back to indexDr. Anna Lembke: Understanding & Treating Addiction | Huberman Lab Podcast #33
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Welcome to the Huberman Lab Podcast,
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where we discuss science and science-based tools
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for everyday life.
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I'm Andrew Huberman, and I'm a professor of neurobiology
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and ophthalmology at Stanford School of Medicine.
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Today, I have the pleasure of introducing Dr. Anna Lemke.
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Dr. Lemke is a psychiatrist
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and the chief of the addiction medicine
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dual diagnosis clinic
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at Stanford University School of Medicine.
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She's a psychiatrist who treats patients
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struggling with addiction.
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She has successfully treated patients
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dealing with drug addiction, alcohol addiction,
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and behavioral addictions,
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such as gambling and sex addiction,
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as well as other types of addiction.
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In fact, during our discussion,
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I learned that there are a huge range of behaviors
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and substances to which people can become addicted to,
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and that there is a common biological underpinning
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of all those addictions.
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I also learned that there's a common path
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to the treatment and recovery
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from essentially all addictions.
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Dr. Lemke explained that to me
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and explained how to think about and conceptualize
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our own addictions,
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as well as the addictions of other people
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who are struggling to get treatment,
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move through treatment,
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and stay sober from their addictions.
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In addition to treating patients,
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Dr. Lemke is an author
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and was featured in the 2020 Netflix documentary,
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''The Social Dilemma.''
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I'm excited to tell you that she has a new book coming out
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called ''Dopamine Nation''
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finding balance in the age of indulgence.
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The book comes out August 24th
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and is an absolutely fascinating read into addiction
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and ways to treat various types of addiction.
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I've read the book cover to cover.
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And all I'll tell you is that at the very first chapter
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and throughout, you're going to be absolutely blown away.
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The stories about her patients are extremely engaging.
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It brings forward the real struggle of addiction
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and the incredible,
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I think it's fair to say heroic battles
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in order to get through addictions of various kinds.
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And all of that is woven through with story,
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and ways that make it very accessible to anyone,
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whether or not you have a science background or not.
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I can't recommend it highly enough.
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So again, the book is ''Dopamine Nation''
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finding balance in the age of indulgence.
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It comes out August 24th of this year, 2021.
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And you can pre-order that book by going to Amazon.
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We will provide a link to that in the show caption.
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I just want to mention that this podcast
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is separate from my teaching and research roles at Stanford.
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part of my desire and effort to bring zero cost
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to consumer information about science
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and science related tools to the general public.
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In keeping with that theme,
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I'd like to thank the sponsors of today's podcast.
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Our first sponsor is Roca.
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Roca makes sunglasses and eyeglasses
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that are of the absolute utmost quality.
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Today's episode is also brought to us by Headspace.
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And now for my discussion with Dr. Anna Lemke.
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All right, great to have you here.
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Thank you for having me.
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I'm excited to be here.
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Yeah, I have a lot of questions for you.
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I and many listeners of this podcast
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are obsessed with dopamine and what is dopamine?
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We all hear that dopamine is this molecule
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associated with pleasure.
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I think the term dopamine hits,
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like I'm getting a dopamine hit from this,
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from Instagram or from likes or from praise
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or from whatever is now commonly heard.
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And what are maybe some things about dopamine
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that most people don't know
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and probably that I don't know either?
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So dopamine is a neurotransmitter
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and neurotransmitters are those molecules
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that bridge the gap between two neurons.
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So they essentially allow one neuron,
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the presynaptic neuron to communicate
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with the postsynaptic neuron.
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Dopamine is intimately associated
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with the experience of reward, but also with movement,
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which I think is really interesting
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because movement and reward are linked, right?
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If you think about early humans,
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you had to move in order to go seek out the water
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or the meat or whatever it was.
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And even in the most primitive organisms,
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dopamine is released when food is sensed in the environment,
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for example, sea elegance, a very primitive worm.
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So dopamine is this really powerful,
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important molecule in the brain
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that helps us experience pleasure.
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It's not the only neurotransmitter involved in pleasure,
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but it's a really, really important one.
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And if you want to think about something
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that most people don't know about dopamine,
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which I think is really interesting
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is that we are always releasing dopamine
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at a kind of tonic baseline rate.
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And it's really the deviation from that baseline
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rather than like hits of dopamine in a vacuum
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that make a difference.
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So when we experience pleasure,
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our dopamine release goes above baseline.
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And likewise, dopamine can go below that tonic baseline,
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and then we experience a kind of pain.
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So is it fair to say that one's baseline levels of dopamine,
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how frequently we are releasing dopamine
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in the absence of some, I don't know, drug or food
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or experience just sitting, being,
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is that associated with how happy somebody is,
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their kind of baseline of happiness or level of depression?
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There is evidence that shows that people who are depressed
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may indeed have lower tonic levels of dopamine.
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So that's a really reasonable thought.
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And there's some evidence to suggest that that may be true.
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The other thing that we know,
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and this is really kind of what the book is about,
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is that if we expose ourselves chronically
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to substances or behaviors
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that repeatedly release large amounts of dopamine
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in our brain's reward pathway,
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that we can change our tonic baseline
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and actually lower it over time
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as our brain tries to compensate for all of that dopamine,
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which is more really than we were designed to experience.
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And is it the case that our baseline levels of dopamine
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are set by our genetics, by our heredity?
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Well, I think if you think about
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sort of the early stages of development in infancy,
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certainly that is true.
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You're kind of born with probably
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whatever is your baseline level,
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but obviously your experiences can have a huge impact
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on where your dopamine level ultimately settles out.
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So if somebody's disposition
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is one of constant excitement and anticipation
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or easily excited,
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these are, I think, about the kind of people where you say,
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hey, do you want to check out this new place for tacos?
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And they're like, yeah, that'd be great.
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And other people are a little more cynical,
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harder to budge, like my bulldog Costello.
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Very, very stable low levels of dopamine
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with big inflections in his case.
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Do you think that's set in terms of our parents
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and obviously nature and nurture interact,
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but is dopamine at the core of our temperament?
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I don't really think we know the answer to that,
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but I will say that people are definitely born
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with different temperaments
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and those temperaments do affect their ability
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to experience joy.
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And we've known that for a long time
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and we describe that in many different ways.
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One of the ways that we describe that in the modern era
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is to use psychiatric nomenclature,
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like this person has a dysthymic temperament,
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or this person has chronic major depressive disorder.
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In terms of looking specifically
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at who's vulnerable to addiction,
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that's an interesting sort of mixed bag,
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because when you look at the research
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on risk factors for addiction,
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so what kind of temperament of a person
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makes them more vulnerable to addiction,
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you see some interesting findings.
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First, you see that people who are more impulsive
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are more vulnerable to addiction.
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So what is impulsivity?
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That means having difficulty putting space
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between the thought or desire to do something
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and actually doing it.
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And people who have difficulty putting a space there
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or who have a thought to do something
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and just do it impulsively
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are people who are more vulnerable to addiction.
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In terms of impulsivity,
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is this something that relates literally
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to the startle reflex?
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Like I've, for instance, as a lab director,
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I'm familiar with walking around my lab
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and when I decide, deciding I'm going to talk to my people,
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of course, when they knock on my door,
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it's always like, wait, why am I being bothered right now?
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Even though I love to talk to them,
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but I walk around my lab from time to time
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and some people I notice I'll say, do you have a moment?
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And they'll slowly turn around and say, yeah, or no,
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And other people will jump the moment I say their name.
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They actually have a kind of a heightened startle reflex.
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Is that related to impulsivity
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or is what you're referring to an attempt
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to withhold behavior that's very deliberate
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under very deliberate conditions?
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Yeah, so I don't think that that startle reflex
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is necessarily related to impulsivity.
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That can be related to anxiety.
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So people who are high anxiety,
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people will tend to have more of a startle reflex.
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Impulsivity is a little bit different.
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And by the way, impulsivity is not always bad, right?
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Impulsivity is that thing where there's not a lot
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of self editing or worrying about future consequences.
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You know, you have the idea to do something and you do it.
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And of course we can imagine many scenarios
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where that's absolutely wonderful.
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You know, there can be a sort of, let's say,
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intimate interactions between people
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where you wouldn't really want to be super inhibited
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You would want to be disinhibited and impulsive.
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I can also like imagine like sort of fight or flight
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scenarios, like battle scenarios, right?
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Where it would really be good to be impulsive
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and just go, rah, you know, just go.
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Where hesitation can cost you your life.
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Yes, that's right, that's right.
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But you know, and I think this brings up a really,
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something that I've come to believe after 25 years
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of practicing psychiatry is that what we now conceptualize
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in our current ecosystem as mental illness
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are actually traits that in another ecosystem
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might be very advantageous.
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They're just not advantageous right now
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because of the world that we live in.
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And I think, you know, impulsivity is potentially
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one of those, right?
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Because we live in this world that's sort of like,
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you have to constantly be thinking sort of rationally
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about the consequences of X, Y, or Z.
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And it's such a sensory rich environment, right?
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That we're being bombarded with all of these opportunities,
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these sensory opportunities.
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And we have to constantly check ourselves.
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And so impulsivity is something that right now
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can be a difficult trait,
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but isn't in and of itself a bad thing.
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Yeah, and it's, I'm beginning to realize
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it's a fine line between spontaneity and impulsivity.
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What is pleasure and how does it work
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at the biological level and if it feels right
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at the psychological level?
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I think we, and if you don't mind painting a picture
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of sort of the range of things that you have observed
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in your clinic or in life that people
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can become addicted to.
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But just to start off really simply,
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what is this thing that we call pleasure?
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Well, I think it's actually really hard to define pleasure
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in any kind of succinct way,
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because certainly there is the seeking out
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of a high or a euphoria,
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or I think the kind of experience
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that most anybody would associate with the word pleasure.
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But also the seeking out of those same substances
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and behaviors is often a way to escape pain.
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So for example, when I talk to people with addiction,
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sometimes their initial foray into using a drug
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is to get pleasure, but very often it's a way
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to escape their suffering, whatever their suffering may be.
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And certainly as people become addicted,
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even those who initially were seeking out pleasure
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are ultimately just trying to avoid the pain of withdrawal
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or the pain of the consequences of their drug use.
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So I think it's very hard to actually define it
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as this unitary thing.
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And it's certainly not just getting a high.
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There are so many ways in which people sort of want
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to escape, which is not the same thing
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as sort of this hedonic wanting to feel pleasure.
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So someone could decide that they want to go out and dance
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or get up and dance because of the pleasure of dancing.
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I can imagine that.
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And maybe it's very difficult for them to stay seated
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when a particular song comes on, for instance.
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But seeking what we would call pleasure
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in order to eliminate pain,
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that evokes a different picture in my mind.
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That evokes a picture of somebody that feels lost
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or depressed or underwhelmed.
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I definitely want to get into the precise
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and general description of addiction and what that is,
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but in a previous conversation we had,
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you said something that really rung in my mind,
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which is that many people who become addicted to things,
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let's call them addicts,
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have this feeling that normal life isn't interesting enough,
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that they are seeking a super normal experience
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and that the day-to-day routine balance,
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which is actually in the title of your book,
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"'Dopamine Nation, Finding Balance
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"'in the Age of Indulgence,'"
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that the word balance itself can sometimes
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be a bit of an aversive term for people.
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And I'm struck by this idea,
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and the reason I want to explore it is
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because so much of what I see online
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is about generating a lack of balance,
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about being tilted forward at all times,
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really leaning into life hard, experiencing life,
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living a full life.
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Even the commencement speech given by Steve Jobs
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on this campus was really about finding passion,
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digging, you know, there's so much in the narrative now.
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So maybe you could just tell us a little bit
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about your experience with this association,
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if it really exists, between people's sense of the normalcy
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or maybe even how boring life can be
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and their tendency to become addicts of some sort.
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Yeah, well, I mean, I think that life
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for humans has always been hard,
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but I think that now it's harder in unprecedented ways.
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And I think that the way that life is really hard now
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is that it actually is really boring.
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And the reason that it's boring is
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because all of our survival needs are met, right?
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I mean, we don't even have to leave our homes
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to meet every single physical need.
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You know, as long as you're of a certain level
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of financial wellbeing, which frankly, you know,
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we talk so much about, you know, the income gap,
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and certainly there is this enormous gap
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between rich and poor, but that gap is smaller
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than it's ever been in like the history of humans.
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Even the poorest of the poor have more excess income
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to spend on leisure goods
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than they ever have before in human history.
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If you look at leisure time, for example,
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so people without a high school education
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have 42% more leisure time than people with a college degree.
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So my point here is that life is hard now
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in this really weird way,
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in that we don't really have anything that we have to do.
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So we're all forced to make stuff up, you know,
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whether it's being a scientist or being a doctor
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or being an Olympic athlete or, you know,
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climbing Mount Everest,
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and people really vary in their need for friction.
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And some people need a lot more than others.
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And if they don't have it, they're really, really unhappy.
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And I do think that a lot of the people that I see
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with addiction and other forms of mental illness
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are people who need more friction.
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Like they're unhappy,
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not necessarily because there's something wrong
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but because their brain is not suited to this world.
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And do you think they have that sense,
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my brain isn't suited to this world,
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or they simply feel a restlessness
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and they're constantly seeking stimulation?
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I think that's right.
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Yeah, I think it's not really knowing what's wrong with me,
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and why am I unhappy?
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How can I be happier?
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And of course, as you talk about,
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what's so pervasive in our narrative now
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is like find your passion, you know,
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find your, you know, whatever it is to save the world.
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And in a way that's good,
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because it has people out in the world and seeking,
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but in a way it can also be misleading
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in the sense that I think people aren't entirely aware
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that the world is a hard place and that life is hard
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and that, you know, like we're all kind of making it up.
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Do you know what I mean?
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Yeah, well, there's a book by Cal Newport.
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I don't know if you know Cal Newport's work,
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but you guys are very symbiotic in your messages.
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He's a professor of computer science at Georgetown.
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Yes, at Georgetown.
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And wrote a book some years ago,
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really ahead of its time,
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called So Good They Can't Ignore You,
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which is about not meditating or doing much work
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to try and figure out what one's passion is by thinking,
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but rather go out and acquire skills
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and develop a sense of passion for something
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by your experience of hard work
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and getting better and feedback.
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A little bit of the growth mindset thing
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of our colleague, Carol Dweck.
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But he's gone on to write books, Deep Work,
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which is all about removing yourself from technology
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and doing deep work.
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And he's been a big proponent of the evils of context
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switching too often throughout the day
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for sake of productivity, mostly.
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His new book is called A World Without Email.
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I'm beginning to realize as I cite off these books
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in your book, Dopamine Nation,
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Finding Balance in the Age of Indulgence,
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that maybe the reason why you two don't know
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about one another is because neither of you
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are on social media.
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That's it, that's it.
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Right, and yet you're two of the most productive people
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that I know, including productive authors.
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So that's a discussion unto itself.
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But I find this fascinating.
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So let's talk about the pleasure,
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pain, balance, and addiction.
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And I've heard you use this seesaw
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or balance scale analogy before.
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And I think it's a wonderful one
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that really, for me, clarified what addiction is,
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at least at the mechanistic level.
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Yeah, so to me, one of the most significant findings
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in neuroscience in the last 75 years
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is that pleasure and pain are co-located,
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which means the same parts of the brain
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that process pleasure also process pain.
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And they work like a balance.
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So when we feel pleasure, our balance tips one way.
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When we feel pain, it tips in the opposite direction.
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And one of the overriding rules governing this balance
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is that it wants to stay level.
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So it doesn't want to remain tipped very long
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to pleasure or to pain.
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And with any deviation from neutrality,
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the brain will work very hard to restore a level balance
link |
or what scientists call homeostasis.
link |
And the way the brain does that
link |
is with any stimulus to one side,
link |
there will be a tip an equal and opposite amount
link |
to the other side.
link |
It's like you have principle laws of physics.
link |
Yes, right, right.
link |
So I like to watch YouTube videos.
link |
When I watch YouTube videos of American Idol,
link |
it tips to the side of pleasure.
link |
And then when I stop watching it, I have a comedown, right,
link |
which is a tip to the equal and opposite amount
link |
on the other side.
link |
And that's that moment of wanting to watch
link |
one more YouTube video, right?
link |
Yeah, and I just want to interject there.
link |
So this moment of wanting to watch another
link |
that is associated with pain, I think,
link |
is are we always aware of that happening?
link |
Because you just described it in a very conscious way.
link |
But when I indulge in something I enjoy,
link |
I'm usually thinking about just wanting more of that thing.
link |
I don't think about the pain, I just think about more.
link |
Right, so really excellent point,
link |
because we're mostly not aware of it.
link |
And it's also reflexive.
link |
So it's not something that consciously happens
link |
or that we're aware of
link |
unless we really begin to pay attention.
link |
And when we begin to pay attention,
link |
we really can become very aware of it in the moment.
link |
Again, it's like a falling away,
link |
like you're on social media and you get a good tweet
link |
of something and then you can't stop yourself
link |
because there's this awareness, a latent awareness
link |
that as soon as I disengage from this behavior,
link |
I'm going to experience a kind of a pain, right?
link |
A falling away, a missing that feeling,
link |
a wanting more of it.
link |
And of course, one way to combat that is to do it more,
link |
right, and more and more and more.
link |
So I think that is really what I want people to tune into
link |
and get an awareness around,
link |
because once you tune into it, you can see it a lot.
link |
And then when you begin to see it, you have,
link |
and if you keep the model of the balance in mind,
link |
I think it gives people kind of a way to imagine
link |
what they're experiencing on a neurobiological level
link |
and understand it.
link |
And in that understanding, get some mastery over it,
link |
which is really what this is all about.
link |
Because ultimately we do need to disengage, right?
link |
We can't live in that space all the time, right?
link |
We have other things we need to do.
link |
And there are also serious consequences that come
link |
with trying to repeat and continue that experience
link |
Yeah, so if I understand this correctly,
link |
when we find something or when something finds us
link |
that we enjoy, that feels pleasureful,
link |
social media, food, sex, gambling, whatever happens to be,
link |
and we will explore the full range of these,
link |
there's some dopamine release when we engage
link |
And then what you're telling me is that very quickly
link |
and beneath my conscious awareness,
link |
there's a tilting back of the scale
link |
where pleasure is reduced by way of increasing pain.
link |
And I've heard you say before that the pain mechanism
link |
has some competitive advantages over the pleasure mechanism
link |
such that it doesn't just bring the scale back to level.
link |
It actually brings pain higher than pleasure.
link |
Could you tell us a little bit more about that?
link |
Yeah, yeah, so what happens again,
link |
so the hallmark of any addictive substance or behavior
link |
is that it releases a lot of dopamine
link |
in our brain's reward pathway, right?
link |
Like broccoli just doesn't release a lot of dopamine,
link |
just doesn't, right?
link |
I'm trying to imagine.
link |
I was about to say maybe, and I stopped myself
link |
because no, broccoli is good.
link |
It can be really good, but broccoli is never amazing.
link |
Right, broccoli is never amazing.
link |
This is the most amazing broccoli.
link |
Honestly, we can probably find somebody on the planet
link |
for whom broccoli is amazing.
link |
And of course, if I'm starving, broccoli is amazing.
link |
Rich Roll, Rich Roll is big on plants
link |
and he has a good relationship to plants, Rich,
link |
tell us how to make broccoli amazing.
link |
If anyone could do it, it'd be rich.
link |
But what happens right after I do something
link |
that is really pleasurable and releases a lot of dopamine
link |
is again, my brain is going to immediately compensate
link |
by down-regulating my own dopamine receptors,
link |
my own dopamine transmission to compensate for that, okay?
link |
And that's that come down or the hangover,
link |
that after effect, that moment of wanting to do it more.
link |
Now, if I just wait for that feeling to pass,
link |
then my dopamine will re-regulate itself
link |
and I'll go back to whatever my chronic baseline is.
link |
But if I don't wait, and here's really the key,
link |
if I keep indulging again and again and again,
link |
ultimately, I have so much on the pain side, right,
link |
that I've essentially reset my brain
link |
to what we call like an anhedonic
link |
or lacking in joy type of state,
link |
which is a dopamine deficit state.
link |
So that's really the way in which pain
link |
can become the main driver is because I've indulged so much
link |
in these high reward behaviors or substances
link |
that my brain has had to compensate
link |
by way down-regulating my own dopamine,
link |
such that even when I'm not doing that drug,
link |
I'm in a dopamine deficit state,
link |
which is akin to a clinical depression.
link |
I have anxiety, irritability, insomnia, dysphoria,
link |
and a lot of mental preoccupation with using again
link |
or getting the drug.
link |
And so that's the piece there.
link |
There's the single use, which easily passes,
link |
but it's the chronic use that can then reset
link |
really our dopamine thresholds.
link |
And then nothing is enjoyable, right?
link |
Then everything sort of pales in comparison
link |
to this one drug that I want to keep doing.
link |
And that one drug could be a person, right?
link |
I mean, I know people in my life
link |
that are still talking about this one relationship,
link |
this one person that was just so great
link |
despite all the challenges of that thing,
link |
that it's almost like they're addicted to the narrative.
link |
They were maybe or still are addicted to the person.
link |
So it could be to any number of things,
link |
video games, sex, gambling, a person, a narrative.
link |
To me, and because of the way you describe this mechanism,
link |
this pleasure-pain balance,
link |
that all speaks to the kind of generalizability
link |
of our brain circuitry.
link |
And this is something that fascinates me,
link |
and I know it fascinates you as well,
link |
which is that nature did not evolve
link |
20 different mechanisms for 20 different types of addiction.
link |
Just like anxiety is a couple of core sets of hormones
link |
and neurotransmitters and pathways,
link |
and one person is triggered by social interactions,
link |
another person is triggered by spiders,
link |
but the underlying response is identical.
link |
It sounds like with addiction as well,
link |
there may be some nuance,
link |
but that they're sort of a core set of processes.
link |
So it doesn't really matter
link |
if it's gambling or video games or sex
link |
or a narrative about a previous lover or partner or whatever.
link |
It's the same addictive process underneath that.
link |
And that's where this whole idea of cross addiction comes in.
link |
So once you've been addicted to a substance,
link |
severely addicted, that makes you more vulnerable
link |
to addiction to any substance.
link |
And when you say substance,
link |
does the same, is what you just said
link |
also true for behaviors?
link |
Yes, so when I use the word drug,
link |
I'm talking about substances and behaviors, really,
link |
and I'm talking about behaviors like gambling, sex,
link |
gaming, porn, absolutely, shopping, work.
link |
You've accused me, just for the record,
link |
Anna, Dr. Lemke has accused me, not accused me,
link |
has diagnosed me outside the clinic
link |
in a playful way of being work addicted.
link |
You're probably right.
link |
The first thoughts I have when I wake up
link |
are typically about work,
link |
certainly within 50 milliseconds or so of waking.
link |
And probably the last thoughts I have,
link |
I would hope, are not about work,
link |
but yeah, I work constantly.
link |
I don't, I do other things,
link |
but I have to actively turn that off.
link |
Yes, that's exactly right.
link |
And you're certainly not alone in that.
link |
At Stanford, no, no, no, no.
link |
Right, I mean, here in Silicon Valley,
link |
it's highly rewarded, right?
link |
So that kind of addiction-
link |
It's embedded in the culture.
link |
Oh, yeah, absolutely, yeah.
link |
And there's this other city, I think it's called New York,
link |
where they also work a lot out here,
link |
and it's heavily rewarded.
link |
I once said, and I'm sure
link |
that I'm not the first person to say it,
link |
but I was thinking about addiction,
link |
and I was thinking about the underlying circuits,
link |
and I posted something to social media,
link |
which said that addiction is a progressive narrowing
link |
of the things that bring you pleasure.
link |
That was the way that I kind of crystallized
link |
the literature in my mind.
link |
And then we met, and you of course came
link |
and gave these amazing lectures in the neuroanatomy course
link |
for the medical students, and the rest is history.
link |
But I tossed out a kind of mirroring statement
link |
for that as well, which was a bit overstepping, I admit,
link |
which I said, addiction is a progressive narrowing
link |
of the things that bring you pleasure.
link |
And I said, dare I say, enlightenment is a progressive
link |
expansion of the things that bring you pleasure.
link |
Not that anybody knows what enlightenment is,
link |
but it was my attempt to take a little bit of a jab
link |
at the fact that nobody knows,
link |
and so why wouldn't I throw a neurobiological explanation,
link |
just to kind of sample the waters?
link |
And people had varying levels of response.
link |
But the reason I bring that up is that I would imagine
link |
that being able to derive pleasure from many things
link |
would be a wonderful attribute.
link |
Well, you know people like this that can experience pleasure
link |
in little things and in big events,
link |
not just the big milestones of life, but also the subtle,
link |
as the yogis would say, the subtle ripples of life.
link |
If such an ability exists, do you think that that reflects
link |
a healthily tuned dopamine system,
link |
one that can engage and enjoy, but then disengage?
link |
Is that what we should be seeking?
link |
And to underscore, I know nothing about enlightenment
link |
meditation or any of it.
link |
I just use these as opportunities to explore.
link |
Yeah, so it's a great question.
link |
And I understand the question as,
link |
so what should we be striving for, right?
link |
Where should we settle out?
link |
And in my book, I really hold out people in recovery
link |
from severe addiction as sort of modern day profits
link |
for the rest of us.
link |
Because I do think that people who have been addicted
link |
and then get into recovery do have a hard-won wisdom
link |
that we can all benefit from.
link |
And the wisdom, I guess, to distill it down,
link |
I mean, it's many things.
link |
But in terms of dopamine, the wisdom is there are adaptive
link |
ways to get your dopamine,
link |
and there are less than adaptive ways.
link |
And in general, you could describe the adaptive ways
link |
as not too potent, so not tipping that balance too hard
link |
or too fast to the side of pleasure.
link |
So does that mean never allowing myself
link |
to be absolutely in complete bliss?
link |
Or does it mean not allowing myself
link |
to stay in that state too long?
link |
The latter, I think the latter.
link |
So, and then that gets to temperament.
link |
So I'm going to get that to a second.
link |
So in general, what we want is some kind of flexibility
link |
in that balance and the ability
link |
to easily reassert homeostasis.
link |
We don't want to break our balance,
link |
which is possible if we overindulge
link |
for enough period of time and end up with a balance tip
link |
to the side of pain, this dopamine deficit state
link |
we've been talking about.
link |
We want a flexible, resilient balance, right?
link |
Which can be sensitive to things going on in the environment
link |
which can experience pleasure and approach,
link |
which can experience pain and recoil, right?
link |
This is all adaptive and healthy and necessary and good.
link |
We would never want a balance that doesn't tilt.
link |
That would be a disaster, but we wouldn't be human.
link |
And we wouldn't want that, it'd be really, really boring.
link |
On the other hand, what people in recovery
link |
from addiction talk about is, to some extent,
link |
having to learn to live with things
link |
being a little boring a lot of the time, right?
link |
So trying to avoid some of this intensity
link |
and thrill-seeking and escapism
link |
that really is at the core of addictive tendencies.
link |
Sorry to interrupt, but when you say boring,
link |
can we add stressful and boring?
link |
Because there are days where I'm not,
link |
I'm one of these people I have to remind myself to have fun
link |
because I sort of forgot what the term means
link |
because I like to think that I experience
link |
a lot of pleasure in little things,
link |
but I'm a pretty hard driving guy.
link |
I like goals and big milestones, all that stuff.
link |
Anyway, the point being that many days,
link |
I'm not bored thinking, oh, there's nothing to do,
link |
but I am kind of overwhelmed by the number of things
link |
that are really not pleasureful that I have to do.
link |
I won't mention what they are
link |
because I don't want my colleagues to be like,
link |
so that's why you don't respond to emails.
link |
No, just your emails.
link |
Not yours, Anna, but theirs.
link |
In any event, so anxiety and boredom
link |
can hang out together, right?
link |
I mean, actually boredom is highly anxiety-provoking.
link |
Okay, that's good to know
link |
because I think people hear boredom
link |
and they think like, oh, there's nothing to do here.
link |
I feel like we have a ton to do.
link |
We just don't really want to do it
link |
as opposed to something that we're excited to do.
link |
Right, okay, so this gets to sort of
link |
some of the core things also we were talking about earlier
link |
about finding your passion.
link |
So I'm going to try to link it all together.
link |
But basically, is boredom,
link |
first of all, boredom is a rare experience for modern humans
link |
because we're constantly distracting ourselves
link |
from the present moment
link |
and we have an infinite number of ways to do that, right?
link |
But boredom is really, I think,
link |
an important and necessary experience.
link |
because when you allow yourself to be bored,
link |
let's say you had that list of all the things you hate to do
link |
and you actually got them all done.
link |
Imagine that, and you got your forthcoming book done,
link |
and you did all your interviews, and then-
link |
Lightning could spread. Right.
link |
And you walked your dog and you cleaned your house
link |
and you went shopping.
link |
Imagine that for a moment.
link |
You would be sitting in your house
link |
and my guess is you would be terrified
link |
because, wow, what am I supposed to do now? Right?
link |
There's nothing I really have to do.
link |
And that is really, really scary.
link |
That can feel like free fall.
link |
And yet that's really an important
link |
and good experience to have.
link |
And I think that is an experience
link |
out of which we can have a lot of creative initiative,
link |
but also really consider our priorities and values.
link |
Okay, here I am on planet earth.
link |
What the hee-haw am I going to do with my life?
link |
What do I really care about?
link |
How do I really want to spend my time
link |
when I'm not distracting myself in order to spend it?
link |
And then this gets back to our conversation
link |
a little bit earlier about finding your passion.
link |
So I think that one of the big problems now
link |
that's very misguided about this idea
link |
of finding your passion,
link |
it's almost as if people are looking to fit the key
link |
into the lock of the thing that was meant for them to do.
link |
Right, and then everything will feel
link |
like a natural progression.
link |
Right, and then everything will be wonderful.
link |
I can attest to the fact that is not how it works
link |
Right, and that you'll have all this great success.
link |
And here's where I really think the answer lies,
link |
and I really, really believe this.
link |
Stop looking for your passion,
link |
and instead look around right where you are.
link |
Stop distracting yourself.
link |
Look around right where you are,
link |
and see what needs to be done.
link |
So not what do I want to do,
link |
but what is the work that needs to be done?
link |
And more importantly,
link |
it doesn't have to be some grandiose work.
link |
Like, does the garbage need to be taken out, right?
link |
Is there some garbage on your neighbor's lawn
link |
that someone threw there
link |
that you could actually bend over and pick up
link |
and put into the garbage can?
link |
There is so much work that needs to be done
link |
that nobody wants to do that is really, really important.
link |
And if we all did that,
link |
I really think the world would be a much better place.
link |
And this is what people who have severe addiction
link |
who get into recovery realize.
link |
They're like, it's not about me and my will
link |
and what I'm going to will in my life or in the world.
link |
It's about looking around what needs to be done.
link |
What is the work that I am called to do in this moment?
link |
Which also is incredibly freeing
link |
because I don't have to search for the perfect thing.
link |
There's a lot of burden now on young people
link |
that they have to find that perfect thing.
link |
And until they've found that perfect thing,
link |
they're going to be miserable.
link |
You don't have to do that.
link |
Look at the life you were given.
link |
Look at the people around you.
link |
Look at the jobs that present themselves to you
link |
and do that job simply and honorably one day at a time.
link |
With a kind of humility.
link |
I think this is really what's so striking to me
link |
about the wisdom of people in recovery.
link |
There's this incredible humility
link |
that comes out of that experience.
link |
You feel so broken, so ashamed,
link |
but you pick yourself up one day at a time
link |
and you build a life that's around what can I do
link |
right in this moment that might benefit another person
link |
and thereby benefit me.
link |
And it's a really important point and if you're willing,
link |
I'd like to actually stay on this issue of passion
link |
because I think the dopamine systems,
link |
if I understand them correctly,
link |
the dopamine systems merge with this work
link |
that you're referring to,
link |
this immediacy of things calling to us
link |
like taking out the trash,
link |
which sounds frankly really boring to be honest.
link |
I hate taking out the trash, but I do it
link |
because I like a clean home
link |
and I like a home that smells good
link |
or at least doesn't smell bad.
link |
So we do these things and not that we want to offer
link |
some larger carrot as a consequence of doing those things,
link |
but if I understand correctly, what you're saying is
link |
in the act of looking at one's immediate environment,
link |
acting on that immediate environment,
link |
we cultivate a relationship to these circuits in our brain
link |
about action and reward that at least to my mind,
link |
span the range of small things being rewarding
link |
and then lead us to bigger things being rewarding.
link |
It's not like all we're going to do is take out trash
link |
and tend to house.
link |
We eventually will venture out
link |
and we eventually will find careers and work on those.
link |
But if I understand correctly,
link |
you're talking about getting into a sort of functional
link |
or adaptive action step.
link |
And it's the action step that these days we tend to overlook
link |
because most of our mindset is in things
link |
that are truly outside of our immediate reality.
link |
Do I have that correct?
link |
Yeah, that was beautifully said.
link |
And I would just add to that.
link |
I see a lot of young people who, for example,
link |
spend most of their waking hours playing video games
link |
and they come to me and they say,
link |
I'm anxious and depressed.
link |
I'm majoring in computer science.
link |
I thought I would like it.
link |
If I could only find that thing
link |
that I was really meant to do, my life would be better.
link |
And my first intervention for the many, many people like that
link |
that I see in clinical care is you have it backwards.
link |
I don't say it quite like that.
link |
You were waiting for that thing to pull you out
link |
of the video game world and you're never going to find it
link |
as long as you're playing video games.
link |
Because video games are so powerfully dopaminergic
link |
that you have this distorted sense of really pleasure
link |
and pain, and you will not be able to find that thing
link |
And so of course the intervention is abstain
link |
from video games, reset your reward pathways,
link |
start with a level balance.
link |
And what invariably happens, and I've just seen it
link |
over 20 years, so many times,
link |
I've become really a believer in this.
link |
All of a sudden it's like, oh wow,
link |
my computer science class is interesting this quarter.
link |
It's like, okay, you have a receptivity then
link |
to experiencing pleasure and reward in a way
link |
you just don't have when you're bombarding
link |
your reward pathways with these high dopamine drugs.
link |
And just to underscore this notion that tending
link |
to the immediate things can lead to super performance.
link |
I may have mentioned it earlier this episode,
link |
but if I didn't, I'll mention it now,
link |
which is I have the great privilege of having
link |
some close friends that were in the SEAL teams
link |
and doing some work with those communities.
link |
And it's a remarkable community for reasons
link |
that I think most people don't understand.
link |
People think they see the images carrying logs
link |
down the beach and all the blowing stuff out,
link |
all the stuff that's fun for guys like that.
link |
But all of the guys I know who are in the SEAL teams
link |
have this sense of duty about immediate things
link |
and not just holding the door and helping with the dishes
link |
and moving things around.
link |
They are constantly scanning their environment
link |
for what can be done.
link |
They essentially conquer every environment they're in.
link |
They are also some of the most competitive human beings
link |
And they do it unless they're in the act of war fighting,
link |
which is their real job.
link |
They do it in every environment in a very benevolent way.
link |
And it's a remarkable thing because I think it's what
link |
is part of what they're selected for.
link |
And there's a range there.
link |
But I think when we hear about tending
link |
to the immediate things or this phrase,
link |
how you do one thing is how you do anything.
link |
That's a tricky one for me because there are certain things
link |
I just don't do well.
link |
But should we always be trying?
link |
I think that the tending to setting the horizon in closely
link |
and tending to things in one's immediate environment,
link |
I think it is very powerful and translates.
link |
Because again, I think the nervous system,
link |
it performs algorithms, it has action steps.
link |
The brain doesn't evolve to do one thing.
link |
It evolves to be able to use the same approach
link |
to doing lots of different things.
link |
I just want to add, so even beyond that,
link |
because that totally resonates for me
link |
and is very consistent with people in recovery
link |
from addiction who learn to take it one day at a time,
link |
which is one of the standard lingo
link |
from Alcoholics Anonymous and other 12 step groups.
link |
But I think also, as you say,
link |
our brain is really wired for the 24 hour period.
link |
We're not very good at sort of the 10 year, 20.
link |
I mean, we have these huge frontal lobes
link |
and yes, we're great planners and we can.
link |
But if we live too much in that space,
link |
we can really get very anxious and depressed and lost
link |
and either catastrophize or get grandiose.
link |
But if you can chunk it down to a day,
link |
what people in recovery talk about
link |
is how if I can just do today right,
link |
then I will get a chain of days
link |
that seem insignificant in their individual units.
link |
But after six months or a year
link |
or two years of those good days,
link |
I've got two very good years, right?
link |
And I look back and it's like, oh wow,
link |
well, I guess I did all that.
link |
But I think that's really one of the keys
link |
is really taking it one day at a time,
link |
which your seals and also this connecting
link |
with the environment, right?
link |
So being awake and alert to your environment
link |
and connecting with your environment,
link |
not trying to escape it.
link |
And of course, escapism is what we all want and desire,
link |
that experience of non-being.
link |
And we get it from the internet or from drugs
link |
or whatever it is, but it's the booby prize
link |
because ultimately it takes you further and further away
link |
from your immediate environment,
link |
which is where we really have to connect
link |
to get that sense of groundedness and authenticity
link |
and like of being in our own lives.
link |
Well, I think the unit of the day
link |
is something that comes up again and again
link |
of in my discussions with colleagues
link |
who are extremely successful
link |
and who also have balanced lives.
link |
This actually came up in the discussion
link |
with Karl Deisseroth, who is also a successful scientist
link |
and clinician and manages a family, et cetera.
link |
So the unit of the day I think is fundamental
link |
and those stack up as you mentioned.
link |
So along those lines, I've heard you say
link |
that in order to reset the dopamine system,
link |
essentially in order to break an addictive pattern,
link |
to become unaddicted, 30 days of zero interaction
link |
with that substance, that person, et cetera.
link |
Yeah, and 30 days is in my clinical experience,
link |
the average amount of time it takes
link |
for the brain to reset reward pathways
link |
for dopamine transmission to regenerate itself.
link |
There's also a little bit of science
link |
that suggests that that's true.
link |
Some imaging studies showing that our brains
link |
are still in a dopamine deficit state two weeks
link |
after we've been using our drug.
link |
And then a study by Shuckett and Brown,
link |
which took a group of depressed men
link |
who also were addicted to alcohol,
link |
put them in a hospital where they had received
link |
no treatment for depression,
link |
but they had no access to alcohol in that time.
link |
And after four weeks, 80% of them no longer met criteria
link |
for major depression.
link |
So again, this idea that by depriving ourselves
link |
of this high dopamine, high reward substance or behavior,
link |
we allow our brains to regenerate its own dopamine
link |
for the balance to really correlate,
link |
and then we're in a place where we can
link |
sort of enjoy other things.
link |
So that progressive narrowing
link |
of what brings one pleasure eventually expands.
link |
So I'd like to dissect out that 30 days a little more,
link |
finally, and I also want to address
link |
how does one stop doing something for 30 days
link |
if the thing is a thought?
link |
So we'll kind of put that on the shelf for the moment.
link |
So days one through 10,
link |
I would imagine will be very uncomfortable.
link |
They're going to suck, basically, to be quite honest,
link |
because the way you describe this pleasure pain balance,
link |
to my mind says that if you remove
link |
what little pleasure one is getting,
link |
or a lot of pleasure from engaging in some behavior,
link |
that's gone, the pain system is really ramped up,
link |
and nothing is making me feel good.
link |
I'll just use myself as an example.
link |
I'm not in recovery,
link |
but that 10 days is going to be miserable.
link |
Anxiety, trouble sleeping, physical agitation
link |
and to the point where maybe impulsive, angry,
link |
should one expect all of that?
link |
Should the family members of people expect all of that?
link |
Yeah, so what I say to patients,
link |
and it's a really important piece of this intervention,
link |
is that you will feel worse before you feel better.
link |
This is probably the first question they ask, right?
link |
And I say, usually in my clinical experience,
link |
you'll feel worse for two weeks,
link |
but if you can make it through those first two weeks,
link |
the sun will start to come out in week three,
link |
most people are feeling a whole lot better than they were
link |
before they stopped using their substance.
link |
So yeah, you have to, it's a hard thing.
link |
Like you have to sign up for it.
link |
And I will say, obviously,
link |
there are people with addictions that are so severe
link |
that as long as they have access to their drug or behavior,
link |
they're not able to stop themselves.
link |
And that's why we have higher levels of care
link |
or residential treatment.
link |
So this is not going to be for everybody, this intervention,
link |
but it's amazing how many people
link |
with really severe addictions to things like heroin,
link |
cocaine, very severe pornography addictions.
link |
I posit this, and I do it as an experiment.
link |
I said, you know what, let's try this experiment.
link |
I'm always amazed, number one,
link |
how many of them are willing,
link |
and number two, how many of them are actually able to do it?
link |
They are able to do it.
link |
And so that little nudge is sort of just what they need.
link |
And the carrot is, there's a better life out there for you,
link |
and you'll be able to taste it in a month.
link |
You really will be able to begin to see
link |
that you can feel better and that there's another way.
link |
So the way you describe it seems like it's hard,
link |
but it's doable for most people, not everybody.
link |
And we'll return to that category
link |
of people who can't do that on their own.
link |
Well, then days 21 through 30, people are feeling better.
link |
The sun is starting to come out, as you mentioned,
link |
which translates in the narrative we've created here
link |
and supported by biology,
link |
that dopamine is starting to be released in response
link |
to the taste of a really good cup of coffee, for instance.
link |
Whereas before it was only to insert addictive behavior.
link |
Right, that's right.
link |
Whichever it happens to.
link |
Of course, coffee can be addictive too,
link |
but we'll leave that aside.
link |
Yeah, I feel like coffee
link |
has a kind of consumption limiting mechanism built in
link |
where at some point you just can't ingest anymore.
link |
But maybe that's wrong.
link |
Sorry to give lift to the caffeine addicts out there
link |
as I clutch my mug.
link |
So days 21 through 30.
link |
I've seen a lot of people go through addiction
link |
and addiction treatment.
link |
I've spent a lot of time in those places, actually,
link |
looking at it, researching.
link |
I've got friends in that community.
link |
I'm close with that community.
link |
One thing I've seen over and over again,
link |
sadly, often in the same individuals,
link |
is they get sober from whatever.
link |
They're doing great.
link |
These are people with families.
link |
These are people that you discard your normal image
link |
of an addict and insert the most normal, typical,
link |
whatever healthy person you can imagine
link |
because a lot of these people you wouldn't know were addicts.
link |
And then all of a sudden you get this call.
link |
So-and-so is back in jail, so-and-so's wife
link |
is going to leave him because he drank two bottles of wine
link |
and took a Xanax at 7 a.m., crashed his truck into a pole.
link |
It's got two beautiful kids.
link |
How did this happen again?
link |
To the point where by the fourth and fifth time,
link |
people are just done.
link |
I mean, maybe people,
link |
you might be able to detect the frustration in my voice.
link |
I'm dealing with this with somebody that's like,
link |
I don't even know that I want to help this time.
link |
It's been so many times.
link |
To the point where I'm starting to wonder,
link |
is this person just an addict?
link |
This is just kind of what they do and who they are.
link |
And you never want to give up on people,
link |
but, and I'm hanging in there for them,
link |
but I will say that many people have given up on them.
link |
And so what I'd like to talk about in this context is
link |
what sorts of things help other people
link |
that we know that are addicted?
link |
What really helps?
link |
Like not what could help, but what really helps.
link |
And are there certain people for whom it's hopeless?
link |
I mean, I don't like to hold the conversation that way,
link |
but I wouldn't be close to the real life data
link |
if I didn't ask, is it hopeless?
link |
Are there people who just will not be able
link |
to quit their substance use or their addictive behavior,
link |
despite, I have to assume, really wanting to?
link |
Yeah, so there are people who will die
link |
of their disease of addiction.
link |
And I think conceptualizing it as a disease
link |
is a helpful frame.
link |
There are other frames that we could use,
link |
but I do think given the brain physiologic changes
link |
that occur with sustained heavy drug use
link |
and what we know happens to the brain,
link |
it is really reasonable to think of it as a brain disease.
link |
And for me, the real window of, let's say,
link |
being able to access my compassion
link |
around people who are repeat relapses
link |
even when their life is so much better,
link |
when they're in recovery.
link |
Yeah, it's like a no-brainer, right?
link |
Is to conceptualize this balance
link |
and the dopamine deficit state
link |
and a balance tilted to the side of pain.
link |
And to imagine that for some people,
link |
after a month or six months, or maybe even six years,
link |
their balance is still tipped to the side of pain,
link |
that on some level, that balance has lost its resilience
link |
and its ability to restore homeostasis.
link |
It's almost like the hinge on that balance is messed up.
link |
Exactly, and so, I mean,
link |
for someone who's never experienced addiction like yourself,
link |
maybe one way to conceptualize it is-
link |
Well, I didn't say that.
link |
No, I was not, to be clear, I was not referring to myself,
link |
but in this example I was given,
link |
if I were, I would come clean, I would reveal that.
link |
But I think that especially after hearing
link |
some of your lectures and descriptions
link |
of the range of things that are addictive,
link |
I think I've been fortunate
link |
I don't have a propensity for drugs or alcohol.
link |
I'm lucky in that way that, frankly,
link |
if they remove all the alcohol from the planet,
link |
I'll just be relieved because no one will offer it to me.
link |
So don't send me any alcohol, it won't go to me.
link |
But I don't have that,
link |
I like to think I have the compassion,
link |
but I don't have that empathy
link |
for taking a really good situation
link |
and what from the outside looks to be throwing it
link |
Yeah, so okay, so is that, let me,
link |
and this is really, I think, important
link |
because I also had to come to an understanding of this
link |
and I feel that I have in my 20 years
link |
of seeing these patients.
link |
And of course, addiction is a spectrum disease, right?
link |
And so you've got the severe end of things.
link |
Imagine that you had an itch somewhere on your body, okay?
link |
And it was, I mean, we've all had that,
link |
like whatever the source, it was super, super itchy.
link |
You can go for, if you really focus,
link |
you could go for a pretty good amount of time
link |
not scratching it, but the moment you stopped focusing
link |
on not scratching it, you would scratch it.
link |
And maybe you do it while you were asleep, right?
link |
And that is what happens to people with severe addiction.
link |
That balance is essentially broken.
link |
Homeostasis does not get restored
link |
despite sustained abstinence.
link |
They're living with that constant specter of that pull.
link |
It never goes away.
link |
So let me say, there are lots of people with addiction
link |
for whom that does go away.
link |
And it goes away at four weeks for many of them.
link |
But in severe cases, that's always there and it's lingering.
link |
And it's the moment when they're not focusing on not using,
link |
it's like a reflex, they fall back into it.
link |
It's not purposeful.
link |
It's not because they wanna get high.
link |
It's not because they value using drugs
link |
more than they do their family.
link |
None of that, it's that really they cannot not do it
link |
when given the opportunity and that moment
link |
when they're not thinking about it.
link |
Does that make sense?
link |
That's a great description.
link |
And actually in that description,
link |
I can feel a bit of empathy
link |
because the way you described
link |
scratching an itch in your sleep.
link |
I've done that with mosquito bites.
link |
In summer, you're scratching and you wake up
link |
scratching that mosquito bite.
link |
And I also have to admit that I've experienced
link |
not feeling like I wanna pick up my phone
link |
because it's so rewarding, but just finding myself doing it.
link |
Like I'm not gonna use this thing.
link |
I'm not gonna use this thing.
link |
And then just finding myself like, what am I doing here?
link |
Sort of the, how did I get back here again?
link |
And I know enough about brain function
link |
to understand that we have circuits
link |
that generate deliberate behavior
link |
and we have circuits that generate reflexive behavior.
link |
And one of the goals of the nervous system
link |
is to make the deliberate stuff reflexive
link |
so you don't have to make the decision
link |
because decision-making is a very costly thing to do.
link |
Decision-making of any kind.
link |
So that does really help.
link |
I wanna just try and weave together this dopamine puzzle,
link |
however, because if by week,
link |
so first phase of this 30 or 40-day detox,
link |
it's like a dopamine fast, right?
link |
First 10 days are miserable.
link |
Middle 10 days, the clouds are out.
link |
There may be some shards of sunlight coming through.
link |
And then all of a sudden, sun starts to come out.
link |
It gets brighter and brighter.
link |
Why is it then that people will relapse,
link |
not just after getting fired from a job
link |
or their spouse leaving them,
link |
but when things are going really well?
link |
Is it this unconscious mechanism?
link |
Because I've seen this before, they have a great win.
link |
I have a friend who's a really impressive creative.
link |
I don't want to reveal any more than that.
link |
And relapsed upon getting another really terrific opportunity
link |
to create for the entire world.
link |
And I was like, how can that happen?
link |
But now I'm beginning to wonder,
link |
was it the dopamine associated with that win
link |
that opened the spigot on this dopamine system?
link |
Because it happened in a phase
link |
of a really great stretch of life.
link |
Yeah, so you raised that great point about triggers, right?
link |
And triggers are things that make us want
link |
to go back to using our drug.
link |
And the key thing about triggers, whatever they are,
link |
is they also release a little bit of dopamine, right?
link |
So just thinking about whatever the trigger is
link |
that we associate with drug use,
link |
or just thinking about drug use,
link |
can already release this anticipatory dopamine,
link |
this new little mini spike.
link |
But here's the part that I think is really fascinating.
link |
That mini spike is followed by a mini deficit state.
link |
So it goes up and then it doesn't go back down to baseline.
link |
It goes below baseline tonic levels.
link |
And that's craving, right?
link |
So that anticipation is immediately followed
link |
by wanting the drug.
link |
And it's that dopamine deficit state
link |
that drives the motivation to go and get the drug.
link |
So many people talk about dopamine
link |
as not really about pleasure,
link |
but about wanting and about motivation.
link |
And so it is that deficit state
link |
that then drives the locomotion to get it.
link |
And earlier, your description of dopamine
link |
being involved in the desire for more,
link |
giving the sense of reward, but also movement,
link |
I have to assume that those things
link |
are braided together in our nervous system
link |
for the specific intention of when you feel something good,
link |
then you feel the pain, or maybe you don't notice it.
link |
And then the next thing you know,
link |
you're pursuing more of the thing that could deliver.
link |
And I love the way you use the word braided together.
link |
And let me also just say something
link |
that I find also fascinating in my work with patients,
link |
and I see this all the time.
link |
There are people for whom bad life experiences,
link |
loss in any form, stress in many different forms,
link |
But there are absolutely people
link |
for whom the trigger is things going well.
link |
And the things going well
link |
can be like the reward of the things going well,
link |
but very often what it is
link |
is the removal of the hypervigilant state
link |
that's required to keep their use in check.
link |
So it's this sense of, I wanna celebrate,
link |
or I wanna, this reward happened,
link |
I wanna put more reward on there.
link |
And it's really, really fascinating
link |
because when people come to that realization
link |
about themselves, that they're most vulnerable
link |
when things are going well,
link |
that's really a valuable insight
link |
because then they can put some things in place
link |
or barriers in place or go to more meetings
link |
or whatever it is that they do to protect themselves.
link |
Along those lines, I have a friend, 40 years sober,
link |
who was a severe drug and alcohol addict
link |
from a very young age, really impressive person,
link |
does a lot of important work
link |
in the kind of at-risk youth community out in Hawaii.
link |
And he said something to me.
link |
He said, as former addicts often do,
link |
they've got these great sayings,
link |
but I think it fits very well with what you're describing.
link |
He said, no matter how far you drive,
link |
you're always the same distance from the ditch.
link |
And I said, well, that's kind of depressing.
link |
And he said, no, that's actually what gives me peace
link |
because what would happen is for so many years
link |
of relapsing and relapsing,
link |
getting recovering and relapsing,
link |
he felt like it was hopeless.
link |
And then somehow conceptualizing
link |
that the vigilance can never go away
link |
instead of making him feel burdened,
link |
it made him feel relieved.
link |
So I often think about that statement,
link |
no matter how far you drive,
link |
you're always the same distance from the ditch
link |
because in my mind, I conceptualize that as,
link |
gosh, that's a tough way to drive down the road,
link |
but actually on a road where you know where the ditch is
link |
and where you know where the lane lines are,
link |
it's actually a pretty nice drive.
link |
It's when you don't know where the shoulder is
link |
that you constantly have to be looking around.
link |
So there's this, we're speaking now
link |
in analogies and imagery and science,
link |
but one of the things I find so incredible
link |
about this community of 12-step,
link |
and there are a variety of them,
link |
are the communities that they create for themselves
link |
and some of these sayings,
link |
which I do believe link back to really
link |
core biological mechanisms.
link |
I do want to ask about those communities.
link |
I have a question which might be a little bit controversial.
link |
Which is, is it possible that people
link |
who were addicted to drugs or alcohol
link |
or some gambling or some other behavior
link |
get addicted to the addiction community?
link |
Because one thing that I think I observe over and over
link |
is that there's some circuit in the brain of human beings
link |
that has to tell you about the dream
link |
they had the night before, for whatever reason.
link |
There's another circuit that leads people to wake you up
link |
if they themselves can't sleep.
link |
I don't know what that circuit is.
link |
I'm being facetious here.
link |
But there does seem to also be a circuit
link |
in the brain of addicts to discuss
link |
and want to kind of talk about their recovery a lot.
link |
And I mentioned this not to poke at them,
link |
but rather the opposite,
link |
because I think that one thing that is challenging,
link |
at least for me and having friends
link |
that have a propensity for drug or alcohol addiction,
link |
not all of them, but certainly some of them,
link |
is when they're talking about their recovery,
link |
I feel like it's all they talk about.
link |
This meeting, that meeting, that meeting.
link |
How are we, so what I'm really asking here is,
link |
is that can we become addicted to sobriety?
link |
Right, so this is a great question.
link |
And it links into some of the other things
link |
we've been talking about having to do with
link |
where do we settle out?
link |
What is the way to live between pleasure and pain?
link |
And I implied earlier that ultimately
link |
we want a resilient balance
link |
that's sensitive to pleasure and pain,
link |
but that can easily restore homeostasis after we indulge,
link |
even when we indulge greatly.
link |
But the truth of the matter is that
link |
people with severe addiction, I believe,
link |
temperamentally want those extremes
link |
and they're wired for that kind of intensity
link |
that is more than just these slight adjustments
link |
around the fulcrum, right?
link |
It's like, they want the big highs and the big lows.
link |
They'll say, great meeting.
link |
They're like, that was such an amazing meeting.
link |
Or they find a group, they find a group in a location.
link |
Like this is almost an inside joke in those communities.
link |
Again, I'm not reporting,
link |
I'm not talking about a friend in quotes.
link |
This isn't me reporting.
link |
Well, they'll talk about how attractive people are
link |
at a given meeting,
link |
or how bonded they feel to people at a given meeting,
link |
that the meetings themselves
link |
become their own form of dopamine hit.
link |
And again, I'm not being disparaging.
link |
I just, I want to understand this.
link |
Right, so yes, so a lot of times patients will say to me,
link |
oh, you know, I don't want to go to AA, it's a cult.
link |
And my response to that is because it's a cult
link |
is exactly why it works, okay?
link |
Because yes, it is much better for you to be addicted to AA
link |
and to recovery than almost any other addiction
link |
And we know from Rob Malenka's work,
link |
who's here at Stanford,
link |
that oxytocin is the hormone that's involved
link |
in human pair bonding and relationships and love.
link |
And it directly links to dopamine neurons
link |
and causes the release of dopamine.
link |
So yes, when we connect with other humans,
link |
especially in a kind of transcendent spiritual way,
link |
that's a huge dopamine hit.
link |
And it does replace the dopamine that people get from drugs.
link |
And for people who have this addiction temperament,
link |
they need it on a more intense level.
link |
They're not going to be generally satisfied
link |
with kind of, you know, a sort of acquaintanceship, right?
link |
They want that intensity of the intimacy that you get
link |
with people when you're cathartically exposing,
link |
you know, warts and all.
link |
So yes, people can get addicted to recovery
link |
and good for them, go for it, you know?
link |
And of course this can be disruptive for friendships
link |
and relationships where the one person is not in recovery.
link |
Like you're going to so many meetings,
link |
you're always talking about recovery, but you know what?
link |
Much better than them being intoxicated, right?
link |
I mean, so although you may tire of your friends
link |
talking about their meetings all the time,
link |
I'm sure you would rather have them do that
link |
than, you know, be in their addiction, so.
link |
And this is now the second time
link |
you've done this during this discussion,
link |
but now I have empathy because the way you describe
link |
their enthusiasm about meetings
link |
is probably the way that people feel about me and your work.
link |
And in neuroscience, I mean,
link |
I've been getting up in front of the class
link |
since I was eight years old
link |
and talking about things I read over the weekend.
link |
Now I just happen to have this thing called a podcast.
link |
I've been doing it since I was little,
link |
and it annoys a lot of people, right?
link |
I've learned to suppress it a little bit.
link |
Some people like it, but I'm poking fun at myself
link |
just to say that I now can understand
link |
that the way I feel about their reports
link |
about yet another amazing meeting,
link |
or there's a different form of this,
link |
but there are some people for which
link |
they just love intense experiences.
link |
They're always like trying to pull me off to Bali
link |
because they're talking about how sensual it is all the time.
link |
I'm sure Bali is wonderful,
link |
but there's this kind of ratcheting up.
link |
It's like seeking Burning Man all year long.
link |
I've never been to Burning Man,
link |
no desire to go to Burning Man,
link |
but inside of academia, I mean,
link |
if I were to just turn the mirror at myself
link |
inside of academia or here in Silicon Valley, work,
link |
and the pursuit of more success,
link |
even if money is kind of divorced from that,
link |
sometimes it is, sometimes it isn't.
link |
Academic work is for sake of pursuit of knowledge.
link |
It sounds to me like the same mechanism.
link |
In fact, it feels to me very much like the same mechanism.
link |
So Andrew, here's what I love about you.
link |
First of all, you're willing to bring your own flaws
link |
and foibles to this conversation.
link |
Well, they're everywhere.
link |
Well, you know what?
link |
And then you're really open and curious
link |
and wanting to understand,
link |
because I can't tell you how many people I have met
link |
who really see addiction as some kind of otherness,
link |
but the truth is we're all wired for addiction.
link |
And if you're not addicted yet,
link |
it's just, it's right around the corner.
link |
Do you know what I mean?
link |
Especially with the incredible panoply of new drugs
link |
and behaviors that are out there.
link |
So I love that you're willing to take a moment
link |
and really try to understand this,
link |
because it is, we can all relate,
link |
and you're relating it to essentially your work addiction
link |
You just happen to be addicted to something
link |
that is really socially rewarded.
link |
You figured that out in an early age.
link |
Oh, when I do X, Y, and Z, all these people go,
link |
look at that smart kid or whatever it is.
link |
For me, it made me feel safe.
link |
I felt like, yeah, I just felt like this,
link |
and I pause there, because it's like peace.
link |
I'm like, ah, I can relax for a moment.
link |
When you're talking about neuroscience.
link |
Or just when I feel like I'm on the right path,
link |
and I'm onto something,
link |
or if I see something that I'm excited about,
link |
I'm like, I feel filled with, it must be dopamine.
link |
I feel flooded with pleasure, literally from head to toe.
link |
And then my next thought is, more.
link |
So true, you're a true addict, you are.
link |
You are, but you just got really,
link |
you really got lucky with the fact
link |
that what you're drawn to is adaptive, essentially.
link |
And then your challenge is going to be
link |
that your life doesn't get too out of balance
link |
in the sense that you're 24-7 work,
link |
and you don't stop and do some other things
link |
or think about it.
link |
And my life, admittedly, is somewhat asymmetric.
link |
I mean, it has other components of physical health, et cetera,
link |
but it is somewhat asymmetric, which is why I got a dog.
link |
Although I talk about him an awful lot, so.
link |
But the dog is good, because that draws you out of yourself
link |
and a little bit away from the work.
link |
But again, I think the key here is,
link |
for people who feel like they've never experienced addiction
link |
or they don't know anybody with addiction,
link |
or if they do, they don't get it,
link |
just think of that one thing
link |
that is the most important thing in your life that you do
link |
that gives you pleasure and meaning and purpose,
link |
and then imagine if you couldn't do it.
link |
Oh yeah, let's not talk about that.
link |
Well, I appreciate the feedback,
link |
and you can send me a bill at the end.
link |
What is the most ridiculous-sounding addiction
link |
that you've ever witnessed
link |
that was actually a real addiction along these lines?
link |
Because I think we all know the standard heroin pill.
link |
You've been very, I should mention,
link |
because it's important, your previous book,
link |
and we will provide a link to that as well,
link |
focused on the opioid crisis
link |
and what we thought was medication.
link |
It turned out to be just as bad, if not worse,
link |
than a lot of so-called street drugs.
link |
So we understand those, you know, gambling,
link |
sex addiction, porn addiction, now video games.
link |
We'll talk about social media a little bit more in depth,
link |
but what's the most, like, wow,
link |
I didn't realize people could get addicted to that.
link |
Really, so I had a very lovely patient
link |
who had a severe alcohol addiction,
link |
and she got into recovery from her alcohol addiction
link |
for many years, but she kind of had a sort of a polydipsia
link |
or an urge to be drinking something a lot,
link |
and so she drank a lot of water,
link |
and slowly, over time, she realized
link |
that if she drank enough water,
link |
she could become hyponatremic and delirious
link |
and be out of herself, which is-
link |
You can die from it, right?
link |
Right, which is, she just wanted to be out of her own head,
link |
and so she would periodically,
link |
intentionally overdose on water in order to,
link |
I know it was so sad, so sad.
link |
What happened to her?
link |
She eventually took her own life.
link |
Wow. Yeah, it was really-
link |
She was a lovely woman.
link |
She was so bright.
link |
She had so many interests and passions,
link |
and of course, it was very sad when she died,
link |
but that was a wow to me.
link |
It was like, wow, if you have this disease of addiction,
link |
you can even get addicted to water.
link |
Wow, and I think it just underscores
link |
the generalizability of these circuits.
link |
There isn't a brain circuit for addiction to water
link |
that she happened to have.
link |
There's a brain circuit for pleasure and pain
link |
and addiction and water plugged into that circuit.
link |
Wow, that's intense.
link |
In your book, Dopamine Nation,
link |
you also describe some amazing paths to recovery.
link |
People that, you know, from reading it,
link |
I won't say which ones and who,
link |
because there's some great surprises in the book too,
link |
both tragic and triumphant, as they say.
link |
You've often described your patients as your heroes.
link |
Yeah, tell us a little bit more about that.
link |
You know, when you think about how hard it is
link |
to give up a drug or a behavior that you're addicted to,
link |
how much courage that takes and fortitude and discipline
link |
and stick-to-it-iveness,
link |
these people are really amazing people.
link |
I mean, that's, I don't know that I could do it,
link |
what they do, you know?
link |
It's, and like, you know, we talked a little bit about,
link |
you know, just the constant, ever-present urge to use,
link |
even after sustained periods of abstinence for some people.
link |
That's really, really hard.
link |
And of course, then you double down on the shame
link |
that they feel because of that urge,
link |
even when their lives are so much better.
link |
I mean, these people are really, really remarkable.
link |
And you take their remarkable accomplishment,
link |
and then you imagine the world that we live in now,
link |
where we are constantly invited and tempted
link |
and really bombarded with opportunities
link |
to become addicted at every turn.
link |
It's like peeling an itch everywhere.
link |
Oh yeah, I mean, you can't escape it.
link |
You know, you cannot escape it,
link |
but you'll get an email in your inbox
link |
inviting you to do X, Y, or Z.
link |
And if you're addicted to that thing,
link |
you know, you tried to like delete all your apps
link |
and not go here, all of a sudden your work inbox,
link |
you're, you know, you're getting those images, let's say,
link |
really, really, really hard.
link |
And yet these people find a way to do it.
link |
I think it's absolutely amazing.
link |
And they're really wise people.
link |
They have so much wisdom to offer.
link |
They've taught me a lot.
link |
You know, as I talk about in my book,
link |
I have my own addictions,
link |
and I really just like took a page right out of their box.
link |
Okay, what do I do now?
link |
All right, what did this patient do?
link |
Okay, I'm gonna try that.
link |
It is an amazing community of people
link |
that are very sage.
link |
I wanted to just touch on something that you mentioned,
link |
which is the shame.
link |
You know, you can't go to a meeting
link |
or talk to addicts without detecting
link |
or hearing about like lies, shame, et cetera.
link |
I heard you say in an interview with somebody else recently
link |
that truth-telling and secrets are sort of
link |
at the core of recovery.
link |
And yeah, tell us more about that.
link |
Yeah, so one of the things that I found really fascinating
link |
about working with people in recovery
link |
was how telling the truth,
link |
even about the merest detail of their lives,
link |
was central to their recovery.
link |
And I became really curious about that.
link |
Like, why would truth-telling be so important?
link |
And of course, there is the obvious thing
link |
that when people are in their addiction,
link |
they're lying about using.
link |
You know, so part of getting into recovery
link |
is to stop lying to the people they care about
link |
But it's really more than that
link |
because what people in recovery have taught me
link |
is that it's not even just not lying about using drugs.
link |
I have to not lie about anything.
link |
I can't lie about why I was late to work this morning,
link |
Oh, I hit traffic.
link |
No, I didn't hit traffic.
link |
I wanted to spend two more minutes reading the paper
link |
drinking my coffee, right?
link |
Or just lying about, you know,
link |
I don't know where I had dinner.
link |
Like, so people with addiction
link |
will get into, you know, the lying habit
link |
where they're lying about random stuff
link |
because they're sort of in the habit of lying.
link |
And how recovery is really about telling the truth,
link |
you know, in all ways.
link |
And so one of the things that I had a lot of fun with
link |
in writing the book is sort of exploring
link |
the neuroscience around why truth-telling is important
link |
to leading a balanced life.
link |
And we know like every religion since the beginning of time
link |
is all about telling the truth.
link |
And there's really interesting neuroscience behind it
link |
that suggests that when we tell the truth,
link |
we actually potentially strengthen
link |
our prefrontal cortical circuits
link |
and their connections to our limbic brain
link |
and our reward brain.
link |
And of course, these are the circuits that get disconnected
link |
when we're in our addiction, right?
link |
Our balance in our reward pathway, our limbic brain,
link |
our emotion brain is doing one thing
link |
and our cortical circuits are completely disengaged
link |
from that ignoring what's happening,
link |
which is easy to do because it's reflexive.
link |
We don't need to think about that balance
link |
for the balance to be happening,
link |
but we have to re-engage those circuits,
link |
anticipate future consequences, think through the drink,
link |
you know, not just how am I gonna feel now if I use,
link |
but how am I gonna feel tomorrow or six months from now?
link |
And that telling the truth is in fact a way to do that,
link |
to make these connections stronger.
link |
And there, I talk about some studies in my book
link |
that kind of indirectly show that.
link |
So I find that really fascinating.
link |
Plus just that like being open and honest with people
link |
really does create very intimate connections
link |
and those intimate connections create dopamine.
link |
So we were talking a little bit about
link |
how you know a bunch of people
link |
who need like intensity in their lives.
link |
For me, I need a lot of intensity in my human connections.
link |
Like I'm really not interested in and bored by
link |
and made anxious by casual interactions.
link |
But you know, like having this kind of discussion with you
link |
that's very intense and also intimate and self-disclosing
link |
is very rewarding for me.
link |
So that's an important source of dopamine.
link |
Thank God I became a psychiatrist.
link |
Like I can't disclose all my stuff,
link |
but I am quite transparent with my patients,
link |
which is a slightly unorthodox.
link |
But you know, when I think it's right,
link |
I'm also transparent with them.
link |
So that's, you know, that's a source of dopamine too,
link |
when we're honest and we disclose
link |
and that you think people are going to run away from you
link |
if you tell them about all like your weird neuroses,
link |
but really they don't.
link |
What they're like is, oh, thank God,
link |
I'm not the only one, right?
link |
Well, what I love about,
link |
I love many things about your book.
link |
I read it in one sweep.
link |
And I was like, wow, is I was pleasantly surprised,
link |
but I was like, wow, she's really opening up in this book
link |
from the very beginning.
link |
And I don't want to give it away,
link |
but it's, yeah, you're very open where it's appropriate.
link |
And also I think that this question about truth telling,
link |
I always think about like, tell the truth,
link |
be, you know, a hundred percent about the truth,
link |
but there's also this element about,
link |
do you report previous lies, right?
link |
Like, what about prior behavior?
link |
And I'm fascinated by this,
link |
because to me, telling the truth has many facets,
link |
but the three sides of this thing in my mind are,
link |
one is reporting everything accurately.
link |
The other is what do you withhold,
link |
what do you not withhold, right?
link |
Because some people will say,
link |
tell the truth or at least don't lie.
link |
That's a lies of omission, lies of omission.
link |
And then there's the, what I have to assume for most people
link |
is a small to enormous batch of things
link |
that they lied about in the past
link |
that still thread into the future.
link |
So how important is it for the addict
link |
or the every person really to,
link |
because it sounds like cultivating the circuitry
link |
between prefrontal cortex and the dopamine system
link |
would be great for anybody,
link |
since we're all addicts, everyone should do it.
link |
But in all seriousness,
link |
it sounds like a good thing for everybody to do.
link |
How much work needs to be done on all the priors,
link |
all the stuff we've hidden?
link |
I mean, not me, but all the stuff that everybody else
link |
Yeah, so the steps of the 12 steps of Alcoholics Anonymous,
link |
a good number of those steps are about that very thing,
link |
the past, the ways that we've harmed people in the past.
link |
And the fourth step is about making amends
link |
by admitting the ways in which that we've contributed
link |
to harming others.
link |
And it is a really big piece of recovery.
link |
So how important, so for people with addiction,
link |
it's really, really important to go back and make amends.
link |
And the key idea there is you just go back
link |
and you apologize and you don't have to get
link |
any particular kind of response
link |
or you don't need to be forgiven.
link |
It's the act itself of apologizing about the ways
link |
in which we've harmed or lied to people in the past
link |
that is cathartic and renewing and allows us
link |
to kind of shed this skin and be new in our lives
link |
and begin again, sort of absolved of past sins, so to speak.
link |
So it is really important.
link |
Are there situations when it's maybe not a good idea
link |
because of that person or the nature?
link |
Sure, there are always gonna be,
link |
it doesn't have to be like,
link |
we're talking about not like Kant's idea about like,
link |
never lie, but robbers in your house and you're stowaway.
link |
You can't lie even about that.
link |
It's like, no, there are probably situations where-
link |
Absolutely, for sake of other people's safety,
link |
children's safety, sure.
link |
I mean, you can think of a million scenarios,
link |
but in general, when we're taking stock,
link |
because I don't know about you,
link |
but I have a lot of regrets and guilt
link |
about a lot of things in my life
link |
and they kind of haunt me.
link |
It's meant to all have nightmares, right?
link |
And I think that's true for most people.
link |
I mean, I occasionally will meet somebody who's like,
link |
I don't have any regrets about it.
link |
I'm like, wow, I cannot relate to that at all.
link |
So this idea of catharsis and well,
link |
I mean, in the 12 steps,
link |
it's telling God or your higher power,
link |
telling another human being
link |
the ways in which you've wronged others,
link |
considering your own character defects
link |
and how those have contributed.
link |
To me, that's a really important piece
link |
and something that we don't do enough in our current culture,
link |
especially in psychiatry, frankly,
link |
where there's a lot of eternally empathizing
link |
with patients, but not a whole lot of likes going,
link |
well, you know, actually you kind of messed that up
link |
or like that was really bad on you, you know?
link |
And in my work, I don't necessarily use that language,
link |
but patients may say like,
link |
I really feel badly about this thing.
link |
I'll be like, yeah, I get it.
link |
I understand that you feel.
link |
Guilt is a, there's a circuit for that too.
link |
Right, and it's important, right?
link |
And it's also important to recovery
link |
and to not becoming addicted,
link |
experiencing a certain amount of appropriate shame
link |
for things that we have done
link |
and feeling the pain that comes with shame,
link |
which is an incredibly painful emotion, right?
link |
And I think that may be the one
link |
that we all try to avoid more than any other
link |
is like that shame of not being liked
link |
or not being accepted or not being celebrated.
link |
Or that the thing that we did is really despicable.
link |
Right, it's really, yeah, like,
link |
oh my God, I did that horrible thing, right, right.
link |
And then, so, I mean, I've done horrible things
link |
that I haven't gone back and said,
link |
I did this horrible thing,
link |
but maybe I've tried to pay it forward.
link |
Like I've told my kids, you know, when I was younger,
link |
I did this horrible thing and it still haunts me.
link |
So if you're ever tempted to do something like what I did,
link |
you might think about my situation.
link |
So, you know, some kind of way,
link |
but I think wrestling with that is important.
link |
I think it's a really important element to all this.
link |
And there's not, I love that there's neuroscience
link |
being done on truth-telling and the value of truth-telling.
link |
I think if I were to predict a new and truly exciting area
link |
that people are going to be really curious about
link |
and in this huge sphere we call neuroscience,
link |
I hope they'll continue to do more work.
link |
Also speaks, I'm so glad to hear
link |
that's happening here at Stanford.
link |
No, that's, well, the literature that I look at
link |
isn't Stanford work, but there's work.
link |
There might be people at Stanford.
link |
Regardless of where it's happening,
link |
more of that and all the rest, please.
link |
I want to ask you about using drugs to treat drug addiction.
link |
These days, there's a growing interest
link |
or at least discussion about Ibogaine,
link |
people going down, going out of country,
link |
because I think it's still illegal here or is illegal here,
link |
going out of country to, I don't know,
link |
either inject it or smoke it or whatever it is,
link |
or people going and doing ayahuasca journeys or MDMA,
link |
which is still an illegal drug in this country,
link |
but there are clinical trials.
link |
There are people on this campus doing experimental studies.
link |
I don't know of clinical trials,
link |
but at Johns Hopkins there are clinical trials, et cetera.
link |
So this is a vast area, right?
link |
Different chemistries for different drugs
link |
and different purposes,
link |
but the rationale, as I understand it,
link |
is take people who are in a pattern of addiction,
link |
launch them into a experience
link |
that's also chemical and extreme,
link |
often of the extreme serotonin and or extreme dopamine type.
link |
So MDMA, ecstasy, for instance, tons of serotonin dumped,
link |
tons of dopamine dumped, how neurotoxic,
link |
if neurotoxic, debatable, et cetera, et cetera,
link |
not a topic for now, but a lot.
link |
And then somehow that extreme experience
link |
wrapped inside of a supported network in there,
link |
whether or not there's just someone there
link |
or whether or not they're actively working through something
link |
with the patient, is supposed to eject the person
link |
into a life where drug use isn't as much of interest.
link |
This violates, at a rash, purely rational level,
link |
this violates everything we've talked about
link |
in terms of dopamine biology.
link |
It would, if this arrangement is the way I described it,
link |
cause more addiction, is anything but a dopamine fast,
link |
it's a dopamine feast.
link |
So we hear about successful transitions through this,
link |
at least anecdotally, and maybe some clinical say,
link |
what is going on, what is going on?
link |
It doesn't make any sense to me.
link |
Yeah, so I think it's good that you're skeptical.
link |
I think we all should be skeptical.
link |
Having said that, there are clinical studies showing,
link |
and these are small studies and they're short duration,
link |
small number of subjects, but taking people, for example,
link |
who are addicted to alcohol and then having them
link |
have this, let's say, psychedelic experience
link |
in a very controlled setting.
link |
So either typically it's a high dose psilocybin
link |
or three dose, as I saw it for the MAP study of MDMA,
link |
Those seem to be the kind of bread and butter
link |
of this kind of work.
link |
But the thing to really keep in mind is that
link |
this is completely interwoven with regular psychotherapy
link |
and that these are highly selected individuals.
link |
And clinical trials.
link |
We're referring to legal clinical trials.
link |
And so I think the metaphor that helps me think about this
link |
is there are many ways to the top of the mountain
link |
and these are sort of like taking the gondola
link |
instead of walking up.
link |
It's sort of, instead of doing like a year of psychoanalysis
link |
where you're sitting on the couch every week,
link |
reflecting on your life, it's a condensed version
link |
of psychoanalysis or psychotherapy plus, you know, MDMA,
link |
which gets you there faster.
link |
Creates the intimacy presumably because of this.
link |
Well, I think the main thing that happens
link |
when it's beneficial is it just allows the person
link |
to get outside of their own head
link |
and look at their lives on a much broader sweep
link |
and to consider themselves not mired in the, you know,
link |
quotidian sort of details of their life,
link |
but rather as a human on the large planet earth
link |
in the vast universe.
link |
So I think it takes, it's like when it works,
link |
it's a transformational experience
link |
because it gives the person another lens
link |
through which to view their life, their lives,
link |
which I think for some people is positive and powerful
link |
because they can come back from that and be like,
link |
oh my gosh, I care about my family
link |
and I want X, Y, or Z for them
link |
and I realize that my continuing to drink
link |
is not going to, you know, achieve that.
link |
So it's almost like a spiritual or values-based.
link |
So I think it can be very powerful,
link |
but having said that, I truly am quite skeptical
link |
because, you know, addiction is a chronic relapsing
link |
and remitting problem.
link |
It's hard for me to imagine that there's something
link |
that works very quickly short-term
link |
that's going to work for a disease
link |
that's really long lasting.
link |
Yeah, the two addicts I know
link |
that did MDMA-assisted psychotherapy
link |
as part of this thing both got worse.
link |
But the people I know who had severe trauma,
link |
who did this, who took this approach,
link |
seemed to be doing better.
link |
Okay, interesting.
link |
And so I think that the discussion as we hear it now
link |
is just sort of psychedelics, which is a huge category
link |
that includes many different drugs
link |
and compounds with different effects.
link |
And we hear about trauma and addiction lumped together
link |
and I think that I'm a splitter, not a lumper,
link |
as we say in science, and I think it's going to be important
link |
for people to know that this is definitely not
link |
a one-size-fits-all kind of thing,
link |
but it sounds like it may have some utility
link |
under certain conditions.
link |
I think I'm trying to be very open-minded
link |
about its potential utility for certain individuals,
link |
but I can tell you in my clinical work,
link |
what is a very concerning unintended consequence
link |
of this narrative is I have a lot of people
link |
who are looking for some kind of spiritual awakening
link |
who on their own, not in the context
link |
of any kind of therapeutic psychological work,
link |
microdose or wanna try psilocybin or MDMA
link |
with a friend or wherever so they can have
link |
this spiritual experience that they can figure out
link |
their lives, that's a disaster
link |
and almost never works out well.
link |
And I've then had people who literally,
link |
supposedly you can't get addicted to psychedelics
link |
because something with the biochemistry,
link |
which I don't fully understand
link |
because it doesn't make any sense to me,
link |
but I have patients clinically who definitely are addicted
link |
to MDMA, to microdosing.
link |
So that's very concerning to me
link |
because Pollan's, How to Change Your Mind,
link |
I respect that work, but on the other hand,
link |
it's penetrated the culture.
link |
Michael Pollan's book.
link |
Well, and I don't know him,
link |
and so I don't have a problem taking a stance.
link |
So I'll just say my stance on that is the narrative
link |
of popular authors can expand and wick out so fast
link |
that pretty soon people are essentially
link |
taking their mental health into their own hands.
link |
And I actually have great optimism for this business
link |
of clinical use of psychedelics, including MDMA.
link |
Matthew Johnson at Johns Hopkins
link |
is doing fabulous work on this.
link |
And there are others too, of course,
link |
but those are controlled settings.
link |
And the pharmacology is being tuned up.
link |
And one thing that I think is coming,
link |
there are several papers published recently
link |
in great journals like Nature and Science, et cetera,
link |
where there are scientists who are removing
link |
the hallucinogenic components of these drugs
link |
and finding that they still have the antidepressant effects.
link |
And so the experience of a psychedelic
link |
and the long-term effects of the psychedelic
link |
might actually be dissociable.
link |
And so I, again, and I'm always careful to say
link |
I'm neither for something or against it.
link |
I just think that treading carefully is what's important.
link |
And I can just tell you that the downstream effect
link |
for the average person, many of whom present in our clinic,
link |
is that they've misconstrued the data
link |
on the use of psychedelics for mental health conditions
link |
to this idea that they're safe
link |
or that anybody can take them in any circumstance
link |
and have this kind of awakening.
link |
And that's not what the data show, right?
link |
The data are these highly controlled settings.
link |
You know, carefully selected patients.
link |
So that's my worry, you know.
link |
And I'm going to be sitting down with Matthew Johnson
link |
at some point, and we'll discuss this.
link |
And I think that that care and that cocoon
link |
of real clinical care does seem to be an important component.
link |
Oh, well, I'm glad we could touch on it.
link |
And, you know, I'm sure I'll get a bunch of comments
link |
telling me that, you know, but I think it is important
link |
to explore things from all sides, and that's what we do
link |
And if Michael Pollan wants to chat, we can do that too.
link |
I very much enjoyed the book, actually.
link |
But I think that people run with ideas.
link |
They don't walk with them, they sprint.
link |
There are a couple other things I just want to touch on,
link |
but they all relate to social media.
link |
You were featured in The Social Dilemma.
link |
It was a powerful movie.
link |
I think many people avoided seeing that movie
link |
because it reflects back on us just how addicted we all are
link |
and how manipulated we all are.
link |
But it doesn't seem to have changed behavior much.
link |
I have to say that the movie changed my understanding
link |
and my perception, but not my behavior too much.
link |
If we look at addiction as a maladaptive thing,
link |
something that's making our lives worse
link |
or us less functional at work and in relationships,
link |
I could imagine a version of social media
link |
where it's making me more connected.
link |
I mean, this is a podcast after all.
link |
This will show up on YouTube
link |
and elements of it on Instagram as well.
link |
So much like sugar or other things,
link |
I have to imagine that we need to regulate,
link |
not necessarily eliminate this behavior.
link |
So I want to talk about what that looks like.
link |
And I want to talk about what you've referred to
link |
as this narcissistic preoccupation
link |
that social media is creating,
link |
that we are all far more keenly aware of how we look
link |
and how we sound and how we are being perceived
link |
than we were 10 years ago.
link |
So first of all, social media,
link |
how addicting is it really?
link |
And what is healthy social media behavior?
link |
So the first message I would want to get across
link |
about social media is that it really is a drug
link |
and it's engineered to be a drug.
link |
And it's based on potency, quantity, variety,
link |
the bottomless bowls, the likes,
link |
the way that it's enumerated, all of that,
link |
which doesn't mean that we can't use it,
link |
but we need to be very thoughtful about the way we use it,
link |
just like we need to be thoughtful
link |
about the way we use any drug.
link |
And so that means with intention
link |
and in advance planning our use, right,
link |
and trying to use it as a really awesome tool
link |
to potentially connect with other people
link |
and not to be used by it or get lost in it.
link |
And of course, people are going to come
link |
with different propensities for addiction to any drug.
link |
And that's true for social media too.
link |
Some people will have no problem using it in moderation
link |
or using it in a way that's adaptive.
link |
And other people will immediately get sucked in.
link |
And the key thing about getting addicted
link |
is when it's happening, nobody who's getting addicted
link |
thinks they're getting addicted, right?
link |
It's only after the fact that we go,
link |
whoops, what was that about?
link |
Well, remember texting and driving?
link |
There were all these books about texting and driving
link |
how terrible it was.
link |
Even the governments have largely given up.
link |
You see these billboards, like don't text and drive
link |
or any text can wait or not worth dying for,
link |
but everybody's texting and driving.
link |
Right, and if you look at young people today, teenagers,
link |
I mean, they're basically cybernetically enhanced.
link |
The phone is there.
link |
It's like they're talking to you
link |
and texting 12 friends at the same time.
link |
And there's no stopping it.
link |
I mean, the genie is out of the bottle.
link |
We're not going back.
link |
So we do need to figure out how to make this tool,
link |
something that's gonna be good for us
link |
and not ultimately harmful.
link |
And I don't have all the answers
link |
by any stretch of the imagination,
link |
but I do think some of the wisdom that we have learned
link |
from using other drugs also applies to social media,
link |
which is to say that we have to, again,
link |
put barriers in place that allow us to remain in control
link |
of our use, which means not too much,
link |
not too often, not too potent.
link |
Do you think in going back to this idea
link |
of the unit of the day being a good tractable unit,
link |
a manageable unit of time for most people,
link |
so you're saying in advance,
link |
so allocating two hours in which you're going
link |
to allow yourself to have free reign use of the phone
link |
and all its apps and all its things,
link |
or even more restricted than that,
link |
meaning, okay, I'm only gonna allow myself 30 minutes a day
link |
to post and comment, and then that's a closeout completely.
link |
Yeah, so I think it depends on the person
link |
and it's sort of a combination.
link |
We talked earlier about having an itch
link |
and scratching yourself at night.
link |
We've gotten to a point with smartphones,
link |
people are pulling them out
link |
and they are utterly unconscious of doing so.
link |
Pulling them out, a couple texts, a couple,
link |
they don't know they're doing it.
link |
I have a friend who works and delivers babies,
link |
and many pregnant mothers won't actually deliver
link |
without their phone in hand,
link |
and this used to be the hand
link |
that was connected to their spouse.
link |
This may be a comment on spouses more than on phones,
link |
but it sounds like it's kind of a security blanket.
link |
Right, like a transitional object, yeah.
link |
Actually, that reminds me, you've referred to the phone.
link |
I think it's the phone, but maybe it's our online persona
link |
or ourselves as we've become sort of infantile
link |
in our need for it.
link |
It's like a baby in a bottle.
link |
And so I do wonder if we have regressed,
link |
and I do think we've regressed a bit
link |
in terms of our online behavior,
link |
our inability to act like,
link |
I always thought an adult was somebody
link |
that couldn't control their behavior.
link |
That's the difference between a baby and an adult.
link |
You don't have to be a developmental neurobiologist
link |
for very long to understand that a young organism
link |
can't control its behavior and an older one can.
link |
So to me, a mature organism, mature in years,
link |
organism that can't control its behavior is a baby.
link |
It's an immature version of itself.
link |
And there's neuroscience to support that statement.
link |
I look at my own behavior with the phone sometimes,
link |
and I think, I'm a grown man.
link |
Like, what is the problem here, right?
link |
I don't eat baby food,
link |
but I'm acting like a baby with the phone, all right?
link |
In the sense that I'm reflexively picking it up.
link |
I'm not being intentioned and deliberate with it.
link |
Do I need a full 30 days, Anna?
link |
So, yeah, as you know,
link |
that's my recommended full 30 days to reset.
link |
If you're severely addicted, I recommend the 30 days,
link |
but if you're just a little bit addicted, like most of us,
link |
you probably don't need 30 days.
link |
In fact, a single day not only would be challenging,
link |
but probably maybe sufficient.
link |
My phone is off for substantial segments of the day.
link |
Okay, that's great.
link |
And it drives other people crazy.
link |
People expect me to respond, but I don't care.
link |
And I actually take a little bit of pleasure
link |
in the fact that, well, because I think the point
link |
I'm trying to make is the right one,
link |
which is that it's not just right for me, but like why?
link |
I don't see a clause on text messages or emails that say,
link |
must be responded to within X amount of time or else.
link |
So I take the liberty of replying when I'm able to.
link |
Yeah, that's right.
link |
Right, but which touches on one of the big challenges
link |
about social media is that as more and more of us
link |
are spending more and more time on social media,
link |
we're divesting our libidinous energies, et cetera,
link |
from real life interactions.
link |
So that means even when we want to choose to not be online
link |
connecting, we go outside and there's no there there, right?
link |
There's nobody else there.
link |
So I think our collective challenge,
link |
and it should be our mission, is to make sure
link |
that we are preserving and maintaining offline ways
link |
to connect with each other.
link |
Because if we don't do that, then we'll be very lonely,
link |
right, if we were not online.
link |
But if you have a tribe of folks that you can be with,
link |
none of whom are on their phones while you're together
link |
for that discrete amount of time,
link |
then it's wonderful and liberating and nobody's distracted.
link |
And I think that's really the key.
link |
And I think young people are figuring that out.
link |
They're trying to create these spaces or try to,
link |
let's say instead of doing a dopamine fast by yourself,
link |
do it with your friends, right?
link |
Then there's the FOMO is less, the fear of missing out
link |
because, oh, you're all doing the dopamine fast together.
link |
So these are some of the tricks that we can come up with.
link |
I don't allow, I have a home gym and I love working out.
link |
I just enjoy it and I always have.
link |
And I don't allow my phone in my gym anymore.
link |
And I live in an area where I don't get any reception
link |
like two meters outside my door.
link |
So all my dog walks now are just,
link |
and they were boring as hell.
link |
I also have a bulldog, he doesn't like to walk.
link |
And it was so boring for a while
link |
because I was so used to taking calls while I walk
link |
and it's super efficient.
link |
Why wouldn't I do that?
link |
The walks now are some of my favorite part of the day
link |
because, and if the phone were,
link |
if I were to get a call on one of those
link |
and they brought reception to the area,
link |
I would be very dismayed.
link |
So I can attest to this.
link |
And I don't think I'm a phone addict,
link |
but I do put work into regulating my phone.
link |
Yeah, so this is the key.
link |
You have to, with intention,
link |
prior to being in that situation,
link |
think of literal physical and metacognitive barriers
link |
that you can put between yourself and your phone
link |
or whatever your drug is
link |
to create these intentional spaces
link |
where you're not constantly interrupting yourself,
link |
essentially, and distracting yourself.
link |
Because I really do think,
link |
I think we talked just before we started with the interview,
link |
we're losing the ability to have a sustained thought, right?
link |
I mean, we get so far
link |
and then you get to that point in the thought
link |
where it's a little bit hard to know what's coming next.
link |
And it's very easy to check your phone or check your email
link |
or look something up on the internet.
link |
And then you never get that opportunity
link |
to finish that thought,
link |
which is really the source of creative energy
link |
and an original thought, right?
link |
You're not just reacting to what's coming at you.
link |
And something that could contribute to the world.
link |
I'm a big believer that you're either consuming
link |
or you are creating.
link |
And there is, I should mention, it's important.
link |
I do believe in neutral time.
link |
I think sleep is great.
link |
I'm a big proponent of sleep
link |
and I've talked a lot about it on the podcast.
link |
I care a lot about sleep.
link |
And not just for sake of performance.
link |
I actually just really like sleep.
link |
I think that being a constant consumer
link |
of visual information
link |
and information of all kinds can be a problem.
link |
But there's some really great sources
link |
of information on the internet.
link |
And I certainly benefit from the fact
link |
that those channels exist.
link |
Narcissistic preoccupation.
link |
Am I a narcissist?
link |
First of all, there's healthy-
link |
Or is the fact that I asked, does that take me out of,
link |
would a narcissist ever ask that question?
link |
Oh yes, a highly sophisticated narcissist
link |
would know to do that.
link |
I'm very sophisticated.
link |
So there's healthy narcissism,
link |
which means that we all invest our personal energies
link |
into things that we care about.
link |
And if our competence in that arena is threatened,
link |
we would all experience a narcissistic injury
link |
and that's normal and healthy.
link |
But we are living in a narcissistic culture.
link |
I mean, that's not news.
link |
This preoccupation with individual achievement
link |
and individual self-worth and individual self-confidence.
link |
And I think all of that is just fueled by social media
link |
where we're not just seeing ourselves,
link |
but we're seeing people's reactions to ourselves
link |
and every single thing we say or do,
link |
we get likes and this and that.
link |
It's really insidious.
link |
And it contributes, I think,
link |
ultimately to a lot of personal shame
link |
because we're not really meant to be individuals
link |
bouncing around in the universe.
link |
We're social animals.
link |
And we're probably generally happiest
link |
even for natural contrarians among us
link |
when we're part of a tribe, right?
link |
And if we do too much to kind of separate ourselves
link |
from that tribe, I think that the brain's natural
link |
and instinctive corrective mechanism against that
link |
is self-loathing and shame.
link |
So it's so ironic because the culture tells us
link |
if we just achieve more, we'll like ourselves more.
link |
But the truth is actually the opposite
link |
that I think when people get these pinnacles
link |
of personal achievement,
link |
you have things like the imposter syndrome or whatever.
link |
Where you just, we're at Stanford
link |
after a lot of high achievers here, right?
link |
Some phenomenal, amazing people like yourself
link |
and other colleagues of mine that just, I'm always in awe.
link |
It's just amazing.
link |
The mean has shifted so high.
link |
And also people who have amazing paths to get here
link |
coming from very little accomplishing so much.
link |
But it's also the pressure, right?
link |
The way that this career was described to me
link |
the day I got my job was one colleague of mine,
link |
the late Ben Barra said, welcome to schizophrenia
link |
because you're never going to be able to complete anything
link |
without getting interrupted.
link |
That was partially true, although I've created buffers.
link |
And the other one, very successful scientist,
link |
a member of the National Academy, et cetera, said to me,
link |
just remember it's pinball.
link |
The best you can do is just keep playing.
link |
And I thought, wow, okay, okay.
link |
And then you just go.
link |
But I think that as we achieve more,
link |
not just academics, of course, but as anyone achieves more,
link |
there's the relishing and the accomplishment.
link |
There's often the desire for more,
link |
but there's also the pressure of,
link |
well, now I have to do this for the next 30 years
link |
even though I love it.
link |
It's the pressure of, well, if the mountain is this high,
link |
then how do I get here and here and here?
link |
And then you start shoveling more dirt on
link |
so you can keep climbing.
link |
And it's a lot of work.
link |
And I think that the perception of success
link |
is that there's a roar of the crowd and you cruise.
link |
They just give you more to do.
link |
Or you give yourself more to do.
link |
Well, what I think is, at least in my life experience,
link |
and I've heard this from other people as well,
link |
it's that prize that we're going for
link |
that if we get it, is so unsatisfying.
link |
And it's the prize that we never imagined
link |
that we kind of go, well, how did that happen?
link |
But gee, that feels good.
link |
And so I'm very, what's the-
link |
It's like a mirage in the one case.
link |
And it's like a, yeah, it's on the one,
link |
it's almost like dopamine can create these mirages
link |
that there's some place there.
link |
If I just, it's that pot of gold, right?
link |
Constant dopamine.
link |
Right, right, that's right, that's right.
link |
And I think this really, I think,
link |
is related to our discussion earlier
link |
about this taking it one day at a time
link |
or paying attention to that 24-hour period
link |
in your environment.
link |
I am absolutely fascinated by the ways
link |
in which we accumulate success when we do that,
link |
totally independent of the desire for success.
link |
It's really process-oriented.
link |
It's like, where am I today?
link |
How can I make today a good and meaningful day,
link |
a little bit better or as good as some other days I've had?
link |
Constantly tweaking and experimenting
link |
with this experiment that we call our human existence.
link |
And when we do that in a way that's authentic
link |
and paying attention and value-driven,
link |
whatever our values are informed by,
link |
it is very, very interesting how those days,
link |
again, accumulate and you find,
link |
well, I guess I contributed something of value there,
link |
but I wasn't trying to do that.
link |
I think that's really,
link |
I mean, what I'm so amazed by is like,
link |
20 years ago when I went to Stanford Medical School,
link |
25 years ago, I was happy to just be a good doctor.
link |
I was like, I guess I'm just gonna try to figure out
link |
how to be a good doctor and I'm here to learn that.
link |
And now I see these medical students and they're wonderful.
link |
They're brilliant and they're well-intentioned, all that.
link |
But they're like, how can I write the great American novel,
link |
do my startup, go to Africa, apply for that grant?
link |
It's like, really?
link |
I was just trying to learn how to be a doctor.
link |
And as you say, it's a lot of pressure on them.
link |
And it's also kind of a weird leapfrogging
link |
of the real way to accomplish something.
link |
Which isn't about like, oh, how can I accomplish something?
link |
It's like, what can I do today that would be of service?
link |
And then finding that of trying to be of service
link |
and not really going for recognition
link |
can sometimes lead to what people call success.
link |
Although that wasn't what you were aiming for.
link |
And it's all the more beautiful
link |
when it's not what you're aiming for.
link |
Oh, so much better, so much better.
link |
I'm a big believer that when one can align their compulsion
link |
with some greater good, a service to humanity
link |
or the planet or animals, whatever it is,
link |
that that's where the really good stuff emerges.
link |
Because there's a lot of reciprocity there.
link |
The world starts to, you're supporting the world
link |
and then it starts to support you
link |
in a way that feels very fluid.
link |
And that comes back.
link |
And I mean, that speaks to your generosity to me,
link |
vis-a-vis my book.
link |
And I have to say-
link |
Well, I love the book.
link |
There's like, we're not in a business deal, folks.
link |
It's just purely that I heard Anna lecture in my course.
link |
I wanted to learn more about dopamine.
link |
She taught me, I asked her if she would come on the podcast.
link |
Turned out, she wrote this amazing book.
link |
She sent me a man's copy of the book.
link |
I read it in one sweep.
link |
It's incredible and I love it.
link |
So just like the eight-year-old version of me,
link |
now the 45 version of myself,
link |
I can't stop blabbing about the things I love.
link |
Well, it's awesome, but I have to say,
link |
I have been surprised by your generosity.
link |
It's not something I've encountered frequently at Stanford,
link |
which is a wonderful place.
link |
But there is a general sense that if I give away
link |
to somebody else, I've lost something,
link |
which is not the right way to think about it,
link |
not how you are, and also not how the world works.
link |
Because when we give away to other people,
link |
we get back so much more, but it takes a long time
link |
and it might not come through that path.
link |
I never think about reciprocity.
link |
But I was weaned by good advisors.
link |
I think I just sort of got drilled into me
link |
that the more you give, the better your immediate life is.
link |
But I also don't have a long-term vision.
link |
I'm just excited about the book.
link |
I'm excited that people are learning
link |
about the brain and dopamine.
link |
I have to admit, having grown up in neuroscience,
link |
essentially, I did not understand that pleasure and pain
link |
were orchestrated the way that they are.
link |
I'm very mindful of it now.
link |
And it's changed a number of my behaviors.
link |
I know a number of people are going to have questions
link |
and want to get in contact with you.
link |
You are not on social media.
link |
You are true to your ideology.
link |
And the reason for that is just,
link |
I wouldn't be able to control myself.
link |
I mean, that really would be my drug.
link |
People are my drug.
link |
Intimacy is my drug, and I wouldn't be able to manage it.
link |
And so it was just easier for me to not do it at all
link |
rather than try to moderate it.
link |
Well, the book, as you mentioned before
link |
and as I can attest to, is it has a certain intimacy.
link |
People get to know you through the book.
link |
So definitely check out the book.
link |
If you have questions about the book, et cetera,
link |
you're welcome to send them my way.
link |
I will buffer you from all those questions.
link |
Anna, Dr. Lemke, I should be a formal,
link |
forgive me, I've been referring to you
link |
the whole way through because we're colleagues,
link |
but thank you so much for sharing this information.
link |
And I know I learned a ton and I know everyone else
link |
is going to learn a lot more about addiction
link |
and the good side of dopamine.
link |
Thank you for having me.
link |
It's been really, really great to talk with you.
link |
Thank you for joining me for my discussion
link |
with Dr. Anna Lemke.
link |
I hope you enjoyed it as much as I did.
link |
Please be sure to check out her new book,
link |
Dopamine Nation, Finding Balance in the Age of Indulgence.
link |
You can pre-order it on Amazon
link |
or any places where books are sold.
link |
It's an absolutely fascinating and engaging read
link |
all about addiction and dopamine.
link |
If you're learning from and or enjoying this podcast,
link |
please follow us on YouTube by subscribing
link |
to the Huberman Lab channel.
link |
In addition, you can subscribe to the podcast
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And on Apple, you have the opportunity to leave us
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If you have comments or suggestions for topics
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In addition, we have a Patreon.
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That's patreon.com slash Andrew Huberman.
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And there you can support us at any level that you like.
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Please also check out our sponsors
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That's a terrific way to support our podcast
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And last but not least,
link |
thank you for your interest in science.
link |
We'll see you in the next episode of the Huberman Lab.