Dopamine Nation: Finding Balance in the Age of Indulgence

by Anna Lembke

I’ve seen a similar paradox in many of my patients over the years: They use drugs, prescribed or otherwise, to compensate for a basic lack of self-care, then attribute the costs to a mental illness, thus necessitating the need for more drugs. Hence poisons become vitamins.

people living in the United States reported being less happy in 2018 than they were in 2008. Other countries with similar measures of wealth, social support, and life expectancy saw similar decreases in self-reported happiness scores, including Belgium, Canada, Denmark, France, Japan, New Zealand, and Italy. Researchers interviewed nearly 150,000 people in twenty-six countries to determine the prevalence of generalized anxiety disorder, defined as excessive and uncontrollable worry that adversely affected their life. They found that richer countries had higher rates of anxiety than poor ones. The authors wrote, “The disorder is significantly more prevalent and impairing in high-income countries than in low- or middle-income countries.”

The number of new cases of depression worldwide increased 50 percent between 1990 and 2017. The highest increases in new cases were seen in regions with the highest sociodemo-graphic index (income), especially North America.

The reason we’re all so miserable may be because we’re working so hard to avoid being miserable.

For a rat in a box, chocolate increases the basal output of dopamine in the brain by 55 percent, sex by 100 percent, nicotine by 150 percent, and cocaine by 225 percent. Amphetamine, the active ingredient in the street drugs “speed,” “ice,” and “shabu” as well as in medications like Adderall that are used to treat attention deficit disorder, increases the release of dopamine by 1,000 percent. By this accounting, one hit off a meth pipe is equal to ten orgasms.

In the 1970s, social scientists Richard Solomon and John Corbit called this reciprocal relationship between pleasure and pain the opponent-process theory: “Any prolonged or repeated departures from hedonic or affective neutrality . . . have a cost.” That cost is an “after-reaction” that is opposite in value to the stimulus. Or as the old saying goes, What goes up must come down.

The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind.

The universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia, and dysphoria.

cue-dependent learning, also known as classical (Pavlovian) conditioning.

Right after the conditioned cue, brain dopamine firing decreases not just to baseline levels (the brain has a tonic level of dopamine firing even in the absence of rewards), but below baseline levels. This transient dopamine mini-deficit state is what motivates us to seek out our reward. Dopamine levels below baseline drive craving. Craving translates into purposeful activity to obtain the drug.

How does cue-induced craving translate to our pleasure-pain balance? The balance tips to the side of pleasure (a dopamine mini spike) in anticipation of future reward, immediately followed by a tip to the side of pain (a dopamine mini deficit) in the aftermath of the cue. The dopamine deficit is craving and drives drug-seeking behavior.

Researchers explored the effects of cocaine exposure on rats by injecting them with the same amount of cocaine on successive days for a week and measuring how much they ran in response to each injection. A rat injected with cocaine will run across the cage instead of keeping to the periphery like normal rats do. The amount of running can be measured by using beams of light that project across the cage. The more times the rat breaks the beams of light, the more it’s running. The scientists found that with each successive day of cocaine exposure, the rats progressed from a lively jog on the first day, to an outright running frenzy on the last, showing a cumulative sensitization to the effects of cocaine. Once the researchers stopped administering cocaine, the rats stopped running. One year later—a veritable lifetime for a rat— the scientists reinjected the rats with cocaine one time, and the rats were immediately running as they had on the final day of the original experiment. When the scientists examined the rats’ brains, they saw cocaine-induced changes in the rats’ reward pathways consistent with persistent cocaine sensitization. These findings show that a drug like cocaine can alter the brain forever.

a case report from the British Medical Journal published in 1995 details the case of a twenty-nine-year-old construction worker who walked into the emergency room after landing footfirst on a fifteen-centimeter nail, which was sticking up out of the top of his construction boot, having penetrated through leather, flesh, and bones. “The smallest movement of the nail was painful [and] he was sedated with fentanyl and midazolam,” powerful opioids and sedatives. But when the nail was pulled out from below and the boot removed, it became apparent that “the nail had penetrated between the toes: the foot was entirely uninjured.”

Science teaches us that every pleasure exacts a price, and the pain that follows is longer lasting and more intense than the pleasure that gave rise to it. With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases.

High-dopamine goods mess with our ability to delay gratification, a phenomenon called delay discounting. Delay discounting refers to the fact that the value of a reward goes down the longer we have to wait for it. Most of us would rather get twenty dollars today than a year from now.

Addictions researcher Warren K. Bickel and his colleagues asked people addicted to opioids and healthy controls to complete a story that started with the line: “After awakening, Bill began to think about his future. In general, he expected to . . .” Opioid-addicted study participants referred to a future that was on average nine days long. Healthy controls referred to a future that was on average 4.7 years long. This striking difference illustrates how “temporal horizons” shrink when we’re under the sway of an addictive drug.

In today’s dopamine-rich ecosystem, we’ve all become primed for immediate gratification. We want to buy something, and the next day it shows up on our doorstep. We want to know something, and the next second the answer appears on our screen. Are we losing the knack of puzzling things out, or being frustrated while we search for the answer, or having to wait for the things we want? The neuroscientist Samuel McClure and his colleagues examined what parts of the brain are involved in choosing immediate versus delayed rewards. They found that when participants chose immediate rewards, emotion-and reward-processing parts of the brain lit up. When participants delayed their reward, the prefrontal cortex— the part of the brain involved in planning and abstract thinking—became active. The implication here is that we are all now vulnerable to prefrontal cortical atrophy as our reward pathway has become the dominant driver of our lives.

By contrast, the amount of leisure time in the United States today increased by 5.1 hours per week between 1965 and 2003, an additional 270 leisure hours per year. By 2040, the number of leisure hours in a typical day in the United States is projected to be 7.2 hours, with just 3.8 hours of daily work.

In 1965, both the less educated and more educated in the United States enjoyed about the same amount of leisure time. Today, adults living in the US without a high school diploma have 42 percent more leisure time than adults with a bachelor’s degree or higher, with the biggest differences in leisure time occurring during weekday hours. This is due in large part to underemployment among those without a college degree.

Unlike pressing on the pleasure side, the dopamine that comes from pain is indirect and potentially more enduring. So how does it work? Pain leads to pleasure by triggering the body’s own regulating homeostatic mechanisms. In this case, the initial pain stimulus is followed by gremlins hopping on the pleasure side of the balance. The pleasure we feel is our body’s natural and reflexive physiological response to pain.

Hormesis is a branch of science that studies the beneficial effects of administering small to moderate doses of noxious and/or painful stimuli, such as cold, heat, gravitational changes, radiation, food restriction, and exercise. Hormesis comes from the ancient Greek hormáein: to set in motion, impel, urge on.

When rats were given access to a running wheel six weeks prior to gaining free access to cocaine, they self-administered the cocaine later and less often than rats who had not had prior wheel training. This finding has been replicated with heroin, methamphetamine, and alcohol. When exercise is not voluntary but rather forced on the animal, it still results in reduced voluntary drug consumption. In humans, high levels of physical activity in junior high, high school, and early adulthood predict lower levels of drug use. Exercise has also been shown to help those already addicted to stop or cut back.

tyranny of convenience.

Alex Honnold, now world-famous for climbing the face of Yosemite’s El Capitan without ropes, was found to have below-normal amygdala activation during brain imaging. For most of us, the amygdala is an area of the brain that lights up in an fMRI machine when we look at scary pictures. The researchers who studied Honnold’s brain speculated that he was born with less innate fear than others, which in turn allowed him, they hypothesized, to accomplish superhuman climbing feats. But Honnold himself disagreed with their interpretation: “I’ve done so much soloing, and worked on my climbing skills so much that my comfort zone is quite large. So these things that I’m doing that look pretty outrageous, to me they seem normal.” The most likely explanation for Honnold’s brain differences is the development of tolerance to fear through neuroadaptation. My guess is that Honnold’s brain started out no different from the average brain in terms of fear sensitivity. What’s different now is that he has trained his brain through years of climbing not to react to fearful stimuli. It takes a lot more to scare Honnold’s brain than the average person’s because he has incrementally exposed himself to death-defying feats. Of note, Honnold nearly had a panic attack when he went inside the fMRI machine to get pictures taken of his “fearless brain,” which also tells us that fear tolerance doesn’t necessarily translate across all experiences.

A study of skydivers compared to a control group (rowers) found that repeat skydivers were more likely to experience anhedonia, a lack of joy, in the rest of their lives. The authors wrote that “skydiving has similarities with addictive behaviors and that frequent exposure to ‘natural high’ experiences is related to anhedonia.” I would hardly call jumping out of an airplane at 13,000 feet a “natural high,” but I do agree with the author’s overall conclusion: Skydiving can be addictive and can lead to persistent dysphoria if engaged in repeatedly.

those with less than a high school education in low-paying jobs are working less than ever, whereas highly educated wage earners are working more. By 2002, the top-paid 20 percent were twice as likely to work long hours as the lowest-paid 20 percent, and that trend continues. Economists speculate that this change is due to higher rewards for those at the top of the economic food chain.

Children begin lying as early as age two. The smarter the kid, the more likely they are to lie, and the better they are at it. Lying tends to decrease between ages three and fourteen, possibly because children become more aware of how lying harms other people. On the other hand, adults are capable of more sophisticated antisocial lies than children, as the ability to plan and remember becomes more advanced.

The average adult tells between 0.59 and 1.56 lies daily.

Intimacy is its own source of dopamine. Oxytocin, a hormone much involved with falling in love, mother-child bonding, and lifetime pair bonding of sexual mates, binds to receptors on the dopamine-secreting neurons in the brain’s reward pathway and enhances the firing of the reward-circuit tract. In other words, oxytocin leads to an increase in brain dopamine, a recent finding by Stanford neuroscientists Lin Hung, Rob Malenka, and their colleagues.

While truth-telling promotes human attachment, compulsive overconsumption of high-dopamine goods is the antithesis of human attachment. Consuming leads to isolation and indifference, as the drug comes to replace the reward obtained from being in relationship with others.

In his real life, he could barely get out of bed, compulsively looked at pornography online, struggled to find gainful employment, and was isolated, depressed, and suicidal. Little of his real day-to-day life was evident on his Facebook page. When our lived experience diverges from our projected image, we are prone to feel detached and unreal, as fake as the false images we’ve created. Psychiatrists call this feeling de-realization and depersonalization. It’s a terrifying feeling, which commonly contributes to thoughts of suicide. After all, if we don’t feel real, ending our lives feels inconsequential.

In 2012, researchers at the University of Rochester altered the 1968 Stanford marshmallow experiment in one crucial way. One group of children experienced a broken promise before the marshmallow test was conducted: The researchers left the room and said they would return when the child rang the bell, but then didn’t. The other group of children were told the same, but when they rang the bell, the researcher returned. The children in the latter group, where the researcher came back, were willing to wait up to four times longer (twelve minutes) for a second marshmallow than the children in the broken-promise group.

The way I understand this is by differentiating what I call the plenty versus the scarcity mindset. Truth-telling engenders a plenty mindset. Lying engenders a scarcity mindset. I’ll explain. When the people around us are reliable and tell us the truth, including keeping promises they’ve made to us, we feel more confident about the world and our own future in it. We feel we can rely not just on them but also on the world to be an orderly, predictable, safe kind of a place. Even in the midst of scarcity, we feel confident that things will turn out okay. This is a plenty mindset. When the people around us lie and don’t keep their promises, we feel less confident about the future. The world becomes a dangerous place that can’t be relied upon to be orderly, predictable, or safe. We go into competitive survival mode and favor short-term gains over long-term ones, independent of actual material wealth. This is a scarcity mindset.

An experiment by the neuroscientist Warren Bickel and his colleagues looked at the impact on study participants’ tendency to delay gratification for a monetary reward after having read a narrative passage that projected a state of plenty versus a state of scarcity. The plenty narrative read like this: “At your job you have just been promoted. You will have the opportunity to move to a part of the country you always wanted to live in OR you may choose to stay where you are. Either way, the company gives you a large amount of money to cover moving expenses and tells you to keep what you don’t spend. You will be making 100 percent more than you previously were.” The scarcity narrative read like this: “You have just been fired from your job. You will now have to move in with a relative who lives in a part of the country you dislike, and you will have to spend all of your savings to move there. You do not qualify for unemployment, so you will not be making any income until you find another job.” The researchers found, not surprisingly, that participants who read the scarcity narrative were less willing to wait for a distant future payoff and more likely to want a reward now. Those who read the plenty narrative were more willing to wait for their reward. It makes intuitive sense that when resources are scarce, people are more invested in immediate gains, and are less confident that those rewards will still be forthcoming in some distant future.

The psychological literature today identifies shame as an emotion distinct from guilt. The thinking goes like this: Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self. Shame is a maladaptive emotion. Guilt is an adaptive emotion.

Lessons of the Balance 1. The relentless pursuit of pleasure (and avoidance of pain) leads to pain. 2. Recovery begins with abstinence. 3. Abstinence resets the brain’s reward pathway and with it our capacity to take joy in simpler pleasures. 4. Self-binding creates literal and metacognitive space between desire and consumption, a modern necessity in our dopamine-overloaded world. 5. Medications can restore homeostasis, but consider what we lose by medicating away our pain. 6. Pressing on the pain side resets our balance to the side of pleasure. 7. Beware of getting addicted to pain. 8. Radical honesty promotes awareness, enhances intimacy, and fosters a plenty mindset. 9. Prosocial shame affirms that we belong to the human tribe. 10. Instead of running away from the world, we can find escape by immersing ourselves in it.