Parwy's Blog: The Dopamine Expert - The Diary of a CEO with Dr Anna Lembke

Dr Anna Lembke is Professor of Psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She is the author of bestselling books such as, ‘Dopamine Nation: Finding Balance in the Age of Indulgence’

Dopamine: The Survival and Motivation Chemical

Dopamine is a chemical produced in the brain that is fundamental to survival because it tells us what to approach, explore, and investigate, functioning almost as the "survival chemical".
One of dopamine's most important functions is helping us experience pleasure, reward, and motivation, potentially being even more crucial for motivation than for pleasure itself.
A famous experiment with rats showed that those engineered to have no dopamine in the brain's reward pathway would eat food if it was placed directly in their mouth, but would starve to death if the food was even a body length away, illustrating that dopamine is necessary to be motivated to do the work to seek things required for survival.
Dopamine is not inherently good or bad; it acts as a signal regarding whether a behaviour is potentially useful for survival and is related to how rewarding or pleasurable something is predicted to be.
Dopamine is fundamental for movement, not just pleasure and reward. For instance, Parkinson's disease, associated with stiffness and tremor, is caused by a depletion of dopamine in the substantia nigra, leading to the loss of the ability to move the body.
Most organisms must locomote toward the object of their desire, exerting effort to obtain rewards, which is likely why the neurotransmitter important for motivation is also crucial for movement.

The Pleasure-Pain Balance and Neuroadaptation

A key finding in neuroscience is that the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance.
The brain has a fundamental drive for homeostasis (a level balance), and it does not want to be tilted for long to the side of either pleasure or pain.
When a highly pleasurable stimulus (like alcohol or drugs) presses on the pleasure side, the brain immediately works to compensate by downregulating dopamine transmission (e.g., by removing postsynaptic dopamine receptors, which act like docking stations for dopamine).
This neuroadaptation process overshoots the level balance and tilts the balance to the side of pain. This deficit state is what is experienced as a hangover or "come down".
The evolutionary reason for this overshoot is hypothesised to be a mechanism to ensure we are never satisfied with what we have, making us "the ultimate Seekers" who are always motivated to pursue more.

The Mismatch Between Ancient Scarcity and Modern Abundance

Humans were evolved to have to do quite a lot of upfront work for a tiny reward, in a world characterised by scarcity, hunger, loneliness, and tiredness.
In the modern world, we have overwhelming overabundance and easy access to "synthetic" rewards (e.g., swiping right, pornography, sugar, video games) that release a lot of dopamine all at once.
This creates a mismatch where our evolutionary wiring is overwhelmed by these potent, easily accessible rewards, leading to the overwhelming of our reward system and our brains "reeling in response".
In this modern context, we are wired to be addicted, or at least prone to addiction, because the brain relentlessly pursues pleasure in a world where pleasure is ubiquitous.

The Development of Addiction

The genetic risk of addiction is high, estimated to be 50% to 60%.
An addictive substance is more likely to be addictive if it releases more dopamine and releases it faster in a given individual's reward pathway. This is related to a "drug of choice" sensitivity.
Continued compulsive use of a substance or behaviour despite harm to self and/or others is the broad definition of addiction. Harm can be subtle, and people are often poor judges of harm when chasing dopamine.
In addiction, the constant bombardment of pleasure causes the "Gremlins on the pain side" to become camped out there permanently, shifting the hedonic (joy) set point to the side of pain.
An addicted person needs more and more of their drug in more potent forms just to level the balance and feel normal, not to feel high or good.
When an addicted person is not using, they walk around with a balance tilted toward the side of pain, experiencing universal symptoms of withdrawal: anxiety, irritability, insomnia, depression, and craving.
Substances and addictive behaviours, reached for to self-medicate psychiatric problems, are ultimately not medicinal and make psychiatric problems worse over time.
Severe addiction is a state where the brain has been hijacked, and the individual confuses the drug (or addictive behaviour) as necessary for survival, leading them to sacrifice loved ones, jobs, and homes in its pursuit.
Trauma and severe life stressors can trigger relapse, as the brain, once it discovers a drug that releases a lot of dopamine, will tell the person to run back to that drug when under stress. Everyday stressors, encapsulated by the acronym H.A.L.T. (Hungry, Angry, Lonely, Tired), can also trigger drug use.

The Impact of Specific Addictions

Pornography and Erotic Novels: Romance novels can function as "socially sanctioned pornography for women", with the narrative itself being the powerful drug. Pornography, or similar erotic material, is engineered to be highly potent, causing individuals to develop tolerance and seek increasingly graphic content. Pornography addiction is seen as one of the biggest, most silent, and most shameful addictions in the modern world. It risks giving young people a distorted view of sex and relationships, and can lower men's motivation to pursue real-world goals (like career or forming intimate relationships), as the smartphone has become a "masturbation machine" meeting physical and emotional needs through technology.
Digital Media: Digital devices and platforms are designed to be addictive, lighting up the same reward pathway as drugs and alcohol to keep users scrolling long beyond what is planned or pleasurable. Irritability, anxiety, inattention, insomnia, and restlessness can be early signals that digital consumption has crossed into the addiction range.
Work: Work can become an addiction, especially because it is now "drug-ified"—made more potent (e.g., bonuses, fame, social media validation), more novel, and more accessible (24/7 access). Workaholics receive cultural reinforcement and praise (e.g., trophies, awards) for their addictive behaviour.
Sugar: Sugar is addictive and releases dopamine in the reward pathway. Abstaining from sugar leads to a two-week period of intense withdrawal and craving before the craving gradually subsides.
Cannabis: Cannabis is very addictive and harmful, primarily to the brain. It often demotivates people and can lead to psychological withdrawal symptoms (anxiety, irritability, depression, insomnia, craving), and in some cases, the hyperemesis syndrome (cyclical vomiting).

The Physical and Cultural Softening

As a consequence of modern life, we have individually and collectively reset our reward pathways to the side of pain because we are so insulated from pain and exposed to so much pleasure.
This leads to a physiological problem where we lack the mental calluses to tolerate pain, meaning the slightest discomfort feels excruciating.
Modern culture reinforces this by suggesting that we should never be in pain and that pain signifies something is wrong (the "trauma society"), making the current generation less resilient.

The Virtue of Personal Responsibility

The way people tell their personal stories is a marker and predictor of mental health.
Victim narratives (seeing oneself as always a victim of others and circumstance) are unhealthy, as they act as a "road map for the future" and literally lead individuals to create victimhood for themselves.
When people with severe addiction enter recovery, a key change is shifting their narrative from blaming others to taking responsibility for their actions and contributions to the problem.
Taking personal responsibility is difficult because we fear the shame associated with it; we prefer to "paper over that shame with anger and resentment toward others".
For those who struggle to accept responsibility, the approach should be to validate their victimhood or trauma first, but then move to the essential question: "Is there anything that I did that contributed to that problem?". Therapy that stops at validation without moving to responsibility can keep people stuck.
A fixed narrative or identity (even a hero's journey) can become a trap, walling one off from the fullness of who they are and causing internal dissonance.

Pathways to Recovery and Balance

Self-binding is necessary because relying on willpower alone is insufficient in a "drug-ified" world. This involves creating both literal physical barriers (e.g., locking up devices, removing substances from the house) and mental barriers between oneself and the drug of choice.
The Dopamine Fast: After honestly assessing the problem behaviour (step one) and listing the harms and conflicts with one's goals (step two), a 30-day fast from the addictive substance/behaviour is recommended.
The purpose of the 30-day fast is to allow time for the brain to move out of the two-week acute withdrawal (dopamine deficit state) and for the Gremlins to hop off the pain side, restoring homeostasis and getting out of the constant state of craving.
Seeking Out Pain and Hardship: The opposite of seeking easy pleasure is intentionally pressing on the pain side of the balance (e.g., exercise, ice cold water baths, intermittent fasting). This causes Gremlins to hop on the pleasure side, leading to a gradual rise in dopamine levels that remain elevated for hours without the subsequent crash/deficit state, making it less vulnerable to compulsive craving.
Be Present and Embrace Discomfort: Rather than living life predicated on the feelgood reward moment, one must learn to be present in the moment and be okay with being uncomfortable, restless, or anxious. Allowing oneself to feel pain, without running from it, is key to finding relief and freedom.
Understanding Personal Impact: Doing an experiment, like the 30-day fast, is crucial because when one is "in the behavior," it is difficult to see the true cause and effect of how the addiction is causing anxiety, depression, and insomnia.

The Social and Ethical Implications of Addiction

Codependency is a phenomenon where loved ones of an addicted person unknowingly enable the addiction, often by becoming addicted to the addicted person and using them to regulate their own feelings (e.g., getting to be the martyr or savior).
Sometimes, withdrawing help (even if it feels harsh) is the only way to allow the addicted person to hit the "rock bottom" consequence necessary to motivate change, as helping can prop up compulsive behaviour.
The most common path to recovery involves confronting real-life negative consequences (e.g., losing a job or partner).
When approaching someone struggling, one must maintain empathy while recognizing that their addiction might require them to face consequences; trying to protect them from negative consequences is not helping them.
In severe cases, especially involving life-threatening withdrawal (e.g., from alcohol or benzodiazepines), professional help and medical detoxification are required before attempting abstinence.

Dopamine's Role in Brain Development and Modernity

If a child is exposed to addictive maladaptive coping (e.g., with digital media, sugar, or drugs) at a young age, they elaborate a neural circuitry based on that coping, which sets them up for addiction in adulthood.
However, the child and adolescent brain is highly plastic and changeable, meaning that if an intervention happens early, rewiring is possible.
The current seamless integration of technology is leading to a future where we will become "cyborgs" or be invisiblely interfaced with technology. The fear is that this will further isolate humans and reduce the incentive structure to engage in physical being and real-world connection.

00:00:00 Intro
00:03:44 Why Does Dopamine Matter?
00:04:08 What Is Dopamine?
00:05:35 How Understanding Dopamine Can Improve Your Life
00:06:09 Biggest Misconceptions About Dopamine
00:07:30 Everyday Activities That Impact Dopamine
00:09:36 Dopamine and Its Relationship to Pleasure and Pain
00:18:26 Why Do Our Brains Overshoot?
00:20:31 How Our Brains Are Wired for Addiction
00:25:22 Finding Ways to Deal With Pain
00:31:51 Stories of Addiction
00:34:52 How Many People Have Addiction Disorders?
00:40:14 Hiding Away From Friends and Family
00:41:21 Distinguishing Between Good and Bad Behaviors
00:45:50 How Addiction Makes You Feel
00:47:50 Is Work an Addiction?
00:54:18 What Activities Provide the Biggest Dopamine Hits?
00:58:59 Can We Inject or Drink Dopamine?
01:01:00 Why We Must Do Hard Things
01:02:37 Can You Get an Exercise Comedown?
01:04:19 How to Optimize for a Better Life
01:05:17 How Should We Be Living?
01:09:29 Being Comfortable With the Uncomfortable
01:10:34 Causes of Anxiety Throughout Life
01:12:43 Living in a World Where It's Easy to Outrun Pain
01:13:09 Where Are You Now in Your Grieving Journey?
01:14:43 Youngest Child Seen With Addictions
01:15:37 Youngest Age When Addiction Can Have an Effect
01:16:50 Youngest Patient With Addiction
01:18:40 Has Society Gone Soft?
01:21:05 Victimhood and Responsibility
01:25:02 How to Help Someone Overcome a Victimhood Mentality
01:28:36 Connection Between Responsibility and Self-Esteem
01:30:13 Importance of Our Self-Narrative
01:37:24 Ads
01:38:22 How Helping a Loved One Too Much Can Hurt Them
01:44:49 Overcoming Pornography Addiction
01:48:35 Harms of Watching Porn
01:51:04 Is Dopamine Responsible for Sugar Cravings?
01:53:05 Turning Addictions Around
01:58:25 Why We Bounce Back to Cravings After Relapsing
02:02:49 Effects of Early Exposure to Addictive Substances on Children
02:04:43 Final Thoughts on Overcoming Addiction
02:05:39 Closing Remarks
02:07:38 What Information Changed Your Life?