is a very dire concern of mine as well, especially because I feel like there is a pretty good solution for it, which is to say, I believe that schools from elementary to middle school to high school should have top-down policies where phones are not allowed during school hours. And this top-down policy means that everybody has to be off of their phone. You eliminate the problem of FOMO or fear of missing out, which is a big driver of what gets kids, you know, going back online, in addition to the fact that these devices are just inherently highly reinforcing and addictive.

• 1:19:09Speaker 04

  But when you have these top-down policies, it's a relief for kids. Everybody's off their phone. They have to be. It's the rule. And there are some really clever things that schools, some schools are doing now. For example, there are these pouches that in some schools, kids, when they come to school in the morning, they put their device in the pouch. The pouch is sealed or locked, and the kid keeps their phone with them, but they can't, you know, receive or transmit during the school day. And at the end of the school day, the device is unlocked and kids can have their phones back and go back on their phones. And schools that are doing this are reporting that schools are noisy again. Why are they noisy?

• 1:19:51Speaker 04

  Because kids are interacting with each other. There's also, it was a private school in Massachusetts, the Buxton School, that took phones away from their private high school students, and they noticed huge improvements in psychological and emotional well-being. And I just think this is just... Both hopeful and also completely tragic that we are not on mass, you know, making this just standard policy for primary schools all the way up through 12th grade. It's not fair to kids. It's not fair to teachers. It's not fair to anybody that these incredibly compelling devices,

• 1:20:36Speaker 04

  you know, create the kinds of environments that make it really difficult for folks to learn. And of course, you know, we're not going to throw the baby out with the bathwater. There are a lot of great things about smartphones and about this kind of connectivity. But gosh, like, let's get a healthier relationship with the technology.

• 1:20:56Shankar Vedantam?

  In some ways, I think this echoes something that you told me when we talked first, Anna, which is that even though addictions are a problem that individuals face, there are times when individuals can't be held responsible for fixing those addictions. Some of those addictions need to be fixed at the structural level, at the level of institutions, at the level of society.

• 1:21:16Speaker 04

  Absolutely. I mean, let's just take alcohol as an example. The majority of people who drink alcohol are not going to go on to become addicted to alcohol. But about 10 to 15% of individuals will at some point in their lives develop an alcohol use disorder. Those are people who just innately have increased vulnerability to the problem of alcohol addiction. Hence, we've recognized as a society that alcohol can do harms. And we've made rules and regulations around how alcohol can be consumed, how it can be sold, how it can be marketed. Especially, we're looking out for children. Children can't buy alcohol until a certain age. Alcohol can't be marketed in a certain way.

• 1:22:00Speaker 04

  These are the types of things that we need to employ, the types of interventions and policies. And just plain old thought process we need to employ when we're thinking about digital devices and digital media.

• 1:22:16Shankar Vedantam?

  When we come back, the paradox of becoming addicted to things that are healthy. You're listening to Hidden Brain. I'm Shankar Vedantam.

• 1:22:41Speaker 06

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• 1:24:10Shankar Vedantam?

  This is Hidden Brain. I'm Shankar Vedantam. Today, we're discussing pain and pleasure with psychiatrist Anna Lembke. Anna is answering your questions about addiction and the most effective ways to treat various forms of it. Anna, many listeners pointed out that addictions to things that are healthy can also be problematic. So, being addicted to food or exercise is not the same thing as an addiction to cocaine or heroin, because food and exercise are in fact good for us. But a listener named Nancy said, "I would like the topic of exercise addiction to be explored. I've had this addiction for most of my life. I'm 65, and I'm sure I'm not alone. It's both a blessing and a curse to feel the need to exercise every day."

• 1:24:55Shankar Vedantam?

  We also received a question from a listener named Kendall in Pennsylvania.

• 1:24:58Speaker 04

  If I'm honest, I find all eating experiences compelling, regardless of the type of food. So, how can I recover from food addiction if I need to eat to be a person and live? I'm just doubtful that after 30 years, I can find balance in my mind and find a part of my mind I can trust.

• 1:25:37Shankar Vedantam?

  What do you think, Anna? In some ways, I think the listener is on to something, which is when you're addicted to something that is also, for the most part, healthy, it creates a very complicated situation.

• 1:25:47Speaker 04

  Yeah, that was a really touching call. The way that I heard it is that she was pushing back directly on this idea of dopamine fasting or cutting out, you know, the particular substance or behavior that's problematic. And what I heard her saying is that all food is problematic for me. It's not a matter of cutting out, you know, cupcakes and cookies and potato chips. Even if you gave me a salad, I have the potential to binge eat on salad. So, that I think is a really important point.

• 1:26:25Speaker 04

  That when it comes to something like food, and I think food can be easily analogized also to the technology that's so embedded in our lives, there is on some level not a way to dopamine fast from something that we need in order to survive or to make our way through modern life, and making it just way, way more difficult to get a handle on those kinds of unhealthy consumptive behaviors. You can basically binge on anything now. I personally think, and my professional experience speaks to this, that's where getting help from others, especially from other individuals struggling with the same problem,

• 1:27:06Speaker 04

  either through 12-step peer support, like Food Addicts Anonymous or Overeaters Anonymous, or other forms of support from people who are struggling with the same or similar problem, even if it's not 12-step. Connecting with others around regulation of our consumptive behaviors is hugely helpful, or has the potential to be hugely helpful. This is a kind of co-regulation that we can engage in, first by being radically honest about the problem with others, recognizing we're not alone, and then in tandem with others and sharing our struggles together,

• 1:27:48Speaker 04

  finding a way to get into balance. I also think that this is where certain psychological techniques can be helpful. Mindfulness is often talked about, and there's a sort of a mindful eating movement. It's interesting, because the mindful eating movement folks, I think, on some level, push back on any kind of restrictions, because their argument is that restricting any food group leads or contributes to the cycle of sort of abstinence, restricting, and then binging, and then starting all over again. And I think that there is

• 1:28:31Speaker 04

  some truth to that, except that what I would say is that... I think it's really important to recognize that our orientation with food is potentially an addiction because we've drugified our food supply and made it so much more reinforcing. So that cutting out addictive foods can really help with this cycle. And that speaks to also just your, the question or comment more broadly about how healthy behaviors have become addicted. And I think that's really the central point here, that things that really we do think of as healthy, like reading, like playing chess, like eating food,

• 1:29:11Speaker 04

  like having sex. We live in a world now in which the technology has turned these otherwise healthy behaviors into something that is potentially addictive for certain vulnerable individuals. And so reconceptualizing our consumptive behaviors around that knowledge, I think can be helpful if we can identify, you know, ways to, to de-drugify those behaviors and substances.

• 1:29:43Shankar Vedantam?

  One question that many listeners asked has to do with how to avoid swapping one addiction for another. We received this question from listener Amritha.

• 1:29:52Speaker 03

  How do I prevent one addiction from replacing another one as I wean myself off of the first one? Do I need to be constantly on the lookout for these kind of behaviors and go through routines of dopamine starvation for the rest of my life?

• 1:30:09Shankar Vedantam?

  What do you think, Anna?

• 1:30:11Speaker 04

  Yeah, so this phenomenon of switching one addiction for another is very well-known. It's sometimes referred to as cross addiction. There are lots of animal studies showing that an animal who gets addicted to one drug will more easily get addicted to another drug when that first drug is made unavailable. So, or even if the first drug isn't made unavailable, like, once we've become addicted, we sort of are primed then for that, that kind of behavior, or we can be primed for that kind of behavior. So, my answer to this caller would be, the first step is just being aware of the problem of cross addiction. In clinical work, what we say to patients is something like, well, now, you're going to try to give up cannabis for this month.

• 1:30:54Speaker 04

  Be really careful that you don't now increase consumption of sugary foods, which you've also talked about as something that's reinforcing for you. So, just sort of openly talking about it and acknowledging it. And then again, I think psychological and spiritual practices around learning to sit with the craving and the urges, to recognize the tendency to want to switch that urge from one reinforcer to another. I, I do think it's really fascinating the way in which we organize time in the modern world around our rewards. So, our entire day, for many of us, including myself, on some level, is structured around this idea of, well, when, when am I going to be done with this thing that I don't want

• 1:31:38Speaker 04

  to be doing, so that I can do the thing that I want to be doing? It's just the way we live now. So, a couple of things that I think are really helpful here is to just recognize that our desire is infinite, and that on some level, we will never be satisfied, no matter how much of those good rewards we get. And then just sort of learning to sit with that. Sometimes I also think that in certain thought experiments, like, imagine going through your whole day and not rewarding yourself with any of your usual rewards. And what I find that does, when, when I engage in that thought experiment, is that it really allows me to be much more present in the moment, because I'm not in the moment, looking

• 1:32:22Speaker 04

  forward to the moment when I'm going to get my reward.

• 1:32:26Shankar Vedantam?

  Some listeners have asked a question. If I notice that I'm heading down a path that looks like it's on a path to addiction, how do I break this cycle? Here's a question we received from a listener named Andrea. Hi, Anna. I'm getting married next year, and looking for wedding dresses online has become online shopping for all sorts of things really quickly. I can see it happening, but... I wanted to ask you, how do you hit stop? How do you make your brain stop doing this? Or how do you work with your brain to stop doing this? When you're catching it early? Thank you so much. What do you think, Anna? When you feel like you're on the road to someplace bad, is there something you can do to nudge yourself in a more positive direction?

• 1:33:12Speaker 04

  Yeah, I think there's a lot you can do. First of all, I think just being open about it, like Andrea has done, and naming it can be really helpful. It can bring it into our awareness in a new way that it's not necessarily going to be if it's just sort of pinging around in the dark recesses of our minds. So, you know, I applaud her for being open about it. But for other listeners, you know, you can tell somebody else what behavior you're engaging in. And again, I'll just say that even if we kind of know that we're doing that behavior, it's often not until we've said it out loud to another human being that it becomes really real to us. And then, once it's become real to us, we kind of can't unsee it.

• 1:33:56Speaker 04

  And then that allow, that awareness allows us then to begin to create the motivation to want to change the behavior. In fact, it may be true that the dopamine fasting project is best suited for individuals who are not yet fully addicted, but who notice that they're on their way to addiction. So, you know, then with intention, setting a specific quit date for when you're going to give up that substance or behavior, getting that substance or access to that behavior out of the house, or creating other self-binding strategies to sort of limit consumption or make it harder to get access. Those are all things you can plan and do in advance.

• 1:34:39Speaker 04

  Tell people you're going to be dopamine fasting. Do it with somebody else. And then really commit to it and frame it not as deprivation, but as an opportunity to really do something positive and healthy for yourself.

• 1:34:54Shankar Vedantam?

  You know, we talked earlier in the conversation, Anna, about how, you know, the term addiction can get used as a form of name-calling, where we're just describing people whom we don't like, or activities we don't like. We brand them as addictions. But we also talked about how people who have addictions often don't have the insight to know that they are on the road to addiction. And a few listeners have asked the question, what if I can see someone in my life, a friend, a family member, a coworker, heading down a path that looks like it's an unhealthy path? How do I bring that up? How do I launch that very difficult conversation to have the person say, do I have a problem?

• 1:35:32Speaker 04

  Hmm, yeah. So I get this question all the time. And of course, every situation is unique, so it's difficult to give a one-size-fits-all answer. But I think the place we can always start is with compassion and empathy, and just expressing to the person that we care about that we'd like to talk with them about something that's difficult to talk about, but it's coming from a place of love, which is just very simply our concern for that individual, given certain behaviors that we've observed. So in a time when you are calm, and your loved one is calm, and not in a time when you're in a state of anxious dysregulation as a parent, or a spouse, or a friend, and

• 1:36:15Speaker 04

  not a time when they're using, so some other time than that, approach your loved one and say, hey, I'd like to share something with you that I've been observing that makes me concerned for you, and I want to share it because I really love you and care about you. And then after sharing it in a brief way, don't say more. Just be quiet and let them hear and process that. And they may not want to discuss further, and that's okay. If they do want to discuss further, the key there is to not keep repeating what you've said once before, again and again, especially not repeating it more emphatically, but to just then listen and ask questions and be curious.

• 1:36:58Speaker 04

  And of course, this is a simulation of what we do in the early stages of psychotherapy. We're just Compassionate and we're curious. And one of my colleagues kind of likened it to being a journalist. Just imagine that you're a journalist trying to get the story. And so you would ask a lot of questions about what that person's subjective experience is like. And again, this is potentially very therapeutic for people because when we say out loud what we're doing, how much, how often, why, et cetera, et cetera, we see it for the first time. And I cannot emphasize it enough, of the ways in which we only become aware of certain types of behaviors when we put them into narrative form and express them with another

• 1:37:42Speaker 04

  human being.

• 1:37:49Shankar Vedantam?

  Anna Lembke is a psychiatrist and researcher in the behavioral sciences at Stanford University. She's the author of Dopamine Nation: Finding Balance in the Age of Indulgence. Anna Lembke, thank you so much for joining me today on Hidden Brain.

• 1:38:03Speaker 04

  Oh, you're welcome. I'm just overjoyed that people want to learn about this.

• 1:38:17Shankar Vedantam?

  Hidden Brain is produced by Hidden Brain Media. Our audio production team includes Annie Murphy-Paul, Kristin Wong, Laura Kwerel, Ryan Katz, Autumn Barnes, Andrew Chadwick, and Nick Woodbury. Tara Boyle is our executive producer. I'm Hidden Brain's executive editor. If you found this episode to be insightful or useful, please share it with one or two people in your life. Your word-of-mouth recommendations play a big role in helping us to connect new listeners with the ideas we explore on the show. I'm Shankar Vedantam. See you soon.

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