“Dopamine Nation” author Anna Lembke explores the link between pleasure and pain: Shots



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Artificial intelligence brain by particle shape.

Yuichiro Chino / Getty Images

Human beings are programmed to approach pleasure and avoid pain. It’s an instinct that dates back millions of years to a time when people had to actively seek food, clothing, and shelter every day, or risk death.

But psychiatrist Anna Lembke says that in today’s world, those basic needs are often readily available, which changes the equation.

“Living in these modern times is very difficult. … We must now face: how can I live in a world where everything is provided? Lembke said. “And if I consume too much – which my reflexes force me to do – I’m going to be even more unhappy.”

Lembke is the medical director of addiction medicine at Stanford University and head of the Stanford Addiction Medicine Dual Diagnosis Clinic. His new book, Dopamine Nation, explores the interconnection of pleasure and pain in the brain and helps explain addictive behaviors – not only to drugs and alcohol, but also to food, sex and smartphones.

Lembke says his addiction patients often believe their addictions are fueled by depression, anxiety and insomnia. But she maintains that the reverse is often true: addictions can become the cause of the pain – not the relief of it. This is because the behavior triggers, among other things, an initial response from the neurotransmitter dopamine, which floods the brain with pleasure. But once the dopamine wears off, a person often feels worse than before.

“They start using the drug to feel good or to feel less pain,” Lembke explains. “Over time, with repeated exposure, this drug works less and less well. But they find themselves unable to stop, because when they do not use, then they are in a state of dopamine deficiency.”

Interview highlights

Dopamine Nation: Finding Balance in the Age of Indulgence, by Anna Lembke
Dopamine Nation: Finding Balance in the Age of Indulgence, by Anna Lembke

On the role of dopamine in addiction

Dopamine is a neurotransmitter that sends signals from one neuron to another, and it’s probably the most important neurotransmitter in our experience of pleasure, motivation, and reward. … Dopamine is the final common pathway for all pleasurable, intoxicating and fulfilling experiences. …

[An] An experiment was carried out on rats, for example, by placing a probe in their brains, measuring the amount of dopamine released in response to different types of substances. Now remember, we all have a basic dopamine release that’s kind of still there. And then when we ingest certain substances or engage in certain behaviors, our dopamine increases or decreases in response to that substance or behavior. So, for example, chocolate increases dopamine above baseline by about 50%. Gender is around 100%. Nicotine is around 150%. And amphetamines are around 1000%.

On how pleasure and pain processing overlap in the brain

One of the most fascinating discoveries in neuroscience over the past 75 years is that the same areas of the brain that process pleasure also process pain, and both pleasure and pain function as a balance. So if you imagine that in your brain there is a seesaw, like something you would find in a children’s play area, and when that seesaw is at its resting base, it is at ground level. When we do something enjoyable – for example, when I eat a piece of chocolate – then my pleasure / pain balance tips a bit towards the pleasure side, and I feel a release of dopamine in my brain’s reward pathway.

But one of the guiding principles governing this balance is that it wants to stay level, which neuroscientists call homeostasis. He doesn’t want to be sidetracked for very long, whether it’s pleasure or pain. So when I eat a piece of chocolate, my brain will immediately adjust to the presence of this pleasant stimulus by tilting my scale an equal and opposite amount on the pain side. And it’s the aftermath or the descent or, in my case, this moment of wanting a second piece of chocolate. Now, if I wait long enough, that feeling goes away – and homeostasis is restored.

On the way down – when the pleasure quickly turns to pain or discomfort

When this pleasure / pain balance tilts toward pain after experiencing pleasure, that pain is subjectively experienced as a number of different things. One of [them] is a subjective feeling of being uncomfortable, restless, irritable, unhappy and wanting to recreate the feeling of pleasure. But that’s also in many ways what desire is: wanting to have fun, again, worrying about eliminating the experience of pain that we feel as a result. And I will also say that it is very reflective. It’s not like I’m even consciously aware of this sequel or the descent. It can be very subtle, but I’m just somehow aware that I want to have another piece of chocolate.

On poverty as a risk factor for addiction

If you look at all these different risk factors for addiction, [they] include poverty, unemployment, multigenerational trauma. They are therefore a priori risk factors for addiction. And then you layer on that easy access to cheap rewards that themselves reinforce [and] what you find is that in the United States the people most vulnerable to drug addiction are the socioeconomically disadvantaged people because not only do they live in poverty but they also have access to good drugs. market that do good.

On whether we can be addicted to social media and our phones

It’s important to recognize that addiction is a spectrum disorder, and it is possible to be a little addicted. In addition, the same brain mechanisms that go into severe addiction are also at the root of our minor addictions. … I think no one is immune from this problem. And I believe smartphones are addictive. They were designed to be addictive and … we don’t really need more studies to show this to be true. All you have to do is go outside and take a look around.

How the pandemic affected various addictions

I think it’s important for me to tell you that I also had a lot of patients who did better during their 40s. And what they tell me is that the world is kind of a hyperstimulated place, a trigger for them. And the quarantine forced them to slow down and also eliminated many types of interactions and stimuli that would typically trigger relapse or reuse for them. So I would say I’ve seen some sort of bimodal distribution in terms of the COVID response in my patient population. Again, for some people this has been absolutely terrible. Of course, we’ve seen a slight increase in overdose-related deaths, including some of my own patients. And it is absolutely tragic. … I’ve also seen more people spend more time on their screens and really struggle and wonder how to deal with compulsive overuse of their digital devices. But again, I think it’s important to say that some patients are doing a lot, a lot better – found it easier not to drink alcohol, for example, because there aren’t that many parties where the people consume large amounts of alcohol. It’s an interesting mix.

Sam Briger and Kayla Lattimore produced and edited the audio for this interview. Bridget Bentz, Molly Seavy-Nesper, and Deborah Franklin adapted it for the web.


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