Understanding of the neurotransmitter dopamine has suffered from a shallow comprehension. We’ve understood it in the context of getting a “dopamine hit” for taking part in rewarding behavior. In her new book, Dopamine Nation, Dr. Anna Lembke offers new information deepening our understanding of the nuanced functioning of dopamine. This deepening understanding reveals that dopamine functions as far more than a simple reward hit. It directs, programs, reinforces, punishes us in its withholding, and more. The impact has an undeniable influence on our daily lives.
For many of us, dopamine has either directly or indirectly impacted us in the form of addiction. In other instances, it impacts our attention, the ability to be productive, and even depression and anxiety.
The book is fairly short but poignant in its simplicity and the vivid stories Lembke uses to illustrate her ideas.
More, More, More!
In our capitalist society, we are socialized to consume. For businesses to be successful, they must achieve eternal growth. Our dopamine system which causes us to seek, the desire to procure, possess, and experience, is bated by advertisements, social media algorithms, and desire for more and more.
Lembke begins with a colorful story of one of her patients addicted to masturbation. Her patient reports beginning masturbation at a very early age. He built a machine out of a record player, a coil, and a soft cloth. He would bring himself to the brink of orgasm for hours at a time. It was the seeking of the sensation that truly made it addictive. The seeking, the taking to the brink, the desire for experience is caused by the dopamine released in our brains.
Though this is a stark example, it illustrates that many of us are subject to what Lembke refers to as our own “masturbation machines.” Addiction often arises in how we perceive and receive dopamine. At the same time, the initial dopaminergic sensation of excitement, exhilaration, and drive towards the “brink” will never be felt as strongly as in the initial instance. So the resulting reaction for most of us is to escalate the intensity of the behaviors that lead towards the goal. The behavior that drives us to the act is often the most destructive part of the addiction. The goal once accomplished, is often only a side note. Dopamine ceases being released once the goal is achieved. And so, we drink more and more, take more and more of the drug, take part in more and more extreme behavior that provided the initial sensation caused by the dopamine release.
Death from all addiction has risen since 1990, especially in those younger than fifty. Poor and uneducated are the most susceptible to addiction, with easy access to high-reward, high-potency, high-novelty drugs. Dr. Lembke also equates lack of meaningful work and life experience to this prevalence. White, middle-class members of our society without a college degree are dying younger than the generations before them due to drug overdoses, alcohol-related liver diseases, and suicide. Lembke posits that this is due to our unprecedented pursuit of pleasure, which inevitably leads to pain.
Lembke puts forth that our culture is obsessed with achieving pleasure. She points to the prevalence of the happiness, self-improvement, and wellness industry as evidence. Modern childhood is often a sheltering of the child, whereas children are taught to avoid pain, both emotionally and physically. This may potentially be the reason that one in four adults in the US takes a psychiatric drug for the purpose of avoiding mental or emotional pain. Opioids have become the solution for physical pain. And of course, psychiatric drugs, opioids, and other drugs have their addictive properties closely related to the functioning of dopamine in the brain.
In one story from the book, Lembke describes one of her younger patient’s predilection to be constantly plugged into a “device” (IE iPhone, iPad, etc). She exhibited addictive behavior around the use of these devices. She also suffered from anxiety and depression. Lembke suggested she walk to class without listing to music or being connected to any other device. Instead of distracting herself from her thoughts, feelings, and perceptions, to just pay attention to how she was feeling, how she was connecting to the world, and how her reality was unfolding around her. The patient was initially reluctant, reporting that she feared boredom. Lembke suggested this might be good as the case of boredom might bring the opportunity to provide new possibilities and awareness. The client gave in and was able to experience this boredom as a way of mental regeneration. The result was a decrease in her symptoms.
Pleasure is often an attempt to distract ourselves from ourselves. The more pleasure we seek out, the more likely we are to be avoiding pain. This appears to only have a negative effect on our well-being. Research suggests that people in almost all areas of the world are less happy than in 2008. Richer countries have a far higher likelihood to report lower levels of well-being than poorer countries. A similar trend is seen in physical pain. Lembke attributes this to our extreme efforts at not being miserable.
Hedonism, the pursuit of pleasure for its own sake, often leads to anhedonia – the inability to experience pleasure of any kind.
We are gaining a better understanding of a balance seeming to exist between pleasure and pain. Though there are other neurochemicals involved in our reward circuitry, dopamine is the most well-known. Dopamine is used to measure the potential of addiction in any substance or behavior. The more dopamine released, the more addictive the activity. Chocolate increases dopamine release by 55%, sex by 100%, and cocaine by 225%. Amphetamines increase dopamine release by 1000%.
Scientists are beginning to understand that pleasure and pain work in an opponent process mechanism, a balance. Our bodies want to preserve this balance. In a process called neuroadaptation, the more exposure to a pleasure stimulus, the more our pain response increases.
With opioids, this mechanism is often key in driving the addiction. Those who take opioids to reduce pain found that after time and increases in medications amounts, their pain continued to increase. The brain reset their pain and pleasure balance to lean heavier on the pain side. This is referred to opioid-induced hyperalgesia.
Dr. Lembke refers to a client she once had. Her client smoked cannabis every day, all day to circumvent anxiety and depression symptoms. Lembke suggested that many of the drugs that could be considered to address her issues would be ineffective due to the use of cannabis. She suggested, as an experiment, her client take one month off from using cannabis in any form. The patient, eventually convinced, found that many of her symptoms had subsided. Lembke believes this is due to return to homeostasis, or the restoring the balance between pain and pleasure.
Dr. Lembke provides that the best way to achieve this return to balance is by dopamine fasting. Her recommendation is to find insight by taking four weeks off of the behavior or activity that is causing friction in life. This is called abstinence or abstaining from the activity.
When behaviors are extremely addictive, and willpower is not effective, relapse may become the norm. Dr. Lembke suggests self-binding. Self-binding is removing the ability to take part in the activity in question by means of space, time, and/or meaning. For example, if you have a gambling addiction, call local casinos and put yourself on the “no entry permitted” list. This example uses the space-oriented self-binding method. To avoid being triggered to gamble, you may use categorical binding. This means that you would not watch any kind of sport or event for which you could gamble, for example. No football, baseball, or horse races – categories of potential gambling events.
In less severe cases, we can limit consuming alcohol to only on weekends, holidays, or special occasions. This is time-oriented self-binding.
In the exploration of balance, Lembke points to the possibility that psychotropic drugs may make the symptoms they are designed to treat worse in the long run. For example, there is growing evidence that ADHD medications are associated with deteriorating academic performance and social relationship quality.
Relatedly, depression medication may relieve the symptoms of depression, but the patient may not be able to feel any deep emotions. The resulting question becomes, what does it cost to relieve these painful symptoms and is it worth it?
Lembke describes the experience of another client who was rich, handsome, and successful. He was overcoming cocaine addiction. The issue wasn’t relapse but a subtle depression where he just couldn’t get back his old zest, as he was known for his energy. He stumbled upon ice baths as a cure. The thought is that this interaction with pain – or as Lembke calls it “pushing on the pain side” – helps bring the equation back into balance by increasing the capacity to experience pleasure in the future.
After reading the book, I have a much better grasp of how to manage dopamine. The “seeking” neurotransmitter has evolved as a survival mechanism to drive us towards behaviors. It is so powerful that the seeking of the sensation of seeking is really what we’re discussing. I think there is some merit to the unfitness of this evolutionary trait in our current society and culture. This is especially true where dopamine drives addictive behaviors. But the meta-theme of the book appears to be that we have the knowledge to better manage our “human-ness” and so we should put this knowledge to good use.
Additionally, it is interesting that our pursuit of pleasure and consequent avoidance of pain may have some causal role in the rise of anxiety, depression, and other mental health issues. It makes sense this may also be true for physical pain in the case of fibromyalgia, for example. However, the sensitivities and lack of research around these ideas make it controversial.
Perhaps my favorite idea from the book is that the avoidance of pain will actually cause pain. Avoiding physical, mental, or emotional pain often exacerbates pain in the form of anxiety or depression. The fear of emotional pain, for example, is often associated with anxiety. And so it is best to embrace pain as a necessary and meaningful part of life.
In sum, the book is very relatable and relevant to our everyday lives. The benefit of reading these types of books that use the therapeutic setting to tell personal stories that illustrate the research being presented in the books makes it extremely digestible and easy to grasp.
- Dr Lembke, A., 2021. Dopamine Nation: Finding Balance in the Age of Indulgence. Dutton Books.