Feel Better, Live More with Dr Rangan Chatterjee - #222 Finding Balance In A Dopamine Overloaded World with Dr Anna Lembke

Episode Date: December 1, 2021

CAUTION: Includes themes of an adult nature. Do you think you have an addiction, or perhaps an unhealthy relationship with a certain behaviour? It may be a behaviour that you have tried to stop in the past that you keep returning back to despite your best intentions. Well, if you do (and I cannot imagine there are many people out there who don't), I think you will find today's conversation eye-opening. My guest is Dr. Anna Lembke, a professor of psychiatry at Stanford University School of Medicine, and author of the brilliant new book, Dopamine Nation: Finding Balance In the Age Of Indulgence, in which she explores the exciting new scientific discoveries that explain why our relentless pursuit of pleasure leads to pain. In today's conversation, we explore the fact that we are living in a dopamine overloaded world where everything has been made more accessible, more abundant, and more potent. We're living in a time of unprecedented access to high-reward, high-dopamine stimuli: drugs, food, news, gambling, shopping, gaming, texting, sexting, Facebooking, Instagramming, YouTubing, tweeting...the list is endless. And the effect is that we are now living in a world that has turned many of us into addicts. We delve into what exactly dopamine is, why we all need it, and how getting too much of it can actually lead to pain. Anna explains that pleasure and pain work like a balance in the brain. In fact, the same parts of the brain that process pleasure, also process pain. If we tip that balance too far in the pursuit of pleasure, the brain responds by overcompensating and pushing us in the direction of pain. But it's not all doom and gloom, there is plenty that we can do to find the right balance and in our conversation, Anna shares some of her best practical advice that has been honed over years and years of treating patients. We cover a wide range of topics, including why radical honesty is important for all of us, the lessons that we can learn from people who have been through recovery and the effect that isolation has on addiction. We also discuss how this problem of overconsumption can affect our kids at crucial stages in their development, and what we can do to protect them. Anna is a world-leading expert in her field but what I love the most about her is her authenticity, compassionate manner and her passion to help as many people as she can. This was a really powerful conversation. I hope you enjoy listening.  Thanks to our sponsors: https://leafyard.com/livemore   https://blublox.com/livemore   http://www.athleticgreens.com/livemore   Show notes available at https://drchatterjee.com/222 Support the podcast and enjoy Ad-Free episodes. Try FREE for 7 days on Apple Podcasts https://apple.co/3oAKmxi. For other podcast platforms go to https://fblm.supercast.com. DISCLAIMER: The content in the podcast and on this webpage is not intended to constitute or be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor or other qualified health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

We're really living in a world that has turned us all into addicts, essentially. 70% of the global deaths today are caused by modifiable risk factors in nations where people have access to all of this abundance. We really have reached a tipping point when we are dying because of our behaviours. Hi, my name is Rangan Chatterjee. Welcome to Feel Better, Live More. Do you think you have an addiction or perhaps an unhealthy relationship with a certain behaviour? A behaviour that you have tried to stop in the past, but you keep returning back to despite your best intentions?

Well, if you do, and I cannot imagine there are many people out there who don't, I think you will find today's conversation eye-opening. My guest is Dr Anna Lembke, a professor of psychiatry at Stanford University School of Medicine and author of the brilliant new book, Dopamine Nation, in which she explores the exciting new scientific discoveries that explain why our relentless pursuit of pleasure leads to pain. In today's conversation, we explore the fact that we are living in a dopamine overloaded world where everything has been made more accessible, more abundant,

and more potent. We're living in a time of unprecedented access to high rewards, high dopamine stimuli. Drugs, food, news, gambling, shopping, gaming, texting, sexting, Facebooking, Instagramming, YouTubing, tweeting. The list really is endless. And the effect is that we are now living in a world that has turned many of us into addicts. So what exactly can we do about it? Well, that is the topic of discussion in today's podcast. We start off by delving into what exactly dopamine is, why we all need it, and how getting too much of it can actually lead to pain. Anna explains that pleasure and pain work like a balance in the brain. In fact, the same parts of the brain that process pleasure also process pain. And if we tip that balance too far in the pursuit of pleasure, as many of us do, the brain responds by overcompensating

and pushing us in the direction of pain. But it's not all doom and gloom. There is plenty that we can do to find the right balance. And in our conversation, Anna shares some of her best practical advice that has been honed over years and years of treating patients. We cover a wide range of topics in our conversation, including why radical honesty is important for all of us, the lessons that we can learn from people who have been through recovery, the effect that isolation has on addiction. And we also discuss how this problem of overconsumption can affect our kids at crucial stages in their development and what we can do to protect them. Anna is a wonderful lady. She is clearly a world-leading expert in her field. But I think what I love the most about her is her authenticity,

But I think what I love the most about her is her authenticity, her compassionate manner, and her passion to help as many people as she can. This was a powerful conversation. I hope you enjoyed listening. And now my conversation with Dr. Anna Lemke. The term dopamine gets spoken about a lot these days in the context of addiction, social media, food. And I wonder if sometimes we misinterpret what it is and what its function is. So I thought we could start perhaps by you explaining what is dopamine, when does it get released, and why is it so important for us? Great. I love starting there. So dopamine is a chemical

that our brain makes, and it's essential to informing us about changes in our environment and in our body state. And we need it in particular to tell us when we are getting a signal from the environment about something that we should approach or do more of or work for or pay attention to. Dopamine is also the molecule that's really fundamental to the process of getting addicted to something because dopamine is released when we do something that's highly pleasurable, highly reinforcing. And remember, our brains have evolved over millions of years to approach pleasure and avoid pain. It's what's kept us alive and thriving

on this planet for so long. But one of the, I think, common misunderstandings about dopamine is that it's only released in response to pleasure. And that's not true. It actually can be released in response to aversive stimuli that are somehow important for our brain to pay attention to. And we can get into that more later. But I mean, as a fundamental sort of function of dopamine, it's really about motivation and the approach signal. You know, interestingly, dopamine is also related to movement, right? It's the chemical that gets depleted in the disease of Parkinsonism, where people become rigid and can't move anymore because they don't have enough dopamine in a part of the brain called the substantia nigra.

So dopamine is essential for pleasure, motivation, one of its functions, as you say, is our pursuit of pleasure. You say it's intimately linked with addiction. So where is that sweet spot where we can use it to gain pleasure, gain those rewards that we all want without it sort of tipping over into addiction you know and I think that's that really I think underpins a lot of your book doesn't it this kind of this balance and this sweet spot because we find it hard yeah yeah no you're right and it's hard not just because we're wired to approach pleasure and avoid pain. It's hard because we're living in a dopamine overloaded world where everything has become drugified.

Everything has been made more accessible, more abundant, more potent, more reinforcing, more novel. And so we're really living in a world that has turned us all into addicts, essentially, plus our primitive wiring that's not really evolved for that ecosystem. And to understand sort of how we get out of that adaptive, healthy seeking of dopamine and fall into that maladaptive, addictive, seeking of dopamine, it's really important to understand that pleasure and pain work like a balance in the brain and that the same parts of the brain that process pleasure also process pain. And if you like, I can describe sort of that relationship. Yeah, yeah, please do. I'd love to hear about it.

Okay. So if you imagine that in your brain, there's a balance like a teeter-totter in a kid's playground, okay? And when we experience pleasure, it tips one way, and when we experience pain, it tips the opposite way. And one of the overarching rules governing that balance is that it wants to remain level. It doesn't want to be tipped for very long to the side of pleasure or pain. And our brains will work very hard to restore a level balance or what neuroscientists call homeostasis. So when we do something pleasurable, okay, so in my case, that might be reading a romance novel or eating a piece of chocolate or my morning cup of coffee. What happens is that I get a little release of dopamine

in a part of our brain called the reward pathway and my balance tips to the side of pleasure. But no sooner has it done that, then my brain will try to restore a level balance by down-regulating dopamine production and dopamine transmission, not just to baseline levels, but below baseline levels. So, and I imagine that as these little gremlins hopping on the pain side of the balance that bring it level again, but they like it on the balance. So they stay on until it's tipped an equal and opposite amount to the side of pain. That's the come down, the after effect, the hangover, or that moment of wanting, you know,

one more cup of coffee or, you coffee or wanting that novel not to end or wanting to watch one more episode. Now, if we wait long enough, those neuroadaptation gremlins hop off and baseline dopamine levels are restored. But if we don't wait, if we continue to consume our drug of choice repeatedly over days to weeks to months to years,

we end up with enough gremlins on the pain side of the balance to fill this whole room. In other words, we end up with a pleasure pain balance that has a new hedonic or joy set point. It's now chronically tilted to the side of pain because those gremlins are camped out there, and we are in a dopamine deficit state. In other words, to compensate for the increase in dopamine in our brain's reward pathway, beyond what our brain has evolved to deal with, we essentially go into this chronic dopamine deficit state. And once we're in that state, we are struggling with the addicted brain. And then we need our drug not to feel good, but just to restore our level

balance and feel normal. And when we're not using, we're experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and intrusive thoughts of wanting to use. Yeah, that sort of idea of a seesaw and we move to the side, we have our drug of choice. And, you know, as we're going to talk about, this doesn't necessarily need to be alcohol or, you know, cocaine, this can be sugar, this can be coffee, this can be Instagram. And so we press on pleasure on the seesaw. And you're saying that actually the body then responds by the seesaw goes in the other direction to move us to try and recreate balance. But if we keep doing this day in day out, the seesaw gets stuck.

And actually, we're just left craving all the time. We take any dopamine hit just to get back to normal. That's right. So in the world in which we live, if I think back to me as a child, the internet did not exist. and we would hear about addiction. We would hear about drug addicts and alcohol addicts, right? So clearly back then without, as you so beautifully call it, what is it? The smartphone is the modern day hypodermic needle. Just such a beautifully evocative way of looking at the modern day smartphone. Addiction was still a problem back then. What has happened with the internet? What has happened with smartphones to our, I guess, our propensity for seeking pleasure, our propensity for addiction?

What has the internet done? So the internet has really turned us all into people struggling with compulsive overconsumption on a number of different levels. First of all, the device itself is quite reinforcing. Screens are like primitive fires that we are drawn toward and gather around. The kind of tapping and swiping I think really taps into, no pun intended, our sort of primitive desire to use our hands in repetitive ways. The phone itself is, you know, indeed a portal to drugs that have been around forever. Like I can use this phone to order cocaine to my doorstep, like ordering a pizza, right? But it's also made drugs that have been around for a long time, but were harder to get like pornography, much, much more accessible. So starting in the early 2000s, I started to see more and the phone that made these graphic images and then ultimately live people so accessible that really then conspired to make

what had been a manageable use of pornography or masturbation into a compulsive, you know, debilitating life threatening problem. And then finally, the internet has created drugs that literally did not exist before things like video games. And yes, games have been around forever, but the internet and the screen and the software have allowed for these incredibly vivid experiences that are really unlike anything that you would find in real life. Social media too. So human connection is healthy and adaptive, but social media manages to take the healthy aspects of human connection and potentially drugify them with the bright lights, the curated profiles, the beautiful images, the bottomless bowls, the likes, the rankings. When we enumerate things, we make them more potent, they release more dopamine. So for all these reasons, very exciting, wonderful technology really does have this dark underbelly. You start your book with a very striking case of sex addiction, and

you are an addiction specialist. People are coming to you, you know, presumably when they've exhausted all other options and they really, really need help. Whereas for me, often it's like their first portal. It's like, okay, I need to go talk to my doctor about this. And I can remember vividly this young man in his early twenties. He came in, he was sort of, wouldn't make eye contact with me. And, you know, he started, you know, once I was sort of wouldn't make eye contact with me and you know he started you know once I'd sort of gained his trust and really tried hard to connect with him soften my tone so he would open up you know he couldn't look at me as he was telling me how much he was using pornography and how it was um frankly destroying his life his social life his life, his social life, his life with his family. And I kind

of feel we really need to talk about this because not enough people are talking about this. We're talking about other addictions. We talk about social media addictions, about alcohol, about sugar, all these things, they're okay. But sex and pornography, this is going on. This is a massive problem. And I think in that secrecy, in the shame that builds up in these people, this addiction thrives, yet no one's really talking about it. So I'm fascinated that you had the courage, I would say, to open up your book with this story. So I wonder if you could talk through why you decided to start with this story. So I wonder if you could talk through why you decided to start with this story, because on one hand, it could put people off. People might go, I don't want to read about this.

But as you so beautifully say, you said these things, instead of putting us off, they really show us what we're all capable of. What exactly did you mean by that? Well, first, let me say thank you for acknowledging that it did take some courage to open with that story. And I also want to just express my deep and enduring gratitude to all of my patients who were willing to allow me to share their stories, you know, anonymously, because that was a tremendous act of courage on their part. And I did get feedback from my editors saying, well, you know, maybe you should hide this sort of more in the middle of the book. Do you really want to open with this? But I agree with you. This is a huge problem. And although there's a lot of stigma and shame

with all kinds of addictions, I think there's more stigma and shame with sex addiction than with any other and more misconceptions where people think that people, you know, can just stop, that it's not that big a clinical work, that for some people, it is a devastating, compulsive, life-threatening condition that is very, very difficult to manage in a world where they're constantly being not just reminded of sex, but literally chased down. I mean, even I, in my professional Stanford email inbox, get solicitations for pornography. Insane, right? I mean, I don't know where they come from or how they get my email, but, you know, if I had a very severe sex addiction, that right there might be a trigger that, you know, in my efforts to maintain recovery would send me down that road. So, you know, I think this is a growing problem, especially among men, growing numbers of young men. It's also, you know, normalized. So pornography use, I think,

has really become very normalized. And so the insidious compulsive nature or the point to which people can get, I think is really not appreciated because it's become sort of so normalized. And as I talk about in my book, you know, this patient who developed the severe sex addiction, wonderful man, a scientist, a brilliant, you know, Stanford scientist, a very kind man, a father, a loving father, scientist, a very kind man, a father, a loving father, a loving spouse, committed to his wife. So this is the way that addiction can just take hold of us and drive us to engage in behaviors that are not consistent with our goals or values or any of it. And the other thing, as you know,

that I talk about in my book is that I saw parallels between my patient with this very severe sex addiction and my own compulsive reading of romance novels. Romance is in many ways sort of socially sanctioned pornography for women. And I started out with The Twilight Saga, which was a vampire romance novel written for teenagers. I was in my early 40s. I just heard some mothers talking about it. I thought, oh, that sounds fun.

They liked it. I read it. I was completely transported by it. And by that, I mean, I was egoless. I was out of my body. I did not experience myself. I achieved non-being, which is what we crave so much

in this modern world of hyper-stimulation. We want to forget ourselves, essentially. And this provided that for me, and then also led to about a two-year trajectory of me reading more and more graphic, essentially pornography novels that I had to acknowledge at some point had become a problem. So when I saw this patient, I did not see him as other than I, I saw him as somebody who could have been me, had my trajectory just been a little bit different. There's something really powerful, I think, about what you just said. You are

a respected neuroscientist, medical doctor, you've written books, you're considered a world leading expert. And you were able to engage in a societally sanctioned version of pornography or, you know, romance. And that's okay. You know, you're a, you know, it's, this kind of speaks to this wider points and problem of addiction, isn't it? And what is okay? And what is deemed as, well, at an extreme, what is deemed as criminal, which is, you know, that's another point altogether. Should people in real needs of help who are in so much pain that they're using whatever they can to numb that pain. At what point do we bring criminal charges against them? As a society, I feel it's a conversation that needs to be had. But that view of a man who might be addicted to sex,

they're shunned, aren't they? That's sort of, that's, um, that's a dirty man. You know, that you mentioned that you were encouraged to perhaps not start the book with that story. And if I could just share that I have just handed in the manuscripts on my next book, uh, which comes out in a few months, uh, to do with happiness and mental wellbeing. And I also have a very small section covering the problem with pornography and pornography addiction. And again, my publisher also said, do we really need this in the book? And I was very firm and I said, look, the problem by not speaking about this, this problem is thriving in silence and secrecy and that secrecy becomes toxic. Yeah. Well, good for you. I'm glad you stood your ground.

Yeah. Well, let's see what happens when it gets printed. I guess they release it, but I'm pretty sure it will be there. I think it's very important. So if we go back to dopamine and this balance, let's broaden this out beyond, you know, sex addiction. What happens with repeated exposure to the same drug? Does the seesaw change? Do we need more and more to get the same hit? I mean, and how does that play out for you when you see patients? Yeah, so that, so, you know, getting back to sort of the rules of the balance, the first rule, remember, is that the balance wants to stay level and it will work hard to restore a level balance. And it does that in this really interesting way, which is to tip an equal and opposite amount to the initial stimulus. So if the initial stimulus is pleasure, there's a price to pay for that,

which is this transient experience of pain before the balance goes back to baseline. Another important rule governing this balance is that with repeated exposure to the same or similar stimulus, that initial response to the side of pleasure gets shorter and weaker, but the after response to the side of pain gets stronger and weaker, but the after response to the side of pain gets stronger and longer. So if we use the same drug over and over again, after a period of time, we will get less pleasure from it. But the price that we pay, the after effects, the come down gets longer and stronger. And this is why repeated exposure ultimately kind of drives us into this chronic dopamine deficit state where nothing else is enjoyable, where our focus narrows

to our drug of choice. And that's the only thing that we look forward to. And then importantly, tolerance develops, meaning that we need more of that drug quantity-wise or more potent forms of that drug in order to get the same effect or in order for it to just work at all. One of the things I commonly see, for example, in cannabis users is that cannabis is this miracle drug for them. It helps them sleep. It relaxes them. It makes them more creative, although I must say they feel more creative, whether they're actually creating is in question. And then over time, what they'll report is that it stops working as well. They need more and more to get the same effect. And then ultimately it turns on them. And this is really fascinating because what it means is that the brain has

thoroughly learned and adapted to that drug such that after a while, it doesn't tip the balance at all to the side of pleasure. But as soon as it's introduced it doesn't tip the balance at all to the side of pleasure. But as soon as it's introduced, slam, the balance will go down to the side of pain. Those neuroadaptation gremlins that our brain creates to restore balance don't go away, right? They're like waiting in the wings, ready to hop on. And as soon as we use, they tilt us.

That's why people will report, you know, now when I use cannabis, I get paranoid. I get anxious. It does the opposite. It makes me vomit the opposite of what it used to do. And that, you know, you can find for a lot of different drugs. Opioids used chronically can actually make physical pain worse. We're seeing this here with chronic pain patients. You know. Any of our drugs of choice, if we really think about them, we can ask ourselves, am I really even enjoying doing this anymore? I'm like caught in it. It's hard to stop, but I'm not sure I even like it anymore, which is why, again, dopamine is so essential to this like wanting something even when we don't necessarily

like that thing the way you describe that i think many if not most people listening or watching to this right now could probably find something in their life that fit that description? Yes, of course, it could be social media, it could be sugar, it could be caffeine. What do you see? How would you define addiction, first of all? And then from that, I think it'll be useful to go into what are some of the things that you find people are probably addicted to, but because they're normalised in society, often people don't actually think of them as addictions. At the one that's top of my head, I think a lot of the world is addicted to caffeine in a big, big way. So yeah, could you maybe sort of unpack some of that and sort of start off maybe with

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limited time offer, all you have to do is go to drinkag1.com forward slash live more. That's drinkag1.com forward slash live more. Very broadly speaking, addiction is the continued compulsive use of a substance or behavior despite harm to self and or others. And if we're going to break it down further, we can talk about the four C's, control, compulsion, craving, and consequences. Control means using more than I plan to use. Compulsion is a lot of my mental real estate focused on using, a sort of

narrowing of my attention as well as level of automaticity to my use. Craving is a physiologic or psychological overwhelming urge to use despite my intention not to use. And then consequences is health consequences, relationship consequences, work consequences, you name it, spiritual consequences as a result of my using, especially when I can see that there are consequences and continue to use. You'll notice, Rangan, that none of those behavioral descriptions or psychological descriptions has anything to do with the physiologic tolerance, dependence, and withdrawal that is also part of addiction, right? Needing more and more to get the same effect. When I stop using, I go into physical withdrawal or more commonly psychological symptoms of withdrawal,

which again are anxiety, irritability, insomnia, depression, intrusive thoughts of using. But sometimes I'll have patients come to me and they'll say, well, you know, I'm not addicted to cannabis or I'm not addicted to alcohol because I can stop using. And when I stop, I don't have any withdrawal. But you don't need to have that physical dependence in order to be addicted because the addiction is happening in the reward centers of the brain where we go into that dopamine deficit state, which might only manifest as psychological symptoms of withdrawal independence, not necessarily physical symptoms of withdrawal independence. So yeah, getting to the second part of your question. So what are the things that many of us are addicted to that we don't even acknowledge? Caffeine is certainly way up there. Alcohol is so ubiquitous and so normalized. And I think many, many people use in ways that are

not healthy, but are able to tell themselves that their use is okay. I would also put really high up on that list, a lot of digital products and devices, and I would put up their work, devices. And I would put up their work, you know, addiction to work. It's so socially rewarded, right? That sort of 24 seven, I'm on it. You know, I'm reachable wherever you want to find me, high stress. And, you know, when we add a shot of adrenaline to something that also releases dopamine, it makes it even more reinforcing. There's a fascinating study looking at rats. If you inject a rat with cocaine, slice open its brain, what you'll see is this incredible arborization of dopamine-releasing neurons in the reward pathway. If you take a rat and subject it to an intense painful foot shock,

you will see the identical arborization of dopamine-releasing neurons in the reward pathway. In other words, we can actually probably get addicted to highly painful stimulus too in the form of work or news. That's why doom scrolling kind of comes in. So there are lots of things that I think are socially sanctioned. Again, I think work is probably, I would put at the top of the list, that we kind of don't acknowledge. Even my own attachment to my email.

So I'm not on social media. I do have a phone, but I mostly keep it turned off in my bag for emergency reasons. But I have to really watch myself with my email, which is sort of my work-sanctioned social media. I try to take a digital Sabbath once a week and it's really hard, but by the end of that day, I don't even want to go back to using, because what I'll notice when I go back to my email is I'll answer the emails that need answering and then I'll linger. I don't want to leave it. I'm sort of waiting for something good or reinforcing to come in, or I'm continuing to scroll through and read the things I've read before, you know, as a way of kind of making myself feel like, okay, I still need to be here

in this space, but really I don't. I should just get out of my email and move on to the next thing. And I've developed some tricks for coping with that, but it's really hard. Yeah. I mean, what you're speaking to as well is ease of access. move on to the next thing. And I've developed some tricks for coping with that, but it's really hard. Yeah. I mean, what you're speaking to as well is ease of access. You know, how easy it is to access clearly makes a huge difference. And I guess work, again, going back 20, 30 years ago, when we didn't have email or the ability to have email in our pockets, you know, when you left the office, you were probably barring an emergency where someone when you left the office, you were probably, barring an emergency where someone phoned your landline, you were probably kind of done, right? You would naturally be able to switch off. And I think there's been this insidious creep.

We've not really, I think with technology, for me, it's about intentionality. We've not really asked ourselves or many of us, what do we want this smartphone for? We take it with, like it's the sweet shop with all the goodies on it. And it's kind of like, well, why don't you think about what do you want from it? Okay, I want to be able to make calls. Okay, great. You want to be able to make text messages. Okay, great. Right. What else? You might want to listen to music okay you know and and actually introduce the apps that you want right that are going to enhance your life rather than make you a slave and i guess that email piece is if you don't have email on your phone it's just a hell of a lot easier to not be checking your work emails right at the weekend yeah which gets to one of the you... So dopamine nation is not just about the

problem. It's also about what we can do about it. And one of the recommendations in addition to the dopamine fast is these self-binding strategies, which is essentially creating literal and metacognitive barriers between ourselves and our drug of choice, exactly what you describe, that if we make it harder to access our drug of choice, that little bit of a pause is often just enough to make us, to allow us to decide not to use in that moment. And that's really, really important. is there something about cheap dopamine versus expensive dopamine and the reason i asked that question is my son really loves to play snooker um so pool billiards he really enjoys that and last year there's a local coach i got him a couple of lessons. He went and really enjoyed it. And I asked the coach, are you getting many kids coming these days? I said, no, we used to get so many kids coming, but he says we hardly get anyone anymore.

And his theory was because people can get dopamine hits so quickly and easily on their phones these days, hit so quickly and easily on their phones these days to come and actually learn a difficult game that requires patience, practice, discipline, before you get to that sort of position where you actually gain the pleasure from it. He's saying, look, I just don't think people have got the desire anymore to work that hard for their dopamine. Now, I don't know, he's not a neuroscientist. So is any part of that accurate? Like, are we sort of bringing up a generation of kids now who are so used to getting their rewards quick and easy, that they're going to be unwilling to do those harder, more challenging things? I mean, absolutely. I mean, this is essentially what I have seen over the last 25 years in my practice. Growing numbers of kids raised in loving homes with incredible privilege and access to the best education, sports, you know, friends, you name it, who are increasingly narrowing their world to themselves in their rooms with their devices. And I mean, it's just, it's, it's terrifying because the result is that progressively

they are shifting their joy set point to the side of pain. They're ending up in this dopamine deficit state with the gremlins camped out in the pain side of their balance, such that they need greater and greater rewards to feel anything at all. And they have more and more pain, any little kind of, you know, injury, no matter how, how slight is truly injurious to them because they have no resilience. They don't have, you know, their dopamine levels are not at healthy baselines. They're inundated with dopamine and just living essentially in their lizard brain, which is that, you know, limbic part of the brain where the reward pathway is mostly located. So I do think this is, you know, this is of great concern. And many of these young people will come in, you know, endorsing anxiety

and depression and thinking that I'm going to prescribe them a pill or that we're going to do some kind of talk therapy, or we're going to find out their trauma, you know, what led to it. I'm like, no, you know, I think what led to it is that you're playing video games all day. And if you would stop that for a reasonable enough length of time for those neuroadaptation gremlins to hop off and for your, you know, your own brain to start to regenerate its own dopamine, you would feel better. Even further, if you go and press on the pain side of your balance and get off the couch and turn off, you know, all of the devices and go outside and go for a walk, something that's really challenging for a lot of people today. You know, you will actually, by pressing on the pain side of the balance, you will tell your body, oh, I need to start to upregulate my own dopamine production, right? Because then the gremlins hop on the pleasure side.

It works both ways. upregulate my own dopamine production, right? Because then the gremlins hop on the pleasure side. It works both ways. And that will create a more resilient, happier brain. But super hard to get people to realize that because in the moment they feel like, oh no, you know, being online and social media and video games, that relieves my anxiety and depression. What they can't see is that in an iterative process over time, that's actually what's causing the anxiety and depression. I mean, this is something that really worries me, if I'm honest.

I, you know, as a doctor looking out at society, but as a father of two young children, this has been something that has really occupied a lot of my brain space for the past few years maybe over a year ago a patient of mine a young adolescent girl who had tried to harm herself and I won't sort of recount the entire story now but essentially the way I managed to help her was primarily by helping her to not use her phone and social media as much. And it was a ripple effect started in her life where six months later, she was unrecognizable, completely happy, grounded, connected kids. And that was probably intervention number one was reducing her phone use.

That's right. Is that something you've seen as well? Oh, absolutely. So that's the prescription from Dopamine Nation. And it's something that I've used repeatedly in my clinical work. The first intervention when I have patients come in with depression, anxiety, insomnia, inattention, I say, let's eliminate your drug of choice, whatever it is, whether it's social media, video games, cannabis, alcohol, we're going to take it

away for a whole month. Why a month? Because a month is typically the minimum amount of time it takes for the brain to restore dopamine levels back to healthy baseline. I also warn them that in the first two weeks of abstention or the dopamine fast, they're going to feel worse before they feel better. Why? Because those gremlins are camped out on the side of pain and they're in a dopamine deficit state, which means when they're not using their drug, they're in withdrawal. So I tell them you're going to be more anxious, more depressed, restless. You're going to have intrusive thoughts of wanting to use your phone, play video games, use cannabis, drink alcohol.

But if you can just get through those first two weeks, by weeks three and four, the light really does come out and you will notice yourself feeling better. And almost universally, that is what happens. And I've been doing this for 25 years. So I really believe that this works because I have a huge sample. And exactly what you described with your, you know, young, young patient on social media, you know, patients will say it's hard, but they definitely have reduced anxiety, depression, insomnia, all of it at a month. Not only that they have insight, because now they're able to really look

back and see the true impact of their use on their lives, which is really hard to do when we're in it. It's only by changing something in that biological system, forcing our brains to start to regenerate our own dopamine that we can look back and say, oh my goodness, that's surreal. I can't believe I was so invested in that. And that I think is a second critical point, because that's empowering for an individual, isn't it? That gives them a sense of control, a sense of agency that, oh, I get it. When I engage in these behaviours, my mood goes down, I get depressed, I get anxious. When I engage in these behaviors, my mood goes down. I get depressed, I get anxious. When I restart again, or when I come off it, I feel better. When I restart again, I get worse. It doesn't mean you're going to get, certainly through what I've seen, it doesn't mean the first

time you're going to get it right. You're going to stop and then you're all good. No, but it's a process of education each time. And every time you go back, you keep reminding yourself, oh, do you know what? I feel better when I'm actually not on this stuff. That's right. And I always frame it to patients as an experiment. I said, you know what? You're the scientist. This is the experiment called your life. Let's gather data. The best way to know how a system is working is to change something in that system and see what happens. So the experiment that we're going to do is you're going to eliminate this drug for a period of time and see what happens. And my hypothesis is that

you will feel initially much worse because you will be in withdrawal and craving, but if you can make it a long enough period to restore homeostasis, you will feel better. And when patients see that for themselves and experience that for themselves, I no longer have to convince them that it's a worthy project. One of the most common questions I'll get asked from family members, what can I do to get my loved one into treatment or to get them to see that they have a problem? I said, you know, the dopamine fast is almost the best thing that they can do because once they do that themselves, they'll be able to connect the dots and then they will be motivated to make the change in their life. Now, Rangan, you know that, you know, abruptly stopping your drug of choice is not something you would recommend in somebody who's at risk for life-threatening alcohol withdrawal,

benzodiazepine withdrawal, or opioid withdrawal. Those individuals may indeed need medically monitored detoxification in order to get into a dopamine fast, which means that they might need a slow taper or another medicine to prevent life-threatening withdrawal. But for the vast majority of us, especially those of us who are addicted to our devices stopping cold turkey is perfectly fine you use the term drug of choice so whichever that patient's drug of choice is they would try and go on this four week dopamine fast. I would love you with your 25 year clinical experience to paint a picture of what variety of drugs have you applied this

dopamine fast to? Because I suspect it's not just the kind of classic ones that we think in our brains. Right. Well, I'll just start with alcohol, nicotine, cannabis, cocaine, methamphetamine, and other stimulants, opioids, benzodiazepines. Although again, with opioids and benzodiazepines, some of those people need a medically managed taper and stopping abruptly would not be appropriate. But then there's the whole raft of behavioral addiction. So these are processes, and often food is put in this category, but food would include

sugar, processed foods, empty carbohydrates, along with processed food that we commonly refer to as junk foods, gambling, which comes in many different forms now, including kind of high class investments in cryptocurrency, which is looked at as sort of really cool. And, you know, sort of that's not gambling because, you know, that's, I don't know, that's what stockbrokers do or something, you know, Stanford undergraduates, that's what they do. But frankly, that's obviously a form of gambling hood. Interfaces like the Robinhood interface know how to make that addictive, right? With flashing lights and congratulations. What is the Robinhood interface? So typically, if you wanted to, and again, money is not my area of expertise, but if you wanted to buy shares

in something, you needed a broker, but now there are apps that sort of take that away and you can just do it yourself. So in a way it's like kind of a democratization in a way of, you know, investment, which is a good thing in many ways I can see, but it also means that the average person with limited education and the potential for addiction is on there, you know, gambling away, you know, the family home for cryptocurrency, right? So potentially super dangerous. All of this stuff, pornography, anything related to sex, much of it now happening online. Games, gamification, video games, YouTube, pretty much anything online has the potential for addiction. Basically, what you're saying is

pretty much anything that people now use to distract themselves from their lives to get a bit of relief, to get some pleasure. It sounds like, again, going back to what you said at the start, right? It's about that balance piece where there is, you know, you want to get that dopamine hit, but you don't want to do it so much that you start to tip the seesaw where it gets locked and then you're in this dopamine deficit states. Yeah. That's right. That's right. And what I'm arguing for in a way is sort of a new form of asceticism, you know, asceticism being the practice of eschewing or avoiding intense pleasures and actually inviting painful practices into your life. But, you know, the

asceticism that would be considered painful in the modern age is literally for some people just getting up off the couch and going outside of their homes for 30 minutes a day and walking around. I mean, that's an unplugged, unplugged, walking around in their neighborhood. That is painful for some people because of the extent to which we are sedentary, the extent to which we're plugged in, the extent to which we are overstimulated. But I really do believe that it's a major cause of our unhappiness. And the epidemiologic data would bear that out. Over the last 30 years, we've seen massive increases in depression, anxiety, suicide, in rich nations more than in poor nations, in nations where people have access to all of this abundance. A world survey happiness report that was done in 2018 surveyed

128 countries and found that people were across the board more unhappy in 2018 than they were in 2008 with people living in rich nations being the most unhappy right so it's a paradox but it's because we've reached this dopamine tipping point yeah it's this apparent contradiction that the more money we get the more material possessions we get the unhappier we become the more depressed the more anxious the fearful. And I guess we all know those kind of simple pleasures, whether it's going camping or going for a long walk in nature with a partner or your family or a friend. You know, we know how good we feel afterwards, how free we feel in our minds.

Yet, it seems like the hardest thing to do these days for so many of us. And I'm sure the smartphones are part of that because you're just sitting there. You can have all the stimulation you want on that phone. I think I first said this on my conversation with Arianna Huffington about a year ago on the podcast. I said to her that for me, one of the problems with smartphones, for all their benefits, is that I strongly believe they are fragmenting the most important relationships in our lives. Because no human being around you can compete with what is on that thing. And, you know, when you have patients who come in, who, because a smartphone is very hard to exist in life now without a smartphone for a variety

of different reasons. So how do you handle that with patients who might have a smartphone addiction? Well, again, I think that the most important initial intervention is a period of abstinence from the drug of choice. So if it is a smartphone addiction, the intervention, the treatment will be to put that phone away for a month. And the two reasons to do that, just to highlight them again, are to restore healthy dopamine pathways, right? To allow the gremlins to hop off so that homeostasis can be restored. Why is that so important? Because when we're in that dopamine deficit state, more modest pleasures are no longer rewarding. So I want to get back to

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

so that after we have a level pleasure pain balance, if we go back to using, we have to make sure to leave enough time in between for the gremlins to hop off the pain side and for homeostasis to be restored. And we want to avoid intoxicants that press our pleasure pain balance too hard and too fast to the side of pain. Because once we're doing that, we're accumulating these great big Arnold Schwarzenegger gremlins on the pain side to bring us level again. And then we're essentially at war with our gremlins. So the trick is to restore homeostasis with a dopamine fast, and then to stay in a supple, dynamic relationship with our pleasure-pain balance so that we are ingesting rewarding things in modest doses infrequently. at the same time that we're inviting painful activities into our lives in order to get those gremlins to hop on the pleasure side, right? Which is essentially telling our bodies, oh, there's a painful stimulus here. I now need to make my own dopamine and serotonin and norepinephrine and endocannabinoids and endo opioids in order to counteract that painful stimulus.

And that's good because that keeps us in this place where, you know, we are not just shutting down our dopamine factories. We've got our own dopamine factories running, you know, making that feel good hormone. As you described there, that compared to what is on our smartphone, a walk in nature with a loved one or going camping actually does feel a bit boring and dry compared to all the excitement and colours and vibrancy we can get on this phone. I thought of sugar as well, in the sense that the way that the food industry has hijacked our taste buds. If our kids and us as adults are constantly having highly processed foods, if we're having all these super sweet, you know, food-like products, I guess, that have been

made by the food industry, then suddenly a beautiful ripe peach on a summer's day is bland. Right. Very well put. Yeah. You know, it's very similar, isn't it? Yeah. Yeah. It's the theory of relativity with regards to pleasure and pain. And they really are relative where our brain is constantly recalibrating in response to the stimuli in our environment. I mean, again, that ability to be adaptive to external and internal stimuli is part of the genius of our species and our ability to have really dominated this planet for so many millions of years.

But that is our downfall as well because this constant recalibration to pleasure and to pain in a world where we're insulated from pain and exposed to incredible overabundance of pleasure means that nothing's pleasurable anymore you know nothing's nothing has pleasure you are a parent like me um i think your kids might be a bit older than mine from what I can tell. My current approach, and I'm interested in your view on this. Of course, I'm always thinking about what I can do to help my patients. I'm also thinking about what I can do to help my kids. And having seen

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

to be social outcasts. Yet at the same time, you are cautious over what they, or certainly I was very cautious about what he's been introduced to. Now I ended up caving in the summer in the sense, I say caving, it was an intentional decision. You know, the high school is a bit further away. All of his peers have a smartphone, every single one. That's how they communicate. And I thought, it's really not fair of me to not allow him to be with his tribe in that way. But we have set some ground rules. I've got to say, he has been exquisite at following them so far. So I touch wood that that continues. Yeah.

But simple things like the phone is not allowed in his room. It always has to be used in the kitchen area where other people are around. You can't take it somewhere to go off. This may sound quite draconian, but we're doing what works for us as a family. And I would never cast judgment on how someone else decides to parent their kids. And actually, so far so good. But what I've decided to do beyond phones is, because my wife and I were talking about gaming, Again, a lot of his friends play video games and they play online together. Now, we've not gone down that route because I just think once you open that door, for me, it's going to be very hard to close it. And another thing that I think has happened across the world,

certainly in the Western world, over the last year and a half, even schools that were not really using technology much because of all the lockdowns, screen time now has become a part of education for a lot of schools. So I said to my wife, look, he's getting enough screen time already just to do his education. I don't want his leisure time to be on a screen as well. So a couple of things there. And the wider point for me is that it's like I say with food, you can't control the environment when you step outside your front door. So you're having to use willpower everywhere you go. So my philosophy has always been, try not to bring foods that you don't

want to eat into your house, because then you're not using willpower in the house and I feel I'm sort of creating a an almost like a dopamine cave or what's the opposite what's the opposite of dopamine like a almost a cave at home where actually there are no quick and easy dopamine fixes available at home what do you think is that approach is that going to get me in trouble in a few. What do you think is that approach? Is that going to get me in trouble in a few years? Or do you think potentially this may have legs? Before we get back to this week's episode, I just wanted to let you know that I am doing my very first national UK theatre tour. I am planning a really special evening where I share how you can break free from the habits that are holding you back and make meaningful changes in your life

that truly last. It is called the Thrive Tour. Be the architect of your health and happiness. So many people tell me that health feels really complicated, but it really doesn't need to be. In my live event, I'm going to simplify health and together we're going to learn the skill of happiness, the secrets to optimal health, how to break free from the habits that are holding you back in your life, and I'm going to teach you how to make changes that actually last. Sound good? All you have to do is go to drchatterjee.com forward slash tour and I can't wait to see you there. This episode is also brought to you by the Three Question Journal, the journal that I designed and created in partnership with Intelligent Change.

Now journaling is something that I've been recommending to my patients for years. It can help improve sleep, lead to better decision making and reduce symptoms of anxiety and depression. It's also been shown to decrease emotional stress, make it easier to turn new behaviours into long-term habits and improve our relationships. There are of course many different ways to journal, and as with most things, it's important that you find the method that works best for you. One method that you may want to consider is the one that I outline in the three-question journal. In it, you will find a really simple and structured way of answering the three most impactful questions I believe that we can all ask ourselves every morning and every evening. Answering these questions will take you less than five minutes, but the practice of answering them regularly will be transformative. Since the journal was published in January, I have received

hundreds of messages from people telling me how much it has helped them and how much more in control of their lives they now feel. Now, if you already have a journal or you don't actually want to buy a journal, that is completely fine. I go through in detail all of the questions within the three question journal completely free on episode 413 of this podcast. But if you are keen to check it out, all you have to do is go to drchatterjee.com forward slash journal, or click on the link in your podcast app. That approach is essentially what I do recommend in my book, Dopamine Nation. It's also the approach that our family followed. And again, I want to echo your statement. This is not a judgment of how other people parent.

This is how what we found works in our family. And also what I've seen work for many, many patients struggling with compulsive overconsumption, that we essentially, in a dopamine overloaded world, have to change our immediate environment if we're going to survive. And that means keeping high dopamine substances and behaviors out of reach. I think it's essential that kids under the age of 10, certainly, and even arguably under the age of 12, do not have access to their own devices. And that when they are on their own devices, that it's heavily monitored by their caregivers, whoever those are. And that's for so many reasons, but most important of all, that in that crucial

time of, you know, the early developing brain, we want to make sure that they develop the social skills and the coping strategies that are healthy and adaptive to last them a lifetime. And that means learning how to interact in real life with real people, right? Learning how to be in their bodies and do physical things and connect the brain and the body. Because everything that happens online is this disconnected experience where we're floating around in our heads, We forget our bodies. It's not in real life. Yes, there's interaction that happens between people online and some of that's really good and meaningful and complex. And even video games can involve, you know, good social collaborative skills, but the medium itself is so incredibly potent, reinforcing, and potentially addictive

that it's going to usurp any other types of learning. There's a very famous experiment where it turns out if you put rats into a very complex maze where they have lots of stuff to explore, and they have running wheels, and they have other rats, that if you examine their brains after exposure to that complex maze, you will see this incredible arborization of dopamine-releasing neurons in the reward pathway, just like you would see in response to drugs. But if you then pre-treat those rats with methamphetamine, a highly addictive drug, and then release them into the maze, what you see is no additional learning as a result of exposure to that maze. In other words, that pre-treatment with methamphetamine is such an intense stimulus

that it essentially usurps the brain's ability to get anything out of learning in a complex environment. And I think the same thing can be said for us when it comes to these digital online products. So we have to protect our children. We have to create that bubble. We have to make sure they have friends in real life, sports that they're doing, creative, sustained attention, systems for organizing themselves. Because once they go online, if they don't already have that foundation, they will not learn them, or at least it will be extremely difficult. And then, you know, I agree with you that, you know, a lot of social stuff happens online. So of course, we don't want our kids to be excluded. On the other hand, you know, those kids, like you say, at school, I mean, you think, I think if you asked your son has, have you played video games?

Of course he has, because he's done it, you know, in between class time or at lunch, or maybe even during class time, you know, if not with his device with other people's devices. So we don't need to worry about our kids not having literacy, computer literacy, or not having computer exposure because they have lots and lots of time that we don't supervise anymore. And once they become teenagers, all bets are off. that we don't supervise anymore. And once they become teenagers, all bets are off.

We have zero control, which is why that first decade is really key to laying down the kinds of reward pathways and learning pathways that we want, but also having important discussions about what is healthy digital use? What is appropriate digital etiquette? What are the values in our family? And how do we expect you to conduct yourself online

and vis-a-vis this device, which is a drug, by the way, which is a potential drug. And then one last thing I want to say is that everybody comes to these drugs with differing degrees of vulnerability. We have four kids. Our older three, when they finally got a phone in high school, and high school here is starting around age essentially 14,

three of them were able to handle it. Our youngest hasn't been able to. And we've had to take the phone away. So you give it to take it away if your kid can't handle it. And essentially, he was just on it all the time. You know, he wasn't paying attention to class. He couldn't break away from this device. He was that kid. So it's also important to acknowledge that there are differing degrees of vulnerability. Most kids will probably be able to handle it and figure it out, but probably about 10 to 15% of kids are going to

get into real trouble. And those kids we can't ignore. Yeah, I appreciate you sharing that. Actually, coming back to your book, and I did say this at the start, but it is one of the favorite books of mine that I've read recently. It is fantastically written. And I'll tell you, Anna, what I love about it the most, you know, I love science, but this is so much more than science. This, to me, speaks of a human being with incredible life experience, a clinician with a lot of practical clinical experience. And you sort of blend in science with, you know, real life human experience, because it doesn't always connect. I found as a clinician that scientific studies

don't always help me one-on-one with my patients. And I love the way you've blended it all together. And if I may say, I kind of feel that there's quite a philosophical component to this book as well. There's lots of really good kind of lessons for life. So I just want to appreciate you and acknowledge you for that. I think it really is fabulous. Thank you. I am very touched by that. It means a lot. Thank you.

No, not at all. I really, I hope everyone goes out to get it. It's a brilliant read. I want to move on to something you wrote right at the start of the book. And I think it's the introduction. You put a quote there from Kent Dunnington. Persons with severe addictions are among those contemporary prophets that we ignore to our own demise. For they show us who we truly are. I read it. I underlined it, and I was immediately drawn to

two conversations I've had on this podcast before. One with Rich Roll, who I know you've been on Rich's show. Rich is obviously, I say obviously if people are familiar with Rich, he in the past suffered with addiction to alcohol. I also had a conversation with a singer-songwriter called Benjamin Francis Lethwich. Again, he had real problems with addiction. He's been sober for I think three or four years now. And I find in the conversations I truth that you don't often get and I feel that there's something about these people and the walls that they've come against come up against in their life that's really forced them to confront what it truly means to live a happy, peaceful, content life. And I think that quote kind of sums it up beautifully. Yeah, I mean, I agree with you. And, you know, I came into treating

people with addiction reluctantly. It's not something I set out to do, but really they've become sort of my spiritual heroes, people in recovery, because of the tremendous courage and fortitude and tenacity that it takes to get into recovery, especially in this dopamine overloaded own lives, to other people, this kind of acknowledgement of suffering and struggling, which I think is so often, you know, hidden in our everyday discourse. I'll never forget early on when I went to a medical meeting of the California Society of Addiction Medicine, which was composed of doctors treating addiction medicine. And I did not realize that many of those individuals were themselves in recovery from addiction. And I had been to so many medical meetings and I actually didn't really care for medical meetings. It's a lot of doctors standing

around talking about how great they are and how much, you know, how much they know. And I would always leave those meetings sort of feeling like, God, what have I done today? You know, what a, what a schlep I am, you know, compared to all these brilliant people. And then I went to this meeting of addiction medicine doctors and there was a lunch, you know, thing to go to. And I went there and the first doc gets up and he starts talking about his cocaine addiction and how he would steal. And I about fell off my chair. I was like, is this really a doctor who's talking about his addiction and what he did in the past, you know, in the service of his? I mean, I was astounded. astounded. And yet it was so incredibly beautiful because it was like, wow, this is a space where we can all be our messed up selves. Like we don't have to pretend anymore that our lives are perfect.

And it was just, it was so attractive and compelling to me that I just had this feeling, yeah, this is, these are the, these are my wounded warriors, right? These are, yeah, these are my wounded warriors, right? These are the people that I want to affiliate with. And that's been, you know, a continual sort of draw for me in the treatment of people with addiction is the other wonderful people who do this work, many of whom are in recovery themselves. And just, you know, the incredible wisdom and humility

that, you know, having an addiction and then getting into recovery, you know, gives people access to, and also the spiritual aspect, which is, you would think spirituality would be a big part of the practice of medicine, but actually it's not, you know, we're sort of not even allowed to say, you know, God or religion or ask people about that, but in addiction medicine, you can still talk about that. It's, you know, it's a, it's an important piece. And so that's been a real draw for me too, a kind of, yeah, you know, science is so important, but there's a lot that science can't answer. And it's great to have a space and a way of talking about the things that science can't solve.

And so, you know, I'm grateful for that too, in the field of addiction medicine. I imagine that doctor who shared his cocaine addiction with you and other colleagues, I would imagine that him being able to do that, him going through that and hopefully coming out the other side of that there's no doubt in my mind that that would absolutely enhance his ability to not only connect with his patients but also help them afterwards right you know and it's i think that's that stuff's important what you said about spirituality there. You're in addiction medicine. You say in addiction medicine, but I think to me as a primary care practitioner, addiction plays a role.

Low-grade addiction actually plays a role in so many of my patients. So many of their, in inverted commas, lifestyle behaviors that they are trying to reduce, they are low-grade addictions. Or the fact that they're getting stressed out and burnt out and they're up too late and they want to help sleeping actually at its core comes down to them being in a dopamine deficit state. than being in a dopamine deficit state. And actually they're engaging in practices that actually the answer isn't necessarily, you know, me helping them with sleep hygiene or, you know, prescribing something to help them. If we're looking at real root cause

in this kind of digital dopamine era of abundance, it's kind of like what you're doing. I think it's relevant to pretty much all of us. Oh, I absolutely agree. And obviously as a primary care doctor, you know, you, I'm guessing like many primary care doctors, you went into it because you cared about having relationships with people through time and you care about preventive medicine, not just about, you know, treating illness once it comes, but actually preventing people from getting ill. 70% of the global deaths today are caused by modifiable risk factors. The top three

are diet, lack of exercise, and smoking. So we really have reached a tipping point when we are dying because of our behaviors. And I really do think that the problem of compulsive overconsumption or addiction is the modern plague that we will be dealing with for the next hundreds of years. Well, ironically, I would say that all the restrictions that have been put in place across the world, well, in many countries across the world over the past, what, 18, 20 months now, they've driven a lot of people into more isolation. Isolation was already a major, major problem. It's got a lot worse, loneliness, being by yourself. And I guess a lot of these addictions are kind of solo pursuits, aren't they? When we're not connected to our tribe and our families and our communities, we seek to, I guess, fill that void with something else. And for many people, that's kind of where addiction is born.

it's, it's both born there and it begets. So isolation, addiction is born in isolation and, but addiction also begets isolation. I think it's important to remember that many people with incredible families and wonderful spouses and amazing friends and a super social network can get addicted. And through that process of getting addicted, then pull away from the people in their lives. So although I agree with you that not having healthy attachments is a risk factor for addiction, it's also true that with all the healthy attachments in the world, you can still get addicted, and that when you do, it will cause you to isolate and pull away. The other important thing is, although I absolutely agree with you that COVID and quarantine has been isolating and devastating for people across the world that has caused many individuals to either become addicted or relapse or die from their addiction or start an addiction.

I also feel like there's a very large swath of people, including many of my patients for whom quarantine was a saving grace. It allowed them to slow down in their lives. You know, if they were living with family, it allowed them to refocus on family, spend more time together, strengthen that sense of belonging to a tribe. And many people got into better recovery from their addictions than they had in decades because they weren't constantly being stimulated by our sort of dopamine overloaded world where you can't even go to the grocery store without being told to buy this or buy that highly reinforcing substance. So COVID was a very fascinating experiment in that way because again, definitely very bad for some people, but for

others, a real respite. Yeah. I would echo that in my own experience as well, that some people, the isolation has been devastating, but for other people, not commuting for two hours a day, suddenly gave them two hours to either go for a walk before work or spend some time with their partner or their kids you know that's right so I guess it depends on who you who you are what your lifestyle was what your job was how much you commuted all those kind of things which I guess speaks to how there's no one- fits all in all of this, particularly in addiction medicine. I'm sure that there are, you know, everything has to be tailored to that individual. That's right.

You know, one of the, I loved all the chapters in the book, but one I really enjoyed was towards the end was this one on honesty, radical honesty. And that's something I think when Benjamin Francis Lefkowitz came to the studio a few months ago, and this is the singer songwriter who had struggled for much of his life with addiction. One thing I was struck with was the kind of raw, brutal honesty. the kind of raw, brutal honesty. I got this sense that I'm not going to say anything that is not completely aligned with who I am. And that chapter was brilliant. Can you talk a little bit about honesty? And why did you write that? Why is it so important? And how can even people who consider ourselves to be non-addicts, how can we benefit from more honesty in our lives? One of the recurring themes I have seen in my patients in recovery from addiction is how important honesty, telling the truth, is to their recovery.

And I've seen it again and again and again, even in patients who haven't gotten into recovery through Alcoholics Anonymous or another 12-step group. And those groups really emphasize the importance of honesty to recovery. And so people who are in those organizations, they know that's part of the philosophy. But even people who have gotten into recovery on their own, almost universally, they will say, oh yeah, I can't, I can't lie. I can't lie about anything. And I had, I became really fascinated by that because I thought, what, what is it about telling the truth? Obviously there's the thing about not lying about drug use, right. Which would be important, but it's not even that it's beyond that. It's not lying about anything at all. I had this one patient who said, oh yeah, when I was

using, I would lie about stuff that didn't even matter. Like if I was getting lunch at McDonald's and somebody would call me, I would say I was at Burger King. If I was at Burger King, I would say I was at McDonald's. He said, it didn't even make any sense. I was just in the lying habit. So part of recovery, and I would contend part of living a good life, is embracing radical honesty, telling the truth about not just important things or big things, but even about little things in the course of our every day. And I have different theories that I sort of explicate in the book to why that is. One of them is that I think

that kind of radical honesty creates true intimacy. You know, we talk so much about relationships being the antidote to addiction, but we don't ever talk about how to get into those intimate relationships. And one of the ways to do it is to be truthful, you know, with the people who we care about, even when being truthful means disclosing shameful things that

we've done or aspects of ourselves that we would rather not people know. And intimacy, true intimacy releases dopamine, right? So there you have a natural source of dopamine that can fight with these unhealthy sources of dopamine. The other thing that's true also about telling the truth about everything, or what I call radical honesty, is that it allows us to develop a truthful autobiographical narrative of our lives. And the stories of our lives are really the only way that we have to document lived time. And if we are not telling true stories about ourselves, then we're liable to perpetuate the same mistakes going forward. And we also then don't have access to truthful, objective data to make informed future decisions. So for example, when I have

a patient who comes in, who tells what I would call the victim narrative, everything is always somebody else's fault. I know those people are not in recovery and they're not going to get into recovery unless they start acknowledging their contribution to the problem. So being able to tell a story that hews as closely as possible to what is actually true in the world is really, really important for being able to actually see that truth, to own our part and to make informed decisions going forward. And then another piece of it is that I really do think that intentionally and mindfully telling the truth upregulates the prefrontal cortex, which is that gray matter part of

our brain right behind our foreheads involved in storytelling, future planning, and delayed gratification. We know that the prefrontal cortex interacts with the reward pathways in the lower brain regions, and that when those two parts of the brain are talking to each other, we are better able to control over consumption to delay gratification and to avoid the pitfalls of addiction. And there's a fascinating experiment that I detail in the book where scientists use transcranial magnetic stimulation to upregulate function of the prefrontal cortex in order to decrease lying in their subjects who are engaged in a dice rolling game,

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

our dopamine reward pathway, and then enabling ourselves to be more resilient in the face of temptations that we're all confronted with every day. Yeah, I know. I love the way you look at that. I think radical honesty, all of us trying to be more honest. As you say, humans are lying machines. And it becomes a habit before you know it. I don't know if you've had much experience of this um of course it's not exclusive to people from immigrant families at all but you know i my parents grew up in india they you know emigrated to the uk for all kinds of reasons and i like many

of my peers in that situation you know often have a conflict of identity where we have a kind of traditional Indian-Asian upbringing at home. And at school, we have our sort of Western friends who have got, let's say, a slightly different set of values to the values you have at home. And so by the time you're a teenager, you get pretty good at lying and you are doing it so often. I'm not saying everyone does this, right, to be really clear. But I know from other people in my boat, other people who also are kids of immigrant parents, there's a big problem with these double lives that people lead. And I feel, the way I look at it is that you're whole when you're born. Who you are is who you are. And then bit by bit, and I think this often starts at school,

we start being someone who we're not in order to fit in. So a fault line starts to show up in who you are. So there's a fracture now. And that keeps going. And then you start lying as a teenager, and that fracture becomes bigger and bigger. And then I feel, and I certainly felt it in my own life, that a lot of these kind of compulsive behaviors are just an attempt to repair that fault line and get back to equilibrium. That is not based on any science. That's based on just me philosophically trying to look at this. But I found, to be brutally honest, as I become a better truth teller, like I think it's something I've really worked hard on in the last few years, even white lies. I don't like telling white lies anymore. Like if I can't make a work function because I'm too busy, I don't say,

oh, I've got another engagement anymore. Like I used to, I said, guys, actually, I'm just too busy at the moment, or actually that sort of weekend and I'm going to spend that with my children. So I'm really sorry. And it is the most freeing thing in the world when you tell the truth and you're accepted for it. Yeah. Yeah. It's so true. I mean, we, we really want, we want to be the same person on the outside that we are on the inside. And we want people to see us and accept us and love us for our truest selves. And of course, we think when we share something that we assume people will consider to be a fault of ours or something unattractive, we assume people will go running. But in fact, the opposite often happens that people feel closer to us because

they're not so alone either in their own limitations and their own brokenness. So, and I do agree with you that there's, you know, Winnicott, a famous psychoanalyst, has written about this concept of the false self and how the constant cultivation of this false self, first of all, takes a lot of energy, right? Because you have to like remember what you said and who you're pretending to be. But it also creates this very painful alienation from ourselves where then we can't, you know, be authentically ourselves in the moment. And then we're really disconnected from our lives. So what telling the truth, radically telling the truth

as you have discovered about things large and small, and by the way, I work on this too, and I learned it from my patients and I've worked on it for the last 20 years and it's still a work in progress, but it allows us, yes, to reconnect with our authentic selves, which is really important, I think, especially in this strange, surreal and digital world, which often can feel like we're living in a think, especially in this strange, surreal, and digital world, which often can feel like we're living in a matrix, especially when so much of the online information isn't true, you know, or people have these curated personas, or maybe are even putting out a curated false persona online, which can really lead to terrible feelings of depersonalization,

derealization, and I think even lead to suicidal thoughts as people feel that they're just not real in the world and they don't know who they are or that even if they know who they are, other people don't know the real them. So I think telling the truth is really fundamental to grounding ourselves, you know, on the earth with other people in our own identities and being able to then be in the moment, which can often be painful, but allow us to authentically, you know, unfold our experience in the moment rather than trying to manage a persona to make a certain impression, to give us this false illusion that we can actually control the world, which of course we can't do, but we keep trying to do that.

How hard was it for you to the book uh hugely it connects the reader to you and your work hugely but what was that like for you was there was there any part of you that was like should i put this in should i keep this out oh my god pretty much the whole book i would say in the two, two months before it was about to come out, I think I was in a constant state of panic. I also talk in the book about, you know, my struggles with my relationship with my mother, which has been a source of both shame and pain for me in my life. And my mother hadn't read the book and didn't know what I was putting in it. And I was just really, really scared and anxious. And it was hard. It was really hard. But, you know,

I felt that my patients had been so brave in sharing their stories that it wouldn't be right for me not to disclose the way that my own refracted lens on this topic had impacted my views. I just felt like that would be disingenuous. And thankfully, really universally, people have responded well to my self-disclosure, including my mom, who, you know, read the book and said, yeah, you got it about right. That's, that's, I would agree with that, which was nice. You know, it wasn't like, yay, our relationship is repaired, nothing like that. But it was like, okay, the way that I sort of saw reality after much reflection was validated by this, this other person who, who could say that I saw it. And that, that's a good feeling, you know, that like, okay, yeah, I I'm seeing it clearly. I don't, I'm sad

about what is the truth, but at least I know what the truth is. And this person who was involved in my truth corroborated it. Yeah. it's fascinating hearing that. Do you think you could have been that open five years ago, 10 years ago? Is this something that as you learn, I guess, this is the feeling I get throughout the book, Karna, there's not only you as the expert, but also you as someone who really listens and pays attention to your patients. And it's actually learned so much about what it means to live a good and proper and calm and peaceful and content life from them. You know, and I guess there's a real personal reason why I'm asking this because I hear my books about to go to print. I am revealing so much more about myself than I

ever have done. In fact, my wife proofread it last week. She's like, baby, you sure you want to put this in? So I guess I'm feeling, I'm looking for reassurance and I'm getting it, but I feel confident now, but I wouldn't have done a few years ago because I would have felt too scared of being judged. And I just wonder if there's anything that resonates with you about that. Is this something that you can do now at this stage in your life, in your career? Would you have been able to do that, do you think, a few years back? I think you're right. I think there's something about getting older, getting more comfortable maybe with ourselves and our choices, feeling that we've actually gained,

you know, some modicum of wisdom that we want other people to benefit from. So I do think that when we make ourselves truly vulnerable, right, not in a manipulative sense, but in a really, it hurts to share kind of way, you know, we're giving people a gift just as our patients give us a gift every time they tell us what's really going on with them. It's a great gift. And it's probably the most powerful gift because you can tell people the lessons that you know, to live by or whatever,

but until you tell them how you're broken and the way that you came through, it will never have the same kind of power or impact. But I mean, and also, you know, you're somebody who's like from the outside, my gosh, I mean, people look at you like, oh, you know, he's so famous and he's a doctor and he has all his world must be perfect and so you know when when we reveal ourselves a guy you know actually every day is kind of a struggle you know and I I suffer with the same kinds of problems as I think I think it really it really helps people that's been my experience that's been my experience yeah it connects us. And as you say, it's in that sort of real maskless interaction

where intimacy is born and coming full circle. As you say, intimacy also gives us dopamine. Yeah. And I love that. So dopamine's not good or bad. It's dopamine just is. And it's where are we getting our dopamine from you know that's the kind of underlying message isn't it it's get it from cuddles and intimacy and time with your tribes and get it less from these devices right you're not saying don't do it at all. You're just saying get the balance right. That's right. Finding that balance. That's the key. Ana, this podcast is called Feel Better, Live More. When we feel better in ourselves, we get more out of our lives. At times in the early part of the book, it's, you know, a pretty depressing picture gets painted off the state of the modern world and how easy it is for us to get addicted.

Of course, there's lots of practical tools in the book as well. Are you optimistic or are you pessimistic about the future? I am definitely optimistic. I am optimistic. I think especially Gen Z is going to figure this out. They're the ones that really were born into this technology. They're basically cybernetically enhanced at this point in terms of the ways in which the technology is embedded in their everyday lives. And I think that they're going to, I'm optimistic that they're going to figure it out. You know, we are incredibly adaptable. And of course we are seeing the terrible dark side of, of so much of what we've built, but I am very optimistic that we will, we will, we will find the balance. Yeah. Me too. From what I've heard from you, from what I've even seen in my own kids, I'm like, okay, well, maybe, actually, maybe it's not as bad as I think. Maybe these kids are going to be able to figure this out. And also just at the end of the conversation, I think many people will have resonated with so many elements of this. They would have heard

little bits and thought, man, maybe I've got an unhealthy relationship with X, Y, or Z. For those people who are now thinking about questioning their relationship with certain things and maybe recalibrating it, I wonder if you could give some sort of final words of wisdom for them? Yeah, you know, first of all, keep the faith. There's always hope. And, you know, if you've tried to stop a substance or behavior and found you haven't been able to, don't give up. You know, keep looking at it, keep strategizing. And, you know, don't be hard on yourself. Self-compassion is key, but do continue. Don't give up. I think that's probably the bottom line. We can make our lives better, especially when we understand the source of our suffering. And the real point of dopamine nation is that paradoxically,

a major source of our suffering may be the very things that give us so much instantaneous pleasure. So by eliminating those things to the extent that we're able for long enough for our brains to recalibrate, I really do believe that that will be an aha moment for a lot of people. So it's a project worth doing. And it's a project that your listeners can do, even those among them who may have despaired at this point.

Lana, thank you for joining me on the podcast today. I have so enjoyed speaking to you. I have relished every single page of your brand new book, Dopamine Nation. Take care, be well, and hopefully at some point in the future, we'll get to meet in person. And maybe if you're up for it, you can come back on the podcast and share some of your wisdom in the future. That would be great. And I'm looking now very looking forward to reading your new book. Really hope you enjoyed that conversation. As always, do think about one thing that you can take away and start applying into your own life. As well as Anna's book, Dopamine Nation, please do consider pre-ordering my fifth book, Happy Minds, Happy Life. It's coming out shortly.

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