This blog post is a brief summary of the book, “Dopamine Nation” written by Dr. Anna Lembke.

Pursuit of Pleasure

The book starts off introducing the problem, “why are we consuming so much and still experiencing pain?” It provides a teaser to the underlying scientific theme of the book which is that the area that processes our pleasure is the same area that processes our pain. Dopamine, the drug mentioned in the title of the book is considered one of the main predictors of addictive behavior. The author again gives a teaser of what’s to come in the book; the way dopamine plays a role in our pleasure seeking behavior and the way it ultimately causes pain.

Three factors

The book makes a case that three factors come in to play for something to become addictive - increased and easy access to the thing that we are addicted to, variety of forms in which we can access the addiction, and the potency of the thing that we are addicted to. You can think of anything that one can be addicted to and these three factors seem to be taking one from a harmless one time excursion in to heightened form of addiction. The author gives her own example where the act of reading twilight lead her in to reading porn and seeking out crappy fantasy books. Now this is no ordinary person, she works in the addiction clinic at Stanford university. It is interesting to read about someone whom you would think would have slayed all addictions, falling for vampire porn addiction. That goes on to show that we are all addicted to something or other in varying degree.

Pleasure pain balance

The chapter on Pleasure-Pain Balance is very interesting to someone like me who has never thought about it from a scientific perspective. The author presents pleasure pain as a balance that exists in each one of us. The more we entertain pleasure in our lives, that much more easier the pain elements come on to the bandwagon and tilt the balance towards pain. Our tolerance for pain decreases massively once we give in to repeated pleasures, seek variety in pleasures and seek more potent pleasures. Now when we say pleasures, it could be a lot of activities that most of us indulge in. Think about binge watching a netflix series. a hard hitting crime thriller. The experience of seeing whodunit with enough violence might make your brain to be on the edge and may be your brain might like it for some reason. I am sure there is a large subset of people who like crime thrillers on netflix; this comes from the simple observation that there are a ton of crime thriller series that are very popular and by definition that means there are many people watching it. However the point the author makes is that once you watch something like that, your brain now wants more variety, more intensity in chosen addiction. Your brain wants to see stuff that has variety in it. May be you have seen a mafia based series on netflix, your brain might want to see something in a different language, in a different setting, more hard hitting. So slowly you are moved in to a direction where your single excursion in to crime thriller, might lead in to an addiction where you keep binging more netflix series. After some point in time, you might not even have the patience to watch the entire series and you might forward it to a point where your brain gets the max pleasure - it could be anything that your brain finds interesting in a crime thriller. Needless to say whenever you binge watch, your brain is no longer fresh, the scenes from binge watching keep playing in your mind; your mood will change and it will be visible with the people you interact on a daily basis. You become more angry, violent, and more edgy even though it is not something you genuinely want. All of this is happening to you because you let something take over you and you have become addicted to it. The above is in the context of a netflix crime thriller addiction. But the same thing can be applied to any form of addiction - drugs, sex, consumption, doom scrolling videos etc.

At a fundamental level the same three forces are coming in to play - easy or convenient access to something that can be addictive, novelty or variety of ways in which you can access the addiction and the potency level of the addiction goes up north with every visit to your addiction. I am sure this will be familiar to most of the readers as we are all addicted something now or in the past, which we wish we can get rid of or have control on. I have a ton of them and when I look back at them, there is always a feeling of guilt and disappointment that i could not metathink about my behavior and correct it when it had all the right cues of it becoming in to an addiction.

Why we seek out more pleasures ?

Why do we even seek out such things ? The author says that there are two main reasons

Reason 1: Pleasure pain balance and set point

We are increasingly seeking an environment that is devoid of any pain. As soon as we experience any pain we run towards pleasure giving objects. Instead of understanding and learning from the pain, we tend to avoid it. We also do the same mistake while bringing up children. We inadvertently, in the garb of ensuring safe environment to them, make the environment super safe and give in to all their asks etc. We make the environment super sanitized that they stop regular excursion to pain moments. This creates a situation where we experience pleasure more, seek pleasure more, and more importantly unknowingly our tolerance to pain starts to reduce. This is wonderfully illustrated using a visual in the book where our pleasure pain balance shifts in such a way that makes it difficult for us to experience pleasure and become less tolerant to pain. Absolutely wonderful observation. In your daily life, if you have an experience that is painful, it is important that you savor it just like you would love a pleasant experience. Why ? The tendency to experience pain improves our tendency to get happiness from simple things. We don’t have to seek out more novel, more intense pleasure seeking activities.

Imagine our brains contain a balance—a scale with a fulcrum in the center. When nothing is on the balance, it’s level with the ground. When we experience pleasure, dopamine is released in our reward pathway and the balance tips to the side of pleasure. The more our balance tips, and the faster it tips, the more pleasure we feel. But here’s the important thing about the balance: It wants to remain level, that is, in equilibrium. It does not want to be tipped for very long to one side or another. Hence, every time the balance tips toward pleasure, powerful self-regulating mechanisms kick into action to bring it level again. These self-regulating mechanisms do not require conscious thought or an act of will. They just happen, like a reflex.

I tend to imagine this self-regulating system as little gremlins hopping on the pain side of the balance to counteract the weight on the pleasure side. The gremlins represent the work of homeostasis: the tendency of any living system to maintain physiologic equilibrium.

• Stages

  • Stage 1:

    This is the way the pleasure pain balance looks, immediately after you experience pleasure

    

  • Stage 2:

    This is the way one feels after the self regulating mechanism kicks in. The pain elements kick in and the balance is slowly restored

    

  • Stage 3

    Once the balance is restored, it keeps tipping an equal and opposite amount to the side of pain

    

  • Stage 4

    Repeated excursion to the same kind of pleasure now makes it tougher to experience the same level of pleasure as more pain gremlins are now occupying the pain side of the balance

    

  • Stage 5

    In this step, a strange this happens, the gremlins have become powerful that they shift the level set completely and then it becomes super difficult to achieve even a modicum of pleasure. In this stage, an addict is merely trying to ward off pain

    

Reason 2: Boredom

Our attitude towards boredom has to change. With the instant availability of so many things in our lives, we cannot tolerate boredom and the world is always trying to give you dopamine hits in various forms. Unless we are ok with boredom, and infact try to use that time, to pause and reflect, we will never be able to do anything original, for creativity happens when you stop and think. It cannot happen in a mindless consumption driven life style. This inability to deal with boredom is pushing us to seek pleasure in more novel forms and ones that are more intense.

Dopamine

The author tries to explain the role of dopamine in the brain through nice analogies such as

• pitcher and catcher analogy to explain the role of presynaptic neuron and post synaptic neuron

When the pitcher and catcher are sluggish, then there are all sorts of problems that attack us such as sluggishness, inability to focus, Attention Deficit Disorder. Usually the medication that is given by the docs for ADD relates to ensuring that pitcher and catcher regain the strength and dopamine generators.

Neurons are like a pitcher and a catcher in baseball. The “baseball” is a neurotransmitter — in this case, dopamine. The space between them is the synaptic cleft.

Think of it like this:

• The pitcher = the sending neuron It wants to send a message.

• The baseball = dopamine This carries the message.

• The catcher = the receiving neuron It grabs the message and reacts.

What actually happens

1. The sending neuron throws dopamine into the gap.
2. Dopamine travels across the tiny space.
3. The receiving neuron catches it and responds (attention, mood, reward, learning).
4. After delivering the message, dopamine is cleaned up either by:
   • being taken back into the sender (reuptake), or
   • being broken down by enzymes.

This entire throw–catch process is how brain cells communicate. And dopamine is one of the “balls” used to send important messages about motivation, attention, and reward.

What’s connection with dopamine and drugs

Certain Drugs release more dopamine in our neural pathways(a brain circuit that links the ventral tegmental area, the nucleus accumbens, and the prefrontal cortex) and release faster. This is what makes the substance addictive.

Anhedonia

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. Reading had always been my primary source of pleasure and escape, so it was a shock and a grief when it stopped working. Even then it was hard to abandon.

This is something that happens when we mindlessly consume something. Think about YT doom scrolling. Every one is guilty of this once in a while but I know a few who spend hours doing this. When I ask them the reason why they doom scroll, the answer I get is something on this lines “I want to numb my senses because I was doing high intense work during the day” . Well I am not sure whether your brain really needs a high dopamine at the end of the day. It might want to relax and rejuvenate so that you can function better. By giving in to addictions like doom scrolling YT videos, we might lose our ability to watch some genuinely good content on YT that will want us to deliberately think about various aspects mentioned in the video. I think many of us will relate to this. Watching a 20 min video without distractions on YT or any other video channel on the web has become difficult. Our brain tricks us to seek more pleasure by clicking some other video. Not that we genuinely want to see the content. Our brains are like monkeys jumping on a tree with no purpose.

Terminology

• experience driven plasticity: dendrites become more longer and more numerous in response to high dopamine rewards
• neuro adaptation: repeated exposure to the same or similar pleasure - the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain gets stronger and longer.
• opoid induced hyperalgesia
• anhedonia

Self Binding

DOPAMINE framework

The author introduces dopamine framework, a framework developed based on her many years of treating patients

Found something interesting in this chapter: author refers to mobile phones as digital drugs. If I expand it to all the devices, then one can think of many forms of device addiction as digital drugs.

What can one learn from the above framework?

• Gather simple facts of consumption
• What are the objectives for using a drug ?
• Are there any unintended consequences of addiction ?
• Is there a way one can abstain for atleast 4 weeks?
• Post abstinence, what insight have you gained about you?
• What can do based on the insights gained from the experiment?

All of the above points look too academic in a way. But I guess the proof is in actually implementing the above steps and checking for one self whether it helps to get rid of addiction

Space, Time and Meaning

The author talks about various kinds of restrictions that various people impose on themselves to escape their addiction. The three types of strategies that people adopt are

1. Physical self-binding: In this one usually resorts to ways in which there is deliberate barrier created to access. Be it alcohol, drugs or phone, one can see to it that one never gets to it easily. In the case of phones, nowadays, they sell safes that don’t open up once locked for a certain period of time. There are drugs that block certain receptors in addicts that reduces their compulsion to indulge. There are also some people who shrink their stomachs so as to cut down their consumption addiction. Across all these strategies, the common theme is limiting access via physical separation
2. Chronological self-binding: This involves restricting consumption to certain times of the day, week, month or year. Essentially restricting the drug usage to a narrow time window. The principle of delayed discounting is explained in this section, a term that I have come across for the first time, thanks to this book
3. Categorical self-binding limits consumption by sorting dopamine into different categories: those subtypes we allow ourselves to consume, and those we do not. You make broad categories of behaviors completely off-limits, removing the need for everyday decisions.

The takeaway from this section is that binding ourselves is a way to be free. In Lembke’s framework, the goal isn’t to rely on willpower, but to design systems that make willpower unnecessary.

Why should a addict consider these self-binding strategies ? Because they

• prevent easy access
• reduce decision fatigue
• introduce friction
• keep urges from translating into action
• retrain the brain’s reward pathways
• create safer habits automatically

A Broken Balance

The author presents a case of one of her patients and questions the validity of drugs such as Buprenorphine that are being given without consideration of the after effects

Pursuit of Pain

Pressing on the pain side

In this chapter, the author presents a different view point of dealing with addiction. Taking the same analogy of pleasure pain balance, there are many addicts who have deliberately veered towards embracing pain as a way to bring the level set back. Some of the examples mentioned are

• cold exposure
• exercise
• fasting
• deep breathing
• difficult tasks
• discipline habits

These produce a dopamine rebound and the brain releases more dopamine afterward, not less.

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. With intermittent exposure to pain, out natural hedonic set point gets weighed to the side of pleasure, such that we become less vulnerable to pain and more able to feel pleasure over time

The author does caution that excessive seeking of pain itself can be an addiction.

Radical Honesty

Radical honesty - telling the truth about things large and small, especially when doing so exposes our foibles and entails consequences - is essential not just to recover from addiction but for all of us trying to live a more balanced life in our reward-saturated ecosystem

Awareness

I loved the way author uses Odysseus myth to illustrate the importance of recounting experiences. Greek myth about Odysseus asking his team to tie him to a mast so as to escape the lure of sirens is mentioned in several books that I have read in the past, but the author mentions another interesting take on the myth, which is, the reason why Odysseus did not just put bee wax and avoid Sirens is that he wanted to have a story that can be narrated to Sirens that would ultimately kill Sirens. It was the story that gave him power over Sirens. Beeswax was only a temporary relief.

Recounting our experiences gives us mastery over them. Whether in the context of psychotherapy, talking to AA sponsor, confessing to a priest, confiding in a friend, or writing in a journal, our honest disclosure brings our behaviour in to relief, allowing us in some cases to see it for the first time. This is especially true for behaviors that involve a level of automaticity outside of conscious awareness.

Intimate Human Connection

This is the slightly counterintuitive part of being honest. We might think we will repel others by completely being honest. On the contrary, others usually appreciate your honesty and stick around with you, be more open with their feedback, be more sympathetic or empathetic in their interactions with you.

Of course, there needs to be a balance too. Excessive sharing of information with an ulterior motive can itself lead to addiction. The author introduced me to the word “disclosure porn”, a term referring to the behavior of revealing intimate aspects of our lives on social media platforms and with others. This behavior itself could be a result of dopamine kick that one gets by sharing. Disclosure porn is usually a way to manipulate others for a certain type of selfish gratification rather than to foster intimacy through a moment of shared humanity.

Truthful Autobiographies

The author puts it so nicely when she says

The stories we narrate about our lives not only serve as a measure of our past but also shape future behavior.

The way we tell our stories is a marker and predictor of mental health

I find journaling to be a great experience where I can narrate my daily life and get over those details in my head. I can put them down on paper honestly and it has made a world of difference. I never knew saw journaling as a way to change the future narrative of our lives. But given what I read from this chapter, I have a far more nuanced view of why one should journal or join an organization to speak up about an addiction

Truthtelling is Contagious

There is a very interesting case that is mentioned in the chapter where a doctor sticks to truth and faces a lot of difficult in life. However sticking to truth despite the difficulties gets him on to a path that has massively helped him in the past

This chapter resonated with me as it reinforces some of the activities that I do on a daily basis like journaling. At the same time, it also has made me realize that some of the lies that I speak with my children or family are probably corrosive in the long run. “What will happen if I lie in this one instance?” is probably my mindset when speaking to my kids sometimes. But now the stories in the chapter has made me feel that maybe going for authenticity come what may, might be better for me as it reduces the cognitive load to put on an act and live a life with no secrets.

Prosocial Shame

The author talks about two kinds of shame and in doing so makes one aware of the situation we are in, when dealing with our addictions.

Destructive shame deepens the emotional experience of shame and sets us up to perpetuate the behaviour that led to feeling shame in the first place. If others respond by holding us closer and providing clear guidance for redemption or recovery, we enter a cycle of prosocial shame. Prosocial shame mitigates the emotional experience of shame and helps us stop or reduce the shameful behavior

Takeaway

My biggest takeaway of the book is the way pleasure pain balance operates in our lives and more so when we are addicted to something, which most of us are, to something or the other. By narrating various real life stories, the author has done a wonderful job of piecing together a narrative that gives any reader a hope to get out of his or her addictions, however small or big those addictions might be. I found the book very interesting and very helpful in resetting some of my unconscious behaviors.