Anna Lembke is professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. A clinician scholar, she has published more than a hundred peer-reviewed papers, book chapters, and commentaries.

She sits on the board of several state and national addiction-focused organizations, has testified before various committees in the United States House of Representatives and Senate, keeps an active speaking calendar, and maintains a thriving clinical practice.

In 2016, she published Drug Dealer, MD – How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop (Johns Hopkins University Press, 2016), which was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic (Zuger, 2018). Dr. Lembke recently appeared on the Netflix documentary The Social Dilemma, an unvarnished look at the impact of social media on our lives.

Her new book, Dopamine Nation: Finding Balance in the Age of Indulgence (Dutton/Penguin Random House, August 2021) explores how to moderate compulsive overconsumption in a world where feeling good is mistaken as the highest good.

The contemporary world is saturated with ways in which we can experience rewards that were historically much more difficult to access. Although this idea of a world filled with dopamine fixes is not new, it can be continually surprising just how extreme this reality has become. Here on the show today to talk about this issue and her most recent book, Dopamine Nation, is Dr. Anna Lembke, and we have a fascinating and important conversation in which she unpacks the human body and mind in relation to the world around us at present. One of the main points from this chat is the weakness of humans, and how unaware we can be of the way our brains compel us to engage in behaviours and seek pleasure. We get into some strategies and solutions for healthier ways to exist, talking about mindfulness, awareness, and dopamine fasting, in the face of accelerating tech and overabundance. Dr. Lembke gives us a great introduction to dopamine and how it functions in our bodies, unpacks the four properties of addictive substances and activities, the different ways to frame and understand addiction, and shares some realistic ideas about moderation. So to hear all this and much more, tune in to this great episode of the Rational Reminder Podcast.

Key Points From This Episode:

• An introduction to dopamine and its functions in the human body. [0:03:03.2]

• The human brain and the current overabundance of addictive experiences and substances. [0:05:36.1]

• Contemporary increasing in different types of addiction. [0:08:13.8]

• Considering the inherently negative connotation of the word 'addiction'. [0:11:44.4]

• The reasons that make gambling so addictive to the human mind. [0:14:12.7]

• Applying what we know about addiction and gambling to speculation and the stock market. [0:18:03.2]

• Why working also falls into the category of addictive behaviours. [0:21:46.8]

• Looking at the addictive nature of spending money and shopping. [0:24:01.5]

• A shocking story about water addiction from Dr. Lembke's practice. [0:25:12.1]

• Thoughts on recognizing addiction and possible ways to stop the behaviours. [0:26:22.2]

• Using in moderation; Dr. Lembke comments on the realities of this idea. [0:29:32.7]

• Long-term decision making versus a dopamine-laden environment; the battle of our time. [0:31:00.4]

• Understanding hormesis, seeking pleasure through pain, and embracing volatility in a portfolio. [0:34:54.6]

• The impacts of increased leisure time and the question of what we need. [0:38:47.6]

• Dr. Lembke's advice around retirement and the dangers of dopamine deficit states. [0:42:43.3]

• How the era of the pandemic has affected these trends in addiction. [0:45:20.2]

• The relationship between radical honesty and dopamine; how lying is related to reward pathways. [0:48:39.6]

• Radical honesty and better parenting; Dr. Lembke's thoughts on transparency. [0:54:01.3]

• Weighing the value of shame and its power as a socially regulating force. [0:55:51.2]

• Dr. Lembke's definition of success and its connection to being a good parent and becoming a positive force in the world. [1:00:01.6]

Read the Transcript:

So off the top, can you describe just we're all in the same level playing field, what dopamine actually is?

Dopamine is a molecule in the brain that has different functions, but one of its very important functions is the experience of pleasure, motivation, and reward. And when it is released in a part of the brain called the reward pathway, we experience pleasure. It's also the molecule that's very important to the development of the disease of addiction. It's changes in dopamine levels over time that are commensurate with the disease of addiction in the human brain.

How does dopamine influence our behaviors on a daily basis?

Well, I mean, we are evolutionarily designed to approach pleasure and avoid pain, and that's what's kept us alive in a world of scarcity and ever present danger and pleasure and pain work very much like a balance. So imagine that there's a balance in your brain, like a teeter-totter in a kid's playground. And when we do something pleasurable or ingest something pleasurable, that balance tips slightly to the side of pleasure and dopamine is released in our brain's reward pathway.

But one of the overriding rules governing that pleasure pain balance is that it wants to remain level. It doesn't want to be tipped for very long to the side of pleasure or pain. And the brain will work very hard to restore a level balance or what's called homeostasis. It does that by downregulating dopamine and dopamine transmission, right after we get a release of dopamine in the reward pathway. But the really key piece is that it doesn't just downregulate dopamine levels back to tonic baseline. It actually decreases dopamine transmission to below baseline.

So there's a dopamine deficit state that occurs in response to a dopamine elevation before dopamine levels go back to baseline. And with the balance, one way to think about this is that you have these little gremlins hopping on the pain side of the balance to bring it level again, but they like it on the balance. So they stay on until it's tipped and equal and opposite amount to the side of pain before jumping off and before homeostasis being restored. That's a really key piece of how pleasure and pain work. That with every pleasure, there's essentially a pain. It's often so subtle that it's outside of our conscious awareness, but it's still operating in the brain.

Wow. So is more dopamine a good thing?

Well, I wouldn't say it's an unqualified good thing or an unqualified bad thing. It's relative, but what is true is that our primitive brains have not evolved for the enormous amount of dopamine that technology has allowed for in the modern age. Not only are we surrounded by an overwhelming abundance of highly reinforcing drugs and behavior, but technology has also made traditional drugs much more potent than they were.

The fundamental difference between things that are highly addictive and those that are just a little bit addictive, is how much dopamine they release in the brain reward pathways. Things that are highly addictive release a whole lot of dopamine. And again, it really sends our brains reeling because we're not adapted for that. We're adapted for a world of scarcity where you have to really work hard to get that tiny little bit of reward that's going to release a tiny little bit of dopamine. Now just sitting on your couch, you can ingest or engage in a highly reinforcing drug or behavior that leads to an explosion of dopamine, that leads to this intense down regulation of dopamine as our brains try to compensate.

There's all this stigma around addiction. Is it normal in the world that we live in with all of these dopamine rich I activities around us? Is it normal to be addicted to something?

It's normal in the sense that we're all vulnerable to addiction today. So if you look at epidemiologically, populations that were vulnerable to addiction historically. So addiction has been around forever. Since the beginning of time, there are reports of people who are not able to use a variety of intoxicants in moderation. But what we see today is an ever growing number of people becoming addicted, including in populations that were previously thought immune like older people and women.

For example, the last two decades have seen an 85% increase in the number of women have an alcohol addiction and a 50% increase in older people with an alcohol addiction. Deaths due to addiction are increasing globally, and 50% of those deaths are occurring in people under the age of 50. And minor addictions are an everyday common occurrence now. Even if it's just an addiction to technology and our smartphones. So I do think that in a sense, addiction has become a normal part of living in the modern world. Not that it's good. I mean, normal implies that it's good and addiction inherent in that word is that it's a form of psychopathology.

So I get the technology aspect and how that's made it easier to access addictive stuff like social media, sitting on your coach. Why do you think other addictive behaviors, like you mentioned, alcoholism in women, why are behaviors like that increasing?

Well, when I think about the four fundamental properties that make anything addictive, I think about access, which you've already talked about, but also quantity, potency and novelty. Quantity is really huge. The more drug we have on hand, the more we are likely to use, and then the more likely we are to get addicted. And again, this goes hand in hand with access, but we are living in a day and age when technology has allowed massive production of all kinds of drugs, and we have new digital drugs that never run out, right?

So Facebook and TikTok, they're never ending. They're endless. Then you think about potency. Technology has made traditional drugs more potent, whether it's cannabis or nicotine products or alcohol products, but also potency is increased by combining drugs. So that's a very old trick. For example, people who get addicted to opioids often combine heroin with Xanax to increase potency over time as they develop tolerance. And we see that very same thing online, on social media. So I'm a big American idol fan, but they've now gamified American idol. It's not just a singing show, it's a singing competition. And they figured out exactly how to create these cliffhangers so that I tune in for the next episode.

There are so many examples of that. Social media combined with beautiful faces, combined with video games, combined with gambling, combined with sex, it's all a way to increase potency. And then of course the delivery mechanism makes it more potent too. The medium itself. The smartphone itself is enhancing rewarding screens itself are primitive fires. We're drawn to them, except now we're sitting by ourselves instead of sitting in a group.

And then finally novelty is really key. Dopamine is very sensitive to new things coming our way, including frankly, aversive stimuli. So not just pleasurable stimuli can release dopamine, but also highly aversive stimuli if they're novel or new. And what the novelty does, it means that it really engages our search and explore function of our brains. We keep looking for that next new cool thing. And of course, AI has engineered social apps to suggest to us one more thing to click or download or watch.

And also, novelty means that people who maybe aren't or weren't addicted to traditional recreational drug drugs, like nicotine, cannabis and alcohol now might find a drug that is just perfect for them. They're locked and key like a video game or a social media app because people are different and do have different drugs of choice. But there are so many drugs now that we're all liable to become addicted.

Unreal.

I know, Cameron. You're shaking your head. I feel badly. I'm sorry to say all this, but I say it with optimism and hopefulness. I do think that by having these conversations, we're going to figure it out, but we have to start having the conversations and recognize how drug-fed our world has become. And in essence, how addicted we're all becoming.

So can addiction ever be a positive thing?

So I think inherent in the word addiction is a negative connotation, which I think we should preserve. Addiction does imply some kind of psychopathology or maladaptive habit. It's not just a benign habit. It's not just an interest or a passion or a fixation. It's really crossed that line into maladaptive unhealthy use. The way that we define addiction is just simply the continued compulsive use of a substance or behavior despite harm to self and/or others.

Oftentimes, when we're diagnosing addiction in the field of addiction medicine or psychiatry, we talk about the four Cs; control, compulsion, cravings, and consequences. So when we're using our drug more than we planned, when we're compulsively ruminating about using or hiding the drug, when we have intrusive thoughts of using our drug that's craving, or even physiologic craving, which can happen, which feels like a sudden sweaty gut wrenching urge to use, and then finally continued use despite consequences. When it's starting to interfere with our relationships, with our work, with our studies, with our values. I've heard people say addiction is that thing we do and lie about which I think is really a nice way to think about it too. Things that we're doing that we're ashamed of and wouldn't want other people to find out about.

We've mentioned social media. Is it addictive in the same way that something traditionally, no one is addictive like cigarettes or cocaine or addictive?

Yeah. I mean, I contend that all of these behavioral or process addictions, which are addictions, which involve a behavior rather than involving a drug are really the same as drug addiction. They work on the same common dopamine reward pathway. They follow the same life trajectory. People usually start out for two reasons, one of two reasons having fun or to solve a problem. If it works for them, for either of those reasons, they use repeatedly over time.

Then they develop tolerance, they need more and more to get the same effect. Then they're using habitually daily or weekly. They're using in larger and larger quantities, and then they start experiencing consequences and then have trouble stopping even when they want to and even when they recognize those consequences. And that's the natural history of addiction, and that's true whether your addiction is sex pornography or cannabis or shopping, it follows a very similar trajectory.

What causes gambling to be addictive?

Well, gambling is, I mean, inherently addictive for a number of different reasons. First of all, it's a game. It's a competition. We're wired to play games and to enjoy playing games and we're wired to compete with each other and want to win. And again, these can be highly adaptive traits if channeled in the right way. But what happens with gambling is that the monetary aspect distills all of the joys of competition and gaming into this very essential component, which is highly potent and which releases a lot of dopamine and which can become very reinforcing for people who enjoy gaming and gambling, and especially once people get deep into it.

And again, then they're kind of chasing that dopamine pleasure pain balance, where they get to a point where they're gambling so much that they're in a kind of chronic dopamine deficit state. That those gremlins are hanging out on the pain side of the balance and now they need to keep gambling not to feel good from winning, but just to not feel bad.

For gambling, is it winning that causes the dopamine or is it taking a risk that causes the dopamine to be released?

So it's both, and there are interesting studies showing that if you take addicted gamblers and you study their brains compared to healthy controls, people who don't gamble, and then you have them both gamble in the same game. What you'll find is that dopamine is released in both the addicted gambler's brain and in the brain of a healthy control. But then if you measure dopamine levels when that individual is... And so that's true with winning, but if you measure dopamine levels, when both of those individuals are losing, what you'll find is that in a healthy person, who's not a gambler, dopamine levels will go back down to no normal when they are losing.

But in a gambler and someone who's addicted to gambling, they'll have an increase in dopamine even when they're losing. And in fact, you'll see the highest dopamine release when there's the highest risk. So when the chances of losing and winning are exactly equal, an addicted gambler will be having the highest release of dopamine, which is often why addicted gamblers will talk about something called loss chasing where they want to win. Explicitly, they'll say they'll want to win, but the most intense pleasure can come when they're losing.

And these studies show that because it's the adrenaline and the excitement that they get, even when they're losing that is also driving repeated gambling. The other thing that's fascinating to me about gamblers is that they'll talk about how... It starts to be totally separate. The pleasure of gambling starts to be separate from the pleasure of winning. The pleasure of gambling starts to be just being in that head space, where they are gambling, which is really an alternate reality where they're not aware of anything else.

And so for me, I think about the way I feel when I'm watching a really good Netflix binge series. Like I'm in a fantasy world, I'm in a separate world, and I don't want that episode to end because I don't want to leave that world. I think that's exactly what happens to compulsive gamblers. They enter the world of gambling. It's highly reinforcing. They experience non-self or self forgetting, which we all crave. And then it doesn't really matter if they're winning or losing. What matters is that they can stay in the game.

Fascinating. Can any of those effects be extrapolated to people's speculating in the stock market?

Oh, absolutely. I mean, the stock market has become more like gambling than ever before. Again, you think of those four factors. It's more accessible. The quantity is nearly endless. There are infinite things to bet on and an infinite modes of betting. The potency is enormous and it's made more by the graphs, the bells, the whistles, the flashing lights. The collective nature of gambling has made it highly potent because, of course, we are social creatures. We want to be in tribes. We release dopamine when we make human connections.

One of the ways that we feel connected is to experience the same emotion at the same time as other people. So when we are winning and other people are winning, we get a release of oxytocin, which is our love hormone, which directly binds to Dopamine releasing hormones and a reward pathway, which then augments the dopamine and reward that we experience, not just because we're winning, but we're winning collectively. We're part of a tribe. And then of course there's novelty. There's all the new different ways that we can gamble and things we can gamble on.

So it's like the perfect storm what happened earlier this year with the meme stock craze, I guess?

Yeah. I think that's right, like Dogecoin and those other things. What's happening there is not just that people are making money, but there's a real tribal aspect to it. And then especially if that tribal aspect has your face insurgency quality to it, then it's even more exciting because it's the adrenaline that from opposing authority or just being countercultural or being anti-authoritarian, which is also really exciting and which releases adrenaline and which releases dopamine.

If we step away from gambling, can earning more money from whatever means also be addictive?

When earning money is separate from the meaning of the work itself, it can become addicted. And by the way, that's happening in all aspects of labor today. Even for example, something as seemingly altruistic as medicine, as being a doctor has become gamified and monetized in a way that separates it from the meaning of the work itself. I'll just give you a small example, starting about 15 or 20 years ago, I in my job as a physician started getting monthly printouts of how well I was doing in terms of what my RVU earning units were though. That's a way of measuring how many patients I've seen and what I've build for my institution versus how many RVU units I'm supposed to get in a given month. So I get a graph and I still get this and it has my target and then it has my actual earnings.

And of course, when I have a month that my actual earnings go above my target and I see that visually on the graph, I get a little jolt of Dopamine. It's like, "Oh cool, I'm above my target." And then of course, in some ways it has incentivized me in the past. I'm mindful of it now so I don't do it now, but oh, what other ways can I commodify my patience and this counter so that I can be even more above my target? Not just because it feels good to be above a target, but it turns out I get a bonus if I'm well above my target. So here, we've taken something that was really meant to be altruistic and about healing and made it largely about money, and that's happened everywhere.

So linked to that, can working become addictive as well?

Working is vulnerable to the same problems of addiction as any other behavior. Again, look at access. We now have a 24/7 work week. It never ends, right? So we're constantly engaging in work and potentially turning it in to an addictive behavior. You've got along with access again quantity, the work is endless. We're never done. I think all of us experience that now where it's like, wow, no matter how much I work, I feel like I can never get to the end of my pile and that then drives this kind of relentless seeking just to finish it. To get to that place of set satisfaction of finishing, which we never get to. It's like the bottomless bowls on social media.

Then you've got potency and novelty in the way, as I just described, work has become divorced from the meaning of work itself. It's become gamified and monetized in a way that can become highly reinforcing. One of the interesting statistics is that if you look at white collar work, white collar workers that is highly educated workers in professions are working more now than ever before and have less leisure time than ever before. And that's probably largely because their work has become gamified full of bonuses and incentives that keeps them you in it.

Whereas if you look at blue collar work or people who have access to lower wage jobs, jobs that people with less education can get, those people are working less than ever because in that work is inherently often not rewarding. It's also separated from the meaning of the work itself, but not because it's gamified for bonuses, but because it's an assembly line work, it's piecemeal work, people don't get to see the results of the end product. Whereas in the 1950s, this especially true for men, people working in low wage jobs, worked about the same amount and had about the same amount of leisure time as people in high wage jobs. That's not true today. People in low wage jobs work less and have more leisure time and people on high wage jobs are working more than ever before.

I'm starting to feel like the questions we should be asking are what isn't addictive. I've got one more question on spending. Can spending money be addictive or maybe, how addictive can spending be?

Yeah. So what's fascinating to me again, is this whole concept of drug of choice. What's reinforcing for one person is not reinforcing for another. There's a surprising not that much neuroscience on drug of choice although we observe this all the time, but I can tell you that shopping is absolutely addictive for some people. As I described in my book, Dopamine Nation. I had a patient who got really addicted to online shopping, which is easy to do, because again, you've got access, you've got quantity, you've got potency. And he got to a point where he got into a hundred thousands of dollars of debt buying things on Amazon, but he couldn't stop himself.

So then he started to just buy things like key chains and mugs and sunglasses and returning them as soon as he got them because he just wanted to keep the cycle going. Very similar to people who are gambling and are losing, they just want to stay in that at world. So for certain individuals, shopping has absolutely become a potent and potential addiction.

I joked that we should maybe be asking what isn't addictive. Maybe another version of that question is what's the most unexpected addiction you've ever seen in your practice.

So I did have a patient who was in recovery from a very severe alcohol addiction. And she really struggled, even in recovery. Addiction can be a terrible and deadly disease. In her case, it really was. What happened to her was she got addicted to water. She discovered that if she drank very high volumes of water, she would become hyponatremic, which means that the sodium levels became a normally low in her blood, which caused her to become altered. So she then had an altered mental status, which is what she wanted. Again, she wanted to be out of herself to be in a place of forgetting. And unfortunately, eventually she ended up taking her life. So that was very sad.

Now that's an extreme example of somebody who was already severely addicted, who got addicted to water. But I use that example just to show that once that wiring gets set up people are really vulnerable to getting addicted to pretty much anything.

I want to ask you if people with addictions realize they're addicted, but I know from reading your book that they do not know that. So are there any kind of tests that we can do ourselves or rules of thumb that we could use to realize if we are addicted to something?

Well, I would qualify that by saying, in the early stages of developing addiction, it's very insidious and most of us don't recognize it. And in the book I talk about my own addiction to romance novels and how I didn't recognize it until later. But the truth is that many people with addiction once it really blossoms, do recognize that they're addicted and even then they can't necessarily stop or they and stop without help. And to me, that's really important and also fascinating because it shows that even when we have insight into the self and other destructive qualities of the behavior, we still can't stop, which really speaks to the overwhelming of physiologic changes in the brain driving this behavior.

So that leads to the next obvious question. How do you stop an addictive behavior?

The thing that I recommend is that if you have a behavior that you're worried might be addictive, or even that you know is addictive, what you might do is start with a 30-day trial of abstinence, otherwise known as a dopamine fast. And what that allows is essentially it allows those neuro adaptation gremlins to hop off the pain side of the balance and for normal dopamine transmission to be restored, which is really important because it allows us to be less anxious, less depressed, less craving, and also to enjoy other things in our lives. What happens in addiction is our focus becomes very narrowed on that one thing and nothing else is pleasurable.

And then we convince ourselves that other things really aren't pleasurable to us that we don't have interest in other things, but a 30-day dopamine fast allows dopamine neurotransmission to be restored based on levels. And for us to realize that, "No, actually I do have other interests. I do like these other things." Like I thought my relationship wasn't worth investing in, but it turns out it really is. I was just overly focused on this other highly reinforcing behavior.

The other really important piece of that dopamine fast is that it allows us to see true cause and effect. Because when we're in our addiction as Cameron was alluding to, it's hard to see the true impact of our addictive behavior on our lives. But when we stop, we can look back and say, "Oh my goodness, I hadn't really realized." I've had many patients who come back and say I barely even recognize that person who was doing those things. It seems so surreal and so far away from who I really am.

I find that always really powerful because it just really speaks to the fact that when we're in that vortex of addiction, it like has a life of its own and we don't see it for what it is. And then after that dopamine fast, then we can choose whether we want to continue to abstain from our drug of choice or whether we want to go back to using in moderation. And if we want to go back to using in moderation, how to do that.

Is that a real thing? Using in moderation after addiction?

Yes, it is a real thing. So we used to say that once a person was addicted, always addicted, they could never go back to using, but the alcohol addiction literature has shown that with a period of abstinence, there are some individuals who actually are able to return to using alcohol in moderation with a lot of effort. Let me emphasize again, with a lot of effort. So they have to put a lot of conscious effort and they have to change their environment and they have to actively engage in moderating. And sometimes people will say, it's not worth the effort. I'd rather abstain. Sometimes people will find that even with effort, they can't abstain and they relapse and sometimes they relapse really hard. Something called the abstinence violation effect and they go back to using even harder.

Again, those are all examples of people who probably in the long-term cannot moderate, but it really is true that a moderation is possible for some people with intense effort after a period of abstinence. I also think it's important to highlight that there are some addictions that we simply can't choose to abstain from. For example, smartphone addiction. For most of us, we are required to have smartphones for our work. Food addiction, we can't not eat. Sex addiction, most of us would say that healthy sex is a good part of a healthy life. So I think the discussion of how to moderate has become really central today.

Fascinating. In our day jobs, Ben and I help people achieve long-term financial goals, which of course are often competing with short-term dopamine seeking behaviors that you mentioned earlier, like spending and gambling. So does this dopamine rich world that you describe make long-term decision making harder for people?

I think it really does. One of my neuroscience colleagues, he did a fascinating experiment where he showed that when people are engaging in a game or a task that involves short-term rewards, that the part of their brain that lights up most prominently is the limbic brain or the emotion brain, which is exactly where this reward pathway, this pleasure pain balance is located. When people are engaging in a task that requires them to think about and anticipate longer term rewards, the part of their brain that lights up most is the prefrontal cortex.

The prefrontal cortex is that big grade matter area right behind our foreheads, that's central to delayed gratification, future consequences, storytelling, planning. So what that tells us is that we're engaging very different parts of our brain when we are anticipating short-term rewards versus long-term rewards. And that short-term rewards are especially dangerous because they do primarily engage our emotion brain. And when we're just living in emotion brain, we're probably not able to truly and objectively see future consequences.

So I do think that in your work it's very important, I would imagine, that you help people understand that they need to sit on those decisions. That this is something that they should give it 24 hours. They shouldn't do it impulsively or in the moment, although the pull to do it then is very, very strong, especially again, if you add in the social media and the herd factor where you see everybody else piling on. But I really think that there's a huge danger of not really objectively being able to engage the prefrontal cortex to see the true data and the true implication of that choice if we're just working out of our limbic brain.

That makes sense. You kind of want to step back and think rationally, so to speak. Is there anything that we can do to help make the longer term decision making feel more pleasurable?

Well, I think one thing to do, which I do with patients with addiction is to think about values and living in line with our values. Having our values inform our decisions as opposed to it just being the monetary reward itself or the instant gratification. Another metacognitive strategy that I think is very effective that I've learned from my patients and try to practice myself is truth telling. So telling the truth about what we're doing, including about how we're investing, being able to go to our loved ones later and say, I did this with our money is also super important because truth telling probably also activates the prefrontal cortex.

And when that prefrontal cortex is upregulated and activated, it's able to then reregulate the dopamine reward pathway. So I think metacognitive strategies like that, living according to our values, telling the truth and being comfortable, telling other people how and when and where and how much we invested. Those are kinds of metacognitive strategies that engage the prefrontal cortex that I think will help people make better choices. I think that can be pleasurable too, right? Because when we're living, according to our values, we have a certain respect for our moral selves. That feels really good.

Something I've thought about a lot since reading your book is the pain side of the balance. I listened to a podcast yesterday where the guest was talking about people should seek out pain more often and view pain as a bit of a reward. This is a business consultant. So the question for you is, is it possible to seek pleasure through pain?

Yes, it is. It's a whole branch of science called hormesis. Hormesis is Greek for to set in motion. I just love that terminology, because if you think again about the pleasure pain balance, remember when we pressed on the pleasure side, we got all those neuro adaptation gremlins on the pain side. And eventually we end up with a whole bunch of gremlins tilting our balance chronically to the side of pain. So we're in a depressed, anxious and dopamine deficit state.

Well, it turns out that if you press on the pain side of the balance as the initial stimulus, what you do is you trigger your body's own reregulating homeostatic response. You start making more of your own dopamine. You start making more norepinephrine, more serotonin. So in fact, physiologically, it's a great way to get dopamine because it's not from the initial stimulus, it's from the secondary reregulating effect, which is a lot healthier and a lot more enduring because it's not vulnerable to the same tolerance at the same rapid rate as those huge boluses of dopamine that we get when we do something that's immediately intoxicating.

And let me just say, when I say pressing on the pain side of the balance, I'm speaking very broadly here of anything that's effortful. So this could be exercise. It could be an ice cold water bath. It could be doing something that's creative and challenging with the appropriate amount of frustration required. It could be reading a difficult text. It could be forcing yourself to do something that causes you anxiety, or that you're afraid. There's a wide range of things that are painful or hard to do, but what essentially happens is that it helps us build up the mental callouses to be more resilient in the face of future pain. And it also ultimately, leads to more dopamine.

So a lot of people will say that volatility in their portfolios is pain painful. A past guest on our podcast, Dave Goetsch talked about how he recommends people learn to hug volatility, learn to embrace volatility as a way of life. And once you get this framing around volatility, it won't be as painful going forward. Do you have any thoughts about that? Any advice you give to people who view volatility is pain?

So I'm not an economist or I don't have the expertise that you have. So I wouldn't want to say... I don't know what volatility would imply about the investment, but I can certainly say that the idea of embracing and welcoming things that are uncomfortable for us or that we would normally shirk away from is a very Buddhist idea and it's really at the heart of the whole idea of the neuroscience of pain and pleasure. Because when we constantly trying to run away from things that are painful or uncomfortable, trust me, we can never run far enough.

It will always catch up with us, but if we stop and turn and face it, and really kind of just look at it and be curious about it and think of it as an opportunity to learn something about ourselves, learn something about the world, to develop more resilience, because we are building up mental callouses, because we're just tolerating that uncomfortable feeling. That certainly is something that neuroscience would support and something that I've seen in my clinical practice, help build resilience and happiness.

You touched briefly earlier on leisure time. The world's getting better over the last couple hundred years. The world's gotten a lot better, I think, for most people. Is the increase in leisure time a good thing for people?

Great question. I think that we haven't yet figured out how to handle all of the time that we have. So not only are we seeing increases in leisure time. So the average person today has, I think, something like four to five hours of leisure to time per day. 100, 150 years ago, it was more like one or two hours a day. At that time there were people who had no leisure time, right? People who worked 24/7, people who worked and lived in slavery. In 2025 or 2050, we're projected to have even more leisure time or some seven or eight hours of leisure per day.

People talk about the universal basic income. That we would give people an income such that they wouldn't have to work at all and they could have a subsistence living. The problem is that we need to be much more thoughtful about how we're using this leisure time. Because as of right now, it looks like we're mainly using it to consume highly rewarding, feel good drugs and behaviors. One statistic that was really powerful for me is that we've seen an Exodus of young men out of the workforce.

There are fewer young men employed and working today than in many prior generations. And what they're mostly lost to is video games. So we really have this situation where people are working less, but they don't know what to do with that extra time, and many of them are using that time to engage in these highly reinforcing escapist behaviors that ultimately I think will make them very unhappy and that are fundamentally addictive.

So I'm concerned. I'm concerned. Also, we're living longer, right? I mean, the average human lived to about age 30 for most of human existence. Now we're living on average to age 80. So we've got more time on any given day. We've got more days. I'm seeing more and more people in retirement coming in with new onset addiction of all sorts. People who could drink alcohol in moderation through their whole lives, retire, have all this time. And then all of a sudden drinking all day long and then cross that physiologic threshold, get dependent, experience withdrawal are really in full-blown addiction.

And of course the danger there is further that as we age, our brains get less plastic. And so these habits that we're creating later in life, it's harder to undo them. So this is, I think something we need to collectively really think about.

It sounds like the universal basic income idea solves an economic problem, but potentially creates some other pretty significant problems to deal with.

Yes, I think so. When I read the economists, what I find fascinating is that although we have a very serious income gap, there's actually a smaller income gap between rich and poor in rich nations than ever before in human history. Plus even the poorest of the poor have more access to luxury consumer goods than ever before.

So we have this terrible situation where people living in poverty today who are at risk for all kinds of social ills and mental illness, including addiction because of poverty and unemployment are also at increased risk because of the increased access to these highly addictive drugs and behaviors. So I really think that poor people living in rich nations are some of the highest risk people on the planet.

So you mentioned retirement earlier. How should someone preparing for retirement think about what they will do or just think about the extra time they're going to have on their hands. They don't end up in some problematic environment?

The number one message I would want to communicate to people in retirement is for them to recognize that Netflix and social media and other online activities are drugs. That these are addictive and that if we engage too much and too often, we will get into this dopamine deficit state where our drive to use is driven, not by the joy of the behavior itself, but by being in a dopamine deficit state and just trying to get out of those universal symptoms of withdrawal, anxiety, irritability, insomnia, depression.

I really worry about the number of older people, IMC, who are spending enormous amounts of time online, spending less and less time in real life with other people and essentially meeting their many all of their cognitive social, emotional needs through the computer. I think that's really, really dangerous. I mean, all good things in, in moderation. None of it's good, but even in retirement homes now where I go visit, people are not socializing as they used to, because they don't have to. They can be in their little individual honeycombs watching a show and I'm really worried about that.

You mentioned a couple times seeing more retired people as patients. Is it largely social media addiction or is it all kinds that you're seeing?

All kinds of addiction, especially alcohol and cannabis. So what is most prevalent is baby boomers who used alcohol and cannabis in reasonable moderation through most of their adult lives and were able to moderate and handle it. Who then as they age either because they have more time or because something happens in the brain, just like any muscle. The brain also is a type of a muscle that can get tired as we get older and work less well. And so whatever limiting or moderating strategies they had before stop working or don't work as well.

And then that can trip them over into excessive compulsive addictive use. And also keep in mind that all drugs now are more potent. So you've got baby boomers who used 9% THC cannabis in the '70s who are now dabbing percent THC and then they can't figure out why they're miserable and why they can't stop using. So it's all of those things converging at once.

Speaking of convergence, how has the pandemic affected all of this?

Pandemic's been fascinating. I think there's really very much a two populations that I've seen. People who have found that the pandemic and quarantine in particular has been a very positive experience for them and people for whom the pandemic has been during negative in terms of compulsive over consumption. So I've just briefly described that. I have many patients who have told me that the pandemic was just a godsend in terms of reducing triggers. Not going out to the grocery store, to parties, to social events, to dinners, made it so much easier for them to abstain or limit their use because they weren't constantly being a subjected to invitations to use.

I had one patient who said my biggest trigger is actually my car. When I get in my car, I want to drive to the places I usually get drugs and use. And with quarantine, I haven't been in my car in months and it's been such a wonderful respite from craving and triggers for me. So that's been really interesting and fascinating to see. On the other hand, I have a patient population, especially those living in isolation, living alone, who like lost human contact, even basic human touch.

Many of those people found it extremely difficult and some of them relapsed. And then there's a third population of folks who were using in moderation pre-pandemic, and then quarantine found them eating more, drinking more, online more and developing addictions for the first time to think is like food, alcohol and social media.

Just back on the leisure time idea, you mentioned for people retiring to be aware of the fact that social media and Netflix can be addictive. Is there anything else people can do to avoid the negative impacts of too much leisure time? Is hobbies or anything like that, a way to solve that problem?

Yeah. Thanks so much for circling back to that, because I should have said that before that basically, there are a lot of things I think that you can do. First is again, just the awareness that it's very easy to get addicted to stuff we're seeing online as well as more traditional drugs, alcohol, cannabis, and to really limit quantity and frequency. So if you're going to use those drugs, use them intermittently and use them for limited quantities and limited duration so that you give enough time for your pleasure pain balance to restore homeostasis in between use. That's really key.

The second thing is that yes, essentially by engaging in hormesis or things that are hard or challenging as a source of dopamine, that's really the way to go including in retirement. So yes, hobbies, difficult reading, gardening, cooking. Anything that requires effort and anything for which the dopamine is delayed or secondary. Those are the kinds of things that I think really in retirement, we can engage in with impunity. We don't really have to limit those. What we have to be wary of you is those substances and those behaviors that make us instantly feel good. It's okay to use them. Just need to use them in extreme moderation.

Fascinating. Can you describe the relationship between radical honesty and dopamine?

Yeah. So radical honesty is the idea of going through the whole day without telling a single lie about anything. Turns out this is really hard. It's one of the effortful things that we can try to do as a source of Dopamine. And the reason it's hard is because we're all natural liars. The average person tells one and a half fibs per day, and we're just prone to do that. Usually, these are little lies. They're not a big deal. "Oh, I'm sorry. I was late for the meeting. Traffic is bad." Instead of, "Oh, I'm sorry. I was late for the meeting. I wanted five more minutes to drink my coffee and read the paper."

But the thing about lies is, this something that I've learned from my patients and the neuroscience backs it up, is that lying contributes to our tendency to want quick fixes and fast rewards. And telling the truth helps us delay gratification and engages the prefrontal cortex so that we're more able to delay those kinds of rewards. There are a number of interesting experiments which have shown this. So for example, there's an experiment where subjects were asked to engage in a die rolling task where the computer generated the die roll that would lead to a monetary reward. And then the subjects would have to say on their die roll, whether or not they got with the computer said.

People lied. I mean, about 60% of the time they lied and said they got the monetary reward die role instead of what they really got. The researchers knew that because they just compared it against the 50% benchmark that you would expect from the probability of getting that die roll. But then very interestingly, what the researchers did was they used transcranial magnetic stimulation, which is a way of creating an electrical field around the brain to stimulate the parts of the brain with electricity.

And they used TMS, transcranial magnetic stimulation to stimulate the prefrontal cortex. Remember, the prefrontal cortex is a big gray matter right behind the forehead. That is the part of our future planning, delayed gratification, storytelling. And what they found was that when they used this stimulator machine to stimulate prefrontal cortex, patients or subjects who did that same exact die rolling task lied less. So in other words, just by stimulating the prefrontal cortex, they got people to be more truthful, which is really, really interesting.

It led me to hypothesize that if stimulating the prefrontal cortex makes people tell the truth, could telling the truth stimulate the prefrontal cortex? So I asked the neuroscientist, who did that experiment, whether he thought that was possible and he said, he thought it was through this simple idea that what wires together fires together. And it really is consistent with what I've seen with people who get into recovery from addiction, that when they're in good robust recovery, they tell the truth about almost everything or they try to, and that they will endorse truth telling as key to their ability to maintain abstinence and not relapse.

And once they start lying and they get into the lying habit, they're very likely to relapse. Because when people are in their addiction, they're not just lying or drug use, they start lying about everything. I had a patient say to me that when he was in his addiction, if he was at Burger King and a friend called him, he'd say he was at McDonald's. When he was at McDonald's, he'd say he was at Burger King. It didn't even make any sense, but he was just in the lying habit. And so telling the truth I think it's a way to reactivate the prefrontal cortex and allow us to better engage and communicate the prefrontal cortex to the reward pathway.

As you're talking just now, I started to wonder something. Is there a relationship between pain and activating the prefrontal cortex?

Yeah. It's a great question. I think the way to think about this is that when our reigns are functioning in a healthy way, the prefrontal cortex is communicating actively with our dopamine reward pathway. And what happens in addiction is that we essentially cut off that communication and our dopamine reward pathway just basically gets a life of its own and it's reflexively doing its pleasure pain thing. So if we force ourselves to willfully do things that are hard and press on the pain side of the balance, already right there, we're engaging the prefrontal cortex because we're going against the natural impulse, which is to just do things that are pleasurable and avoid pain.

Remember, we have evolved over millions of years to approach pleasure and avoid pain and it's what kept us alive in a world of scarcity and ever present danger. The problem is that we don't live in that world. We live in this world of overwhelming abundance. So we really have to consciously and with intention recreate a world of scarcity and a world of danger. And we can do that by intentionally doing things that are hard, doing things that are painful, and I do think that that then allows our prefrontal cortex to reactivate and reengage with those dopamine reward pathways. Also, it's a good source of Dopamine.

A question back to radical honesty, I'm curious how you think it might extend to how parents talk to their kids about things like the household finances.

Yeah. So I'm really into what I'll call transparent parenting. I think that we can think as parents, that if we present ourselves as morally perfect and good that we will then serve as role models for our kids. Bu I don't think that really works. I think instead our kids are going to learn from our mistakes and we're much better off being transparent about our own foibles, flaws, errors and just general so that they know they're not the only one and that they feel that the family unit is a place where they can bring those struggles. I think that applies equally well to financial struggles or financial worries. I also think it's really good early on to talk to kids and give them an education about finances.

When I was raised, I didn't get that and I came into adulthood, really knowing nothing about money or how to manage it. I had an intuitive sense, but just because of my beliefs about truth telling and parenting and transparent parenting, I do think that it's very, very good to let kids in early, not just with your financial successes, but also your financial failures and what went wrong. We have done that with our children, gotten them going early with their own money that they need to be responsible for that they can invest and lose without coming to rescue them if that's what's going to happen. And just being honest about the struggles that we all face and feel about finances.

Can a little bit of shame be a good thing to avoid unwanted behaviors?

So shame is fundamentally our strongest pro social emotion. It actually is the fundamental social emotion. We experience shame when we do something that is not consistent with group norms and shame comes as a powerful gut punch of an emotion and a huge amount of fear that we will be shunned from our tribe. So I think that an appropriate amount of shame is really positive and really good as long as it's not excessive and as long as the person who is shamed has a pathway for redemption.

So for example, in raising children, I think it's important to let kids know when they have erred and when they have done something that they should be ashamed of. It doesn't mean wagging your finger at them and making them feel like dirt, but it certainly means acknowledging, "Hey, this was the wrong thing." Or they'll come back and they'll say, "Oh, the co coach said this to me about being late." Or my teacher said this to me about this assignment. It's like, well, sounds like you're too was right. You were late for practice or it doesn't look like you put much effort into that assignment. So really validating what's true and real about the source of the shame while at the same time, trying to create a solution based pathway for that person to do better next time.

We talked about spending being potentially addictive earlier, which can often be a source of frustration or disagreement in relationships with spouses. Where would the balance be between pro-social shame and destructive shame. If a couple has agreed, like, hey, you're going to stop spending on whatever something is. Where a balance?

Well, I mean, I think the couple has agreed is the key point there. If the couple has come together and made an agreement about how they're going to spend their money and then a person in that couple deviates from that agreement, that person should feel shame simply from deviating from the agreed upon contract. If that person wants to renegotiate the agreed upon contract, okay, that's something different, but the trust is broken when we promise to do something and then we break that promise. One of the experiments I talk about in my book is the Stanford marshmallow experiment and how these kids were given a marshmallow and told, "Hey, if you can wait in this room for 15 minutes without even the first marshmallow, we'll give you a second marshmallow."

What they found is that the older the kid was, the more likely they could delay gratification for a second marshmallow. And then some kids were just better at it than others. But a very interesting twist on this experiment was they told some kids, if you ring that bell, I'll come back in before the 15 minutes is over. And for some of those kids, when they rang the bell, they went back in and for another set of those kids, when they rang the bell, they didn't go back in. So they lied to those kids. Those kids were less likely to be able to wait the full 15 minutes than the kids who were told the truth.

So in other words, when people lie to us, it creates a sense of scarcity, even in the absence of scarcity, which then makes us favor short term rewards. So if you have a couple lying to each other or one person deviating from an agreed upon contract, I would not be at all surprised then if the other spouse goes out and spends a bunch of money on something else, right? Because it's this sense of scarcity. I can't trust the world and other people to be the place that I thought it was going to be or for that person to do what they said they were we're going to do.

And then that feeds right into craving and our desire for our own immediate gratification, which is really important because we are living in this place of overwhelming abundance here in the United States and yet so many people feel a sense of scarcity. I think it has to do with the lying. All of the lying. People feel they can't rely on other and they can't rely on the world. So if we could just tell the truth, then maybe people would feel better about not instantly gratifying their desires.

Wow. Speaking of scarcity, it's too bad we're out of time. I'm sure Ben and I could ask you questions all afternoon, but we've come to our final one of our favorite questions, which is Anna, how do you success in your life?

I define success mostly around trying to be the best parent that I can be. And then I would say on a deeper philosophical level and trying to be a good doctor too. My patients are kind of like my kids. And then every day, I try to seek a way of being in the world that allows me to forget about me and see it as not about me, but as about trying to do some good in the world, that really isn't even from me, but is from some deeper life force. A good force in the world that I think we can all tap been to. That is how I define success.

Wow. What a beautiful answer. This has been a great hour. Anna, thanks so much. I'm so happy that you agreed to join us. This has been an incredibly, it's safe to say important conversation. So thank you.

Oh, well thank you. You're you're very welcome. It's been a joy for me. You've had great questions.

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