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January 16, 2025 55 mins

This week Scott is joined by Stanford Psychiatrist and addiction expert, Dr. Anna Lembke. Scott and Dr. Lembke discuss how to reset your dopamine system to take back control of your life and turn the things that you really want into their own reward.

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Speaker 1 (00:00):
Anything that we experience as reinforcing releases dope mean in
our brain's reward pathway. Some of those things released dope
mean 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 indigenous GABBA system and

(00:21):
then ultimately releases dope mean in the reward pathway, or
sex which works on our seratonergic system also our indogenous
opioid system and ultimately releases dope mean. So we're all
wired a little bit differently, and what may release a
lot of dope mean in your brain may not release
as much dop mean in my brain. And advice VERSA.

Speaker 2 (00:48):
Happy new year and welcome to the twenty twenty five
season of The Psychology Podcast. I'm doctor 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

(01:11):
psychiatrist and addiction expert doctor Anna Lemke on the show.
Doctor Lempke's latest book, which is the main topic of
discussion for today, is called Dopamine Nation, Finding Balance in
the Age of Indulgence. This book is very timely. Dopamine
is a transmitter that affects our motivation, exploration, and our pleasure.
While dopamine is not the pleasure molecule necessarily, it is

(01:34):
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 doctor Lemke's research for helping
you do a dopamine reset and take control over your
life and what you actually want to be rewarding. So,

(01:57):
without further ado, I bring you doctor Anna lem Hey,
doctor Lemke, welcome to the Psychology Podcast.

Speaker 1 (02:04):
Thank you for inviting me. I'm excited to be here.

Speaker 2 (02:07):
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
drives quite literally drives so much of our lives. Dopamine
of course, is what I'm referring to. You know, I
was wondering if we could just start off with you

(02:28):
giving me the most succinct and accurate definition of what
in the world dope mean is for.

Speaker 1 (02:39):
You know, I think the shortest way to describe it
is that dope mean 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,

(03:01):
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 lions den was, and a lot
of the purpose of our existence is essentially taking in novelty,
metabolizing it, so to speak, making sense of it, and

(03:24):
then using that information to inform our next steps. And
dopemine 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.

Speaker 2 (03:43):
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 had
been able to operate on evolutionary mechanisms more than other things.
So for some reason, for well, for that, for that reason,
things like sex, uh, well we didn't have money, you know,

(04:07):
back then, but just what the whole concept of money,
you know, and and power are things that were The
things we call competitive 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

(04:30):
the prefontal cortex. So we could talk about that later.
But it seems like from evolutionary point of view, is
that is that right? Is that? Is that? Is that
a fair statement that there are certain things that are
just more captivating to our dopamine system because of our
evolutionary systems.

Speaker 1 (04:43):
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 the things release dopamine directly,
like cocaine or methamphetamines. Some of those things work through

(05:07):
a complex chemical cascade, like alcohol which works on our
endogenous opioid system or indogenous GABBA system and then ultimately
releases dope mean in the reward pathway, or sex which
which works on our serotonergic system also our indogenous opioid
system and ultimately releases dope mean. So you've got both

(05:28):
proximal and distant levers contributing to the release and how
much of dope mean in our dedicated reward pathway. And
then on top of that, you have enormous interindividual variability,
so we're all wired a little bit differently, and what
may release a lot of dope mean in your brain

(05:50):
may not release as much dop mean 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

(06:13):
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 dope me in the reward pathway,
and I could you know, it makes sense that you

(06:33):
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

(06:57):
they tend to release a whole lot of dope mean
very quickly, whereas things that release dope mean that tend
to be less addictive are things that release less dope
mean more slowly and often require more upfront effort to
get them.

Speaker 2 (07:15):
Yes, thank you for that. And I think that it's
worth mentioning explicitly that there's a basic consensus in the
field that dope means more about wanting than liking, because
I think a lot of people will say they'll see
things in the media like the pleasure molecule, you know,
as characterized as that, and that that's not quite right right.

Speaker 1 (07:35):
So there is controversy around this, But the way that
I would describe it is that dope mean 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

(07:56):
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

(08:23):
or like the initial exposure, 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

(08:46):
our seeking mechanism is propelled primarily by wanting and primarily
dopaine is then primarily mediating motivation rather than pleasure or liking.
But it must us to begin with salience, some degree
of pleasure, some Oh, yes, this is something that felt

(09:06):
good and I want to do it. I'd like to
do it again. If that makes any sense.

Speaker 2 (09:14):
It makes tons of sense. And what I see quite
often is not just pleasure, but I see Hope's 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 a continual pleasure
in the future, even if you're no longer receiving that
pleasure at a certain point. And so it's quite a

(09:36):
paradox go balkst, isn't it, Because on the one hand,
it's the thing that keeps us going. It's a thing
that gets us out of bed in the morning. Yes,
if we didn't have any dopamine production, you know, as
as some disorders, right, we see what happens. You know,
there's a rate with lethargy, you know, lack of motivation.

(09:58):
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 maybe never even served
our growth, because there's a differencing pleasure and meaning, right.

Speaker 1 (10:11):
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 deeply in

(10:34):
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

(11:00):
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 youphic recall, where we're now

(11:22):
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

(11:46):
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

(12:09):
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
dopening levels because of exposing our brains to these high
rewards over time. And then there are other forms of

(12:32):
psychopathology characterized by abnormalities in dopamine levels.

Speaker 2 (12:38):
Yeah, I was thinking Parkinson's disease.

Speaker 1 (12:40):
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 substantial niagra, not
in the reward pathway itself, which gets very complicated in
terms of the treatment of Parkinson's because what we give
is dope mean precursors. We don't give dopamine because dopamine

(13:02):
itself cannot cross the blood brain barrier. So we give
these dopamine precursors that get converted to dopamine in the
brain and then bind to dopamine receptors in the substantial
nigro which allow for a more 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

(13:26):
dopeminergic 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 Parkinsons will actually end
up with a compulsive shopping disorder or a compulsive sex

(13:48):
to pornography and masturbation disorder. And these disorders tend to
be dose dependent, So when the dopamine precursor has stopped,
the symptoms not in all cases, but most often tend
to get better or resolve.

Speaker 2 (14:03):
Well. I love that you you brought in that nuance
that there I mean, there are different pathways in the
brain where dope mean sense its projections, and I think
one of the one of the projection routes that a
lot of that's not as often discussed as the one
to the dorsalato or prefont to cortex. Right, it's not
it's not all being sent to the like the straatum. Right.

(14:24):
So so in that sense, you know, as a cognitive
scientist by the way, who studied intelligence and working memory,
I don't think we realize the extent to which dope
mean also plays a role in our working memory and
how some people have genes. I mean, we can really
nerd out here d r D for there are certain
genes that that uh, for certain individuals from an individual
difference perspective, too much dope mean influx in the prefilt

(14:48):
the cortex can cause them to have reduced working memory capacity.
And I find that super super interesting. There seems to
be like an optimal balance there.

Speaker 1 (14:55):
That is really interesting. I don't know much about that.
Tell me more.

Speaker 2 (14:58):
There is uh, you know, there are certain genes that
encode for for how much you know there's going to
be a natural sort of projection of dopamine to certain
brain areas. But the one in our higher order of
courts see is like our prefront our dorsal dorsal area
or pre prefunt the cortex. There is an interesting relationship
between dopamine production and the ability to you know, for instance,

(15:18):
ADHD is relevant here, right, you know, being able to concentrate,
being able to focus, being able to hold multiple pieces
of information in your in your cognition at once. And
I only bring this up as just just to explain
and to and for just purpose of discussion that we're
not when we talked about dopamine. It has far reaching
consequences across the brain, and we're not just talking about

(15:39):
sex and druss.

Speaker 1 (15:41):
Right, Yes, great, great point. And 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 real expertise, but what I do know is

(16:06):
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 a priori
to get any kind of reward response at all, which

(16:26):
may go some way into explaining the kind of impulsivity
that's often associated with ADHD, impulsivity being difficulty putting the
breaks between a thought or desire to do something and
actually doing it because they're in an embodied way experiencing

(16:46):
the stimulus differently than people who don't have ADHD. So
I think those types of findings are really interesting.

Speaker 2 (16:55):
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 apipenia everywhere, and so there

(17:15):
seems to be like an a level for creativity as well.
And that's just my own area of research, is a
link between creativity and mental illness.

Speaker 1 (17:23):
And 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 psychopathology, but we could equally well conceptualize that

(17:44):
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 those symptoms, those symptoms tend to reduce.
So we infer from that that don't meine is involved

(18:07):
in this experience of hearing voices other people don't hear,
seeing things that other people don't don't see, you know,
which we have organized into this this bucket we call
schizophrenicform disorders. But it's all very interesting.

Speaker 2 (18:28):
Yeah, it just it just shows the pervasiveness of this
molecule in our lives and far reaching about you know,
almost every aspect of our lives. You can find it
playing some role. And as your your your subtitle of
your book notes, it's important to find balance in this
age of indulgence, and your book is all about the balance.

(18:49):
It's not about living a life of pure pleasure or
living a life of pure pain, right, It's about a
little a little of both. There's one finding in your
book that really I fell off my chair and I
just had to I just I can't stop thinking about it.

Speaker 1 (19:05):
Okay, I'm excited to hear.

Speaker 2 (19:08):
And yeah, so it seems like peak dopamine production. Peak
is when you've had you know, this work, this prior
learning experience of pleasure, but you start to get to
the point where it's about fifty to fifty uncertainty whether
or not it's going to be pain or pleasure if
you get to this maximumster And now, obviously like gambling
and casinos, Vegas gets that. But we're not just talking

(19:31):
about gambling, we're talking about anything, and that is so
interesting to me. Could you explain that finding a little
bit more.

Speaker 1 (19:37):
Yeah, So, this was a study that was done comparing
pathological gamblers 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

(19:58):
they measured dopamine firing when pathological gamblers won at gambling
and compared that to when non pathological gamblers, what we'll
call moderate, non risky or healthy gamblers, just recreational gamblers.
And what they found was that with winning in a

(20:18):
game that required that it included uncertainty and risk and
monetary reward, the potential for a monetary award was that
with winning, both pathological gamblers and recreational gamblers had increased
dopemin firing, but with losing. Recreational gamblers did not have

(20:42):
an increase in dope mean, 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 chain, where they
actually want to lose because losing justifies in their minds

(21:06):
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 and dopamine release
was when there was an equal chance of winning and losing,

(21:27):
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

(21:50):
efforts in our lives to kind of try to control
the outcome and control our experience.

Speaker 2 (21:57):
It's so fascinating. Obviously, there's some thing unique about humans
and other animals in the way dopamine plays out. One
of my heroes, intellectually heroes, Robert Sapolski, 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.

Speaker 1 (22:20):
Well, you know who knows? I don't know. I mean,
the more the more 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

(22:43):
in France who did rig up this contraption where mice,
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

(23:06):
saw the selfie and with repeated use, even when the
even when the sugar water was stopped, the rats compulsively
pressed 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 for.

Speaker 2 (23:25):
Too, if they could conceptually understand. Yeah, think think that through. Perhaps,
you know, we talked about individually. 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

(23:46):
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 falling all over him, but he keeps all
of them at this sort of fifty percent uncertainty and
he drives them crazy. Now there's this archetype of this guy.

(24:07):
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 them, And you can see
it with codependency relationships. Perhaps, so am I making any sense?
Does this? Can we link this?

Speaker 1 (24:20):
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 onto the next person.
We also see people clinically who are in addictive relationships,

(24:45):
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

(25:09):
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 the term
codependency originates from the addiction world right where you have

(25:34):
the person who's the addict, and then you have their
codependent loved one who is trying, 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

(25:55):
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 engage
with that person as a way to try to predict
and control their emotions. So the evil we know is

(26:17):
better than the good that seems out of reach. That
kind of thing. There's also speculation that domestic violence is
related to dope mean release right right, The kind of
uncertainty of knowing if your partner will lash out, and
then the pain when they do, followed by the making

(26:40):
it up afterwards. This whole cycle can become for some
individuals reinforcing and quite addictive, and is probably mediated by dopamins.
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 me itself has distilled human

(27:02):
relationships down into their most addictive components. So we know that,
for example, oxytocin, the love hormone, is released 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

(27:23):
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 surprise is there.
But social media has essentially again distilled human connection down
to its most addictive components, where for very little upfront work,

(27:45):
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

(28:05):
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

(28:26):
keep looking for other people. So there's you know, there
are ways in which the medium itself really does contribute
to compulsive, addictive orientation on human relationships.

Speaker 2 (28:40):
Oh for sure. And I'm really glad that you bring
that up, and you talk about that about that a
lot in the section of your book. The problem we
talk about, you know, over consumption and the kind of
society living in. So let's talk about let's get out
of the darkness 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 in

(29:01):
the book Self Binding with really, you know, good advice,
and I thought it was really clever. Part of your
advice was you would go through you go through each
other acronym. It's dopamine. You turn out, you turned dopamine
into an acronym, right, right, So could do you mind
if we go through that a little bit?

Speaker 1 (29:16):
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

(29:36):
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

(29:57):
of mild to moderate forms of 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,

(30:22):
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 constitutes heavy
necessarily for a given individual, but you know, you have
a sort of a good shelt of like, oh gosh,
this person's repeatedly staying up till one, two three in

(30:42):
the morning, waking and 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? Raadly speaking, people use
for one of two reasons to have fun or to

(31:03):
solve a problem. Importantly, what starts out is fun and adaptive.
Often with repeated use becomes not fun and not problem solving.
But we'll get to the next letter, which is the P,
which refers to problems related to use. And this is
where we just asked them talk about what are the physical, mental, relationship, work, school, psychological,

(31:28):
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 abstinence and asceticism.
Abstinence is where we ask them to do a thirty

(31:49):
day dopamine fast from their drug of choice. So with
a sex addiction, that means no orgasms with yourself or
others for thirty days. Somebody, 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

(32:10):
you could go without. But that is the ask. We
always want people that they're going to feel worse before
they feel better, because they're going to be in withdrawal,
but that the bad feelings, the universal symptoms of withdrawal, anxiety, irritability, insomnia, depression,
and craving are they peak within about ten to fourteen days,
and then they tend to get better, and people can

(32:32):
make it the full thirty days, they find that they
feel so much better, not just better than they did
when they were going to keete 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

(32:54):
for that, the day will never come. We have to
have them experience, in an bodied 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

(33:15):
important to emphasize that, and I think especially in mentalhealth,
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's not going
to come. You just have to you have to try

(33:38):
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 we know, for example, that exercise

(33:58):
is immediately taught sick to cells, but we also know
this 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 up regulates feel good
neurotransmitters like dopamine, and then those dopamine levels will stay
elevated even hours after we stop exercise, before coming back

(34:21):
down to baseline levels without going into that dopamine deficit state.
That set that 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 asset of SIMS is leaning into right sized
pain in order to upregulate dopamine levels. And let me

(34:42):
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.

Speaker 2 (35:02):
I know a lot of It's interesting because I know
a lot of people who are addicted exercise. Yes, yeah,
so it can go the other direction.

Speaker 1 (35:09):
It definitely can that that is a danger. We sometimes
see that people with exercise addiction don't 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.

(35:32):
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 leader boards and other social media sites. People are
counting themselves and counting their heart rates and their steps,
and you know, down to the micro how hard they're working.

(35:53):
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 unfortunately unfortunate.

Speaker 2 (36:12):
Did you go through all the acronymics, Oh?

Speaker 1 (36:13):
Sorry, yes, thanks, So the am stance 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

(36:34):
when we give up our drug of choice that we
usually use to numb our feelings, 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 eye 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

(36:57):
knowledge that's impossible to acquire any other way. It is
experiential knowledge. The end 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,

(37:18):
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 exactly what they will look
that will 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

(37:39):
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.

(38:01):
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
try another discussion, another intervention. So it's an iterative process.

Speaker 2 (38:20):
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 I'm sure you've seen it all.

Speaker 1 (38:29):
You know. That's 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.

Speaker 2 (38:36):
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's it's so interesting the way the way doping can
can kind of manifest itself in modern to humans, you know,
and a whole variety of different things. And one thing

(38:58):
that I'm not sure I fully understand and yet as
a psychologist is what the threshold is for addiction, what
counts as addiction and what counts as just dopea mein
coursing through your system. And there's so much heated debates.
I go to psychological conferences where some people are adamant
there's no such thing as sex addiction. There's a whole

(39:20):
group of sex therapists who are well respected, who really
believe No, it's just a compulsion. But then I'm getting
all confused. I'm like, then, what's a compul what's the
difference soon a compulsion and an addiction? I mean, I'm
a psychologist twenty years of experience, I still don't fully
wrap my head around around all these distinctions. Can you
help us shed some light on some of these distinctions

(39:42):
for me? Sure?

Speaker 1 (39:44):
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 repeat themselves across individuals,
time periods, geographic locations. Inherent. The definition of addiction is
the continued compulsive use of a substance or behavior despite

(40:06):
harm to self and or others, often constituted by the
three c's, 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

(40:28):
of automaticity around initiating drug use even when we planned
not to. So again, some'm a 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 notion that every

(40:51):
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

(41:13):
the behavioral definitions of 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 are
going to think about sex addiction, very often, what we'll

(41:36):
see clinically as people who start out with kind of
vanilla 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,

(42:01):
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,

(42:26):
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
it 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

(42:48):
they're withdrawing, they have hyper arousal. 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 of the opposite. Again, the universal finems
of withdrawal from any addictive substance or anxiety or ability,
and so depression and craving. And for behavioral addictions, we

(43:12):
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,

(43:34):
and as they will have nausea, they will have hyperventilation.
So it's it can be you know, the mind and
body are so connective, of course it's going to be physical.
So yeah, so that that's how you diagnose it. You know,
at the end of the day, sitting around sort of
splitting hairs. Is this a you know, is this OCD?

(43:54):
Is this an eating disorder? Is this an addictive disorder?

Speaker 2 (43:58):
Helping people?

Speaker 1 (43:59):
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 to
understand these behaviors and we use an intervention that is
an addiction intervention, people get better. And it's not gonna

(44:20):
We're not going to 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,

(44:42):
but it works for enough people that it seems to
me quite valid to use that addiction lens.

Speaker 2 (44:48):
Well, thank you. It's I mean, 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 that the flow state of consciousness itself can
become very I personally love getting fully engaged and absorbed
in my work and it's a it's a wonderful feeling.
I can't just snap my fingers and get into it.

(45:09):
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 is some of
the people who were addicted described that they lost track
of time. Some of the things that they said seemed
to seem to reflect that flow state of consciousness that
we can apply towards maybe more healthier pursuits. But it

(45:32):
just made me think philosophically a lot about I wanted to.
I want to just like step up a second, you know,
a 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 uh destroy, you know, like negativity towards harm,
harm towards yourself and others. You can have a compulsion

(45:54):
and not have harm. Right, 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

(46:16):
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 check 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 like ruining my life, and
it's bringing people joy. So I guess I'm really having

(46:37):
a hard time articulating what exactly my point is, but
it's something I just wanted to like talk through with
you because I'm so I'm such a non judgmental person,
and I feel like what brings one person flow and passion? Well,
you know what's the difference between passion and addiction? You know, Like,
don't we want people to be passionate about what they do?

(47:01):
Am I making any sense at all?

Speaker 1 (47:02):
Does?

Speaker 2 (47:02):
Yes?

Speaker 1 (47:03):
And I think I think it's 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 if somebody has certain sexual preferences that
you know may not fall into whatever you know, we

(47:27):
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 withdraw when I stop.

(47:51):
So I think that's really important to make that distinction.
You know, I'm not saying that anybody uses pornography as addictive,
or anybody who makes pornography as 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. Okay, let's talk about what's going

(48:16):
on there now. Your other question, or the related question, was, well,
how do we distinguish between an addiction and a passion? Right,
something that's a passionate hobbyer that I'm thinking a lot about.
You know, 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

(48:38):
world in a positive 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 you're mad. Passion for mad

(49:00):
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 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,

(49:22):
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,

(49:43):
such that even something seemingly innocent as learning magic tricks
actually could become an addiction. Where you know, fifty one hundred,
one hundred and fifty 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

(50:05):
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 behaviors

(50:27):
now have the potential to be to become compulsive, you know.

Speaker 2 (50:32):
Because people will exploit, exploit that that tendency of humans.
Do you do you feel comfortable talking about your own
personal experience what you talk about in your book? Sure, yeah,
you feel.

Speaker 1 (50:44):
Yep, yep. So just very briefly, you know, in my
mid forties, my life was going along pretty well. There
were no major crises. I had never had any prior addictive,
significant addictive problems, or really even anything I would character
as addiction. I got into romance novels and they were

(51:06):
very reinforcing. I'd always been a reader, but this particular
genre 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

(51:28):
reading twenty four to seven. 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 two three in the morning reading,
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

(51:50):
didn't see what was happening to me until it was
pointed out by somebody else exactly what my patients described
when they get addicted to drugs. Now, I decided to
fast from romance novels for four weeks, as I recommend
my patients. I was shocked by how difficult it was.
I had a terrible time sleeping at night.

Speaker 2 (52:13):
You said you had an existential crisis.

Speaker 1 (52:15):
Yeah, I mean on some level, yes, right. I was
certainly buzzing for a while, and then after a month
felt better. I 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 that's what I did, And interestingly,
now there's no appeal for me in the genre. It's

(52:37):
like I've sort of burned out those neurons, which is
that 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,

(52:58):
but then I begin to read them, I don't experienced
pleasure for them. It's like 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

(53:21):
level of feeling a real kind of grief reaction.

Speaker 2 (53:23):
To having to do that. Make me, You just made
me think of a clockwork Orange, the scene where they
try to reprogram his lust and oversack his brain and
images so he can't stand it. And yeah, yeah, so
you talk, you know about other things that really are
helpful to people like radical honesty and pro social shame.

(53:46):
And also you say that pain is not necessarily bad.
You know, we can have a good balance between pain
and pleasure. I think a lot of people responsively practice BDSM,
you know, have enjoyed pain, but do it in irresponsible,
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 to I

(54:08):
think this point of your book is people need to
find in their own way the best healthiest balance. Yes,
iain and pleasure. I do agree, and I think.

Speaker 1 (54:19):
It's important to come as a healthcare provider mental health
care right to become with a non judgmental stance. And
I try to do that too.

Speaker 2 (54:26):
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, and I dare you to walk toward it.

(54:49):
In this way, the world may reveal itself to you
as something magical and all inspiring that does not require escape. Instead,
the world may become something worth paying attention to. Doctor Lemke.
Is 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 discovered, maybe for the
first time, the meaning and all that exists in the world.

Speaker 1 (55:11):
Oh, thank you. That's such a nice thing to say.
I appreciate it.
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Scott Barry Kaufman

Scott Barry Kaufman

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