Hidden Brain - The Paradox of Pleasure

Episode Date: July 10, 2023

All of us think we know what addiction looks like: it’s the compulsive consumption of drugs, alcohol, or nicotine. But psychiatrist Anna Lembke argues that this definition is far too narrow — and that a broader understanding of addiction might help us to understand why so many people are anxious and depressed. This week, we begin a two-part series that explains how and why humans are wired to pursue pleasure, and all the ways the modern world tempts us with addictive substances and behaviors.Do you like the ideas and insights we feature on Hidden Brain? Then please consider supporting our work by joining our new podcast subscription, Hidden Brain+. You can find it in the Apple Podcasts app, or by going to apple.co/hiddenbrain. Thanks! 

This is Hidden Brain, I'm Shankar Vedanthan. In the hit television show Ozark, a bright financial advisor finds himself suddenly working on the wrong side of the law. What's our story for the kids? Well, we could tell them the truth, Wendy. How would that be? Following a series of bad decisions by his business partner, Marty Bird, played by Jason Bateman, begins working for a drug cartel. I want you to be ready to set up shop within a week. Yeah, the Marty.

When I drive by you house, there better be a foreshale sign on the wrong. Almost from the start, the body start to fall. People get thrown off balconies, people get shot, people are electrocuted. When government officials get involved, more violence unfolds. People betray one another. They cheat each other. They act in selfish and short-sighted ways. Let me just jog your memory for a minute. There was an innocent man who was murdered. Gary, he was a good man.

You might say this is the genre of the drug movie or television show. You see it in critically acclaimed TV shows like The Wire and Breaking Bad, and in movies such as Traffic and Scarface. Shell off to my live friend! and in movies such as traffic and Scarface. Running through these dramas, we sense the irresistible power of drug addiction, the implacable draw of heroin or cocaine or methamphetamine, the chaos and crime that follow everywhere the drug trade is blight. I've watched many of these TV shows in movies as entertainment. For many years,

I also reported on the work of researchers who studied the science of drug addiction. But some time ago I came by a mind-bending idea that transformed my understanding of addiction. It challenged how I think about drugs and what it means to be addicted. And it told me that as gripping as TV shows in movies about the drug trade might be, they don't begin to capture the profound story of addiction in all of our lives. of addiction in all of our lives. Today we begin with a story we are telling across two episodes. It will change the way you think about your brain and offer some profound insights into what it means to live a life of happiness and contentment. Pleasure, pain and balance this week on Hidden Brain.

All of us think we know what addictions look like. We've seen the movies and TV shows about gang violence and drug dens. At Stanford University Anna Lemke studies the science of addiction. She argues our conception of addiction is far too narrow. Anna Lemke, welcome to Hidden Brain. Thank you for having me. I'm excited to be here. Anna, you're a practicing psychiatrist in the heart of Silicon Valley, and I think of California's Bay Area as perhaps the, you know, the richest part of the richest country in the history of humankind. So a time traveler from the 17th century might assume that, you know, even if the streets were not paved with gold, at a minimum, people would be very happy with so much material success. Is your psychiatric practice empty? Ha, I still marvel at the gap between how people present outwardly and the truth of their inner experience. We see people every day who seem to have everything

you could ever want, wealth, beauty, meaningful work, and yet when you look under the hood, they're miserably unhappy. So over time, on a you've seen more and more patients suffering from depression, anxiety, and chronic pain, ailments for which they are hard-pressed sometimes to find a source or a cause. And as you say, often these are healthy, affluent, educated people with seemingly everything they could want in life. One patient of yours was a young physician with a very promising career. Can you describe what he was like when you first met him?

Delightful young man, handsome, kind, thoughtful, considerate. He came to me in fact because he got considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable considerable online gambling sports betting. And his story went like this. He was a very successful high school and collegiate athlete on Division 1, all kinds of accolades, really a remarkable athlete. And that cycle of engagement in high level athletics, the adrenaline that goes along with high-level competition,

the wins, the losses that absolutely was his jam, right? It kept him busy and engaged and really, really happy. But when that career came to its natural end, like so many high-level athletes, there was sort of a free-falling disappointment to kind of an existential, profound disappointment, a bit of an identity crisis. And although he was headed to medical school, which you know, gave him kind of a new identity to latch onto, he really missed that cycle of intensity that he got through participation in sports. And then he was invited by his collegiate buddies to participate in Fantasy Football in a Fantasy Football League. And you know they all get together and they

choose their teams and then there was, you know, minor money involved in that. But he got really, really into it. More so than his buddies from college. And that was really almost the spark for him then to begin to want to engage athletically through sports betting and sports gambling. And you know it started with 50 bucks, 100 bucks. And at this time he's now started medical school, he's doing his pre-med courses, you know he's getting ready for his clinical years.

He had this phone, he could pull it out. During grand rounds you know when he was supposed to be listening to the speaker and scroll through, you know, results of all the different sports, and then he could place a bet. And that accessibility just absolutely ensnared him. And he found himself completely caught up in it to the point where he was now spending not hundreds of dollars, but thousands of dollars, not monthly but weekly and eventually daily. And in about six months he completely spent the trust fund that he had inherited from his parents in order to pay for medical school. He was so ashamed that he didn't tell anybody and he thought to himself, well, if I can just win, then I can get all the money back and then I'll be fine. So he took out an

enormous loan without telling anybody to pay for medical school and he thought, okay, I'm gonna put it in the bank, you know, I'm gonna pay it back and instead he gambled that away too. that away too. Anna had another patient who started doing something that might seem even more harmless than sports betting. So this was somebody who just found himself really getting intense pleasure out of the cycle of shopping online. He would spend quite a bit of time searching for different items that he was interested in buying

and the process of kind of like the treasure hunting was very, I'm entrancing and rewarding for him. All kind of building up slowly to the point where he would choose the items that he would buy, and then buy it. And then he would be waiting in anticipation for it to be delivered to his home, and all of that was very pleasurable. And then it would be delivered, and he would open it and take it out, and it was the thing

that he wanted, and it felt so good, and it was just, you know, wonderfulness for him. So because that cycle was so entrancing for him, he started to do it more and more. And he kind of came to rely on it as a physiologic crutch for managing his mood. But over time, what he found was that the cycle got shorter and shorter and the anticipation and pleasure that he got from it got less and less to the point where as soon as he opened the box and got what he had ordered,

it was over and then he'd be online again trying to buy the next thing. And eventually he ended up with rooms in his house full of stuff that he didn't need or want and tens of thousands of dollars of credit card debt. And yet even then he couldn't stop. So what he started to do is kind of a last resort is he bought like these cheap items, key chains, mugs, caps, cheap sunglasses, things he didn't need or want. And then as soon as he got them he would return them. Wow. Because he didn't need or want, and then as soon as he got them, he would return them. Wow. Because he didn't have any money, but he couldn't break the shopping cycle. I want to talk about one last patient, a man you call Jacob, and a note for listeners

that this next story includes references to both sex and suicide. Jacob was middle-aged or maybe even a little older when you first met him. What was a story, Anna? Jacob was a Stanford scientist. And by the way, let me just emphasize that I got permission from my patients to relay their stories. And I used pseudonyms and hide other identifying features. So Jacob was a Stanford scientist who came to me seeking help specifically for a severe sex addiction, a sex pornography compulsive masturbation.

And what he described was in the 90s he used pornography and he masturbated, you know, as much as daily, but it was never unmanageable. He was still able to function as a father, as a husband. He was successful in his profession. But with the advent of the internats and especially in the early 2000s in the smartphone, he found that this pursuit of his became unmanageable, which is to say that he was using more and more pornography for more hours every day, lead into the night, not showing up at a conference that he was supposed to speak at, prepared to give that speech because he had been up the entire night before of watching pornography, repeatedly masturbating,

and over time he needed more and more potent forms to get the same effect. So he escalated from sort of vanilla toast pornography to more deviant forms of pornography and then pornography itself, was an adequate, so then he was going to live shows and meeting up with prostitutes and eventually you know his addiction progressed to the point where he was going into chat rooms, doing dangerous things with other people in chat

rooms, spending all of his available time engaged in this activity to the point that essentially his life completely fell apart, his wife left him, and he was thinking about ending his life and even found a spot near his office where he thought about hanging himself. Each of these cases, of course, is different. Online shopping is not the same as gambling, and gambling is not the same thing as pornography. But in time, Ana came to see connections, not just between these patients, but to many people who are not seeking help from a psychiatrist. People like herself.

You're listening to Hidden Brain. I'm Shankar Vedanta. This is Hidden Brain. I'm Shankar Vedanta. Over many years of practice at Stanford University, psychiatrist Anna Lemke has found that lots of people living in the Bay Area, one of the wealthiest parts of the United States, was suffering from a strange malady. Despite being blessed with great success in terms of education and material wealth, many of her patients were unhappy. At one point Anna saw something in herself that reminded her of the patients she was treating. Anna, I want to zoom into your life around the time you turned 40. What was going on in your life at this time? My life was good then. You know, my marriage was fine. My kids were healthy. My work was

rewarding and meaningful. I was in relatively good health for a 40-ish year-old woman, so things were good. Now, you've always loved reading and around this time you fell in love with a very popular book series. What was it? It was the Twilight Saga. And can you tell me a little bit about what the Twilight Saga is? I confess I have not read the books. What is their broad plot and what is the good plot? What is that broad plot and what is it? Well, you know, I was turned on to the Twilight Saga when I dropped my kids off to elementary school and there was a group of moms clustered around.

Megan was one of the moms, my friend, and they were all laughing hysterically and I went over and I said, hey, what's so funny. And Megan said, oh, I've been reading this romance novel that I absolutely love and I went into the bookstore to try to get the sequel and I couldn't find it. So I went up to the bookstore owner and I said, hey, you know, where's the the sequel? And he said, it's in the teenager section. Right. So all the moms started cracking up.

They thought that was the funniest thing. But she said, but you guys have to read it. It's so good. So I said, okay, Megan, what is it called? Because I'm always looking for a good read, right? She said, oh, it's called the Twilight Saga. So I thought, okay, I'll give it a try. And it was absolutely mesmerizing for me. It was as if I had never read a novel in my life, and all of a sudden, this novel about a bunch of teenage vampires running around biting each other on the neck, it just absolutely transported me. It was really weird.

So the Twilight books eventually spawned a very popular series of films. I want to play your clip from one of those movies. A teenage girl named Bella is confronting a boy she knows, Edward, about his true nature. I know what you are. See it. Outbound. See it. Vampire.

Are you afraid? No. Okay, so there are a lot of, you know, breathless pauses here, but I'm hearing, you know, fantasy, paranormal stuff, but it sounds like an innocent enough pastime, Ana. Oh, an innocent enough pastime? Sure. It always starts out, innocence. And of course, you know, it was, but what happened was it changed the way I felt in the moment,

in a way that resonated so deeply that I wanted to keep recreating that feeling. And what was that feeling? It was essentially a feeling of non-being. While I was reading the Twilight saga, it just transported me to another time and place such that I completely forgot myself. And that self-forgetting was clearly something that I needed and wanted. You know, I read the whole saga, I think it's like four books, and then I wanted to recreate that feeling again, so I read the whole saga again. Wow. Pleasurable, but not as pleasurable as the first time around. But by then I was completely tapped into this whole genre of vampire romance novels. And so I started to invest larger and larger amounts of time, energy, and creativity into obtaining and reading vampire romance novels. You know, seemingly innocent to start with, but it became a bit of an

obsession and when I ran out of vampire romance novels, I moved on to Werewolf romance novels and then there was necromancers and sous-sayers and all kinds of paranormal romance novels. Where were you procuring these books? So I live right next to a little library, which has a limited collection. So when I went through the limited collection at my local library, I either biked over to the main library or you can order through the interlibrary loan. And you know, some of these romance novels have very revealing covers. Like it was some modest ripper with some hunk on the cover, you know, at the prow of a ship or something.

Like, I wouldn't want to be seen reading that anywhere. So Anna came up with a way to hide what she was reading from her family and friends. I haven't revealed this to anybody. This is terrible. But I would actually put the book inside another book so that if one of my kids came by or my husband came by, I could look like I was reading the other book. Wow. Like a medical journal or something. Except that might not really trick them because like, you know, they would know that I wouldn't spend that much time reading a medical journal.

I mean, I used to do this in eighth grade, Anna. I felt like, you know, the trick of the book inside the book was something I had perfected in eighth grade. I know, I know, and I discovered it in my 40s, but can I tell you, I was a late bloomer. So at one point, Anna, your love of this literature received a turbocharge when you moved from the printed page to the electronic domain.

Tell me how that happened. Well my friend Susan said, you should get a Kindle because then you don't have to be carrying these books around. Kindles had just come out then. And of course that was very, I liked that idea because it would be easy access. But pretty soon I also started regularly going on Amazon and looking for, you know, things that were similar to the Twilight saga. And guess what? Amazon will suggest those to you as we all know now. And so the Amazon did the work for me. All I had to do was look in my feed and say, oh, they're telling me I should read this one. They're telling me I should read that one. And like later on in the process,

I also discovered that you can get free books on Amazon. So anything that was free, that was in the romance category, I would download and read. And that was really the beginning of the end for me, because once I had that electronic reader, I essentially became a chain reader. Like as soon as I finished one book, I would either borrow from the local library or buy on Amazon another book. These were all romance novels. And I got to a point where whenever I wasn't doing something that I absolutely had to do like for my work or my family, I was reading romance novels.

And then it got where to wear it, like that's all I wanted to do. And I didn't enjoy anything else. I didn't even really want to like be with my kids or my husband, right? I just wanted those times to rush through them so that I could go back to reading romance novels. The other thing that I only realized in retrospect

was that these sort of tamer versions of romance where the sex scenes aren't super graphic, although it stopped working for me. And now I needed ever more graphic types of romance novels in order to get that zing that I was looking for. in order to get that zing that I was looking for. So this was no longer about the pleasure of reading at this point or your love of language, it had become something else. Oh, it had absolutely become something else. And of course, it was rooted in the pleasure of

reading and the pleasure that I've always gotten from fiction. But what happened was I got to a point where I really didn't care if it was badly written or badly plotted or the characters were uninteresting. I would just flip through to the climax pun intended. So then I got to where I was like reading really graphic erotic on the more graphic, the better, the more sex scenes, the better. But it was all about getting to that moment and getting a certain, very specific feeling. And I became the possessor of the knowledge that if you take any romance novel and you open it up to two thirds of three quarters of the way through, you know, you'll get right to the point, which is to say these are these romance novels are engineered. They're written according to a recipe.

So at this point, you know, you're a respected researcher in psychiatrists at Stanford University, you have a great family. But no longer, soon to be no longer. But that's what I want to ask you about, you know, you have, you know, what you are doing in some ways must have felt at odds with your public persona, the sense that you had, that you were a mom, that you had a great family. Were you embarrassed by your newfound love

of steamy literature? First of all, I didn't really see what was happening as it was happening. I would occasionally joke to friends, oh, I'm so addicted to vampire romance novels or romance novels in general, but just by being able to joke about it, I felt that that must mean I'm really not addicted to it or it's not really a problem. The other thing was that because of the technology in large part, I could do the behavior secretly. Once I got the Kindle, you know, I could be reading something on that Kindle

that nobody else knew what I was reading. Whereas before, I wouldn't want to be seen reading that anywhere. That would just be really embarrassing. But on a Kindle, like it was anonymous. How did this affect your patient care? Because presumably through all of this, you were still treating other patients and helping people with their addictions. Right. As it was happening, I didn't really see it happening and I didn't relate it as being

similar to what my patients were going through. That I really only saw in retrospect. But it started to be less interested in my work. Like again, the work that had given me meaning and purpose and joy started to be dull and gray and boring, and I found myself less engaged and more just wanted to rush through the work so that I could go home and read romance novels. So you weren't reading these at work? You reserved the reading at home.

Well, there was one day, and this was sort of near the sort of combination of this behavior. Time is weird for me then, but I think it developed over the course of about a year or two. But I did bring a Roman Savocha work and was reading in the ten minutes between patients. So, I don't want to play armchair psychiatrist, but it seems that you were. That's okay. That's okay. You know, you were using your emotion in these books

as a kind of escape. What do you think you were escaping from? Well, that's what's so fascinating. I really didn't have anything to escape from. I have a great husband. I have got these great kids. I have work that I adore. My patients are just so fantastic. There was nothing wrong. I was really just escaping too. And the thing

that I was escaping too was just not having to be in my body, not having to think, being able to experience this kind of intense euphoria, you know, this other place, which was very, very pleasant for me, just it just felt good. The other thing I just want to flag here is that the pattern we've seen over and over again, which is that something starts out being pleasurable. So your friend tells you about this romance novel. You read the Twilight saga. You find it fun. You find it enjoyable. And so you go back for more. But somewhere along this process, sort of the balance shifts. And now you're no longer actually reading these things because they're giving you pleasure.

It's that, you know, you're reading them almost to avoid pain. Because that's not right. That's really the key that we start out doing whatever the behavior is for rational reasons and it succeeds in achieving what we're trying to achieve, either to give us pleasure or to accomplish some other goal. But if it then hijacks our brains or word pathway, it gets a life of its own. And then even when it stops doing what we want it to do, we can't stop. And that's really the hallmark of addiction. When we come back, the brain science behind an increasingly global melody. You're listening to Hidden Brain, I'm Shankar Vedantam.

This is Hidden Brain, I'm Shankar Vedantam. Analemki is a psychiatrist and researcher in the behavioral sciences at Stanford University. She's the author of Dopamine Nation, Finding Balance in the Age of Indulgence. On a many of your patients suffered from problems related to compulsive overconsumption, and you experienced some of this yourself, but you had a big advantage over your patients. You were a researcher and a scientist who studies the brain, and you knew about a very important discovery in neuroscience that has to do with the relationship between pain and pleasure

inside the brain. What was this discovery? This discovery was the fact that pain and pleasure are co-located in the brain. So the same parts of the brain, that process, pleasure, also process pain, and they work like opposite sides of a balance. So almost like a seesaw? Exactly.

Like a seesaw or a teeter totter in a kid's playground. And when that teeter totter or that beam on a central fulcrum is level with the ground, it's at rest. Humber what neuroscientists call homeostasis. And when we experience pleasure, it tips one way and when we experience pain, it tips in the opposite direction. And there are certain rules governing this balance. And the first and most important rule is that the balance wants to remain level. That is at homeostasis. And our brains will work very hard to restore a level

balance after any deviation from neutrality. So when we reach for things that are pleasurable when I bite into a delicious dessert, for example, I'm imagining that I'm essentially pressing down on the pleasure side of that CISA. That's right. So when we do something that's pleasurable and we release, stoke me in the reward pathway and the balance tilt to the side of pleasure, no sooner has that happened than our brains will work very hard to restore a level balance and they do that first by tilting an equal and opposite amount to the side of pain before going back to the level position. And I like to imagine that is these little

neuro-adaptation gremlins hopping on the pain side of the balance. And that's the come down, the hang over it, the after effect. And it often happens, even while we're still experiencing the dopamine hit, and it often happens outside of conscious awareness. So if I have this image here about pressing down

on one side of the seesaw and these gremlins are jumping on the other side, why is it they want to press down on the side of pain? Why not just try and get to equilibrium? Why press down so much that it tips over in the other direction? That's a great question, and I don't exactly know why the mechanism is built like that, why we pay a price for every pleasure, but I suspect it has to do with the fact that that kind of mechanism makes us the ultimate

seekers never satisfied with what we have, always looking for more. And if you think about it, we are evolved over millions of years of evolution to approach, pleasure, and avoid pain. And then on top of that, you have this pleasure pain balance whereby as soon as we get whatever reward we're looking for, we experience pleasure, we immediately remember where and how that happened and we want to recreate it. And that recreation is accelerated by the fact that as soon as we get that hit of dopamine,

we essentially go into dopamine free fall. That's those gremlins on the pain side of the balance. And now we're in a dopamine deficit state and we feel this overwhelming motivation to do the work it takes to get the next reward, which for most of human existence has meant walking tens of kilometers every day, has involved doing enormous work in order to get just a little bit of reward.

So it's not that dopamine is good or bad, it's that dopamine is essential for survival and it keeps us moving and always looking for the next thing. So dopamine is not involved only in feeling pleasure, perhaps more importantly, it's also involved in motivation, which is of course what you're talking about just now. Can you explain that connection between dopamine as a messenger of pleasure, but also dopamine as the architect for motivation? Yes, so there's a very famous experiment in which rats were bioengineered to not have dopamine receptors in the reward pathway

of the brain. And what the scientists discovered was that if they put food into the rat's mouth, the rat would eat the food and seem to get pleasure from the food, but if they put the food even, you know, a single body length away, the rat would starve to death. In other words, we need dopamine, not just for the experience of pleasure, but also for the motivation to do the work to go get the reward. And probably the way that dopamine makes us motivated is to create this dopamine deficit state or those gremlins on the pain side of the balance. So what happens when we transport this brain that evolved over millions of years into the modern environment where everything is

now available at the touch of a button? This ancient wiring that has us experiencing pain in the immediate aftermath of pleasure is woefully mismatched for our modern ecosystem. Why? Because we are surrounded by pleasure. We have more access to more reinforcing drugs and behaviors than at any point in human history. Even things that previously, you could have thought of as healthy, like reading or exercise, or playing games has become a drugified, has been turned into a drug in some way, making us all more vulnerable to the problem of addiction, and also making us more vulnerable to

the problem of this dopamine deficit state whereby our brains try to compensate for this excess of pleasure by down-regulating our own dopamine production and transmission, not just a baseline, but below baseline, creating this constant physiologic craving for more pleasure, but also the things that go along with craving, which are anxiety, irritability, and depression. So the mechanisms in our brain that compel us to approach pleasure and avoid pain, you say, were evolved over millions of years for a world of scarcity, whereas today, because we're surrounded by so much stuff, we're sort of drinking from a fire hose of dopamine as you put it. Yeah, this is the plenty paradox, right?

It's the literal physiologic stress of overabundance. So walk me through the same CSA analogy that we talked about earlier. You know, again, a hundred thousand years ago, you know, I found a date tree and the date tree had delicious dates, and it made my brain very happy to eat some of those dates but they were not very many dates on that one tree I had to find the next tree and the next tree might have been as you say three miles away and so it required a huge amount of effort to get to that next date tree. What's happening with that seesaw now in the world in which we live where things are in fact available at the touch of a button? Yeah, well let's go back for a second and talk about what's happening with the seesaw

when you're looking for the date tree. Because what happens as you're scouring your environment to try to find, you know, one date tree with a couple of dates on it is that your pleasure pain balance goes onto the pain side, right? Because you're hungry and you're walking and you're tired. And then finally, you find this date tree and you, you know, you're ecstatic and you eat this date and your balance, your pleasure pain balance, goes back to the level position, which feels like euphoria because part of the key here

is the directionality of the pleasure pain balance. So if I'm in pain because I'm hungry, and then I find something to eat and it moves me in the direction of pleasure That's as pleasurable as if I start out with a level balance and I use an intoxicant and I get high Interesting and so now the same pain pleasure or balance now what happens now? Yeah, so now in the modern world Let's say yet take Silicon Valley because it's a prime example, but it's also true all over the world now. You go and you're hungry, right? And you're looking for a date tree and all of a sudden, you know, you've got like a whole crate of dates shipped to you from Amazon right on your kitchen table.

And by the way, they're giant. Like they're like abnormally giant dates, right? So you eat a giant date from Amazon, and it releases dopamine in your reward path, because they've also added sugar and salt and fat and flavorings. It's like coffee dates or something who knows. And you get the release of dopamine. And wow, that feels great, because like, wow,

who's ever had a date like that in the history of humans. And then, you know, as soon as it's over, your pleasure pain balanced, tips to the side of pain, because those gremlins are trying to compensate for all that dopamine. And as soon as you're in that dopamine deficit state with the gremlins on the pain side of the balance, you want to restore a level balance. And what is the easiest way to do that? Well, you could wait till the gremlins hop off, because if you wait long enough, they will hop off and homeostasis will be restored or you could eat another date. And if you eat another date, because there's a whole crate of dates right in front of you, that would work faster, right? And maybe you'll eat to this time because then that'll level your balance, but also get you over

to the pleasure side. And pretty soon you've eaten the whole crate of dates. And now you're essentially at war with those neuro-adaptation gremlins. And the more we then try and press down on the pleasure side of the seesaw, and the more the gremlins try and press down on the other side to achieve homeostasis, you make the case that over time the gremlins start to push down on the opposite side of achieve homeostasis, you make the case that over time, the gremlins start to push down on the opposite side of the seesaw and then we end up depressed and anxious. Explain how this happens on it.

Well, what happens as we continually bombard our reward pathway with highly reinforcing substances and behaviors is that we accumulate more and more gremlins on the pain side of the balance. They're just doing their job, you know, trying to restore homeostasis. And over time, you know, those gremlins essentially are camped out on the pain side of the balance, tense and barbecues in tow. And now we're in addicted brain. We've changed our hedonic or joy set point, such that now we need more of our drug, quantity-wise, and more potent forms of our drug, not to get high, but just to level the balance and feel normal. And most importantly, when we're not using, we're walking around with a pleasure-paying

balance tilted to the side of pain, which means we are experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and craving. I mean, you're an addiction psychiatrist and you treat many patients who are dependent on drugs. So drugs in the conventional sense of a chemical that is swallowed or smoked or snorted or ingested. And obviously, that is a very big problem. But, you know, you're making a much more radical claim here. You're saying that a problem with addiction is not just limited to nicotine and cocaine and heroin.

You're absolutely right. What I'm saying is that science, technology and innovation has allowed us to drugify almost every human behavior. If you're not addicted yet, it's coming soon to a website near you. And my bigger claim is that the rising rates of depression, anxiety, and suicide, which by the way are rising fastest in the richest nations in the world, are due in part to the fact that we are overloading our brains reward pathway with too much dopamine. And that in our brains effort to compensate for too much pleasure, we are essentially individually and collectively down-regulating our own dopamine production and transmission,

not just to baseline levels, but actually below baseline levels. So we are in a dopamine deficit state, which means that we're all unhappier, more anxious, more depressed, more irritable, less able to take joy in the things that used to give us joy or that have given people joy for generations, and also more susceptible to paint, right? Even the mirror's slight now can make us paint and that we're not, this isn't happening because somehow we're spoiled or our values have changed, it's because we've literally physiologically changed our brains as a result of constantly

bombarding them with these high reward substances and behaviors. So in some ways this feels really mind-bending to meana because you know I can see how nicotine and alcohol and marijuana or heroin or cocaine. I can see how these could be addictive but many of the things you're talking about, you know, food or social connection or sexual intimacy, these are not things that are inherently problems. In fact, many of them are part of what it means to be human. Talk about how our modern societies have taken these normal healthy things, and in effect, as you would put it, drugify them. So the way that our modern society has drugified these things that used to be normal and healthy like having sex or eating food or playing games is essentially by increasing four factors, quantity, access, potency and novelty. novelty because our incredible manufacturing system has allowed us to make

these reinforcing substances in enormous quantities and our amazing supply chain allows us to ship them all over the world. You know one of my favorite sort of anecdotes is that in the 1880s the cigarette rolling machine was invented allowing manufacturers of cigarettes to go from manufacturing for cigarettes, a minute to 20,000 cigarettes a minute. That's just one example of what we've done all around. My own romance novel reading addiction that developed. One of the things that I discovered when I went looking for other romance novels is that there's a whole universe of romance

novels out there. There was no, it was really a never-ending quantity. And quantity really matters because the more we use our drug of choice, our substance or behavior that's reinforcing, the more that we expose our brains to and the more often, the more likely we are to change our brains to this addicted kind of circuitry. So quantity is the first driver. What are the others? Yeah, so quantity is the first one.

Availability or access is huge. So if you grow up in a neighborhood where drugs are sold in the street corner, we have lots of epidemiologic data showing that you're more likely to try drugs and more likely to get addicted to them. And now we live in a world where we all have more access to our substance or behavior of choice, whether it's vampire romance novels or potato chips or games or pornography or you know old-fashioned drugs like alcohol, cannabis and

nicotine. And of course the smartphone is essentially the equivalent of the hypodermic syringe delivering digital dopamine 24-7 for our wired generation and that's really what it is. The smartphone totally changed things. When people could carry in their pocket this device that gave them the access to digital media and digital content 24-7, we all essentially became more addicted to these kinds of digital drugs. All right, so we've talked about quantity and we've talked about accessibility. What's next?

Yeah, availability accessibility. And the other one is potency. So one of the ways to overcome these gremlins on the pain side of the balance, or what's often referred to as tolerance, is to either use more of the drug or use more potent forms or have a more potent drug delivery mechanism. So for example, with opioids, someone might start out using opium, but eventually go to heroin, which is about 10 times more potent, and then eventually progress to fentanyl, which is 5200 times more potent. And this would allow them to at least temporarily win that battle with their gremlins and get the feeling that they're looking for. But another way to

achieve potency is to combine two drugs to make yet a third more novel drug. And this is done all the time. For example, people combining opioids with things like benzodiazepines or now this new veterinary sedative trink, which people are sadly using. By combining two distinct drugs together, we get a new novel drug, which then changes it up for our brain receptors and allows us to overcome tolerance. And in the realm of non-illegal substances,

you can also have combinations like French toast ice cream. Exactly. Or, you know, I very easily get hooked on YouTube videos, especially outtakes of American Idol. When I think about why on earth is American Idol so entrancing for me, well, they've figured it out. They've taken music, which is already reinforcing for most people's brains, releases dopamine, feels good. And then they've combined that with gaming and they've turned it into a competition and thereby really made a very potent drug.

Can you talk a moment about the factor that's known as novelty? This is true in drugs of abuse, but it's also true for many of the other things that previously we might not have thought as being problematic. Yeah, so dopamine is extremely sensitive to novelty, which is why for example people can get addicted to things like the news. That's the definition of news. It's new stuff coming your way. But what's become so toxic about the modern world is that in order to maintain customers and

keep them coming back, you've got to take the thing that they like before and then package it as slightly new or different or better. The internet has absolutely mastered that, right? These AI algorithms learn us, figure out where we've spent time before, what we've liked before, and then profit or suggest to us things that are similar, but a little bit different. That absolutely engages this treasure-seeking function where we keep going because we're hoping that the next hit will be something that's just a little bit better, but similar to what we had before.

You know, I remember when I was in 8th grade, or maybe 7th grade, on teachers would tell me to avoid a local park, me and all of my classmates, because the rumor was that drugs were being bought and sold and used at this park. But if everything can be drugified, if addictions can be beamed and streamed and wified into our living rooms and bedrooms, it becomes really now very hard to put a fence around it and say avoid going to this park, because the problem is no longer just with one park. That's the problem we're all facing as individuals, as parents, as schools. I mean, I don't know about you, but when I walk around and see the way that people are

just glued to their phones, it just makes me really sad. And yet I totally get it. I mean, these things are, they're literally mesmerizing. We are put in a trance by these devices. They're highly reinforcing for our very fragile little human brains. When we combine the ancient pleasure pain CISO in the brain, with a modern world that is ready to push hard and often on the pleasure side of the balance. We get trouble. We end up with compulsive overconsumption and all the associated problems it causes for people's health, well-being and relationships.

We also end up with a plague of depression and anxiety. In the second part of our story, coming up in the next episode, how to reset our relationship with a world of plenty and turn unhappiness into thriving? Anna Lemke, thank you for joining me today on Hidden Brain. Oh, you're very welcome. If you have follow-up questions that you'd like to ask Anna and that you'd be comfortable sharing with a larger hidden brain audience, please send a voice memo to ideas at hiddenbrain.org. Use the subject line, Addiction. That email address again is ideas at hiddenbrain.org. 60 seconds is plenty, and please be sure to include your name and phone number.

Hidden Brain is produced by Hidden Brain Media. Our audio production team includes Bridget McCarthy, Annie Murphy Paul, Kristen Wong, Laura Quarelle, Ryan Katz, Autumn Barnes, and Andrew Chadwick. Tara Boyle is our executive producer. I'm Hidden Brain's executive editor. Our unsung hero this week is Angelica or Jelly Monteros. Jelly works on the podcast operations team at Apple and she played an essential role in the launch of our new podcast subscription Hidden Brain

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I'm Shankar Vedantam. See you soon. I'm Shankar Vedantim. See you soon.