0:00

This is Hidden Brain. I'm Shankar Vedantam.

0:03

In the hit television show Ozark,

0:05

a bright financial advisor finds

0:08

himself suddenly working on the

0:10

wrong side of the law.

0:11

What's our story for the kids? Well,

0:15

we could tell them the truth, Wendy. How would that be? Following

0:19

a series of bad decisions by his business partner,

0:21

Marty Byrd, played by Jason Bateman, begins

0:24

working for a drug cartel. I

0:26

want you to be ready to set up shop within a week. Yeah.

0:31

And Marty, when I drive

0:33

by your house, there better

0:35

be a for sale sign on their lawn.

0:39

Almost from the start, the

0:41

bodies start to fall. People

0:43

get thrown off balconies. People get

0:45

shot. People are electrocuted.

0:49

When government officials get involved, more

0:51

violence unfolds. People betray

0:53

one another.

0:54

They cheat each other. They act in

0:57

selfish and short-sighted ways. Let

1:00

me just jog your memory for a minute. There

1:02

was an innocent man who was murdered.

1:06

Gary. He

1:08

was a good man.

1:12

You might say this is the genre of the drug movie

1:14

or television show. You see it in

1:16

critically acclaimed TV shows like The Wire

1:19

and Breaking Bad, and in movies

1:21

such as Traffic and Scarface.

1:23

Say hello to my little friend.

1:28

OK. You want to play rough? OK.

1:33

Running through these dramas, we sense

1:36

the irresistible power of drug addiction,

1:39

the implacable draw of heroin or

1:41

cocaine or methamphetamine,

1:43

the chaos and crime that follow

1:46

everywhere the drug trade is plied.

1:50

I've watched many of these TV shows and movies

1:53

as entertainment. For many years, I

1:55

also reported on the work of researchers who

1:57

study the science of drug addiction.

1:59

But some time ago, I came by

2:02

a mind-bending idea

2:03

that transformed my understanding

2:06

of addiction.

2:07

It challenged how I think about drugs

2:09

and what it means to be addicted. And

2:12

it told me that as gripping as TV shows

2:14

and movies about the drug trade might be,

2:17

they don't begin to capture the

2:19

profound story of addiction in

2:21

all of our lives.

2:27

Today,

2:28

we begin with a story we are telling across

2:30

two episodes. It will change

2:32

the way you think about your brain and

2:34

offer some profound insights into what

2:36

it means to live a life of happiness and

2:38

contentment.

2:40

Pleasure, pain and

2:42

balance.

2:43

This week on Hidden Brain.

3:00

All of us think we know what addictions look like.

3:02

We've seen the movies and TV shows about

3:05

gang violence and drug dens.

3:07

At Stanford University, Anna Lemke

3:09

studies the science of addiction. She

3:12

argues our conception of addiction is

3:14

far too narrow. Anna Lemke,

3:17

welcome to Hidden Brain. Thank

3:19

you for having me. I'm excited to be here. Anna,

3:22

you're a practicing psychiatrist in the heart

3:24

of Silicon Valley. And I

3:26

think of California's Bay Area as perhaps

3:29

the richest part of the richest country

3:32

in the history of humankind. So

3:35

a time traveler from the 17th century might

3:37

assume that even if the streets were

3:39

not paved with gold, at a minimum,

3:41

people would be very happy with so

3:43

much material success. Is

3:46

your psychiatric practice empty?

3:48

I still marvel

3:51

at the gap between how people present

3:53

outwardly and the truth of

3:55

their inner experience. We

3:58

see people every day who seem to be happy.

3:59

to have everything you could ever want,

4:02

wealth, beauty, meaningful

4:06

work. And yet, when you look

4:08

under the hood, they're miserably unhappy.

4:11

So over time, Anna, you've seen more

4:13

and more patients

4:14

suffering from depression, anxiety,

4:16

and chronic pain, ailments for which

4:18

they are hard pressed sometimes to find

4:21

a source or a cause. And as you say,

4:23

often these are healthy, affluent, educated

4:26

people with seemingly everything they could

4:28

want in life. One patient

4:30

of yours was a young physician with

4:32

a very promising career. Can you describe

4:34

what he was like when you first met him?

4:37

Delightful young man, handsome, kind,

4:39

thoughtful, considerate. He

4:42

came to me, in fact, because

4:44

he got a DUI. He was driving under the influence.

4:48

But as it turned out, alcohol was not his

4:50

primary problem. Once he was in my office,

4:53

he revealed to me that he did, in fact, have

4:55

an addiction problem. But it was an addiction

4:57

to alcohol. It was an addiction to

4:59

online gambling sports

5:02

betting. And his story

5:04

went like this. He was a very successful

5:07

high school and collegiate athlete division

5:10

one, all kinds of accolades,

5:13

really a remarkable athlete. And

5:16

that

5:17

cycle of

5:19

engagement in high level

5:21

athletics, the adrenaline that goes

5:24

along with high level competition,

5:27

the wins, the losses, that absolutely

5:30

was his jam. It kept him busy

5:32

and engaged and really, really happy. But

5:35

when that career came to its natural

5:38

end, like so many high

5:40

level athletes, there was a sort

5:42

of a free falling

5:44

disappointment to kind of an existential,

5:47

profound disappointment,

5:50

a bit of an identity crisis. And

5:53

although he was headed to medical school, which gave

5:56

him kind of a new identity to latch onto,

5:59

he really missed.

5:59

that cycle of

6:02

intensity that

6:04

he got through participation in

6:06

sports. And

6:08

then he was invited by his

6:11

collegiate buddies to

6:14

participate in fantasy football in

6:16

a fantasy football league. And

6:19

you know they all get together and they choose their

6:21

teams and then there was you know minor

6:24

money involved in that. But he got

6:26

really really into it more

6:29

so than his buddies from college.

6:33

And that was really almost the spark

6:35

for him then to begin to

6:39

want to engage athletically

6:41

through sports

6:43

betting and sports gambling. And

6:47

you know it started with 50 bucks, 100

6:50

bucks. And at this time he's now

6:52

started medical school. He's doing his pre-med courses.

6:55

You know he's getting ready for his clinical years.

6:58

He had this phone. He could pull it out

7:00

during grand rounds. You know when he was supposed

7:03

to be listening to the speaker and scroll

7:05

through you know results of all the

7:07

different sports. And then he could place

7:09

a bet. And that accessibility

7:12

just absolutely ensnared

7:15

him. And he found himself completely

7:17

caught up in it to the point where he was now

7:19

spending not hundreds of dollars

7:21

but thousands of dollars. Not monthly

7:24

but weekly and eventually daily.

7:27

And in about

7:28

six months he

7:31

completely spent the trust

7:33

fund that he had inherited from his parents

7:35

in

7:36

order to pay for medical school. And

7:39

he was so ashamed that he didn't

7:41

tell anybody. And he thought to himself

7:43

well if I can just win

7:46

then I can get all the money back and

7:48

then I'll be fine. So he took

7:50

out an enormous loan without telling anybody

7:54

to pay for medical school. And he thought okay I'm gonna

7:56

put it in the bank. You know I'm gonna pay it back.

7:58

And instead he gambled

7:59

that away too.

8:06

Ana had another patient who started doing something

8:08

that might seem even more harmless than

8:11

sports betting. So this was somebody

8:13

who just found himself

8:16

really getting intense pleasure

8:19

out of the cycle of

8:21

shopping

8:23

online. He would

8:25

spend quite a bit of time searching

8:28

for different items that he was interested

8:30

in buying and the process

8:32

of the treasure hunting was

8:35

very entrancing and rewarding

8:38

for him.

8:39

All kind of building up slowly to

8:42

the point where he would choose the item that

8:44

he would buy and then

8:46

buy it and then he would be

8:48

waiting in anticipation for it to be delivered

8:50

to his home and all of that was very pleasurable.

8:54

And then it would be delivered and he would open it

8:56

and take it out and it was the thing that he

8:58

wanted and it felt so good and it was just,

9:00

you know, wonderfulness for him. So

9:04

because that cycle was so

9:06

entrancing for him, he started

9:08

to do it more and more and he kind of came

9:11

to rely on it as a physiologic

9:14

crutch for managing his

9:17

mood. But over time what he

9:19

found was that the

9:22

cycle got shorter and shorter and

9:25

the anticipation and pleasure

9:27

that he got from it got less and less

9:29

to the point where as soon as

9:31

he opened the box and got what he had

9:33

ordered, it was over and

9:36

then he'd be online again trying

9:38

to buy the next thing. And

9:41

eventually he ended up with rooms

9:44

in his house full of stuff that he

9:46

didn't need or want

9:48

and tens of thousands of dollars of

9:50

credit card debt and yet even

9:52

then he couldn't stop. So

9:54

what he started to do as kind of a last resort is he bought like

9:57

these cheap items, key chains,

9:59

mugs, cash.

9:59

caps, cheap sunglasses, things he didn't

10:02

need or want, and then as soon as he got them, he would return

10:04

them. Wow. Because he didn't have

10:07

any money. But he couldn't break the shopping cycle.

10:16

I want to talk about one last patient, a man

10:18

you call Jacob, and a note for

10:20

listeners that this next story includes references

10:22

to both sex and suicide. Jacob

10:25

was middle-aged or maybe even a little older

10:27

when you first met him. Who is a story,

10:30

Anna?

10:31

Jacob was a Stanford

10:33

scientist. And by the way, let me just emphasize that

10:36

I got permission from my patients to

10:38

relay their stories, and I use pseudonyms

10:40

and hide other identifying

10:43

features. So

10:46

Jacob was a Stanford

10:48

scientist who came

10:50

to me seeking help specifically for

10:53

severe sex addiction, so sex

10:55

pornography, compulsive masturbation.

10:58

And what he described was in the

11:01

90s, he used pornography

11:04

and he masturbated

11:06

as much as daily,

11:09

but it was never unmanageable. He

11:11

was still able to function as

11:14

a father, as a husband. He

11:16

was successful in his profession. But

11:18

with the advent of the internet,

11:21

and especially in the early 2000s, the

11:24

smartphone, he found that this

11:27

pursuit of his became unmanageable,

11:30

which is to say that he

11:32

was using more and more pornography

11:34

for more hours every day, late into the

11:37

night, not showing up at

11:39

a conference that he was supposed to speak at,

11:42

prepared to give that speech because he had

11:44

been up the

11:45

entire night before watching pornography,

11:47

repeatedly masturbating. And

11:49

over time, he needed more

11:52

and more potent forms to get the same effect,

11:54

so he escalated from sort of vanilla toast

11:56

pornography to more deviant forms

11:58

of pornography and then pornography.

11:59

itself wasn't adequate

12:02

so then he was going to live shows

12:05

and meeting up with prostitutes

12:07

and eventually you know his addiction

12:09

progressed to the point where he

12:11

was going into chat rooms

12:14

doing dangerous things with other people in chat

12:16

rooms spending all of his available

12:19

time engaged in this activity

12:21

to the point that essentially his life completely

12:23

fell apart his wife left him and

12:27

he was thinking about ending his life and even found

12:29

a spot near his office where

12:31

he

12:32

thought about hanging himself

12:38

each of these cases of course is different

12:41

online shopping is not the same as gambling

12:44

and gambling is not the same thing as pornography

12:48

but in time and I came to see connections

12:50

not just between these patients

12:52

but to many people who are not seeking

12:54

help from a psychiatrist people

12:58

like herself you're

12:59

listening to

13:01

hidden brain I'm Shankar Vedanta

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14:45

This is Hidden Brain. I'm Shankar Vedantam.

14:48

Over many years of practice at Stanford University,

14:51

psychiatrist Anna Lemke has found that

14:53

lots of people living in the Bay Area, one

14:55

of the wealthiest parts of the United States, was

14:57

suffering from a strange malady. Despite

15:00

being blessed with great success in terms of education

15:03

and material wealth, many of her patients

15:05

were unhappy.

15:06

At one point, Anna saw something

15:08

in herself

15:09

that reminded her of the patients she was

15:11

treating.

15:12

Anna, I want to zoom into your life

15:14

around the time you turned 40. What

15:17

was going on in your life at this time?

15:20

My life was good then. You

15:22

know, my marriage was fine. My

15:24

kids were healthy. My

15:27

work was rewarding and meaningful.

15:29

I was in relatively good health for a 40-ish

15:32

year old woman, so things were good.

15:34

Now, you've always loved

15:36

reading and around this time you fell in

15:38

love with a very popular book

15:40

series. What was it?

15:42

It was the Twilight Saga.

15:49

And can you tell me a little bit about what the Twilight Saga

15:51

is? I confess I have not read the books. What

15:54

is their broad plot? Well,

15:58

you know, I was turned on to the Twilight saga

16:00

when I dropped my kids off to elementary school

16:02

and there was a group of moms clustered around.

16:05

Megan was one of the moms, my friend,

16:07

and they were all laughing hysterically and I

16:10

went over and I said, hey what's so funny? And

16:12

Megan said, oh I've been reading this romance novel

16:14

that I absolutely love and

16:16

I went into the bookstore to try to get the sequel

16:19

and I couldn't find it so I went up to the bookstore

16:21

owner and I said, hey you know where's the the

16:24

sequel? And he said, it's in the teenager section.

16:30

Right? So all the moms started cracking

16:33

up, they thought that was the funniest thing, but

16:35

she said, but you guys have to read it, it's so good.

16:38

So I said, okay Megan, what is it called? Because

16:40

I'm always looking for a good read, right? She

16:42

said, oh it's called the Twilight saga.

16:45

So I thought, okay I'll give it a try and it

16:47

was absolutely mesmerizing

16:49

for me. It was as if I had never

16:51

read a novel in my life and all of a

16:53

sudden this novel about a bunch

16:56

of teenage vampires running around

16:58

biting each other on the neck just

16:59

absolutely transported me. It was really

17:02

weird.

17:06

So the Twilight books eventually spawned a very popular

17:08

series of films. I want to play your clip

17:11

from one of those movies. A teenage girl

17:13

named Bella is confronting a boy she knows,

17:16

Edward,

17:16

about his true nature.

17:18

I know what you are.

17:23

Say it. Out,

17:28

Mound.

17:32

Say it.

17:39

Vampire.

17:43

Are you afraid? No.

17:55

Okay so there are a lot of you know breathless

17:58

pauses here but I'm hearing you know.

17:59

fantasy, paranormal stuff, but

18:02

it sounds like an innocent enough pastime, Anna. Oh,

18:06

an innocent enough pastime? Sure.

18:08

It always starts out innocent. And

18:13

of course, you know, it was, but what

18:15

happened was it changed

18:18

the way I felt in the moment

18:21

in a way that resonated

18:24

so deeply that I wanted to keep

18:26

recreating that feeling. And what was that

18:28

feeling? It was essentially a feeling of non-being.

18:31

While I was reading the

18:34

Twilight Saga, it just transported

18:36

me to another time in play such that I

18:38

completely forgot myself. And

18:41

that self-forgetting was clearly something

18:43

that I needed and wanted. You

18:45

know, I read the whole saga. I think it's

18:47

like four books. And

18:50

then I wanted to recreate that feeling again. So

18:52

I read the whole saga again. Wow.

18:55

Not pleasurable, but not as pleasurable as the first

18:57

time around. But by then

19:00

I was completely tapped into this

19:02

whole genre of vampire romance

19:04

novels. And so I started

19:07

to invest larger and larger

19:09

amounts of time, energy and creativity

19:11

into obtaining

19:13

and reading vampire romance novels. You

19:16

know, seemingly innocent to start

19:18

with, but it became a bit

19:21

of an obsession. And when I ran out

19:23

of vampire romance novels, I moved on to werewolf

19:26

romance novels. And then there was necromancers

19:29

and soothsayers and all

19:31

kinds of paranormal romance novels.

19:36

Where were you procuring these books? So

19:38

I live right next to a little library, which

19:40

has a limited collection. So when I went

19:43

through the limited collection at my local

19:45

library, I either biked

19:47

over to the main library or you can

19:50

order through the interlibrary loan.

19:53

And you know, some of these romance novels have

19:55

very revealing covers. Like it was some

19:58

bodice ripper with some hunk on the cover.

19:59

at the prow of a ship or something. I

20:02

wouldn't want to be seen reading that anywhere.

20:05

So

20:07

Anna came up with a way to hide what she was reading

20:10

from her family and friends. I

20:12

haven't revealed this to anybody. This

20:14

is terrible. But I would actually

20:17

put the book inside another

20:19

book

20:21

so that if one of my kids

20:23

came by or my husband came by,

20:25

I could look like I was reading the other

20:27

book. Wow, like a medical journal or something.

20:30

Except that might not really trick them because, like, you know, they would

20:32

know that I wouldn't spend that much time reading

20:35

a medical journal. I

20:38

mean, I used to do this in eighth grade. I

20:40

felt like, you know, the trick of the book

20:42

inside the book was something I had perfected

20:44

in eighth grade.

20:45

I know, I know, and I discovered

20:47

it in my forties. What can I tell you? I was a late bloomer.

20:53

So at one point,

20:54

Anna, your love of this literature

20:57

received a turbocharge when

20:59

you moved from the printed

21:01

page to the electronic

21:03

domain. Tell me how that happened.

21:05

Well, my friend Susan

21:08

said, Anna, you should get a Kindle because then you

21:10

don't have to, you know, be carrying these books around.

21:13

Kindles had just come out then. And of course,

21:15

that was very, I liked that idea because it

21:17

would be easy access. But

21:19

pretty soon, I also started regularly

21:21

going on Amazon and looking

21:24

for, you know, things that were similar

21:26

to the Twilight saga. And guess

21:28

what? Amazon will suggest those

21:30

to you, as we all know now. And so

21:33

Amazon did the work for me. All I had to do was

21:35

look in my feed and say, oh, they're telling me I should read

21:37

this one. They're telling me I should read that

21:39

one. And like later on in the process, I

21:42

also discovered that you can get free

21:44

books on Amazon. So anything that was free

21:46

that was in the romance category, I

21:48

would download and read. And that

21:50

was really the beginning of the end for me, because

21:53

once I had that electronic reader, I

21:56

essentially became a chain reader. Like

21:58

as soon as I finished one book,

21:59

I would either borrow from

22:02

the local library or buy on Amazon

22:04

another book. These were all romance

22:06

novels. And I got

22:09

to a point where

22:11

whenever I wasn't doing something that

22:13

I absolutely had to do, like for my work

22:15

or my family, I was reading

22:18

romance novels. Wow. And then it got

22:20

to where, like, that's all I wanted to do.

22:23

And I didn't enjoy anything else. I

22:26

didn't even really want to, like, be with my

22:28

kids or my husband, right? I just

22:30

wanted those times to rush through

22:32

them so that I could

22:33

go back to reading romance novels. The

22:36

other thing that I only realized in retrospect

22:39

was that these sort of tamer

22:42

versions of romance where, you

22:45

know, the sex scenes aren't super graphic, well, those

22:47

stopped working for me. And now

22:49

I needed ever more graphic

22:52

types of

22:52

romance novels in order to get

22:55

that zing that I was looking for.

23:02

So this was no longer about the pleasure

23:04

of reading at this point or your love of language.

23:06

It had become something else.

23:08

Oh, it had absolutely become something

23:10

else. And of course, it was rooted in the pleasure of

23:12

reading and the pleasure that I've always gotten from

23:14

fiction. But what happened was

23:17

I got to a point where I really

23:19

didn't care if it

23:21

was badly written or badly plotted

23:24

or the characters were uninteresting.

23:27

I would just flip through to the climax,

23:30

pun intended. So then I got to where I was,

23:32

like,

23:32

reading really graphic erotica. And

23:34

the more graphic, the better. The more sex

23:36

scenes, the better. But it was

23:38

all about getting to that moment

23:42

and getting a certain very specific

23:44

feeling. Yeah. And

23:47

I became the possessor of

23:49

the knowledge that if you take any romance

23:51

novel and you open it up to two thirds

23:54

or three quarters of the way through, you know,

23:56

you'll get right to the point, which is

23:58

to say these are these romance novels.

23:59

are engineered, they're

24:01

written according to a recipe. So

24:04

at this point, you know, you're a respected researcher

24:06

and psychiatrist at Stanford University, you have

24:08

a great family. But no longer, soon to be no

24:10

longer. But

24:13

that's what I want to ask you about, you know, you have,

24:17

you know, what you are doing in some ways must have felt

24:19

at odds with your public persona,

24:21

the sense that you had, that you were

24:23

a mom, that you had a great family. Were

24:26

you

24:26

embarrassed by your newfound love

24:28

of steamy literature? First

24:30

of all, I didn't really see what

24:32

was happening as it was happening. I

24:34

would occasionally joke to friends, oh,

24:36

I'm so addicted to vampire romance novels

24:39

or romance novels in general. But just

24:41

by being able to joke about it, I

24:44

felt that that must mean I'm really

24:46

not addicted

24:46

to it or it's not really a problem.

24:50

The other thing was that because

24:53

of the technology in large part, I

24:55

could do the behavior secretly. Once

24:59

I got the Kindle, you know, I could be reading

25:01

something on that Kindle that nobody else

25:03

knew what I was reading. Whereas

25:06

before, I wouldn't want to be seen reading

25:08

that anywhere. That would just be really

25:10

embarrassing. But on a Kindle, like

25:12

it was anonymous.

25:14

How did this affect your patient care?

25:16

Because presumably through all of this, you were still

25:18

treating other patients and helping people with their

25:20

addictions.

25:21

Right. As it was happening, I didn't really

25:24

see it happening. And I didn't relate

25:26

it as being similar to what my patients

25:28

were going through that that I really only saw

25:31

in retrospect, but I started

25:33

to be less interested in my work.

25:35

Like again, that the work that had given

25:38

me meaning and purpose and joy started to be

25:41

dull and gray and

25:43

boring. And I found myself less

25:45

engaged and more just wanting to

25:47

rush through the work so that I could go

25:49

home and read romance novels.

25:52

So you weren't reading these at work. Do

25:54

you reserve the reading at home? Well, there

25:56

was one day and this was sort of near

25:59

the sort of of culmination of this behavior.

26:02

Time is weird for me then, but

26:04

I think it developed over the course of about

26:06

a year or two. But

26:09

I did bring a romance novel

26:11

to work and was

26:13

reading in the 10 minutes between patients.

26:16

So I don't want to play armchair psychiatrist,

26:19

but it seems that you are... That's okay. You

26:22

know, you were using your emotion in these

26:25

books as a kind of escape. What

26:27

do you think you were escaping from?

26:29

Well, that's what's so fascinating. I

26:31

really didn't have anything to escape from.

26:35

I have a great husband. I have

26:37

got these great kids. I have work

26:39

that I adore. My patients are just

26:42

so fantastic. There was

26:44

nothing wrong.

26:46

I was really just escaping too. And

26:49

the thing that I was escaping too was just not

26:52

having to be in my body, not having to

26:54

think, being able to experience this

26:56

kind of intense euphoria,

26:59

this other place, which was

27:02

very, very pleasant for me. It

27:04

just felt good.

27:11

The other thing I just want

27:12

to flag here is that the

27:14

pattern we've seen over and over again, which is

27:16

that something starts out being

27:18

pleasurable. So your friend tells you about this

27:21

romance novel. You read the Twilight Saga.

27:23

You find it fun. You find it enjoyable. And

27:25

so you go back for more. But somewhere

27:28

along this process, sort of the balance

27:30

shifts. And now you're no longer actually

27:32

reading these things because they're giving

27:34

you pleasure. It's that you're reading them

27:36

almost to avoid pain.

27:38

Does that sound right? That's really

27:40

the key, that we start out doing

27:43

whatever the behavior is for rational

27:46

reasons. And it succeeds

27:48

in achieving what we're trying to achieve,

27:51

either to give us pleasure or to accomplish

27:53

some other goal. But if it then

27:56

hijacks our brain's reward pathway,

27:59

it gets a life.

27:59

of its own. And then,

28:02

even when it stops doing what we

28:05

want it to do, we can't stop. And that's

28:07

really the hallmark of addiction.

28:14

When we come back, the brain science

28:16

behind an increasingly global malady.

28:18

You're listening to Hidden Brain. I'm Shankar

28:21

Vedantam.

28:29

In the 1980s, the scientific consensus

28:31

on growing old was grim.

28:34

But with every study it became clear

28:36

that older people were happier

28:39

in their day-to-day lives on balance

28:41

than younger people were.

28:44

Psychologist Laura Carstensen says some

28:46

things in life really do get better as

28:48

we age. And the reasons offer

28:50

lessons to everyone, regardless

28:52

of age.

28:54

If you missed our conversation with Laura Carstensen,

28:57

be sure to check it out. It's the episode

28:59

called, The Best Years of Your Life,

29:02

available now in this podcast

29:04

feed.

29:11

Love

29:26

the ideas we explore and you want more of them?

29:29

Then please join Hidden Brain Plus. You'll

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29:57

This is Hidden Brain. I'm Shankar Vedantam.

30:00

Anna Lemke is a psychiatrist and

30:02

researcher in the behavioral sciences at

30:04

Stanford University. She's the author

30:07

of Dopamine Nation, Finding Balance

30:10

in the Age of Indulgence.

30:12

Anna, many of your patients suffered

30:14

from problems related to compulsive

30:17

overconsumption, and you experienced

30:19

some of this yourself, but you had

30:21

a big advantage over your patients. You

30:23

were a researcher and a scientist

30:25

who studies the brain, and you knew about

30:27

a very important discovery in neuroscience

30:29

that has to do with the relationship between pain

30:32

and pleasure inside the brain. What

30:34

was this discovery?

30:36

This discovery was

30:39

the fact that pain and pleasure

30:41

are co-located in the brain. So

30:43

the same parts of the brain that process

30:46

pleasure also process pain, and

30:48

they work like opposite sides of the balance.

30:50

So almost like a seesaw?

30:53

Exactly. Like a seesaw or a teeter-totter

30:55

in a kid's playground. And when

30:57

that teeter-totter, that beam

30:59

on a central fulcrum is level with

31:02

the ground, it's at rest, or

31:04

what neuroscientists call homeostasis.

31:07

And when we experience pleasure, it tips

31:09

one way, and when

31:10

we experience pain, it tips in the opposite

31:12

direction. And there are

31:14

certain rules governing this balance,

31:16

and the first and most important rule is that the

31:19

balance wants to remain level. That

31:22

is, at homeostasis. And our

31:24

brains will work very hard to

31:26

restore a level balance after

31:28

any deviation from neutrality.

31:31

So when we reach for things

31:33

that are pleasurable, when I bite into a delicious

31:36

dessert, for example, I'm imagining that I'm essentially

31:38

pressing down on the pleasure side

31:40

of that seesaw.

31:41

That's right. So when we

31:44

do something that's pleasurable and we really stope me

31:46

in the reward pathway and the balance tilts to the

31:48

side of pleasure, no sooner has that

31:50

happened than our brains will work very

31:52

hard to

31:53

restore a level balance. And they do

31:55

that first by tilting an equal and opposite

31:58

amount

31:59

to the side of pain.

32:00

before going back to the level position.

32:04

And I like to imagine that as these little neuro-adaptation gremlins

32:06

hopping on the pain side of the balance, and

32:08

that's the come down, the hangover, the

32:10

after effect. And

32:13

it often happens even while we're still experiencing

32:16

the dopamine hit, and it often happens outside

32:19

of conscious awareness.

32:21

So if I have this image here about pressing down on

32:24

one side of the seesaw and these gremlins are

32:26

jumping on the other side, why is

32:29

it they want to press down on the side of pain? Why

32:31

not just try and get to equilibrium?

32:34

Why press down so much that it tips

32:36

over in the other direction?

32:37

That's a great question, and I don't

32:39

exactly know why the mechanism

32:42

is built like that, why we pay a price

32:44

for every pleasure. But I suspect

32:46

it has to do with the fact that

32:49

that kind of mechanism makes

32:51

us the ultimate seekers, never satisfied

32:54

with what we have, always looking for more.

32:57

And if you think about it, we are evolved

33:00

over millions of years of evolution

33:02

to approach pleasure and avoid

33:04

pain. And then on top of that,

33:06

you have this pleasure-pain balance,

33:09

whereby as soon as we get whatever

33:11

reward we're looking

33:13

for, we experience pleasure,

33:16

we immediately remember where

33:18

and how that happened, and we want to

33:20

recreate it. And that

33:23

recreation is accelerated by the

33:25

fact that as soon as we get that

33:27

hit of dopamine, we essentially go into dopamine

33:29

freefall. That's those gremlins on

33:31

the pain side of the balance. And now we're

33:33

in a dopamine deficit state, and we feel this

33:36

overwhelming motivation to

33:38

do the work it takes to get the next reward,

33:40

which for most of

33:43

human existence has meant walking tens of

33:45

kilometers every day, has

33:48

involved doing enormous

33:49

work in order to get just a little bit

33:51

of reward. So it's not that

33:53

dopamine is good or bad, it's that dopamine's essential

33:55

for survival, and it keeps us moving

33:58

and always looking for the next thing.

34:00

So, dopamine is not involved

34:03

only in feeling pleasure. Perhaps more

34:05

importantly, it's also involved in

34:07

motivation, which is of course what you're

34:09

talking about just now. Can you explain

34:12

that connection between dopamine as

34:14

a messenger of pleasure, but also dopamine

34:16

as the architect for motivation?

34:18

Yeah. So, there's a very famous

34:20

experiment in which rats were bioengineered

34:23

to not have dopamine receptors

34:26

in the reward pathway of the brain. And

34:29

what the scientists discovered was that if

34:31

they put food into the rat's mouth,

34:33

the rat would eat the food and seem to get pleasure

34:35

from the food. But if they put the food

34:37

even, you know, a single body length away,

34:39

the rat would

34:40

starve to death. In

34:42

other words, we need dopamine not

34:45

just for the experience of pleasure, but

34:47

also for the motivation to do the

34:49

work to go get the reward. And

34:51

probably the way that dopamine

34:55

makes us motivated is to create

34:57

this dopamine deficit state

34:58

or those gremlins on the pain

35:00

side of the balance. So

35:03

what happens when we transport

35:05

this brain that evolved, you

35:07

know, over millions of years into

35:09

the modern environment where everything

35:11

is now available at the touch of a button?

35:13

This ancient wiring that has us

35:16

experiencing pain in the immediate aftermath

35:19

of pleasure is woefully

35:21

mismatched for our modern ecosystem.

35:23

Why? Because we are surrounded

35:26

by pleasure. We have more

35:28

access to more reinforcing drugs and behaviors

35:31

than at any point in human history. Even

35:33

things that previously, you know,

35:35

you could have thought of as healthy, like

35:38

reading or exercise or

35:41

playing games has become drugified,

35:44

has been turned into a drug in some way,

35:47

making us all more vulnerable to the

35:49

problem of addiction and also making

35:51

us more vulnerable to the problem of

35:53

this dopamine deficit

35:54

state whereby our brains try

35:56

to compensate for this excess

35:58

of pleasure.

35:59

by downregulating our own dopamine production

36:02

and transmission, not just a baseline but below

36:04

baseline, creating this

36:06

constant physiologic craving

36:10

for more pleasure, but also the

36:12

things that go along with craving,

36:13

which are anxiety, irritability, and

36:15

depression.

36:21

So the mechanisms in our brain that compel

36:23

us to approach pleasure

36:26

and avoid pain, you say were

36:28

evolved over millions of years for a world of

36:30

scarcity, whereas today, because

36:32

we're surrounded by so much stuff, we're

36:35

sort of drinking from a fire hose of dopamine,

36:37

as you put it.

36:38

Yeah, this is the plenty paradox,

36:40

right? It's the literal physiologic stress

36:43

of overabundance.

36:49

So walk me through the same seesaw

36:52

analogy that we talked about earlier. You

36:54

know, again, 100,000 years ago, you

36:57

know, I found a date tree

36:59

and the date tree had delicious dates

37:01

and it made my brain very happy

37:03

to eat some of those dates, but there were not very

37:06

many dates on that one tree. I had to find the next tree

37:08

and the next tree might have been, as you say, three miles

37:10

away. And so it required a huge amount of effort to get to

37:12

that next date tree. What's happening

37:15

with that seesaw now in the world in which we

37:17

live, where things are in fact available at the touch of

37:19

a button?

37:19

Yeah, well, let's go back for a

37:21

second and talk about what's happening with the seesaw

37:23

when you're looking for the date tree. Because

37:26

what happens as you're scouring

37:28

your environment to try to find

37:31

one date tree with a couple of dates on

37:33

it is that your pleasure pain

37:36

balance goes onto the pain side,

37:38

right? Because you're hungry and

37:40

you're walking and you're tired. And

37:42

then finally, you find this date tree

37:45

and you're ecstatic and you

37:47

eat this date and your

37:50

balance, your pleasure pain balance goes back to the level

37:52

position, which feels

37:55

like euphoria because part of the key

37:57

here is the directionality of

37:59

the pleasure. pain balance. So if I'm in pain

38:01

because I'm hungry and then I find

38:04

something to eat and it moves me in the direction of

38:06

pleasure, that's as pleasurable as

38:08

if I start out with a level balance and I use

38:11

an intoxicant and I get high.

38:13

Interesting. And so now the same

38:15

pain, pleasure, balance now, what

38:18

happens now?

38:19

Yeah. So now in the modern world,

38:21

let's say, yeah, take Silicon Valley, because it's a prime

38:23

example, but it's also true all over the world now.

38:26

You go and you're hungry, right?

38:29

And you're looking for a date tree.

38:32

And all of a sudden, you know, you've got

38:34

like a whole crate of dates shipped to you

38:37

from Amazon, right on your kitchen

38:39

table. And by the way, they're

38:41

giant, like they're like, like abnormally

38:44

giant dates, right? So you

38:46

eat a giant date from Amazon.

38:49

And you know, it releases dopamine in your reward pathway,

38:51

because they've also added sugar and salt and fat

38:54

and flavorings, you know, it's like coffee

38:56

dates or something who knows. And

38:58

you get the release of dopamine. And wow,

39:01

that feels great. Because like, wow, who's ever

39:03

had a date like that in the history of humans. And

39:05

then, you know, as soon as it's over,

39:08

your pleasure pain balance tips to the side

39:10

of pain, because those gremlins are trying to compensate

39:12

for all that dopamine. And as soon

39:15

as you're in that dopamine deficit state with the gremlins

39:17

on the pain side of the balance,

39:19

you want to restore a level

39:21

balance. And what is the easiest way to do that?

39:23

Well, you could wait until the gremlins

39:25

hop off, because if you wait long enough, they will

39:28

hop off and homeostasis will be restored. Or

39:30

you could eat another date.

39:33

And if you eat another date, because there's

39:35

a whole crate of dates right in front

39:37

of you,

39:38

that would work faster, right? And

39:40

maybe you'll eat two this time, because then that'll

39:43

level your balance, but also get you over

39:45

to the pleasure side. And pretty soon, you've

39:47

eaten the whole crate of dates. And

39:50

now you're essentially at war with those narrow

39:52

adaptation gremlins.

39:53

And the more we then try and press

39:56

down on the pleasure side of the seesaw,

39:58

and the more

39:59

and press down on the other side to achieve

40:02

homeostasis, you make the case that over

40:04

time, the gremlins start to push

40:06

down on the opposite side of the seesaw, and

40:09

then we end up depressed and anxious. Explain

40:11

how this happens, Anna.

40:12

Well, what happens as we continually

40:15

bombard our reward pathway

40:17

with highly reinforcing substances

40:19

and behaviors is that we accumulate

40:21

more and more gremlins on the pain side of the balance.

40:24

They're just doing their job, you know, trying

40:27

to restore homeostasis. And over

40:29

time, you know, those gremlins essentially

40:31

are camped out on the pain side of the balance, tents

40:33

and barbecues in tow, and now we're

40:36

in addicted brain. We've changed our hedonic

40:38

or joy set point such

40:41

that now we need more of our drug,

40:43

quantity-wise, and more potent forms

40:45

of our drug, not to get high,

40:47

but just to level the balance and feel normal.

40:50

And most importantly, when we're not using,

40:53

we're walking around with a pleasure pain balance

40:55

tilted to the side of pain, which

40:57

means we are experiencing the universal

40:59

symptoms of withdrawal from any addictive

41:02

substance, which are anxiety, irritability,

41:04

insomnia, depression,

41:06

and craving.

41:12

I mean, you're an addiction psychiatrist

41:14

and you treat many patients who are dependent on drugs,

41:17

so drugs in the conventional sense of

41:19

a chemical that is swallowed or smoked

41:21

or snorted or ingested, and obviously

41:23

that is a very big problem, but you're

41:26

making a much more radical claim here. You're saying

41:28

that our problem with addiction is not

41:30

just limited to nicotine and cocaine and heroin.

41:34

You're absolutely right. What I'm saying

41:36

is that science, technology, and

41:38

innovation has allowed us to drugify

41:41

almost every human behavior.

41:44

If you're not addicted yet, it's coming soon

41:46

to a website near you. And

41:48

my bigger claim is that the

41:51

rising rates of depression, anxiety, and

41:53

suicide, which by the way are rising

41:55

fastest in the richest nations

41:57

in the world,

41:59

in part to

42:01

the fact that we are overloading

42:04

our brain's reward pathway with too

42:07

much dopamine.

42:08

And that in our brain's effort to compensate

42:11

for too much pleasure, we

42:14

are essentially individually and collectively

42:16

down-regulating our own dopamine production and

42:18

transmission, not just to baseline

42:21

levels, but actually below baseline

42:23

levels. So we are in a dopamine deficit

42:26

state.

42:30

Which means that we're all unhappier,

42:33

more anxious, more depressed, more irritable,

42:36

less able to take joy in the things

42:38

that used to give us joy or that have given

42:40

people joy for generations, and

42:43

also more susceptible to pain, right?

42:45

Even the merest slight now can make

42:47

us pain. And that we're not, this isn't happening

42:49

because somehow we're spoiled or

42:52

our values have changed, it's because we've literally

42:56

physiologically changed our

42:58

brains as a result of constantly

43:00

bombarding them with these high

43:02

reward substances

43:04

and behaviors. So

43:12

in some ways this feels really mind-bending to

43:14

me Anna, because you know I can see

43:16

how nicotine and alcohol and

43:19

marijuana or heroin or cocaine,

43:21

I can see how these could be addictive, but many

43:24

of the things you're talking about, you know food or

43:26

social connection or sexual intimacy, these

43:29

are not things that are inherently problems.

43:31

In fact, many of them are part of what it

43:33

means to be human. Talk

43:35

about how our modern societies have taken

43:38

these normal healthy things and in effect,

43:40

as you would put it, drugify

43:41

them. So

43:44

the way that our modern society has drugified

43:47

these things that used to be normal

43:49

and healthy like having sex or

43:51

eating food or playing games

43:54

is essentially by increasing

43:56

four factors, quantity,

43:59

access,

43:59

potency and novelty. Because

44:03

our incredible manufacturing

44:06

system has allowed us to

44:09

make these reinforcing substances in

44:12

enormous quantities and our amazing

44:14

supply chain allows us to ship them all

44:16

over the world. One of my favorite

44:19

sort of anecdotes is that in the 1880s,

44:21

the cigarette rolling

44:23

machine was invented, allowing

44:26

manufacturers of cigarettes to go from

44:28

manufacturing for cigarettes, you

44:31

know, a minute to 20,000 cigarettes

44:33

a minute. And that's just one example

44:36

of what we've done all around. And

44:38

my, you know, my own romance novel

44:40

reading addiction that developed. And

44:42

one of the things that I discovered when I went looking for

44:45

other romance novels is that there's a

44:47

whole universe of romance novels out

44:49

there. There was no, it was really a never

44:52

ending quantity. And quantity really matters.

44:55

Because the

44:56

more we use our drug

44:58

of choice, our substance or behavior that's reinforcing,

45:01

the more that we expose our brains to

45:03

and the more often, the more likely we are to

45:05

change our brains to this addicted

45:08

kind of

45:10

circuitry.

45:11

So quantity is the first driver.

45:13

What are the others?

45:15

Yeah, so quantity is the first one. Availability

45:17

or access is huge. So if you if

45:19

you grow up in a neighborhood where drugs are sold

45:22

on the street corner, we have lots of epidemiologic

45:24

data showing that you're more likely to

45:26

try drugs and more likely to get addicted to them.

45:29

And now we live in a world where we all

45:31

have more access to our substance

45:34

or behavior of choice, whether it's a

45:37

vampire romance novels or potato

45:39

chips, or games,

45:42

or pornography,

45:43

or, you know, old fashioned

45:45

drugs like alcohol, cannabis and

45:48

nicotine. And of course, the smartphone

45:50

is essentially the equivalent of the

45:52

hypodermic syringe delivering digital

45:54

dopamine 24 seven for our

45:57

wired generation. And that's really what

45:59

it is.

45:59

The smartphone totally changed

46:02

things. When people could carry in

46:04

their pocket this device that

46:06

gave them access to digital

46:09

media and digital content 24-7, we

46:12

all essentially

46:12

became more addicted to these kinds

46:15

of digital drugs.

46:22

All right, so we've talked about quantity and

46:24

we've talked about accessibility. What's next?

46:26

Yeah, availability, accessibility. Then the other one is

46:29

potency. So one of

46:31

the ways to overcome these gremlins

46:33

on the pain side of the balance, or

46:36

what's often referred to as tolerance, is to

46:39

either use more of the drug or use more

46:41

potent forms or have a more potent

46:43

drug delivery mechanism. So for example,

46:45

with opioids, someone might start

46:47

out using opium, but

46:49

eventually go to heroin,

46:52

which is about 10 times more potent,

46:55

and then eventually progress to fentanyl,

46:57

which is 50 to 100 times more potent. And

47:01

this would allow them to at least temporarily

47:03

win that battle with their gremlins and get

47:06

the feeling that they're looking for. But

47:09

another way to achieve potency

47:11

is to combine two drugs that make

47:13

yet a third more novel drug. And

47:15

this is done all the time. For example,

47:18

people combining opioids

47:19

with things like benzodiazepines

47:22

or now this new veterinary

47:25

sedative tranq, which people are

47:27

sadly using. By combining two

47:29

distinct drugs together, we get a new

47:32

novel drug, which then changes it up

47:34

for our brain receptors and allows us to

47:36

overcome tolerance. And

47:38

in the realm of non-illegal substances,

47:40

you can also have combinations like French

47:42

toast ice cream.

47:44

Exactly. Or, you

47:46

know, I very easily get hooked on

47:48

YouTube videos, especially

47:51

outtakes of American Idol. And

47:53

when I think about why on earth is American

47:55

Idol so entrancing for me, well,

47:58

they've figured it out, right? They've taken it out.

47:59

in music, which is already reinforcing

48:02

for most people's brains, releases dopamine, feels

48:05

good. And then they've combined that

48:07

with gaming and they've turned it into a competition

48:10

and thereby

48:10

really made a very potent

48:12

drug.

48:13

Can you talk a moment about the factor

48:16

that's known as novelty? This is

48:18

true in drugs of abuse, but it's also

48:20

true for many of the other things that

48:22

previously we might not have thought as being problematic.

48:25

Yeah, so dopamine is extremely sensitive

48:27

to novelty, which is why, for example, people

48:30

can get addicted to things like the news. That's

48:32

the definition of news. It's new stuff

48:34

coming your way. But what's

48:36

become so, so toxic about the

48:38

modern world is that, you know,

48:40

in order to maintain customers and keep them

48:42

coming back, you've got to take the thing that they

48:44

like before and then package it as

48:47

slightly new or different or better. And

48:50

the internet has absolutely mastered

48:52

that, right? These AI algorithms learn

48:55

us, figure out where we've spent time before,

48:57

what we've liked before, and then

48:59

proffer or suggest to us things

49:01

that are similar, but a little bit

49:03

different. And that absolutely

49:05

engages this treasure seeking function where

49:08

we keep going because we're hoping

49:10

that the next hit will be something that's

49:12

just a little bit better, but similar

49:14

to what we had

49:15

before. You know, I remember when

49:17

I was in eighth grade

49:19

or maybe seventh grade on teachers who

49:22

would tell me to avoid a local park,

49:24

me and all of my classmates, because

49:27

the rumor was that drugs were being bought and sold

49:29

and used at this park. But, you know,

49:31

if everything can be drugified, if addictions

49:33

can be beamed and streamed and, you

49:36

know, Wi-Fi'd into our living rooms and bedrooms,

49:38

it becomes really now very hard to put

49:40

a fence around it and say, avoid going

49:43

to this park because the problem is no longer just

49:45

with one park.

49:45

That's the problem we're

49:47

all facing as individuals, as

49:50

parents, as schools. I

49:52

mean, I don't know about you, but when I

49:54

walk around and see the way that people are just

49:56

glued to their phones, it just makes me really

49:58

sad. And you know, I'm not a kid, but I'm a kid.

49:59

And yet I totally get it. I

50:02

mean, these things are, they're literally

50:04

mesmerizing. We are put in

50:06

a trance by these devices. They're highly

50:08

reinforcing for our very fragile

50:11

little human brains.

50:20

When we combine the ancient pleasure-pain

50:22

seesaw in the brain with a modern

50:24

world that is ready to push hard and often

50:27

on the pleasure side of the balance,

50:29

we get trouble.

50:30

We end up with compulsive over-consumption

50:33

and all the associated problems it causes

50:36

for people's health, wellbeing, and

50:38

relationships. We also

50:40

end up with a plague of depression and anxiety.

50:45

In the second part of our story, coming

50:47

up in the next episode, how to reset

50:50

our relationship with a world of plenty and

50:52

turn unhappiness into thriving.

50:55

Ana Lemke, thank you for joining me

50:57

today on Hidden Brain. Oh, you're very welcome.

51:04

If you have follow-up questions that you'd like to ask

51:06

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51:08

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51:11

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51:13

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51:15

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