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- [00:02]
Laurie Santos
Every step, every mile, every course. At the Boston Marathon presented by bank of America, Thousands of athletes are running to make an impact. Some are racing for a cure, others for their communities, but all are running for something more than time. Join bank of America in supporting athletes who are running for a cause. Find a runner, help a cause and give if you can@bofa.com helpacors what would you like the power to do? Bank of America when it comes to.
- [00:36]
Scott Barry Kaufman
Your health and well being, the right care can change everything. That's why Cleveland Clinic has been elevating world class patient care for over a century. From the latest in heart neurology and cancer care to advanced diagnostics and beyond, Cleveland Clinic is here for every care in the world. Explore a wide variety of health and wellness info by visiting clevelandclinic.org today.
- [00:59]
Radhi Devlukia
Bring spring to your door with Target Circle 360 get all you need for Easter hosting spring get togethers and more with unlimited same day Delivery through Target Circle360 from Easter Basket goodies to fresh florals, getting everything the same day is easy. Open the Target app and bring the magic of the season to your door with unlimited same day Delivery through Target Circle360. Visit target.com circle or the Target app for more details. Subscription Required Same day delivery is subject to terms applies to orders over $35.
- [01:28]
Anna Lembke
PayPal lets you pay all your pals like your graduation gifters.
- [01:32]
Unnamed Speaker
Who's paying for the mattress topper?
- [01:35]
Radhi Devlukia
You mean the beanbag chair?
- [01:38]
Unnamed Speaker
Aren't we getting a mini fridge?
- [01:40]
Can we create a pool on PayPal? It lets us collect the money before we buy.
- [01:47]
Anna Lembke
Ooh, yes, that's smart.
- [01:49]
Radhi Devlukia
Glad we can agree on something easily.
- [01:52]
Anna Lembke
Pool split and Send Money with PayPal get started in the PayPal app. A PayPal account is required to send and receive money. A balance account is required to create a pool. Anything that we experience as reinforcing releases dopamine in our brain's reward pathway. Some of those things release dopamine directly, like cocaine or methamphetamine. Some of those things work through a complex chemical cascade like alcohol, which works on our endogenous opioid system or endogenous GABA system, and then ultimately releases dopamine in the reward pathway or sex, which which works on our serotonergic system, also our endogenous opioid system, and ultimately releases dopamine. So we're all wired a little bit differently. And what may release a lot of dopamine in your brain may not release as much dopamine in my brain and vice versa.
- [02:48]
Scott Barry Kaufman
Happy New Year and welcome to the 2025 season of the Psychology Podcast. I'm Dr. Scott Barry Kaufman, host of the Psychology Podcast, where we share with you the latest science of human potential from scientists who are doing cutting edge research that can help you self actualize and realize the best version of yourself. To kick off our new season, it's a real pleasure to have Stanford psychiatrist and addiction expert Dr. Anna Lembke on the show. Dr. Lembke's latest book, which is the main topic of discussion for today, is called Dopamine Finding Balance in the Age of Indulgence.
- [03:23]
Unnamed Speaker
This book is very timely.
- [03:25]
Scott Barry Kaufman
Dopamine is a transmitter that affects our motivation, exploration, and our pleasure. While dopamine is not the pleasure molecule necessarily, it is involved in setting our expectations of reward in the future based on past experiences. This can cause all sorts of problems, especially when we are no longer receiving pleasure from engaging in something that once gave us pleasure. In this episode, we discuss the implications of Dr. Lembke's research for helping you do a dopamine reset and take control over your life and what you actually want to be rewarding. So, without further ado, I bring you Dr. Anna Lembke.
- [04:01]
Unnamed Speaker
Hey, Dr. Lemke. Welcome to the Psychology Podcast.
- [04:04]
Anna Lembke
Thank you for inviting me. I'm excited to be here.
- [04:07]
Unnamed Speaker
Yes, I've been looking forward to this conversation for a long time. Really excited to chat with you and really dive into this molecule that is just so fascinating and quite literally drives so much of our lives. Dopamine, of course, is what I'm referring to. I was wondering if we could just start off with you giving me the most succinct and accurate definition of what in the world dopamine is for.
- [04:39]
Anna Lembke
You know, I think the shortest way to describe it is that dopamine is crucial for our survival. It tells us what we should approach and what we should avoid. And in a world of scarcity and ever present danger, which is the world that humans have lived in for most of the time that we've been on the Earth, that was really important, right? You had to know which berries were safe to eat and which weren't. You had to know where the lion's den was. And a lot of, you know, the purpose of our existence is essentially taking in novelty, metabolizing it, so to speak, making sense of it, and then using that information to inform our next steps. And dopamine is crucial for that. It's the chemical that says, hey, this is something you need to pay attention to, potentially approach, get more of investigate because it's important for survival.
- [05:43]
Unnamed Speaker
Great. That's a great launching off point because it's just so interesting because from an evolutionary perspective, clearly we've had some things that have been more reoccurring and have been able to operate on evolutionary mechanisms more than other things. So for some reason. Well, for that reason, things like sex, well, we didn't have money back then, but just the whole concept of money and power are things that we, the things we call appetitive rewards seem to be more inherently dopamine inducing than intellectual stimulation. But we can get to that later because it is interesting. I think some people do have what I've called a nerdy dopamine pathway in the prefrontal cortex. So we can talk about that later. But it seems like from an evolutionary point of view, Is that right? Is that a fair statement that there are certain things that are just more captivating to our dopamine system because of our evolutionary systems?
- [06:43]
Anna Lembke
It is a great question. I think the answer is a little bit more nuanced, which is to say that anything that we experience as reinforcing releases dopamine in our brain's reward pathway. Some of those things release dopamine directly, like cocaine or methamphetamines. Some of those things work through a complex chemical cascade like alcohol, which works on our endogenous opioid system, our endogenous GABA system, and then ultimately releases dopamine in the reward pathway. Or sex, which, which works on our serotonergic system, also our endogenous opioid system, and ultimately releases dopamine. So you've got both proximal and distant levers contributing to the release and how much of dopamine in our dedicated reward pathway. And then on top of that, you have enormous intra individual variability. So we're all wired a little bit differently. And what may release a lot of dopamine in your brain may not release as much dopamine in my brain and vice versa. And from an evolutionary perspective, that makes sense. If you have a tribe that needs to shepherd scarce resources in order to survive, you don't want everybody going for bison or everybody going for blueberries, right? You want folks to be attracted to different things so that collectively we have all the things that we need. So that's how I would think about that in terms of you're mentioning sort of nerdy dopamine hits or intellectual rewards. We know that learning releases dopamine in the reward pathway. And I could know. It makes sense that you have some people who are wired more for learning than others sometimes. Some of us are more cerebral, some of us are more physical. So our appetites will differ based on our uniqueness. The key thing about substances and behaviors that ultimately end up addicting a lot of people are that they tend to release a whole lot of dopamine very quickly, Whereas things that release dopamine that tend to be less addictive are things that release less dopamine more slowly and often require more upfront effort to get them.
- [09:15]
Unnamed Speaker
Yes, thank you for that. And I think that it's worth mentioning explicitly that there's a basic consensus in the field that dopamine is more about wanting than liking. Because I think a lot of people will say, I'll see things in the media like dopamine, pleasure molecule, you know, is characterized as that. And that's not quite right. Right.
- [09:35]
Anna Lembke
So there is controversy around this. But the way that I would describe it is that dopamine is both pleasure and motivation. It is both liking and wanting. And let me describe that a little bit because it really depends on time sequence, when we initially are exposed to a reinforcing substance or behavior. Or let me just rephrase that. When we're exposed to a substance or behavior initially, if it has what's called salience for us, what we mean by that is that it releases dopamine, so it is triggering our approach response. So it is related to pleasure or.
- [10:23]
Unnamed Speaker
Light, at least initially, the initial exposure.
- [10:27]
Anna Lembke
But with repeated exposure, our brain adapts and ultimately resets dopamine not at baseline levels of dopamine firing, but below baseline in a chronic dopamine deficit state, which is the addicted brain. And then, then our seeking mechanism is propelled primarily by wanting. And primarily dopamine is then primarily mediating motivation rather than pleasure or liking. But it must begin with salience, some degree of pleasure, some. Oh, yes, this is something that felt good. And I. I want to do it. I'd like to do it again, if that makes any sense.
- [11:14]
Unnamed Speaker
It makes tons of sense. And what I see quite often is not just pleasure, but I see hope. There's something about this, there's something about dopamine that has so much to do with expectations and your hope for. I'm going to use the word hope for continual pleasure in the future, even if you're no longer receiving that pleasure at a certain point. And so it's quite a paradoxical molecule, isn't it? Isn't it? Because on the one hand, it's the thing that keeps us going. It's the thing that gets Us out of bed in the morning if we didn't have any dopamine production. As some disorders, we see what happens. There's a great lethargy, lack of motivation, so we want it, but at the same time, it can cause us to run for things that are no longer serving our growth. Or maybe it even. Maybe never even served our growth. Because there's a difference between pleasure and meaning, right?
- [12:11]
Anna Lembke
Yeah. So it is a very paradoxical molecule. And what's sort of baffling about it is that we tend to have very good memory or recollection for initial exposure to pleasure and pain. And that encodes itself very deep, deeply in our minds. And with addictive substances, when we get that initial pleasure or we solve that initial problem. Because sometimes the way in is that it's a problem solver. Right. It's alleviating pain, which is directional. When we, from a directionality perspective, the same as getting pleasure in terms of, you know, how our brain is reading that largely we have a very vivid memory for those initial exposures, but with repeated use after it stops working and then can even turn on us and do the opposite of what we're seeking. We tend to not encode that with the same kind of fidelity. And we have what's often referred to in the field as euphoric recall, where we're now just remembering those initial exposures, the early highs. And the rest of our sort of behavior is in the service of trying to recreate those initial highs, which can get us into a lot of trouble because then we can't see clearly when it's no longer serving that purpose. I would also just add that you're absolutely right that, you know, we're all releasing dopamine at a kind of tonic baseline level. But that can differ between persons. And people who have depression, for example, are thought to probably have lower baseline tonic levels of dopamine firing. The state of being addicted is essentially the state of progressing toward a lower level of dopamine firing. So really looks very much like a clinical depression. So whether, you know, in other words, some of us come into the world with a lower baseline dopamine level, some of us acquire a lower baseline dopamine levels because of exposing our brains to these high rewards over time. And then there are other forms of psychopathology characterized by abnormalities in dopamine levels.
- [14:38]
Unnamed Speaker
Yeah, I was thinking Parkinson's disease.
- [14:40]
Anna Lembke
Parkinson's disease is a good one. But interestingly, Parkinson's disease is characterized by below normal levels of dopamine in a different part of the brain called the substantia nigra, not in the reward pathway itself, which gets very complicated in terms of the treatment of Parkinson's. Because what we give is dopamine precursors. We don't give dopamine because dopamine itself cannot cross the blood brain barrier. We give these dopamine precursors that get converted to dopamine in the brain and then bind to dopamine receptors in the substantia nigra, which allow for more fluid, fluid movement, alleviating the symptoms of Parkinson's, but problematically also bind to dopamine receptors in the reward pathway, the reward circuitry, just like other dopaminergic substances and behaviors, I.e. intoxicants do, leading to addictive behaviors in people who take dopamine precursors for the treatment of dopamine. So about a quarter of folks who get dopamine precursors to treat their Parkinson's will actually end up with a compulsive shopping disorder or compulsive sex, pornography and masturbation disorder. And these disorders tend to be dose dependent. So when the dopamine precursor is stopped, the symptoms, not in all cases, but most often tend to get better or resolve.
- [16:03]
Unnamed Speaker
Well, I love that you, you brought in that nuance that there, I mean, there are different patients pathways in the brain where dopamine sends its projections. And I think one of the projection routes that's not as often discussed is the one to the dorsolateral prefrontal cortex. It's not all being sent to the striatum. So in that sense, as a cognitive scientist, by the way, who studied intelligence and working memory, I don't think we realize the extent to which dopamine also plays a role in our working memory and how some people have genes. I mean, we can really nerd out here. Drd for there are certain genes that for certain individuals, from an individual difference perspective, too much dopamine influx in the prefrontal cortex can cause them to have reduced working memory capacity. And I find that super, super interesting. There seems to be like an optimal.
- [16:54]
Anna Lembke
Balance there that is really interesting. I don't know much about that. Tell me more.
- [16:59]
Unnamed Speaker
There are certain genes that encode for how much there's going to be a natural sort of projection of dopamine to certain brain areas, but the one in our higher order cortexes, like our prefrontal, our dorsal area or prefrontal cortex. There is an interesting relationship between dopamine production and the ability to, for instance, ADHD is relevant here. Being able to concentrate, being able to focus, being able to hold multiple pieces of information in your cognition at once. And I only bring this up as, as just to explain and to, and, and for just purpose of discussion, that we're not just. We talk about dopamine. It has far reaching consequences across the brain. We're not just talking about sex and drugs.
- [17:41]
Anna Lembke
Right. You know, yes, great, great point. And I'm. I've been very impressed by how many questions I get about the relationship between ADHD and dopamine. I think people are very wanting knowledge about that. And I mean, I wouldn't say it's my area of, you know, real expertise, but what I do know is that there are studies showing that people with ADHD may indeed come into this world with a lower baseline level of dopamine firing, which means that they're relatively insensate to rewards, which means that they need more potent rewards. Rewards a priori to get any kind of reward response at all. Which may go some way into explaining the kind of impulsivity that's often associated with adhd. Impulsivity being difficulty putting the brakes between a thought or desire to do something and actually doing it, because they're in an embodied way experiencing the stimulus differently than people who don't have adhd. So I think those types of findings are really interesting.
- [18:55]
Unnamed Speaker
So interesting. And it seems like either extreme is not good because there's some research called about the cliff of schizophrenia. Too much dopamine production can cause you to not be able to discern what's relevant and what's irrelevant. And so you see everything as meaningful apopenia everywhere. And so there seems to be like an optimal level for creativity as well. And that's just my own area of research is the link between creativity and mental illness and various things.
- [19:24]
Anna Lembke
Yeah, yeah. It's even what we characterize as mental illness. Right. The sort of auditory or visual experiences that people with schizophrenia have. You know, we think of that as a form of psychopathic pathology, but we could equally well conceptualize that as just a different way of processing information, a different way of experiencing certain types of emotions, mediated in part probably by dopamine. Because we know that when we give dopamine blockers to people with those symptoms, those symptoms tend to reduce. So we infer from that that dopamine is involved in this experience of hearing voices other people don't hear, seeing things that other people don't see. You know, which we have organized into this bucket we call schizophreniform disorders. But it's all very interesting.
- [20:26]
Scott Barry Kaufman
This is Dr. Laurie Santos from the Happiness Lab Every runner has a reason, a goal, a story at the Boston Marathon presented by bank of America, there are thousands of athletes who are running for something more than time. This iconic race isn't just about 26.2 miles. It's about making a difference. Runners from all walks of life are pushing their limits on one of the world's most famous courses, and many are doing it to fundraise for causes close to their hearts. No matter how you're involved, whether you're running supporting from the sidelines or just inspired by the cause, your contributions are are making a difference. The countdown to race day is on. Join bank of America in supporting the incredible runners, their causes and help them reach their fundraising goals. Together, we can make a real difference. Give if you can@bofa.com helpacause references to charitable organizations are not an endorsement by bank of America corporations. Copyright 2025 bring spring to your door.
- [21:27]
Radhi Devlukia
With Target Circle360 get all you need for Easter hosting Spring get togethers and more with unlimited same day delivery Through Target Circle 360. From Easter basket goodies to fresh florals, getting everything the same day is easy. Open the Target app and bring the magic of the season to your door with unlimited same day Delivery through Target Circle360. Visit target.com circle or the Target app for more details. Subscription required Same day delivery is subject to terms applies to orders over $35.
- [21:55]
Scott Barry Kaufman
From prioritizing time to keep our bodies active to simply creating space to check on our well being, Happiness Lab listeners take their health very seriously. But when it comes to treating complex issues like heart disease, neurological disorders or even cancer, the right care can make all the difference. That's why Cleveland Clinic has been elevating world class patient care for over a century. Whether they're raising the bar in heart care, uncovering the mysteries of the brain, or researching new treatments for cancer, Cleveland Clinic continues to redefine what's possible for every breakthrough in health for every care in the world. Explore a wide array of health and wellness information by visiting clevelandclinic.org today.
- [22:36]
Radhi Devlukia
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- [23:29]
Unnamed Speaker
Yeah. It just shows the pervasiveness of this molecule in our lives and far reaching about almost every aspect of our lives. You could find it playing some role. And as your subtitle of your book notes, it's important to find balance in this age of indulgence. And, and your book is all about the balance. It's not about living a life of pure pleasure or living a life of pure pain. Right. It's about a little of both. There's one finding in your book that really I fell off my chair and I just had to. I can't stop thinking about it.
- [24:07]
Anna Lembke
Okay, I'm excited to hear.
- [24:10]
Unnamed Speaker
Yeah. So it seems like peak dopamine products peak in is when you've had this prior learning experience of pleasure. But you start to get to the point where it's about 50, 50 uncertainty whether or not it's going to be pain or pleasure. If you get to this maximum, obviously gambling and casinos, Vegas gets that. But we're not just talking about gambling. We're talking about anything. And that is so interesting to me. Could you explain that finding a little bit more?
- [24:38]
Anna Lembke
Yeah. So this was a study that was done comparing pathological gamblers to. To non pathological gamblers. Pathological gamblers being people who gamble to the point of continued compulsive use despite harm to self and or others, which broadly speaking is the definition of addiction. And what the researchers did was they measured dopamine firing when pathological gamblers won at gambling and compared that to when non pathological gamblers, what we'll call moderate, non riskier, healthy gamblers, just recreational gamblers. And what they found was that with, with winning in, in a game that, that required. That included uncertainty and risk and monetary reward. The potential for monetary reward was that with winning, both pathological gamblers and recreational gamblers had increased dopamine firing. But with losing, recreational gamblers did not have an increase in dopamine, but pathological gamblers had an increase in dopamine firing even when losing. Which maps very nicely onto the phenomenology or the subjective experience of pathological gamblers who will often report what's called loss chasing, where they actually want to lose, because losing justifies, in their minds, staying longer gambling or staying in the game longer, which is essentially what they want. The game itself is the drug. It's not necessarily the monetary reward. And for pathological gamblers, the highest dopamine release, or the peak in dopamine release, was when there was an equal chance of winning and losing, losing. So that point of maximal uncertainty was the biggest high for pathological gamblers, which is really fascinating because what it suggests is that on some level, we like uncertainty and we crave and need it, even as we're making enormous efforts in our lives to kind of try to control the outcome and control our experience.
- [26:58]
Unnamed Speaker
It's so fascinating. Obviously, there's something unique about humans and other animals and the way dopamine plays out. One of my heroes, intellectual heroes, Robert Sapolsky, has a lecture about dopamine once where he says, at the end, he says there's no rat in the world that's going to keep lever pressing with the hopes of getting into heaven.
- [27:21]
Anna Lembke
Well, you know, who. Who knows? I don't know. I mean, the more. The more we. We find out, the more we see homology. For example, you know, unfortunately, we don't have little smartphones we can give to rats to sort of see their dopamine levels in response to social media, for example, or pornography or online shopping. But there are some scientists in France who did rig up this contraption where mice, or mice and rats, rodents were able to press a lever to get a selfie and see a selfie of themselves. And initially they paired lever pressing with sugar release, which is rewarding for rats. So they will press. Rats will press a lever just for sugar water, but they also saw the selfie. And with repeated use, even when the. Even when the sugar water was stopped, the rats compulsively press the lever to get selfies of themselves. So, in fact, even rats like to look at their own image. Who knows, maybe there's a rat heaven they'd be willing to press a lever.
- [28:26]
Unnamed Speaker
For, too, if they could conceptually understand or think that through. Perhaps we talked about. I still want to talk about individual differences because it's so fascinating to me. We talked a little bit about sex addiction. I think people can wrap their head around that. But I don't think most people really think about love addiction when they think about dopamine. And I've been thinking about that. You know, I've seen there's a certain kind of Guy that, you know, has women fawning all over him, but he, he keeps all of them at this sort of 50% uncertainty.
- [29:02]
Anna Lembke
So he treats them well. Right.
- [29:04]
Unnamed Speaker
And he drives them crazy.
- [29:06]
Anna Lembke
Yeah.
- [29:06]
Unnamed Speaker
Now there is, there's this archetype of this guy. And I've had friends, I've had guy friends. So I think humans can co opt this, right. To kind of like have people dependent on, on them. And you can see it with codependency, relationships, perhaps.
- [29:19]
Anna Lembke
Right.
- [29:19]
Unnamed Speaker
So am I making any sense? Does this, can we link this to.
- [29:23]
Anna Lembke
Absolutely. So first of all, clinically, phenomenologically, we see people who are addicted not just to sex, but even more to the pursuit of a partner. And once they obtain that person, their interest disappears and they're on to the next person. We also see people clinically who are in addictive relationships, not even around sex, but just around the relationship itself. Most often these just happen to be women more often than men, who are often connected or pursuing or in relationship with a man with more of a narcissistic type of character structure. And what we essentially mean by love addiction or codependency is that the individual becomes addicted to the other individual and then essentially uses that person as a way to manage their own emotionality, manage their own emotional needs. Often when a codependent person, and like the term codependency originates from the addiction world, right. Where you have the person who's the addict and then you have their codependent loved one who is often nominally trying to help them, but also simultaneously can, in their behaviors perpetuate, or what we call enable the addiction. So you have a very strange kind of push me, pull me situation where it looks on the surface as if the loved one is trying to help this person get out of addiction, but really they're not, because the dynamics of the relationship itself become a drug to them. And then they, they engage with that person as a way to try to predict and control their emotions. So the, the, the evil we know is better than the good. That seems out of reach, that kind of thing. There's also speculation that domestic violence is related to dopamine release. Right, Right. The kind of uncertainty of knowing if you know your partner will lash out, and then the pain when they do, followed by the making it up afterwards. This whole cycle can become, for some individuals, reinforcing and quite addictive and is probably mediated by dopamine. So, yeah, And I think in this day and age of social media, we're all more vulnerable to getting addicted to other people because the medium itself has distilled human relationships down into their most addictive components. So we know that, for example, oxytocin, the love hormone, is released when. When we have an intimate connection to another human being. It's involved in mother pair bonding and love bonding. And the work of my colleague Rob Malenka here at Stanford has shown that oxytocin binds to dopamine, releasing neurons in the reward pathway and leads to the release of dopamine, which is why falling in love feels good. No surprises there. But social media has essentially, again, distilled human connection down to its most addictive components, where for very little upfront work, we can have a lot of reward, beautiful face, and intimate connection. And the moment it becomes distressing or frustrating, we can just delete it or swipe right or swipe left and find somebody else. So that now more and more of us, I think, are engaging with other people in a way that is really addictive. And this explicitly plays out with dating apps. We see lots of patients who are addicted and harmed by dating apps. Dating apps, on some level, you could argue, are engineered to be addictive because they really don't want people to successfully match with a partner and leave the dating app. What they want people is to stay in the dating app and keep looking for other people. So, so there's a, you know, there, there are ways in which the medium itself really does contribute to compulsive, addictive orientation on human relationships.
- [33:41]
Unnamed Speaker
Oh, for sure. And I'm really glad that you bring that up. You talk about that a lot in the section of your book. The problem you talk about over consumption and the kind of society we're living in. So let's talk about. Let's get out of the darkness for a second and let's talk about what people can do to really help themselves if they're caught in this bind. So you have this beautiful section of the book, Self Binding with really good advice, and I thought it was really clever. Part of your advice was you went, go through. You go through each of the acronym dopamine. You turn out, you turn dopamine into an acronym.
- [34:13]
Anna Lembke
Right, Right.
- [34:15]
Unnamed Speaker
So could. Do you mind if we go through that a little bit?
- [34:17]
Anna Lembke
Sure. So the dopamine acronym is essentially the clinical framework that we use with new patients when we're trying to discover whether or not they've developed a compulsive consumptive behavior, and then provide an early intervention to see if you know what the causal effects are of that behavior. And I want to emphasize early because it's not an intervention we would do with somebody who was at risk of life threatening withdrawal or who had repeatedly tried to stop on their own and wasn't able to. This is really an early intervention for people with, you know, the sort of mild to moderate forms of addiction. But D essentially stands for data. That's where we try to get information, what people are consuming, how much and how often. Not just for drugs and alcohol, but also for all of the digital media that essentially represent digital drugs. So how much time on social media, on YouTube, on pornography, on online shopping, on LinkedIn, on the Internet, more globally. And when we discover heavy daily use. And you could, you know, we don't have a lot of data on what, what constitutes heavy necessarily for a given individual. But you know, you have a sort of a gestalt of like, oh gosh, this person's repeatedly staying up till 1, 2, 3 in the morning, waking, not getting enough sleep, waking up, tired, using even when they shouldn't. Those are the types of things that we're looking for. So data is a way to just get the information. What are people doing, how much and how often? O of the dopamine acronym stands for objectives. Why are they using? Broadly speaking, people use for one of two reasons, to have fun or to solve a problem. Importantly, what starts out as fun and adaptive, often with repeated use becomes not fun and not problem solving. But we'll get to that. The next letter which is the P which refers to problems related to use. And this is where we just ask them, talk about what are the physical, mental, relationship work, school, psychological, spiritual problems as a result of this behavior. And sometimes the problem is just an opportunity cost, right? The things I'm not doing because I'm spending so much time watching YouTube. So we try to lay out those things. And then the A of the dopamine acronym stands for abstract abstinence and asceticism. Abstinence is where we ask them to do a 30 day dopamine fast from their drug of choice. So with a sex addiction that means no orgasms with yourself or others for 30 days. Somebody torture? Yeah, yes, it's, you know, admittedly, especially if you've been using, let's say masturbation as a coping strategy for emotion regulation. It's hard to imagine how you could go, go without. But that, that is the ask. We always warn people that they're going to feel worse before they feel better because they're going to be in withdrawal. But that the, the bad feelings, the universal symptoms of withdrawal, anxiety, irritability, insomnia depression and craving are they peak within about 10 to 14 days and then they tend to get better. And if people can make it the full 30 days, they find that they feel so much better, not just better than they did when they were in acute with withdrawal, but actually better than they have in a really long time. And what I want to emphasize here is that actions have to come before feelings. We can't wait until people feel like giving up their drug of choice. And I use the term drug very broadly to encompass behaviors. If we wait for that, the day will never come. We have to have them experience in an embodied way a difference in their lives to be able to then form cognitions and emotions based on this lived experience that will allow them to make better choices in the future. So really, really important to emphasize that. And I think especially in mental health, where, you know, in many instances we appropriately spend a lot of time asking people about their feelings, their motivation, their thoughts, but don't necessarily move them to action. We're waiting for them to be motivated for action. Sometimes you just have to say, you know what, that that's not going to come. You just have to, you have to, you know, try to change, change this behavior and then the feelings will follow. And the A also stands for asceticism, which is this idea of doing something more painful than the pain of withdrawal as a way to speed up the process of resetting reward pathways. Because reward. We know, for example, that exercise is immediately toxic to cells, but we also know exercise is good for us and makes us feel good. Why is that? Because the body senses injury and then in response to that micro injury, upregulates feel good neurotransmitters like dopamine. And then those dopamine levels will stay elevated even hours after we stop exercise before coming back down to baseline levels without going into that dopamine deficit state that sets up, sets up the craving, which is why most of us don't crave exercise the next day. We have to remind ourselves, oh wait, I feel better after exercise. So the aesthetic symptom is leaning into right sized pain in order to upregulate dopamine levels. And let me just emphasize, in our patient population, for many of our patients today, living in the world today, just getting up off the couch, turning off the phone, going outside without a device and walking around the block is extraordinarily difficult and painful. That is leaning into pain.
- [40:03]
Unnamed Speaker
I know a lot of it's interesting because I know a lot of people who are addicted to exercise.
- [40:07]
Anna Lembke
Yes, yeah.
- [40:09]
Unnamed Speaker
So it can go the other direction.
- [40:10]
Anna Lembke
It definitely can. That is a danger. We sometimes see that people with exercise addiction don't take, typically come in for treatment, but sometimes they do. And of course, we have all of this technology that takes things that used to be good for us and has turned them into something that's essentially addictive. I talked about social media, you know, human connection. We know human connection is good for us. Digital media has turned human connection into a drug. Same thing with exercise. Exercise is good for us, but now it's tied to social media. We're now making these comparisons on leaderboards and, and other social media sites. People are counting themselves and counting their heart rates and their, their steps and, you know, down to the micro, how hard they're working. And that enumeration also increases the addictive nature of these activities because then we get very fixated on the numbers, wanting to improve the numbers, improve our rankings. So we've also, you know, drugified exercise, which is unfortunate, fortunate.
- [41:13]
Unnamed Speaker
Did you go through all the acronyms?
- [41:14]
Anna Lembke
Oh, sorry, yes. Thanks. So the M stands for mindfulness. So this is a great opportunity to practice mindfulness as you know and as you teach all the time. Mindfulness is a skill that we can learn and practice. It's the ability to observe our thoughts and feelings without judgment and also without trying to escape those thoughts and feelings. And when we give up our drug of choice that we usually use use to numb our feelings, we. We're practicing mindfulness, right? We have to learn to sit with those uncomfortable emotions and watch them kind of pass over us like a wave. The I stands for insight. It's amazing again how much we learn about ourselves when we do a dopamine fast and give up our drug of choice. That's really impossible. Knowledge that's impossible to acquire in any other way. It is experiential knowledge, knowledge. The N stands for next steps. People come back after four weeks of abstaining from their drug. Oftentimes they're very surprised at how much better they feel. Some don't feel better. And that's information too. But in general, even those folks who do feel better, typically they want to go back to using their drug of choice, but they want to use less. They want to use in moderation. So then we talk about luck, exactly what they will look, look like, and the devil's in the details. I spend a lot of time with patients going through, okay, what days are you going to use, how much with whom, in what circumstances? What are your red flags for knowing that you're slipping again or for people who want to continue to abstain from their drug of choice, how is that going to look? What self binding strategies are you going to put in place so that the drug is not immediately available? And then E stands for experiment. That's where folks then take this new plan and these reset reward pathways and they go out into the world and they try again. So it's a cyclical thing. You know, sometimes people are able to maintain their gains, other times they slip up immediately and they're back to using possibly even more than they were before. Then we have to, you know, try another discussion, another intervention. So it's an iterative process.
- [43:18]
Scott Barry Kaufman
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Radhi Devlukia
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- [46:23]
Unnamed Speaker
Thank you for going through that. You know, you have so much experience with patients, you know, on the front lines, dealing with people who've. I'm sure you've seen it all, you.
- [46:32]
Anna Lembke
Know, or just when I think I've seen it all, I see something new. Because also the drugs are always changing. But yes, I have seen a lot.
- [46:39]
Unnamed Speaker
Well, I mean, even in your book, you bring up examples that I've never heard of before. Someone who got off on electrical currents or something like that. Right. And so it's so interesting the way dopamine can kind of manifest itself in modern day humans, you know, and a whole variety of different things. Things. And one thing that I'm not sure I fully understand yet as a psychologist is what the threshold is for addiction, what counts as addiction, and what counts as just dopamine coursing through your system. And there's such heated debates. I go to psychological conferences where some people are adamant there's no such thing as sex addiction. There's a whole group of sex therapists who are well respected who really believe that it's just a compulsion. But then I'm getting all confused. I'm like, then what's the difference between a compulsion and an addiction? I mean, I'm a psychologist, 20 years of experience. I still don't fully can wrap my head around all these distinctions. Can you help us shed some light on some of these Distinctions for me, sure.
- [47:46]
Anna Lembke
So first it's important to establish that there's no blood test or brain scan to diagnose addiction. It's based on phenomenology or patterns of behavior that reproduces, repeat themselves across individuals, time periods, geographic locations. Inherent in the definition of addiction is the continued compulsive use of a substance or behavior despite harm to self and or others, often constituted by the three Cs as well as tolerance and withdrawal. So the first C is control or out of control use. Repeatedly planning to use a certain amount and repeatedly going over that. Second C is compulsive use. What do we mean by that? We mean a lot of mental real estate occupied with thinking about the drug and a certain level of automaticity around initiating drug use, even when we planned not to. So again, some loss of agency is really at the heart of the compulsive aspect of the disease. And then the third C is consequences, especially continued use despite consequences. So there's sort of this, this notion that every single person with addiction is in denial and doesn't see the consequences. Denial is a big problem with this disease where we don't really see true cause and effect of our behaviors on our lives, especially the negative behaviors. But there are many, many people with addiction who can clearly see the harm and still can't stop. So those are the behavioral definitions or the behavioral broadly summarize the behavioral manifestations of addiction. And then there's tolerance, which speaks to the physiologic changes. Tolerance is needing more of the drug over time to get the same effect or finding at the current dose, it stops working. So if we were going to think about sex addiction, very often what we'll see clinically is people who start out with kind of the Noah Toast pornography and over time it stops working. So they need more and more deviant forms and might end up ultimately using child pornography, getting into trouble with the law, having serious legal consequences, being suicidal. So the continued use despite consequences, including life threatening consequences. And we see that, which is why I think the argument about whether or not, you know, sex addiction is real. You know, I would invite folks, if it were possible, to be a fly on the wall in my office because clearly there are individuals for whom this phenomenology plays out in an identical way with pornography or other forms of sexual gratification as with drugs and alcohol. And then the final one is withdrawal. That is to say, when we try to stop or reduce our use of the drug, we experience a withdrawal phenomenon for various drugs. The withdrawal phenomenon is usually the opposite of whatever the drug does. So people who are addicted to alcohol, which is a sedative, when they're withdrawing, they have hyperarousal, they can even have seizures, a kind of physiologic storm. People who are addicted to stimulants like cocaine, their withdrawal will be characterized by extreme sedation and depression. The opposite again. The universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia, depression and craving. And for behavioral addictions, we see those psychiatric symptoms, but we also often see physical signs of withdrawal. So getting back to sex addiction, I have lots of patients who, when they give up pornography and masturbation for a month, or try to, they will have extreme debilitating fatigue, extreme insomnia, they will have headaches, they will have nausea, they will have hyperventilation. So it's, it can be, you know, the mind and body are so connected. Of course it's going to be physical. So, yeah, so that, that's how you diagnose it. I, you know, at the end of the day, sitting around, sort of splitting hairs, is this a, you know, is this ocd? Is this an eating disorder? Is this an addictive disorder?
- [52:00]
Unnamed Speaker
How's that helping people?
- [52:01]
Anna Lembke
Yeah, what to me, what I care about is how can we help people get better? And what I have found is when we use the addiction lens to understand these behaviors and we use an intervention that is an addiction intervention, people get better. And it's not gonna, we're not gonna help all people, but there are a lot of people with sex addiction or compulsive sexual behaviors or eating, you know, so called eating disorders who, when you use the lens of addiction, can make a lot of recovery and really get their lives back. And so it works, right? It works, it doesn't work for everybody, but it works for enough people that it seems to me quite valid to use that addiction lens.
- [52:51]
Unnamed Speaker
Well, thank you. It's a real privilege to be able to talk to you and the expertise that you bring to the table. So, for instance, I think that the flow state of consciousness itself can become very addicting. I personally love getting fully engaged and absorbed in my work. And it's a wonderful feeling. I can't just snap my fingers and get into it. I wish, I wish I could. But I think all of us can resonate with that. Something that I found so interesting in reading your book is some of the people who were addicted described that they lost track of time. Some of the things that they said seemed to reflect that flow state of consciousness that we can apply towards maybe more healthier pursuits. But it just made me think philosophically a lot about I wanted to just step up a second level in a very non judgmental way. So I guess I think you can have a compulsion without an addiction, right? Like you said that addiction involves the compulsion component but also involves negativity towards harm, harm towards yourself and others. You can have a compulsion and not have harm.
- [53:58]
Scott Barry Kaufman
Right.
- [53:58]
Unnamed Speaker
So for me personally, I'll give you a personal example. I took up magic as a hobby in January of this for actually for the past year I've become, I'll use the word, obsessed with mentalism. And I've been spending way too much money and magic tricks and I can't stop thinking about it now. And every day I wake up and I look forward to the day. I look forward to like mastering a new trick, you know. So I'm like, okay, well I think maybe I'm addicted to magic at this point. But it's not really, I mean it's causing some harm with money, the issues. But that aside, it's not ruining my life and it's bringing people joy. So I guess I'm really having a hard time articulating what exactly my point is. But it's something I just wanted to talk through with you because I'm such a non judgmental person and I feel like what brings one person flow and passion? What's the difference between passion and addiction? You know, like, don't we want people to be passionate about what they do? Am I making any sense at all?
- [55:05]
Anna Lembke
Dr. Yes, and I think, I think it, I think it's a problem, a little bit of language. So when I use the term addiction, I'm really talking about a form of psychopathology in which there's harm to self and, or others. You know, if somebody has certain sexual preferences that you know, may not fall into whatever, you know, we consider to be sort of standard categories. I wouldn't diagnose that person with anything at all unless they came to me and said these behaviors are causing problems in my life because that of control use, compulsive use, continued use despite consequences, tolerance, why I need to use more over time to get the same effect and withdrawal when I stop. So I think that's really important to make that distinction. You know, I'm not saying that anybody uses pornography is addictive or anybody who makes pornography is a bad person or any that, oh, there's only one type of sex that people should be have. No, I'm saying that the people who come to Me who identify this as a problematic behavior and want help. Um, okay, let's talk about what's going on there. Now, your other question, or the. The related question was, well, how do we distinguish between an addiction and a passion? Right. Something that's a passionate hobby or that I'm thinking a lot about. You know, we. We have. We all have very busy minds, and it is generally healthy for us to have something for our busy minds to land on that's adaptive, contributing to the world in a positive way, way creative, engaging. We need. We need to stay busy. If we don't keep our minds engaged in a healthy way, we will ruminate on other things that we don't want to be ruminating on. Right. That are not healthy or adaptive. So, again, the same thing kind of holds if your mat. Passion for magic is healthy, gives you a reason to get out of bed in the morning, isn't hurting you, isn't hurting anybody else. You're not going into financial debt because, you know, you're. You're. You know, because you're spending all your money you don't have on magic tricks if you don't have a partner who says they want to leave you because you never pay attention to them because you're always doing magic. I mean, these are the things that, you know, that we would look for. And I want to contextualize all of that by saying we live in a drugified world where it has now become so easy to make all of these passionate hobbies more accessible, more potent, more bountiful, more novel, such that even something seemingly innocent as learning magic tricks actually could become an addiction where, you know, 50, 100, 150 years ago, it couldn't, because there weren't a million YouTube videos that you could get sucked into. There weren't a million things you could buy on Amazon. There wasn't the same amount of leisure time. There wasn't the same amount of disposable income. So I think we need to qualify and circumscribe what we mean by addiction, how it's different from a passion, you know, how it's different from just somebody's preferences. But we also need to contextualize it in a world that has pretty much made everything addictive, such that even putatively healthy and adaptive behavior behaviors now have the potential to be.
- [58:32]
Unnamed Speaker
To become compulsive, you know, because people exploit. Exploit that. That tendency of humans.
- [58:39]
Anna Lembke
Do you.
- [58:40]
Unnamed Speaker
Do you feel comfortable talking about your own personal experience, which you talk about in your book, maybe made you feel.
- [58:47]
Anna Lembke
Yeah. Yep. So Just very briefly, you know, in my mid-40s, my life was going along pretty well. There were no major cracks, crises. I had never had any prior addictive, significant addictive problems or really even anything I would characterize addiction. I got into romance novels and I, they were very reinforcing. I'd always been a reader, but this particular genre of, of novel was not something I had ever read before. It started with the Twilight Saga and I was just sort of off and running, facilitated by a Kindle that I got, which then allowed me to sort of, as soon as I finished one, I got another. Then I got all these free samples and then I was essentially reading 24 7. I couldn't wait to get home at night so I could just read. I wanted to be done with my kids so I could read. I was up till 2, 3 in the morning reading took, took romance novels to work, reading in between patients. I just didn't want to be in my own body. I just wanted to be in this kind of escape fantasy place and ultimately started to get more depressed, more anxious and didn't see what was happening to me until it was pointed out by somebody else exactly what my patients describe when they get addicted to drugs and alcohol. I decided to fast from romance novels for four weeks, as I recommend to my patients. I was shocked by how difficult it was, was I had a terrible time sleeping at night.
- [60:15]
Unnamed Speaker
Yes. You said you had an existential crisis.
- [60:17]
Anna Lembke
Yeah, I mean, on some level, yes. Right. I was certainly buzzing for a while and then after a month felt better, thought I'd go back to reading. Immediately binged and realized, oh well, I can't, I can't moderate this thing. I really need to abstain for a long period of time. So that's what I did. And interestingly now I, there's no, there's no appeal for me in the genre. It's like I've sort of burned out those neurons, which is the wanting more than liking thing that we started with, right. Where you get to a point where you've kind of, in a way you've exposed your brain to your drug of choice for so long that there's no possibility of pleasure there anymore. Even though I'm still drawn to them. Like, I see them and I want to read them, but then I begin to read them and I don't experience pleasure from them. It's like I, I, I've changed my reward threshold for romance novels and they probably will never be pleasurable, pleasurable again. Which is sad, Right. It's a grief reaction and that's a lot of what people addicted to drugs and alcohol feel. Knowing they have to give up their drug, on some level wanting to, but on the other level feeling a real kind of grief reaction to having to do that.
- [61:27]
Unnamed Speaker
Make me. You just made me think of Clockwork Orange.
- [61:30]
Anna Lembke
Yes.
- [61:31]
Unnamed Speaker
The scene where they try to reprogram his lust and over saturated his brain with images so he couldn't stand it anymore. So you talk about other things that really are helpful to people, like radical honesty and pro social shame. And also you say that pain is not necessarily bad. We can have a good balance between pain and pleasure. I think a lot of people responsibly practice bdsm, you know, have enjoy pain, but do it in a responsible, healthy way. As you can tell, I'm very open minded and non judgmental about people if they do things in consensual, healthy ways, you know, and so people need, I think this point of your book is people need to find in their own way the best, healthiest balance.
- [62:18]
Anna Lembke
Yes, I agree.
- [62:18]
Unnamed Speaker
Pain and pleasure.
- [62:19]
Anna Lembke
I agree. I do agree. Yeah. And I think it's important to come as a healthcare provider, mental health care provider, to become come with a non judgmental stance. And I try to do that too.
- [62:29]
Unnamed Speaker
Yeah, I love it, you say. And I'll end this interview today, you say. Because I love it. What if instead of seeking oblivion by escaping from the world, we turn toward it? What if instead of leaving the world behind, we immerse ourselves in it? I urge you to find a way to immerse yourself full in the life that you've been given. To stop running from whatever you're trying to escape and instead to stop and turn and face whatever it is. Then I dare you to walk toward it. In this way, the world may reveal itself to you as something magical and awe inspiring that does not require escape. Instead, the world may become something worth paying attention to. Dr. Lemke, it's such an honor to talk to you today and thank you for all the work you've done to really heal and help people rediscover or discover maybe for the first time, the meaning and all that exists in the world.
- [63:14]
Anna Lembke
Aw, thank you. That's such a nice thing to say. I appreciate it.
- [63:21]
Scott Barry Kaufman
This is Dr. Laurie Santos from the Happiness Lab at the Boston Marathon. Presented by bank of America. Thousands of runners are raising funds for life changing causes and you can help make an impact. Visit bofa.com helpacause to donate and support a runner's fundraising efforts. Together we're making a difference. One step at a time. What would you like the power to do? Bank of America let's be honest, our.
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