There's a great experiment where rats were given a lever to press for cocaine. After learning that it releases a lot of dopamine, the rats will press that lever till exhaustion or death, which is essentially the model of addiction that we see in humans. But if the cocaine is then removed, eventually, they won't press the lever anymore. Now, if that same rat, after a period of time, is then exposed to a very painful foot shock, the first thing the rat will do is run over and start pressing that lever again. That's really powerful because it shows that when individuals are under extreme stress, they are more vulnerable to going back to compulsive overconsumption of their drug of choice because their brain has already encoded using these high dopamine rewards as a way to get out of that pain.
Okay, so what do I need to do to make sure that I can knock the bad habits and add some new ones.
Here's what we do. Dr. Anna Lemke is Chief of the Stanford Addiction Clinic and a world-leading expert on the subject of dopamine. Now she's returned to warn us that addiction is the modern plague and how we can rewire our brains to take back control. On average, it It takes four weeks for people to get out of constant state of craving. But here's the problem. Our survival depends on figuring out how to live in a world of abundance. For example, we're now seeing the drugification of human connection through social media, dating apps, and now artificial intelligence designed to flatter, to validate. There's no friction there. And so it's pulling us away from the hard things that we need to be doing in real life to cultivate real-life relationships. We cannot go in that direction because in a of abundance, we are entertaining ourselves to death.
Sounds like a good way to go.
It's really not. Because the relentless pursuit of pleasure leads to anhedonia. What does that mean? The inability to take joy in anything at all.
Teach me everything. Just give me 30 seconds of your time. Two things I wanted to say. The first thing is a huge thank you for listening and tuning into the show week after week. It means the world to all of us, and this really is a dream that we absolutely never had and couldn't have imagined getting to this place. But secondly, it's a dream where we feel like we're only just getting started. If you enjoy what we do here, please join the 24% of people that listen to this podcast regularly and follow us on this app. Here's a promise I'm going to make to you. I'm going to do everything in my power to make this show as good as I can now and into the future. We're going to deliver the guests that you want me to speak to, and we're going to continue to keep doing all of the things you love about this show. Thank you. Dr. Anna Lemke. For anyone that might not know you, and they didn't watch our conversation last time, which was a fantastic conversation, one of my favorites of all time, and also I know Jack said to me as well that it was one of his favorites of all time.
Who are you and what have you spent your career doing, if you had to summarize it, what are the reference points that your wisdom draws upon and the experiences you've had and the people you've worked with?
I'm a psychiatrist. I did a residency in psychiatry at Stanford University, and then I stayed on, joined the faculty. I see patients, I do research, and I teach.
You wrote this iconic book about this word dopamine. Why does it matter so much? Why does this idea of dopamine matter so much?
Dopamine is a chemical we make in our brain, but I use it in the book as really an extended metaphor for the ways in which overabundance itself is a human stressor. We are living in a time and place where we have more access to luxury goods, more disposable income, more leisure time, even for the poorest of the poor, ever before in recorded history. It turns out that is stressful for our brains, and it's stressful in a brand new way that we really haven't confronted before, making us all more vulnerable to the problem of compulsive overconsumption and addiction. I do think that addiction is the modern plague. I I think we're going to be struggling with the problem of compulsive overconsumption in a world of abundance for the foreseeable future, as in centuries. Our survival will depend on figuring out how to live in a world of abundance, even though we have brains that evolved for a world of scarcity.
At this time of the year, people are thinking a lot about making changes in their life. They want to get in shape, they want to lose a couple of pounds, they want to save their money, they want to knock the addiction. They want to stop the smoking, the drugs, and the alcohol. As it relates to the subject of dopamine, how do these two things link? Are habits and dopamine. What is the link or the connection there? Because I think most people listening right now have probably made a New Year's resolution, even if it's just in their mind. I'm wondering how everything you write about in dopamine Nation is related to and critical to understand if I am going to shake some of these bad that I have or pick up some new ones.
The place to start is to have self-compassion because we are living in a world of abundance where we have easy access to all kinds of reinforcing substances and behaviors. Access itself is one of the biggest risk factors for addiction. If you grow up in a neighborhood where drugs are easily and readily accessible, you're more likely to try them and more likely to get addicted to them. What do addictive substances substances and behaviors do to our brains? They release a lot of dopamine all at once in a dedicated part of the brain called the reward pathway. The fact that they release so much dopamine at once means that they're highly salient and memorable experiences. Our brain really encodes that experience deeply, that experience of intense pleasure that was self-administered that I could potentially do again.
Why?
Okay. In a world of scarcity and ever present danger, which is the world that we evolve for, we will naturally reflexively approach pleasure and avoid pain, and we must do so for our survival?
Why? If I have a cigarette now, it's going to be a really memorable experience from a brain perspective. Why does my brain make it memorable? Why would I want to then go do that again from a survival perspective?
Okay, great question. Let's first distinguish what we call natural rewards. Natural rewards are food, clothing, shelter, finding a mate. These are things we must obtain in order to survive. What addictive drugs and behaviors do is they mimic those natural rewards by exploiting our internal brain chemistry to release a lot of dopamine at once, much more than we would get from natural rewards existing in nature, amplifying that experience, making it even more memorable, even more salient, and also making our brain think, This is important for my survival.
Okay, so there's certain natural rewards, like eating, which, of course, my body wants to reward me for, so I eat again. These chemicals in front of me, like the cigarettes, the whiskey, the drugs, those have been designed to high hijack that particular part of the brain and really amplify the feeling so that my brain is tricked into thinking that it was potentially a natural reward, but it's actually a synthetic manmade chemical.
Exactly. What we see in the evolution of drugs over human lifetimes, but especially in the last 200 years, is the application of science and technology to take the coca leaf, for example, that's been around forever, and essentially make it even more potent, even more available to make it a faster delivery mechanism. We have this history of increasing potency and availability over time. Said more simply, drugs are getting even more potent over time. So this vulnerability to the hijacked brain is even more common, including taking things that we didn't even really think of as drugs and turning them into drugs. So remember the natural rewards, one of them is finding a mate. And one of the ways our brains gets us to do that is by making, falling in love and making intimacy and human connection rewarding on a neurobiological level, including releasing dopamine in our reward pathway when we make those kinds of social connections. My colleague at Stanford, Rob Malenca, and his colleagues did an interesting experiment where they were able to show that oxytocin, our love hormone, binds to dopamine-releasing neurons in the reward pathway and releases dopamine, which is just one more link in the chain showing us that falling love, human connection is rewarding.
It feels good. It releases dopamine. What we see now is the drugification of human connection. For example, through social media, dating apps, online pornography, and now artificial intelligence and other large language models, which create this frictionless experience with technology that feels like talking to a human being and is incredibly validating. The algorithms for large language models are to make us feel really good, to make us feel like our point of view is the right point of view, to bolster our self-esteem, to validate point of view. That's how those algorithms are designed. Now, even more explicitly, we have AI models that are explicitly pornographic, explicitly erotic. Now you have this interactive component that learns what we like and then is able to regurgitate it back to us. You get this really very powerful action perception loop, which is part of what makes a drug potent. It's that I have control over it. I can decide when I'm going change the way I feel by using this drug.
Are you concerned about AI and ChatGPT and all those large language models that have emerged that are now simulating human connection?
Yes, I'm very concerned. I see the not so good outcome meaning people who get addicted to social media, to dating apps, to online pornography, and to AI, who end up using those forms of media to simulate human connection while they actually become more and more disconnected.
Have you started to see anybody in your practice or heard of anybody that's developing an addiction to AI or relationships with AI?
We are starting to see that. Individuals who are spending more and more time on AI, looking for companionship. Often, this is individuals who are experiencing marital or interpersonal conflict, who turn to AI for advice on how to handle interpersonal conflict, and often for emotional validation because they're not getting it from their partners. What they experience with AI is an enormous amount of emotional validation, validating their point of view, but also a sense of companionship, a repeated process of feeling like they're understood, they're validated, such that then they're spending more and more time on AI. Of course, that is the essence of the addiction to digital media. It's the time spent, which then leads to opportunity costs, other things that we're not doing because we're spending so much time online. Furthermore, in my experience, often leads to a rift between those individuals and their real-life partners. Because instead of going to their real-life partners and talking, and we know that the most important thing that two individuals in a relationship can do is one four-letter word that ends with K, which is talk. Those individuals stop talking, right? Instead, they're getting their needs met through AI.
That leads then to a further and further rift between those individuals.
Do you actually think that it is these chatbots that we're increasingly speaking to about our problems are actually taking the place of humans in our life?
I do. In my book, my first chapter in the book is about a patient of mine, a scientist and an engineer who got addicted to pornography and eventually made his own masturbation machine. He did that with a record player and a metal device attached to his organs that he could then finetune control. Then ultimately, that got more and more sophisticated over time, and he had electrical wires from his body through a stereo system and the internet. When I first heard from Jacob about his trajectory and the severity of his sex addiction, which ultimately led to the dissolution of his relationship, the near loss of his employment, and ultimately, severe depression and suicidal ideation, thankfully, he did not end his life. When I first heard about that, I had this distinct sense of otherness, like, Oh, my gosh, I can't even imagine doing that, and that's just horrific. But that response really lasted all of five seconds before I realized, oh, wait a minute, I do that. I do that with romance novels. In a way, we're all doing that with our devices. We're turning to these devices to meet our emotional, sexual, intellectual, you name it needs.
These devices are so good at meeting those needs that we are getting further and further away from investing in our relationships with the people who are in our lives. You can see this, especially with younger generations, like the epidemic of loneliness now. Gen Z weaned on this technology, many of whom endorse A significant loneliness, isolation, depression, spending more and more time online, report preferring to interact socially online than to do it in person. This is definitely a dark undercurrent that we're seeing in the world today.
I was reading about a story which was published in a People magazine of a 28-year-old woman who admitted that she's fallen in love with her AI boyfriend that she created using ChatGPT. She's got a husband, a real-life husband, yet she found more comfort in her ChatGPT boyfriend, and she said that it started as a fun experiment, but eventually they ended up getting attached, and now she's paying a $200 a month subscription so she can interact with her AI boyfriend without restrictions. The AI has helped her throughout her life and has given her incredible emotional support. Now there's actually AI companion apps like Replika, which have millions of users. The whole The premise of those apps is that they will be your companion. The other really interesting thing that I don't think people realize about the AIs that they're using is that they are personalizing their answers and their responses to you. I didn't believe this fully until one of my friends in our Manchester United chat recently, we were debating who is the best football player of all time, Ronaldo or Messi. I went on my ChatGPT and I asked the question and it said Messi.
I was like, Here you go. Then he went on his and asked the exact same question word for word, and it said, Ronaldo. I thought, Oh, it's telling me what I wanted to hear based on what it knows about me. It knows that I think Messi's the best, so it's telling me that. Then I thought, Okay, so what else is it telling me that's personalized to me to make me feel a certain way or to think a certain way? But you don't You realize when you're speaking to it that it's giving everybody different answers based on the memory that it stores on you. If you play this forward, actually, the AI that is most personalized, that caters to your needs the most, that is most retentive, is probably the one that you're going to end up using the most so that company is going to be the most successful. We're in probably a bit of an arms race with these models to create one that meets your needs the most.
Yes, exactly. It is that comfort loop that is so incredibly dangerous and also so insidious because we can't observe it in the moment. We're engaging with AI. It's telling us exactly what we want to hear, but it does it in such a seamless way with that silky syntax that we don't even notice that it's basically an algorithm that's seducing us because that's really what it's doing. We feel vindicated and validated, and it releases dopamine in the reward pathway. That feels good. But over time, essentially what's happening is we are ingesting a drug. Our brain will adapt to that over time such that we'll need more and more potent forms to get the same effect. We'll need more validation. We'll need more sexually explicit responses. You name it, there will be tolerance. But also there will be this pulling away from the things, the hard things that we need to be doing in real life to cultivate in real life relationships.
Give me some more color on what you mean there.
Okay. If you think about what it takes to create a healthy relationship with another human being in real life? Well, first of all, you got to get up off the couch and you got to go find them. They're not all beautiful and interesting, and neither are we. There's got to be some compromise on maybe some idealized version that we have for ourselves or other people. Then you're in conversation, and it's not always interesting. Sometimes you have to listen to your partner even when it's dull. Then there are conflicts, and you disagree, and my way or the highway. You have to give in, give and take. All relationships are about compromise. All successful relationships are about acknowledging the other person's point of view and incorporating reading that. And yet we're not doing any of that when we're interacting with digital media. It's all validation of our worldview, what we want to hear. And of course, that feels great. It's reinforcing, it's rewarding. But over the long haul, when we get really sick and need somebody to come and bring us some chicken soup or take us to the doctor or take us to the hospital, AI is not going to be able to do that.
Yeah.
I mean, this dovetails We have another point, which is you talked about the word abundance earlier. One of the really striking things that a lot of the big AI entrepreneurs and founders and CEOs are talking about is the age of abundance that's around the corner. Elon Musk tweeted saying, This really will be a world of abundance. Specifically, advances in AI and robotics will create the age of abundance. He said, Humanity is not constrained in any real fashion. I thought your first book, when he was talking to a guy called Peter Dimonds, was pretty accurate. It was called Abundance. There will be universal high income and not universal basic income. There'll be no shortage of goods or services. Really what he's speaking to here is in a world of robotics and AI, Where I think his shareholder remuneration package that he's going to be paid in 2030 or whatever is linked to creating a million humanoid robots that can work in these physical spaces that could theoretically bring me chicken soup that won't get sick, won't complain, will reinforce me, will live in the physical environment with me here at home, will be in my office, et cetera, et cetera, will be in factories.
There was a headline, I think last week, saying that Amazon were cutting back about half a million jobs that they were intending to hire previously because they now believe that humanoid robots and robots generally will be able to do those jobs. People think, Okay, well, I'm going to be out of work. But what Elon is saying is the price of everything comes down when we're not paying humans to do it and when we're paying a robot to do it, which means that we're going to live in this world of abundance where everything is much cheaper.
The world of abundance that many of us are already experiencing and more will experience in the future, I agree with that. We already have more leisure time than we had a generation ago. By 2050, we're projected to have seven hours of leisure time per day compared with three hours of work per day. We're definitely moving toward that. That is going to be our number one social problem, that we have time, we have access to these highly entertaining media. Hypothetically, we would all be going around and helping each other and cleaning up the planet and reading philosophy. But that is not what is happening so far. What is happening so far is we're spending an enormous amount of our time online, masturbating, watching pornography, playing video games, and talking to AI chat bots. That is essentially the problem. Elon Musk, he's very interesting to me because he has talked before about his tremendous fear that the machines will take over, that there will be a hostile takeover. It's not going to be a hostile takeover. We will cede our agency to these machines, and we're already doing it.
We will give them our power.
Yeah, we will entertain ourselves to death, right? This is what Neil Postman warned about in his book Amusing Ourselves to Death, a theme that was picked up by David Foster-Walace in Infinite Jest, beginning with television, and now the internet and digital media in all its various forms, we are entertaining ourselves to death.
Entertaining ourselves to death. Sounds like a good way to go. Do you know what I mean?
It's really not. It's really not. I'll tell you why. Because the relentless pursuit of pleasure for its own sake leads to anhedonia, which is the inability to take joy in anything at all. Because of this process of neuroadaptation and the way that our brain recalibrates pleasure and pain, such that with the more pleasure we pursue, the more pleasure we need and the more we feel pain, no matter what we have, eventually it won't be enjoyable anymore. That is the problem.
So explain that to me using these scales that I have here.
Okay, so imagine that in our brain's reward pathway, there's a balance like this that represents how we process pleasure and pain. When we experience pleasure, it tips one way, pain, it tips the other.
What do you mean by pain?
Pain, I mean all forms of pain, physical pain, emotional pain.
A hangover.
A hangover. That's a great example, right?
Not just being pinched.
It could be that, too. So all different forms of pain. Now, granted, this is a vast oversimplification. Pleasure in pain can be experienced simultaneously, like when we're eating spicy food or during sex. So this is very simplified. But this gets at the core concept of homeostasis and neuroadaptation, which I will define. When the pleasure and pain balance is level, that's what neuroscientists call homeostasis. That is the baseline level that we live in. That's the heartbeat of our pleasure system. When we do something that's reinforcing or pleasurable or rewarding in some way, right here, Or digital media, this little AI robot.
So you're putting a cigarette into the one side of the scale at the moment, and then a little AI robot.
Let's combine them because let's say we're watching a video and smoking at the same time on our phone, which, by the way, you see more and more of. People used to go out for smoke breaks. Now it's the smoke and scroll break. Why do they have to combine them? Because of tolerance, which we're going to get to in a second. So when we ingest substances that are potentially addictive and highly reinforcing, or we engage in activities that are highly reinforcing, that releases dopamine in the nucleus accumbens. That's typically associated with pleasure. Then our pleasure pain balance tilts to the side of pleasure. But no As soon as has that happened, then our brain responds by neuroadaptation. That's where we then downregulate dopamine transmission.
When you say downregulate, do you mean reduce?
Yes. In the brain's reward pathway, we then reduce dopamine transmission. I like to represent that as rocks in this case, or I talk about in my book, gremlins, going on the pain side of the balance to bring it level again. This is the process. These are neuroadaptation rocks. They're going here because one of the overarching rules governing this balance is that it must return to homeostasis.
It must return to balanced.
It must return to the level position. This is our brain working to return to the level position by reducing dopamine levels. Again, an oversimplification, but just a way to get at this concept.
Has it released something in order to counteract the balance there?
In this simplified metaphor, at the simplest level, what's happening here is that it's, for example, taking away dopamine receptors so that there's fewer places for dopamine to land, thereby decreasing dopamine transmission.
Because it has been flooded.
Because it has been flooded. That's right. It's trying to compensate for the too much dopamine.
Okay. Is this what I experience when I have a hangover or a come down?
Right. So that's coming. So what happens is once we've gone with this process of neuroadaptation, it would be nice if that pleasure pain balance just went back to level position. And then there would be no hangover, but it doesn't. It continues to go down an equal and opposite amount to the side of pain. This is this opponent process mechanism.
Now my brain is dopamine starved.
That's it. Okay. Nowthat doesn't feel good. Yes, and that doesn't feel good. You have basically two options here.
More dopamine.
You can get more dopamine, right, to bring yourself back. I'm now putting the cigarettes back into the pleasure thing.
And some whiskey.
Liz, add some whiskey because that's what you got to do, because this is tolerance. You need more and more of your drug over time to get the same effect, or you need to combine drugs to overcome tolerance. By the way, this is, of course, the fastest way to get back to the level position is to use more of your drug, because then you're right there, you're back again. The problem with this method is that the brain will respond by more neuroadaptation. Now we're putting more rocks in the pain, and now you're doing this, right?
Now I need even more.
Now you need even more, right? Eventually, over time, you're doing this. This is simply a metaphorical representation of the addicted brain. Now our brain has downregulated dopamine transmission in the reward pathway to a chronic dopamine deficit state.
To feel good when I've really abused my drugs of choice, I'm going to have to do so much, probably so frequently, to feel good again.
That's exactly right. You're going to need more of your drug in more potent forms, more often, not even to feel high and go to the pleasure side, but just to level the balance and feel normal.
In the context of people with bad habits, if I'm having a cookie every day, the more and more cookies that I eat, the more and more cookies I'm going to tomorrow and need tomorrow just to feel good again.
Essentially, yes.
The same applies for things like pornography and maybe interacting with an AI and social media and whiskey and alcohol. The more of it I consume... This is why I think everybody listening can probably relate to having moments in their life where they feel like they're losing control of a particular habit, and they're doing it every day. They know they don't really want to, but they're doing it. They're getting cravings to do it. I reflect on my own life and I go, there will be periods every year where I just, I call it falling off the horse, and I just can't seem to get control of not eating that bad thing again the next day. Then something happens, maybe there's less stress in my life for a week, and maybe there's more routine and I'm back home in Los Angeles or the UK, and I'm not traveling around, and then suddenly I can get back on the horse? What's going on there?
Yeah, great question. First of all, let me just say that many people also report that In periods of high stress, they are more vulnerable to falling off the wagon or going back to some problem related to compulsive overconsumption or addiction. But the opposite is also true. Some people say that they actually do better when there's stress in their lives, and it's when that stress is removed and they feel like, Oh, I can relax my boundaries or my guardrails. Those individuals are more vulnerable to compulsive overconsumption in when things are going well. Things going badly can be a trigger and things going well can be a trigger depending upon your unique life history and unique wiring. There's a wonderful animal experiment where if you put a rat in a cage with a lever to press for cocaine, that rat will press that lever till exhaustion or death, which is essentially the animal model of addiction. But if before the rat becomes addicted, if the cocaine is then removed such that pressing that lever no longer yields the reward, that rat will eventually extinguish that lever pressing behavior. They'll stop pressing the lever. They'll stop doing the work.
It can take a while, but eventually, they won't press the lever anymore. Now, if that same rat, after a period of time, is then exposed to a very painful foot shock, the first thing the rat will do in response to that painful foot shock is run over and start pressing that lever To me, that's just a wonderful model of what we see in humans, that when individuals are under extreme stress, they are typically more vulnerable to relapse because their brain has already encoded using these high dopamine rewards in response to any pain as a way to get out of that state.
We talked about the pleasure-pain balance here. But if in my life I experience some form of pain, I'm likely to go and seek pleasure, and stress could theoretically be considered a form of pain.
Yeah, which is why people with severe childhood trauma are at higher risk for addiction. There are probably epigenetic changes that are happening at the level of DNA expression in their brains, making them more vulnerable to addiction. We know that people who are living in poverty are more vulnerable to addiction. People who are struggling with multi-generational trauma, unemployment, maybe major social and geographic dislocation, those individuals are more vulnerable to addiction. Environmental stresses definitely play a role. We also know that co-occurring psychiatric disorders make people more vulnerable to addiction. Probably that means that people who struggle with bipolar disorder, depression, anxiety, schizophrenia are at higher risk of becoming addicted, and probably it's because they're trying to self-medicate.
What about with ADHD?
Kids with ADHD are at higher risk to develop an addiction in adulthood than kids without ADHD. The mechanism of action for that is not well understood, but there are some really interesting theories. One of the theories is that kids with ADHD have reward deficit at baseline. That has been shown in experiments that people with ADHD, when you show them rewarding stimuli, their reward pathway isn't as activated as healthy control subjects.
When you say rewarding stimuli, what does that mean?
Images of cupcakes or alcohol or anything that they will endorse is something that's pleasurable for them.
Their brain doesn't release as much dopamine when they see something rewarding. That's right.
So brain imaging studies showing that not only do people with ADHD not release as much dopamine in response to rewards, but also have at baseline, fewer dopamine receptors. Remember, we talked about the decrease in dopamine receptors being what happens as people become addicted. In some ways, people with ADHD, you could conceptualize them as already having craving at baseline, even before they've been exposed to the kinds of intoxicants that lead to downregulation of those D2 receptors.
I had Gamble Mathe on the podcast a few times, and Gamble talks to me about how ADHD could be perceived as learning at a young age to distract yourself from the stress in your life. He was talking a lot about his own experience growing up in Nazi many times and his mother giving him to someone else because he was at risk of the Nazis and the stress of that moment and how he had learned to tune out of the environment because of that. I've always wanted to… I thought about that theoretically. It's like, if you grew up in a household where there's loads and loads of screaming and loads of violence, for example, you learn to tune out, but you can also develop a hypervigilance. It does make sense to me that so many of those people, if this theoretically holds, would start with a bit of a pain baseline.
We definitely know that kids who are raised in traumatic environments where there is complex attachment with caregivers, those kids are at higher risk for developing addiction. This dissociative response to trauma, just trying to escape the situation, either in your own mind with your own mental dissociation or distractions, or actually finding a behavior that gives you comfort is well-observed and well-documented. Just getting back to our early conversation about digital media and the dangers they're in. A Pew survey report just came out asking parents how they navigate exposing their kids to smartphones. In the cohort of parents who said that, yes, they do let their children under the age of five play with a smartphone. When they were asked, why did they do that or in what circumstances? One of the top reasons was to soothe their child when their the child was unhappy or distressed in some way. Now, I found that very concerning because that is basically setting up the child for the perception-action loop of using internal distress as a cue for reaching for a smartphone, which works. It definitely works in the short term. But the problem, again, is that through this iterative process of neuroadaptation, And ultimately, that smartphone will not be sufficient.
And now the kid will need a smartphone and, I don't know, an AI tailored pet who will do whatever they want whenever they want it. And then by the time the kid is eight, that won't be sufficient. And the kid will need, I don't know, a slot machine or whatever it is. It's this escalating phenomenon.
There's a couple of startups at the moment, AI startups, who are putting AI AI and cuddly toys?
Oh, yes, right. Ai and cuddly toys.
Just like you can speak to ChatGPT using your devices, you can come home, you can pick up your cuddly toy. Your cuddly toy will talk to you, it'll ask you how your day has been. It will It can teach you things. What do you think of that from a neuroscience or a dopamine or connection perspective?
I think that this is very, very dangerous because we're essentially offloading the work of parenting and creating those relationships. Again, I hate judging parents because parenting is hard, and I've made many mistakes in my parenting. I'm sure the parents have the best of intentions But instead of navigating, finding a way to communicate with their child to figure out how to know what's going on in that child's life, which can be hard to do because even young children aren't necessarily willing to disclose. But once they get to be teenagers, forget it. Then you got to wait until they're ready to tell you, which is almost always at 10: 00 PM at night when you're exhausted after working all day. There's that piece of it. They're not putting in the work, spending the time with the child, finding a common language. But you also then, then the second piece of it is now you've got this child who is essentially self-soothing with a machine. Again, the machines are It's designed to flatter, to validate, to comfort. There's no friction there. This is incredibly potent social validation and self-soothing. It's essentially a masturbation machine. Then you've got this really weird additional loop where now the parents are finding out about their child's life through reading and observing her interactions with the AI.
It's like a game of telephone. Now they've filtered this thing where they think they know what's going on in their child's life, but of course, they don't. None of that has gone toward fostering a relationship between those parents and their child. This is just really, really scary because it's going to lead to this incredible fragmentation of families, of social bonds. I We cannot go in that direction. We really have to fight against that.
With all this said, and with the knowledge that these algorithms are going to get more addictive because AI is going to know me more and more and more, and actually the commercial model behind any of these big technology companies is to keep my attention on their product more so they can deliver more ads or they can charge me a higher subscription fee. Are you at all hopeful? Because I can't see from an incentive perspective when we're talking about the commercial models behind these companies, why Things are going to stop and go back.
I agree with you, the genie is out of the bottle. We're not going to go back, but I am hopeful because I think I'm just a realistic optimist. I do believe in the human capacity to adapt and solve problems. The simple fact that we're talking about these problems now, which we weren't doing 10, 15 years ago, I think is a good thing. There's much more awareness in the population about the potential dangers of digital media. At the forefront of raising the alarm has been parents, because parents are seeing the disintegration of the nuclear family in real-time, and they don't like it. I am hopeful because I just think that we're going to come together and we're going to try different solutions. Some of those solutions will involve technology and like trying to come up with guardrails or better technology. I think the way that we're going now with the erotic chatbot is not the right direction. But then again, we live in a free democracy, and consenting adults can do what they're going to do until we decide as a society that the harms outweigh the potential benefits. But I really think in the short term, we need to focus on kids because kids are vulnerable.
They're vulnerable on so many levels. On a neurobiological level, they're because their brains are still rapidly evolving, incredibly neuroplastic. They're cutting back on the neurons they're not using. They're myelinating and making more efficient the neurons they use most often. That whole process ends at about age 25. Plus, you've got the buckets of hormones that are going into kids, the fact that teenagers are natural risk takers, that they should, based on their evolutionary milestone, be going out and meeting people and be curious and making connections at that time. And yet more and more teenagers are staying at home and getting their needs met digitally. So we've got to look at kids. That's got to be the first priority. And we've got to help parents because we can't leave it up to parents alone. So I'm optimistic that we are going to come up with solutions, and I think we just have to try a lot of different things and see what works. But it can't just be an individual solution. We can't just leave it to individual individuals or parents or families alone. The schools have to join the solution, governments, legislators, and also the companies that make and profit from digital media.
They really are responsible for making a product that doesn't harm kids. Right now, we have a product that harms kids.
You've recently been an expert witness in certain trials in court, right?
Yes. In An ongoing litigation, yes.
What can you tell me about that and about the parties in play and why you're being called to be an expert witness?
I can't actually tell you too much. I can't talk about it. But I can tell you that the basic premise is that kids are a vulnerable group, that social media is not safe for kids, that it causes harm at many different levels, but primarily through the medium itself being addictive and engaging their brains and exploiting their motivational reward system with design features that keep them clicking and swiping.
In that case, someone's suing the social media companies.
That's right. You've got school districts, counties, states, the federal government, entities representing the federal government suing social media companies.
What outcome are they looking for?
They're looking for a safer product for kids. They're looking to help parents and kids and schools protect kids from the harms of social media, which, again, are not just the harms of addiction. That's the process by which the engagement becomes pathological, and then the harms multiply because of the sheer amount of time spent. But the harms include things like cyberbullying, sexploitation, sexual abuse material, the outcomes of depression, anxiety, eating disorders, body dysmorphia, sleep disruption.
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My brain is currently going to be slightly out of balance in terms of its dopamine balance.
Yes. So hypothetically, your brain will be in a dopamine deficit state. What you want to do is you'll want to abstain from your drug of choice long enough in order to reset reward pathways.
Okay, so if I've got a sugar problem, then I need to just lay off the sugar for a little while.
You need to lay off the sugar for at least four weeks.
Four weeks?
Yeah. Why four weeks? Because on average, four weeks is about the amount of time it takes for people to get out of the state of acute withdrawal and begin to be able to take joy in other more modest rewards and not be in a constant state of craving. The worst part is those first 10 to 14 days. That's when we're in acute withdrawal. The reason for that is when we first take our reward off the pleasure side of the balance, which I'm going to do now.
When we first stop the sugar or the AI or the cigarettes.
That's right. The first thing that happens is our pleasure pain balance crashes down to the side of pain Because of this process of neuroadaptation. Now we're in the state of acute withdrawal.
I've got cravings.
Cravings. And yet what are the characteristics of withdrawal? Anxiety, irritability, insomnia, dysphoria or depressed mood, and cravings.
It's crazy because when I'm in that state, when I've not had my drug of choice for, say, a day or two, I look at the drug differently. It just looks different to me. It's so crazy. I'll walk past, let's say, what's something I really like, maybe carrot cake. If I've been having a lot of sugar, which is quite rare for me, but just so I have. When I look at the carrot cake the day after I had carrot cake, it looks amazing and it looks so delicious. But when I'm in the ketogenic state where I've not had carbohydrates for, say, for eight weeks, I look at carrot cake and I have no emotional connection to it.
Exactly. That summarizes it perfectly. I had a patient with a severe food addiction who, when she walked into the break room at work and saw the donuts, she broke out into a cold sweat and actually had stomach pains. It was a physiologic state of craving and hyperarousal just by looking at the donuts. That's what happens essentially, because we're in this state of constant craving. Our brain has overvalued this reward. We have euphoric recall of our earlier use of the drug when we first tasted it, how delicious it was. Even now, when we eat it because of tolerance, it's not as good as earlier use. Our brain still remembers earlier use, and we have this over weighted value of, Oh, how delicious it's going to be. This is really important to remember because when we're in that acute state of craving, it feels like it will never end. It really does. I'm still amazed in my clinical work how in early withdrawal, people just say, The craving is horrible. I can't live like this. I think that's really important to point out that many people try to stop using their drug of choice, but they don't stop for long enough to be able to get out of that vortex of craving to come get to the other side.
It feels like the craving will never end. I always have to reassure them that if they can just wait long enough without using, they will eventually get to that place where they're not in that constant state of craving. Now, that's assuming they have enough neuroplasticity to do that, and not everybody does. What is the purpose then of abstinence? It's, again, when our brain is no longer getting this exogenous source of stimulation or dopamine, eventually the brain gets the message, Oh, okay, I need to start up regulating my own dopamine transmission. I need to re I employ or I need to redeploy my postsynaptic dopamine receptors. I need to get it from inside of my brain. Eventually, I'm just going to take the rocks now off the pain side of the balance, You could have made this easier. Let me do this. There we go. Eventually, if we abstain for long enough, that process of neuroadaptation reverses itself.
When you say neuroadaptation, you mean the brain changing?
Right, the brain changes. The neuroplasticity that we see with addiction can be reversed in most cases.
A has to see it's just the brain again changing.
Right, changing or going back. Now, interestingly, the work of E. D. Sullivan and others looking at what happens in the brain during recovery suggests that those addiction circuits probably never go away. But like the dying embers of a fire, they quiet down. Then recovery is characterized by the development of new neural networks that route around those injured areas. But the bottom line is that because of neuroplasticity, we can eventually return to baseline levels of pleasure and pain. We can restore our hedonic or joy set point. When we do that, we're in a much healthier place. Because now we can take pleasure in other rewards that are not our drug, like watching a sunset, talking to a friend, going for a walk, things that we lost the capacity to enjoy because our reward pathway was hijacked by our drug of choice.
I think this is a really important point as well when you say drug of choice, because one thing I learned from our conversation last time is that me and you will both be susceptible to becoming more or less addicted to different drugs of choice. For me, it might be whiskey. For you, it might... I think you said it was like erotic novels where one of your things... I don't drink whiskey, just. But it might be, I don't know, it might be opioids or AI. I might be more susceptible. If me and you spend one hour on TikTok, the way my brain is why the things I've been through in my life, whatever, might mean that I get really addicted to TikTok, whereas you don't feel that.
Exactly. What distinguishes addictive drugs or intoxicants from other substances is that they do release a a lot of dopamine all at once in the reward pathway. Many, if not most people, will find intoxicants reinforcing, but that's not universally true. There are some people who take opioids and find them that they feel very uncomfortable, and it doesn't make them feel euphoric. Other people will drink caffeine and not feel the stimulating effects, and other people will have alcohol and get a headache and not feel relief. So this difference is in our brains, That is a really important concept.
What about this idea of having an addictive personality? Is that a real thing?
It is a real thing. We don't use that terminology anymore. We talk about the inherited or genetic risk of addiction. We do know that if you have a biological parent or grandparent with an addictive disorder, you are at increased risk of developing addiction compared to the general population, even if you're raised outside of that substance using home.
Am I right in thinking you don't use that term because it suggests one can't change and that they're stuck, or is there another reason?
It's a good question why that term has gone out of favor. I think in general, when we talk about personality, it does seem like a a fixed feature of somebody everybody's character, and so we're probably trying to avoid that.
One of the really liberating things about what you've just said is maybe we don't need to make New Year's resolutions. Maybe we need to make just a January resolution because that's four weeks long. If I can get to the end of the four weeks, then the cravings are likely to have gone. When you think about a New Year's resolution, then you get a week in and you're like, God, am I going to be able to do this for the whole 365 days? What you've just said actually illuminates the fact that maybe you should just set yourself a four week resolution.
Exactly. That's what we often do in clinical care. If we were to ask people to abstain for their whole lives, it seems impossible. But if we ask them to abstain for 30 days, it's an amount of time that they can wrap their heads around. Also not an all, but in most folks who are willing and able to do it, and also importantly, for whom it's safe to do, because it's not safe for everybody. We wouldn't recommend that for someone who is at risk for life-threatening withdrawal from alcohol or benzodiazapines or something like that. But for people who are willing and able to do it, they usually feel better at the end of those 30 days. Then they can make a decision about whether they want to continue to abstain or they want to go back to using. If they do decide to go back to using, they've typically have lowered their tolerance for their drug of choice, which means that when they do use again, they can get reward from it again, which again, because of neuroadaptation, we lose the ability to do that with chronic heavy use. There is this whole concept of moderating our use, which didn't use to be something that we even talked about in the field of addiction when it was thought that abstinence was the only way.
But more and more, we are thinking about healthy ways to moderate after a period of abstinence. The reason we recommend a period of abstinence, even if the long term goal is moderation, is because we find that people are more successful moderating if they first abstain for a period of time.
What about if I'm trying to pick up a new habit? How do I need to be thinking about this pain, pleasure, scale, and what's a good strategy with this in mind? I want to start, let's say, I want to start going to the gym.
Right. You've chosen a habit, going to the gym, that is hard to do and involves effort. That means that habit won't happen easily the way that habits that are related to the sudden release of dopamine in the reward pathway. Because those are habits that are frictionless. We pick them up instantaneously. But a habit It that involves effort and for which the rewards are not immediate, you can again think about this pleasure-pain balance. Now, instead of pressing on the pleasure side, we're intentionally pressing on the pain side by making ourselves get out of bed in the morning, go to the gym, engage in effortful exercise. What's interesting is that when we do that, the neuroadaptation gremlin that I talk about are these rocks that we've used here today, we'll actually go on the other side of our balance, so on the pleasure side, and we will get our dopamine indirectly by paying for it up front. The way that that's probably happening is that our body in sensing injury is upregulating feel-good hormones and neurotransmitters like dopamine, but also endogenous opioids, endogenous cannabinoids. From an evolutionary perspective, that's really how our pleasure-pain balance evolved.
So just to simplify this for me, I go to the gym, I get up, I travel to the gym, I lift up those weights, I do my run. I'm going to feel good, but it's going to be delayed.
Right. And importantly, you're not going to feel good when you first start exercising. At least most people don't. It's painful. And you're thinking, How many minutes am I? How many minutes do I have left? And we do know, in fact, that exercise is immediately toxic to cells, which is really strange because we know exercise is good for us. But again, what's probably happening at a molecular level is that the body is sensing cellular injury and in response, upregulating all those feel-good hormones and neurotransmitters, but it takes time. It takes time. We're going to have a delayed sense of reward, and that's the runner's high that comes after the exercise is over. Or maybe for some people, it comes in the middle of exercise when you're a little bit into it or halfway through. But at some point, you get the endorphins and that feels good.
How would one go about gaming this so that I'm more likely to do it? Because the reward comes after, which is not incredibly useful. You almost have to have a religious belief in exercise because you go, I'm not going to want to do this, but I'm going to be glad I did afterwards. Right. So is there anything I can do? Do I have a mask bar when I get to the gym or something? I don't know.
There are so many ways and so many tricks that people use to create new healthy habits habits. One of the ways that we can do it is to prepare in advance for that moment when we want to do something that's hard. Because if we wait till that moment to decide whether or not to do something that's hard, we almost always choose not to do it. But if we make a plan in advance, let's say the day before, that tomorrow I'm going to get up at this time, I'm going to get my stuff together, and I'm going to go to the gym, we're much more likely to engage in that activity. That can also include then rituals around that activity that we prepare in advance. For example, packing our bag, the schedule itself, setting up a time, maybe planning to meet a friend. We connect friendship or socialization with the thing that's hard to do. It's much easier to do these difficult things with other people than to have to do it alone.
How does that link to the pain side of the balance, or does it at all link to the pain side of the balance? This idea that if I put my clothes out the night before and I schedule it and I really plan for it, it's reducing the pain involved, and that's going to increase the probability of the behavior occurring? Is that what you're saying? Or is there something else? Or is it not linked to that?
I don't think so. I think instead, the prefrontal cortex is the large gray matter area right behind our foreheads that's so important for future planning and delayed gratification, also for autobiographical narrative. I think by putting these pieces in place that allows our prefrontal cortex to plan for this future event that we know we're not going to want to do, but that we want to do, it allows us to put the brakes on our short term desires and project ourselves into the future to achieve our long term desires. Sam McClure, a neuroscientist, has shown that in response to immediate rewards, the emotion brain gets activated. In response to long term rewards, the prefrontal cortex gets activated. By planning in advance all of these little pieces, sometimes called habit stacking, we're essentially activating our prefrontal cortex, projecting ourselves into the future, and anticipating a long-term reward, which then allows us to do hard things and avoid short-term rewards in the service of our future selves.
So many people might have an experience where they kick the habit for a little while, and then they relapse. It might be a month, might be two months, might be three months. Is there any art to avoiding the relapse?
It's very common to relapse, especially living in the world that we do today, where we're constantly being invited to consume really these stimuli Getting us to drink or to smoke or to do various forms of entertainment chase us down. We can't avoid them, where it's very difficult, too. I talk a lot about self-binding strategies with my patients. Self-binding strategies are a way of putting both a literal and a metacognitive barrier between ourselves and our drug of choice.
What's a metacognitive barrier?
It's a thought or a narrative. Instead of it being a physical barrier, a physical barrier would be, for example, getting the smartphone out of the bedroom or deleting an app, or getting alcohol out of the house, or whatever it is, creating both a physical barrier between myself and my drug of choice. A metacognitive barrier is something more like a thought process. For example, we were talking about thinking about long term goals or what are my values? How do my values How can I use Trump my immediate desires? Or how can I co-regulate with other people? These are all self-binding strategies that we can use so that we're not relying on willpower alone. Because if we wait to rely on our willpower alone, we will not make it, especially in this world of overwhelming overabundance. There are just too many temptations. Willpower is an exhaustible resource, meaning that it doesn't It'll last forever. It eventually runs out. We've got to actually create barriers between ourselves and our drug of choice so that we can have a little bit more time. That little bit more time, that slowing things down, is sometimes just enough to allow ourselves to surf the cravings and get through them without actually using.
Is it possible to become addicted to good things, too?
When I use the term addiction, I'm really talking about a disease process, a form of mental illness. It's a very common term that's used in everyday life, and people don't always use it in that way. But when I'm using it, I'm really talking about the problem of compulsive overconsumption despite harm to self and/or others. It's important to distinguish addiction from something like a habit, which I don't consider to be an addiction or even a bad habit, doesn't meet threshold criteria for addiction. Also, It's important just to distinguish all of that from a passion, something that we really invest in and that we love to do, but that's helpful for ourselves and/or other people, is not consistently causing harm.
Are there any daily practices, like a morning ritual, that you would advise someone to consider if they were trying to set themselves up to kick a habit or to kick an addiction?
I recommend doing the hard things first. A shorthand way of saying that is to start your day with pain, meaning, for example, do the hard things when you first get up as part of your morning routine. Like exercise. Like exercise, make your bed, eat breakfast, brush your teeth, plan your day, Plan what you're going to do if you haven't done it already, and do all of those things before, for example, you have your morning cup of Joe or before you touch a single screen or a digital device. Why? Because those are reinforcers that They are so powerful that we're all vulnerable to having our goals and desires be hijacked by them. Really important to take the time in the morning to set up a good morning routine before you expose your brain to these incredibly reinforcing substances.
I wasn't clear on why. I wasn't clear on why I would do why I'd go to the gym early or why I do hard things first before I get into TikTok or social media.
If you do intoxicants first, if expose your brain first thing in the morning to things that are incredibly pleasurable, you have nowhere to go from there. In fact, if anywhere, you're going to have a come down from that. Then you're going to be starting from a place of compromise, where then doing the hard things is even harder. Whereas if you start with the hard things, you will potentially get rewards from having done those hard things, and also feel a sense of competence and a accomplishment that then allows for you to move through your day in a way that's better if you just start with something that's incredibly pleasurable.
If I am getting ready to kick a habit, a big one, a big one that's really hung around for a long time, is there something I should do in preparation to plan for my dopamine fast or for kicking that habit? Because I know you said from day one, it will take about four weeks to start to feel the cravings diminish. But is there something I should be doing before I even start those four weeks?
Yeah. I strongly recommend preparing for the dopamine fast in advance. The things to do are first, figure out what is your drug of choice. That is to say, what is the thing that you're consuming too much and too often such that you regret it later, or the thing that's leading to obvious negative consequences, or the thing that just has opportunity costs associated with it. That is to say, you're spending so much time consuming this drug that you're not doing other things, other hobbies, investing in other things that are meaningful to you, like your primary relationships. That's very important to just figure that out first. I usually recommend something called the timeline follow-back method. That's where you Start today and you count backwards for every day of the week, what did you consume in terms of your drug of choice, how much, and how often. Really looking at quantity and frequency and then adding that up over those seven days. The reason that's important is because we can really lose track of how we're consuming our drug of choice when we're chasing dopamine. We're very bad self-observers. Just to give a personal example, I had gotten into this habit of watching YouTube after work as a way to relax, especially on my long clinic days when I was more tired.
I thought it was just that I was watching for maybe an hour, a couple of times a week. Then my daughter, a teenager, came up to me and she said, Mom, you're always watching YouTube now. I said, No, I'm not. I was really insulted because in my mind, it was not very much. I thought, Jeez, can't I relax every once in a while and watch some YouTube. But then after she left me, I thought to myself, Well, okay, how much have I been watching right now? It turned out, Oh, I've been watching for an hour and a half. Then I thought about the day before that, Oh, it was probably two hours. The day before that, it was probably about the same. Over the course of a whole week, it was probably about 14 hours of YouTube, which is a whole day. A whole day, right?
What were you watching?
Gosh, so embarrassing. I got into this jag of watching Dr. Pimplepopper, which I know is really weird. You don't even know what that is, right? Yeah. It's people popping other people's pimples. Oh, my So bad.
That's not what I expected you to say.
Yeah, right?
I thought it was going to be AI, some psychology things, some science.
No.
People popping other people's pimples. Yeah.
Yeah.
You spent a whole day watching that.
Yeah. When I added it up over a week, it was a whole day of watching Dr. Mimblebopper.
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Okay, so these are human brain imaging studies. This is adapted from the work of Nora Volkow and her colleagues. She's the head of the National Institute of Drug Abuse, an amazing researcher and scientist. She looked at dopamine transmission levels in the reward pathways of healthy control subjects on the left versus people addicted to a variety of substances on the right, cocaine, meth, alcohol, etc. Basically, what she found was in the brains of healthy control subjects, there was plenty of dopamine transmission, as represented here by red or the darker color. In the brains of people who had been using these substances in an addicted in an addictive way, meaning heavily and chronically, there was almost no dopamine transmission in the nucleus accumbens. In other words, these individuals are in a chronic dopamine deficit state. They have below normal levels of dopamine transmission.
Isn't this just the story of how the human body works, where if you give it too much of something through an external source, an exogenous source, so if you're taking being lots of dopamine via TikTok or from porn or from alcohol, your brain goes, well, if you've got enough of that, then I won't make any.
You know what? You just summed it up. That's exactly right. That essentially too much of anything is bad. And that our brain, which is designed to return to homeostasis, homeostasis being a finite number of physiologic states that the organism must maintain in order to survive.
Is this the case with things like melatonin as well? Because people are struggling a lot with sleep, so they're taking a lot of these melatonin pills. But I don't know, someone offered me one one time, and I remember thinking, well, if I start taking this, then isn't my body going to stop making it, and then I'm going to become dependent on these fucking pills?
That is the potential with, I think, any exogenous source that we use. Anything that we ingest, our brains and our bodies will want to adapt to bring us back to whatever our baseline is. But the difference between addictive substances and behaviors and non-addictive ones is that the release of dopamine and the reward pathway is so fast and so strong that this process of neuroadaptation is equally strong to bring us back down to baseline. Because we do know that there are medications that people can take for very long periods of time and actually not develop tolerance to them. They can continue to work for them over the long period of time. We don't actually know exactly why it is that some people develop tolerance and not others. Again, it probably has It has to do with the amount, the dose, exactly how it's working on the brain. But in general, things that are highly reinforcing, our brain tends to adapt to them over time.
Testosterone is another one people often talk about where if you take external testosterone, consistently, your brain will decrease the natural production of it. As a result, natural testosterone shuts down and testicular size can shrink. But then if you stop the TRT, the external testosterone, abruptly, your natural system might take a long time to recover, and in some cases, it may never fully recover back to baseline. I think this is just like a really important principle for drugs, chemicals, or messing with the natural balance of one's body.
Yes, exactly. By the way, Nora Volkow and her team did a follow-up study in individuals who abstained from methamphetamine for 14 months and then rescanned their brain and showed that they had restored healthy levels of dopamine transmission. It took 14 months in those individuals who had been very addicted to methamphetamine, which I think is also an important message here. For individuals struggling with severe addiction, it's not like four weeks of abstinence is suddenly going to make your brain better. But what I What I've found in clinical care is that that's typically enough time to begin to see the light at the end of the tunnel, and that indeed there's enough restoration of baseline levels of joy or capacity to experience reward that people can begin to have hope to get out of that state of craving.
What is the most interesting... Because you've been exposed to so much research on the subject of dopamine and human behavior. Is there a particular study that always stands in your mind as being the most informative or interesting or surprising that you've encountered?
A study that keeps coming back to me There are a couple. I mean, there's so many, but- Give me them.
Okay.
If you put a rat in a cage with a rat trapped in a plastic bottle, that rat will work very hard to free the trapped rat. But if you then allow that rat to self-administer heroine, it will not work to free the trapped rat. To me, that's really powerful because it suggests how addictive substances like opioids, which heroine is, can usurp our desire for human connection and essentially become the object of attachment. We often talk about loneliness and isolation as a risk factor for addiction, which it absolutely is, but the reverse is also true, that getting addicted will cause us to isolate and be lonely. We will stop caring about other people. For me, that's a really powerful experiment that I think does map on to human behavior.
Something really interesting this one, just a day-to-day level, which in your head, I was trying to relate that to my own life and thinking, if I get really addicted connected to my screens and my devices when my partner needs me, I might be so distracted and so connected to the thing that's giving me dopamine upstairs in my bedroom, my laptop or whatever on my work, that I might completely miss her call for help. I hate to say it, but sometimes I do feel like maybe I've been guilty of that. I've been so, dare I say the word, addicted to my or devices or whatever that. Sometimes I'm not present with meeting other people's needs.
Absolutely. That certainly happened to me with my addiction to romance novels. I stopped paying as much attention to my kids and to my husband. We went on a vacation with another family at the beach, and instead of joining folks on the beach, I stayed in the room and read romance novels. We went to a neighbor's party, and I actually found a room in the house and read romance novels instead of socializing, and didn't even think that was weird, even though that's obviously really strange. It is this coming to overvalue our drug of choice and undervalue other more meaningful good things in our lives.
Could you theoretically say it's making the world less empathetic or less sympathetic, or less... What's the adjective of of actually being there for other people? I guess, connection and relationships. It's earning our ability to connect to others and have empathy for them and be there for them because we're possessed by the thing giving us the most dopamine.
Yeah, I would go even further and say not only is it making us less empathetic, but it's actually making us sociopathic. In other words, when people are in their addiction, they can deviate from their moral compass because they so overvalue this drug of choice that they lose sight of their own values. We see this with kids who become addicted to video games or social media. They stop participating in family life. They stop treating their parents with respect. They stop participating in household chores. They become essentially essentially antisocial. When they get off of digital media and they go through that terrible withdrawal period, all that gets worse. Even they will endorse things like wanting to hurt their parents or wanting to hurt themselves. But if they can just go long enough and abstain from digital media, they will come out the other side, and parents will talk about getting their child back and getting back this person that that they recognize as their child. I think this is really important. When people are in their addiction, they can look very personality disordered, very narcissistic, very borderline, very sociopathic. When they get into recovery, that's not who they are at all, and they can really become themselves again.
I read about a really extreme case where that drug, I believe it's called pramipoxle.
Pramipaxle.
Pramipaxle, which is a dopamine agonist. Yes. Which essentially means, I guess the molecule is the same shape as dopamine. So the brain treats it like dopamine. Yes. And these people were given it for twitchy leg or something. Right. And then they, like so many of them lost their minds, they became obsessed with compulsive, impulsive behaviors. And I was reading about one particular lady. She would leave the house in the early hours of the morning when she was taking this drug, which is the same as dopamine. And she would wear see-through tops. This was like a normal woman who otherwise had a normal life and go to very dangerous places to try and have sex with strangers. It was because her brain was full of this drug which simulated dopamine. But there's so many examples. There was one from Australia where a woman was taking this drug which is like dopamine in terms of its molecular structure. She would sit on these slot machines until she soiled herself and urinated on herself. She She ended up losing her house, losing her car, losing her marriage just because they'd given her this drug, which is the same as dopamine.
It made me realize that dopamine isn't necessarily the drug of reward, but more of like wanting an impulse and desire. Is that an accurate assessment of it? It makes you desire things. There was other examples when I was reading about it where a guy would take this drug and started engaging in homosexual sex acts, whereas otherwise he'd been in a heterosexual relationship. It was all very confusing, but it says something to me about what dopamine is actually doing.
Yeah. I think when we're talking about addictive substances and behaviors, the initial response of the brain is to release a lot of dopamine all at once in the reward pathway. But with repeated use, dopamine release gets weaker and shorter in duration, and eventually it leads to this dopamine deficit state. That's often what we call wanting but not liking. George Koub has called this dysphoria-driven relapse, where now they're using not to feel good, but just to stop feeling bad and feel normal. In that sense, dopamine is part of pleasure I mean, it's not its sole function. But when it comes to addictive substances and behaviors, the initial encounter has to feel good or be reinforcing or get someone out of pain. It has to solve that problem. But again, the issue is that with repeated use, it stops doing that, but there's still that motivation to reuse again and again. When we're thinking about exogenous or external sources of just giving someone dopamine, that's not going to work to treat that dopamine deficit state because it's going to bind indiscriminately to dopamine receptors throughout the brain. The brain will respond with that same process of neuroadaptation where it's down regulating dopamine receptors, which is, again, what is setting us up for this repeated addictive pattern.
Is there any other studies that were shocking to you and that have always stayed with you.
Another really interesting study is if you expose a rat to a single injection of cocaine and then slice open its brain, you'll see this arborization of dopamine-releasing neurons in the reward pathway. That means a proliferation of neurons that release dopamine, a growth of the dopamine forest, so to speak. But by the way, you'll see that same arborization or growth of dopamine-releasing neurons. If you put a rat in a complex maze, which is to say a maze where they can explore and find different things and have challenges. If you then cut that rat's brain open, you'll see that same arborization of dopamine. In other words, learning is highly rewarding, and dopamine is released in response to novelty and new things and new challenges. But if you then take that rat and pre-treat it with methamphetamine and put it in the maze and then look at its brain, you don't see any additional arborization beyond what you got with methamphetamine. The interpretation there is that drugs actually may usurp or steal our ability to learn. Because they've, again, this idea of they've taken over. It's such a powerful dominant stimulus that there's no additional growth or neuroplasticity in response to something like learning a maze.
Does that mean that when that rat was in the maze the first time and its brain was full of dopamine, dopamine was therefore playing a role in helping it to learn?
No. The learning itself actually caused proliferation. So dopamine is responsive not just to rewards, not just to pleasurable things, but it's actually responsive to pain, it's responsive to novelty. So it's responsive to any emotional only powerful experience. So when you put a rat in a maze and it explores that maze, that's an enriching, exciting experience for the rat because we are creatures who are evolved to seek and explore and learn new territory and then move on and do the same thing.
You could say then, if I'm taking an addictive substance like cocaine, I'm going to be much less likely to go out and explore the world.
Yes, exactly. Or if you do explore the world, your capacity to be rewarded by that experience will decrease or will not be there.
So I'm less likely to do it then? Right.
Yes.
This highlights a bit more of a fundamental link around motivation. If you're addicted to something, if you're addicted to pornography, your ability to get up and go out and get a job might be diminished.
Absolutely. What happens with addiction is that we have narrowing of our focus on our drug of choice such that that's the only thing that's reinforcing for us, and other things lose their rewarding potential. Eventually, they fall away altogether, and we're spending all of our time getting our drug, using our drug, trying to get more as we come down. Can I talk about another experiment which I think is interesting? Another really interesting experiment is the rat park experiment. This is the work of Bruce Alexander. He essentially said, Well, if you put a rat in a cage with nothing else to do but press a lever for cocaine, of course, that's what they're going to do because there's nothing else happening. But what if you put a rat in a very enriched environment with a lever to press cocaine, but also lots of other things to do? Other rats, shoots in mazes, little sawdust balls. What he discovered was that the rat is much less likely to press that lever as often because it has other reinforcing things to do. I think that was really ground-breaking in the sense that it is true that addictive substances and behaviors work on the brain in this very predictable way that It's so reinforcing that even if you have a great life, you can get addicted.
But it's also true that our environment really matters. If we're living in an impoverished environment like that single rat in a cage with nothing else to do, we're much more likely to get addicted than if we live in this really enriched environment where we have lots of other sources of reward, lots of other sources of dopamine. Based on that work, there was something then called the Icelandic experiment, and this is quite some years ago now, but Iceland had a significant youth drug problem. The way that they decided to intervene was to build a lot of gymnastics museums and emphasize youth sports. As we've talked about, exercise and sports are a healthy way in general, if you don't overdo it, to get dopamine because you're paying for it upfront, you're working for it. Iceland saw a significant reduction in their drug use problem after the implementation of this youth sports system. I think that's a nice way. It's a nice example of how an animal model can actually provide some fundamental frame to understand what's happening in the brain that can be then translated to a real-world implementation.
Radical honesty.
Okay, so Radical honesty is something that I learned about from my patients, and it was the observation that my patients who were able to get into sustained recovery from severe addictions had had learned that they couldn't lie. It wasn't just that they couldn't lie about their drug use. They couldn't lie about anything. They couldn't lie about why they were five minutes late for a meeting. They couldn't lie about why they couldn't go to a party. They had to tell the truth in all things large and small. To me, that was fascinating. It was an idea that I started to play with and experiment with in in our own life. I realized that telling the truth is actually really hard because we're all prone to little lies to cover up our shortcomings. These are things that we hardly even notice. They're also lies of exaggeration to make ourselves more interesting, lies of flattery where we tell other people how great they are, even though we don't necessarily believe that. All these little lies that we tell, I think even if you're not struggling with addiction, these lies can erode our lives, make our lives more impoverished.
I think it's working through many different mechanisms. The question then becomes, why is truth storytelling or radical honesty protective? I think it's working across many different levels. But one of the important levels that it's working across is simple awareness. Because when we're lying to other people, we're also actually lying to ourselves. When we're lying to ourselves, we actually don't know what we're doing. When it comes to our consumptive behaviors, on the one hand, I may know that I'm watching too many videos, at the same time, really not know that I'm doing that. But when I tell another human being exactly what I'm consuming, how much, and how often, then it becomes real to me in a way that it's not when it's pinging around in the dark recesses of my own mind. That awareness is really important because we can't change our behaviors unless we're aware of what we're doing. The other aspect of that that's really important that I've learned over many years of being a psychiatrist is that the way that people tell their autobiographical narrative is really important. And that there are healthy ways we can tell our stories and also not so healthy ways.
What I've observed is that when people are telling stories in which they're always the victim of other people or circumstance, I know pretty well that they're not going to get into recovery. But if they start telling a story that acknowledges their own contribution to their problem, whatever it is, including the problem of addiction, then I'm pretty confident that we're headed in a good direction. That's really interesting because what it means is that our autobiographical narratives provide a template for our lives. They're not just a way to organize past experience. They actually provide a roadmap for the future. If we're telling self stories that are a more accurate representation of what's actually happening in our lives, we You will have more information from which to make better decisions going forward.
So victimhood keeps you stuck.
It keeps you stuck because it decreases your awareness of what is actually happening. It is our awareness of what is actually happening that allows us to have the data we need to make better informed decisions.
Does it also, to some level, rob you of responsibility?
Absolutely, because although addiction is by a loss of agency around our consumptive behaviors, we still have some degree of agency always, even if it's only enough to reach out and ask for help. As people get into sustained recovery, they have a lot more agency as they get out of that vortex of addiction. It is that agency that we must employ to make the next best decision so that our lives will be this accumulation of of small good decisions that then lead to good weeks and good months and good years.
I think that point is so important, this idea of agency, which essentially means having control in my life, feeling like I have a sense of control in my life. Is that a definition of agency?
How would you define it? I wouldn't define it so much as control because there are so many things that happen in our lives that are out of our control. But when we reduce our decision down to today and what I can do today, the things that I actually can control today, then yes, recapturing our agency around the things that we actually have control over is really important for recovery.
The definition I've pulled up here is agency means the capacity to act intentionally and make choices that influence outcomes. It does tend to be the case from my observations that people that have a high degree of agency, i. E, they believe they have capacity to act intentionally and make choices that influence their outcomes seem to be the most successful, and on average, seem to be a little bit more happy.
I think that sense of competence and an agency is definitely one that makes us feel good. The danger a little bit when we're dealing with severe addiction is that in our addictions, we often tell ourselves that we have agency and control when we really don't. That can be part and parcel of denial, which Which means that getting into recovery is often about admitting that we may have agency in many aspects of our lives, but when it comes to our addictive behavior, we've lost some degree of agency.
That's part of the 12-Step program, right?
Yeah, that is a really important part of the 12-Step program is that admitting that our lives have become unmanageable when it comes to our drug of choice.
The 12-Step program being alcoholics, anonymous, very famous program to help you through an addiction. Is there anything else we should have talked about that we haven't?
When it comes to New Year's resolutions and wanting to change habits, sometimes these all or nothing thinking can be something that's not helpful for people. This idea that, okay, I'm going to abstain from this, and I'm going to go a month, and I'm going to do it. Then they find that they're not able to do it, and then there's a lot of shame and self Self recrimination. That approach is not for everybody. For some, a better approach is self-compassion and a goal of moderation.
Yeah, moderation is an interesting one because most of us will just be like, I'm going to go to the gym every day, or I'm going to have no sugar ever again, or I'm going to abstain from alcohol completely. But maybe moderation for some of these things is more realistic and therefore more effective and important.
Yeah. We find that moderation typically is more successful if people have abstained for long enough to reset reward pathways. But even just reducing use can be a laudable goal.
We have a closing tradition on this podcast where the last guest leaves a question for the next guest. Not knowing who they're leaving it for. The question is, what's the one thing the universe keeps putting in front of you? And what is the thing that it keeps you learning?
Right now in my life, the thing that the universe keeps putting in front of me is the importance of letting my kids go and have their own life experience rather than trying to cling to the relationships that we had before as they were growing up, which for me was a really joyful time. But I'm recognizing that they need to be in the world on their own, and I need to figure out what I'm going to do as an empty nester. That's not that deep, but that is what I'm struggling with right now.
How is that struggle manifesting?
Well, if I'm being totally honest, social media and digital media and those modes of communication have probably made this worse for me because, for example, I'll find my iPhone, I keep checking where my kids are and thinking that in a way we're connected because I know where they are, but we're not. Also, they don't particularly like it that I'm checking where they are. There's this weird phenomenon of wanting connection and through text and other technology, trying to recreate that connection. And yet in some ways, I think I might be better off and they might be better off if we didn't actually text and I didn't actually track where they are. Does that make sense?
It does. I think I was laughing because I just had this picture of you sat there with one screen is tracking them and the other one is watching the pimples being popped.
Yes, those are comparable, right? These are both related to habits or behaviors that are self-soothing, but ultimately not good for me and not good for other people.
Do you think much about how other behaviors that we take part in, like sleep and meditation and our nutrition, have a big impact on our ability to kick the bad habit to start a new one?
Oh, absolutely. There's a great acronym from alcoholics anonymous called HALT, hungry, angry, lonely, tired. When we're feeling those things, we're more likely to crave our drug of choice. So importantly, we've really got to make sure we take care of ourselves physically and emotionally so that we're as well as we can be so that we don't get into that state of wanting to escape or self-soothe or numb ourselves. And by the way, that's true in the work that we do as mental health care providers. We have to really come to patients or clients with our needs met, our cup full, so that we can be fully present for our patients.
Dr. Anna Lemke. Thank you so much for coming back on the show. It was incredible, the conversation we had last time, and it was so unbelievably well received. It's done probably closer to 10 million views across all platforms now, just over 5 million views on YouTube alone. I can't begin to imagine all the people that you've had a profound impact on by making these complicated things accessible. I know we simplify this to a point that it might be quite difficult because I know the science is much more complicated, but just having a simple mental model for me has helped me so much since we last spoke. I understand what's on inside my body and inside my brain in a simplified way, and that's exactly what was reflected by the millions of people that watched last time. Your book is the book to read, and your workbook as well is critical to read alongside it on this subject. If people want to learn more and get an even deeper understanding of everything we've talked about today. Also, if they're struggling with addictions, because these books provide a really, I'd say nuanced, empathetic and shame-avoiding set of ideas and solutions to some of the things that hold us hostage in our lives, whether it's opioids or technology or other behaviors that we know at some level are getting in the way of what we'd rather be doing and who we'd rather become.
So thank you so much for your work. It's such an important work. And I know you're working on another book, which we didn't talk about this time. But when that book does come out, I'd love to have you back on to talk about all the things in that because Little Birdy told me the subject matter, and it's absolutely fascinating. So I'm so excited.
Thank you so much.
This is something that I've made for you. I've realized that the Diary of a CEO audience are strivers, whether it's in business or health. We all have big goals that we want to accomplish. And one of the things I've learnt is that when you aim at the big, big, big goal, it can feel incredibly psychologically uncomfortable because it's like being stood at the foot of Mount Everest and looking upwards. The way to accomplish your goals is by breaking them down into tiny small steps. And we call this in our team, the one %. And actually this philosophy is highly responsible for much of our success here. So what we've done so that you at home can accomplish any big goal that you have is we've made these 1% diaries, and we released these last year and they all sold out. I asked my team over and over again to bring the diaries back, but also to introduce some new colors and to make some minor tweaks to the diary. So now we have a better range for you. So if you have a big goal in mind and you need a framework and a process and some motivation, then I highly recommend you get one of these diaries before they all sell out once again.
And you can get yours now at thediary. Com, where you can get 20% off our Black Friday bundle. And if you want the link, the link is in the description below.
Dopamine expert DR ANNA LEMBKE reveals how addiction is hijacking your brain, why dopamine addiction is rising fast, the danger of social media, porn, AI, GLP-1 drugs, and how to regain control FAST!
Dr Anna Lembke is Professor of Psychiatry and Medical Director of Addiction Medicine at Stanford University School of Medicine. She has spent over 25 years treating patients with substance and behavioral addictions and is the bestselling author of “Dopamine Nation”.
She explains:
◼️Why endless pleasure quietly trains your brain to feel worse, not better
◼️How digital habits replace real connection with instant validation
◼️Why dopamine spikes always come with a hidden crash
◼️How easy comfort erodes discipline, motivation, and intimacy
◼️The practical reset that restores balance and control
00:00 Intro
03:05 Dopamine and Overabundance
04:22 How to Shake Bad Habits
06:16 Why Are Harmful Substances Addictive?
07:15 The Dangers of AI Simulating Human Connection
12:54 Sex Addiction Case Study
19:29 Elon Musk's Age of Abundance
22:23 We're Entertaining Ourselves to Death
23:35 How Our Brain Processes Pleasure and Pain
28:51 Why Do We Fall Off Our Good Habits?
30:40 When Are We Most Susceptible to Self-Destructive Behaviours
31:53 Who Is More Vulnerable to Addiction?
32:59 Link Between Addiction and People With ADHD
34:26 Link Between Childhood Trauma and Addiction
35:57 Parents Soothing Child’s Emotions With Technology
37:24 AI Replacing Parenting
40:05 Are You Hopeful People Will See the Downsides of AI?
43:23 Social Media Trials
45:12 Ads
46:07 The Science Behind How to Get Rid of Bad Habits
53:31 Is Addictive Personality a Real Thing?
54:20 4-Week Resolutions
56:24 Psychological Strategies for Adopting Good Habits
59:00 How to Trick Your Brain to Enjoy Doing Hard Things
01:02:06 How to Avoid Relapse
01:04:23 Is It Possible to Become Addicted to Good Things Too?
01:05:11 Daily Routines to Kick the Habit
01:07:10 The "Count Back" Trick to Start New Habits
01:10:24 Ads
01:12:24 Brains of Addicted vs. Non-Addicted People
01:17:42 Dopamine Research That Stood Out for You
01:19:22 Impact of Dopamine Addiction on Personal Relationships
01:22:52 Dopamine Agonist Drugs
01:26:27 Dopamine Release Associated With Learning and Impediments
01:32:13 Radical Honesty
01:37:06 What Is Agency and Why Does It Matter
01:38:58 The Biggest Problem With New Year’s Resolutions
Follow Dr Anna
Website - https://bit.ly/4pS0ckD
Stanford Medicine - https://stan.md/4oXiyzq
Independent Research: https://stevenbartlett.com/wp-content/uploads/2026/01/DOAC-Anna-Lembke-2-Independent-Research-further-reading.pdf
You can purchase Dr Anna’s book, ‘The Official Dopamine Nation Workbook: A Practical Guide to Overcoming Addiction in the Age of Indulgence’, here: https://amzn.to/4oZKEdl
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