The Paradox of Pleasure

This is Hidden Brain. I'm Shankar Vedantam. In the hit television show Ozark, a bright financial advisor finds himself suddenly working on the wrong side of the law.

What's our story for the kids?

Well, we could tell them the truth, Wendy.

How would that be?

Following a series of bad decisions by his business partner, Marty Byrde, played by Jason Bateman, begins working for a drug cartel. I want you to be ready to set up shop within a week.

Yeah.

And Marty, When I drive by your house, there better be a for sale sign on your lawn. Almost from the start, the bodies start to fall. People get thrown off balconies. People get shot. People are electrocuted. When government officials get involved, more violence unfolds. People betray one another. They cheat each other. They act in selfish and shortsighted ways.

Let me just jog your memory for a minute. There was an innocent man who was murdered. Gary. He was a good man.

You might say this is the genre of the drug movie or television show. You see it in critically acclaimed TV shows like The Wire and Breaking Bad, and in movies such as Traffic and Scarface. Say hello to my little friend!

OK, you want to play rough? Okay. God. Okay.

Running through these dramas, we sense the irresistible power of drug addiction, the implacable draw of heroin or cocaine or methamphetamine, the chaos and crime that follow everywhere the drug trade is plied. I've watched many of these TV shows and movies as entertainment. For many years, I also reported on the work of researchers who who study the science of drug addiction. But some time ago, I came by a mind-bending idea that transformed my understanding of addiction. It challenged how I think about drugs and what it means to be addicted. And it told me that as gripping as TV shows and movies about the drug trade might be, they don't begin to capture the profound story of addiction in all of our lives. Today, we begin with a story we are telling across 2 episodes. It will change the way you think about your brain and offer some profound insights into what it means to live a life of happiness and contentment. Pleasure, pain, and balance, this week on Hidden Brain. Support for Hidden Brain comes from Planet Visionaries. Professional climber and environmental advocate Alex Honnold hosts Planet Visionaries, a podcast spotlighting the people tackling climate challenges with real hopeful solutions. Throughout season 6, Alex brings together extraordinary changemakers for powerful conversations about grit, determination, and the power of hope to fuel our fight for a better future.

In partnership with TEDx.org, Hidden Brain is proud to present Planet Visionaries.

In partnership with the Rolex Perpetual Planet Initiative, this is Planet Visionaries. Listen or watch wherever you get your podcasts. Quick question, do people come to you for answers at work? Maybe you're managing projects, training new hires, or just the one everyone relies on. That's leadership. Through UVA Darden's Part-Time MBA in Rosslyn, we help professionals like you turn real-world experience into recognized leadership credentials without stepping away from your career. Whether you work in healthcare, education, government, or business, this is how you take the next step. Learn more at darden.virginia.edu/ptmba. Support for Hidden Brain comes from Progressive. Whoever says saving money is hard doesn't know that new customers who bundle and save with Progressive save hundreds. Because switching your home and auto insurance is better than cutting down on those iced lattes you love. Switch to Progressive and see if you could save. Get your quote today at progressive.com/hiddenbrain. Progressive.com, Progressive Casualty Insurance Company, affiliates, and other insurers. Not available in all states. All of us think we know what addictions look like. We've seen the movies and TV shows about gang violence and drug dens. At Stanford University, Anna Lembke studies the science of addiction. She argues our conception of addiction is far too narrow. Anna Lembke, welcome to Hidden Brain.

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

Anna, you're a practicing psychiatrist in the heart of Silicon Valley, and I think of California's Bay Area as perhaps the richest part of the richest country in the history of humankind. So a time traveler from the 17th century might assume that even if the streets were not paved with gold, At a minimum, people would be very happy with so much material success. Is your psychiatric practice empty? Ha.

I still marvel at the gap between how people present outwardly and the truth of their inner experience. We see people every day who seem to have everything you could ever want— wealth, beauty, meaningful work. And yet, when you look under the hood, they're miserably unhappy.

So over time, Anna, you've seen more and more patients suffering from depression, anxiety, and chronic pain, ailments for which they are hard-pressed sometimes to find a source or a cause. And as you say, often these are healthy, affluent, educated people with seemingly everything they could want in life. One patient of yours was a young physician with a very promising career. Can you describe what he was like when you first met him?

Delightful young man. Handsome, kind, thoughtful, considerate. He came to me, in fact, because he got a DUI. He was driving under the influence. But as it turned out, alcohol was not his primary problem. Once he was in my office, he revealed to me that he did in fact have an addiction problem, but it wasn't addiction to alcohol. It was an addiction to online gambling sites. sports betting. And his story went like this. He was a very successful high school and collegiate athlete, Division I, all kinds of accolades, really a remarkable athlete. And that cycle of engagement in high-level athletics, the adrenaline that goes along with high-level competition, the wins, the losses, that absolutely was his jam, right? It kept him busy and engaged and really happy. But when that career came to its natural end, like so many high-level athletes, there was a sort of a free-falling disappointment, a kind of an existential, profound disappointment, a bit of an identity crisis. And although he was headed to medical school, which, you know, gave him kind of a new identity to latch onto, he really missed that cycle of intensity that he got through participation in sports. And then he was invited by his collegiate buddies to participate in fantasy football, in a fantasy football league. And, you know, they all get together and they choose their teams, and then there was, you know, minor money involved in that. But he got really, really into it, more so than his buddies from college. And that was really almost the spark for him then To begin to want to engage athletically through sports betting and sports gambling. And, you know, it started with $50, $100. And at this time, he's now started medical school. He's doing his pre-med courses. You know, he's getting ready for his clinical years. He had this phone. He could pull it out during grand rounds, you know, when he was supposed to be listening to the speaker, and scroll through, you know, results of all the different sports. And And then he could place a bet. And that accessibility just absolutely ensnared him, and he found himself completely caught up in it to the point where he was now spending not hundreds of dollars, but thousands of dollars, not monthly, but weekly, and eventually daily. And in about 6 months, he completely spent the trust fund that he had inherited from his parents. In order to pay for medical school. And he was so ashamed that he didn't tell anybody. And he thought to himself, well, if I can just win, then I can get all the money back and then I'll be fine. So he took out an enormous loan without telling anybody to pay for medical school. And he thought, okay, I'm gonna put it in the bank, you know, I'm gonna pay it back. And instead he gambled that away too.

Anna had another patient who started doing something that might seem even more harmless than sports betting.

So this was somebody who just found himself really getting intense pleasure out of the cycle of shopping online. He would spend quite a bit of time searching for different items that he was interested in buying, and the process of kind of like the treasure hunting was very entrancing and rewarding for him. All kind of building up slowly to the point where he would choose the item that he would buy and then buy it, and then he would be waiting in anticipation for it to be delivered to his home. And all of that was very pleasurable. And then it would be delivered and he would open it and take it out and it was the thing that he wanted and it felt so good and it was just You know, wonderfulness for him. So because that cycle was so entrancing for him, he started to do it more and more, and he kind of came to rely on it as a physiologic crutch for managing his mood. But over time, what he found was that the cycle got shorter and shorter, and the anticipation and pleasure that he got from it got less and less, to the point where— As soon as he opened the box and got what he had ordered, it was over. And then he'd be online again trying to buy the next thing. And eventually he ended up with rooms in his house full of stuff that he didn't need or want and tens of thousands of dollars of credit card debt. And yet even then he couldn't stop. So what he started to do as kind of a last resort is he bought like these cheap items, keychains, mugs, caps, cheap sunglasses, things he didn't need or want. And then as soon as he got them, he would return them.

Wow.

Because he didn't have any money, but he couldn't break the shopping cycle.

I want to talk about one last patient, a man you called Jacob. And a note for listeners that this next story includes references to both sex and suicide. Jacob was middle-aged or maybe even a little older when you first met him. What was his story, Anna?

Jacob was a Stanford scientist. And by the way, let me just emphasize that I got permission from my patients to relay their stories, and I use pseudonyms and hide other identifying features. So Jacob was a Stanford scientist who came to me seeking help specifically for a severe sex addiction. So sex, pornography, compulsive masturbation. And what he described was in the '90s he used pornography and he masturbated, you know, as much as daily, but it was never unmanageable. He was still able to function as a father, as a husband. He was successful in his profession. But with the advent of the internet, and especially in the early 2000s, uh, The smartphone. He found that this pursuit of his became unmanageable, which is to say that he was using more and more pornography for more hours every day, late into the night, not showing up at a conference that he was supposed to speak at prepared to give that speech because he had been up the entire night before watching pornography, repeatedly masturbating. And over time, he You know, he needed more and more potent forms to get the same effect. So he escalated from sort of vanilla toast pornography to more deviant forms of pornography. And then pornography itself wasn't adequate. So then he was going to live shows and meeting up with prostitutes. And eventually, you know, his addiction progressed to the point where he was going into chat rooms, doing dangerous things with other people in chat rooms, spending all of his available time engaged in this activity to the point that essentially his life His life completely fell apart. His wife left him. Oh my God. And he was thinking about ending his life and even found a spot near his office where he thought about hanging himself.

Each of these cases, of course, is different. Online shopping is not the same as gambling, and gambling is not the same thing as pornography. But in time, Anna came to see connections Not just between these patients, but to many people who are not seeking help from a psychiatrist. People like herself. You're listening to Hidden Brain. I'm Shankar Vedantam. Support for Hidden Brain comes from Progressive. Whoever says saving money is hard doesn't know that new customers who bundle and save with Progressive save hundreds. Because switching your home and auto insurance is better than cutting down on those iced lattes you love. Switch to Progressive and see if you could save. Get your quote today at progressive.com. Progressive Casualty Insurance Company, affiliates, and other insurers. Not available in all states. Support for Hidden Brain comes from Quince. We all have those pieces in our closet that we can count on: the versatile jacket, the perfect t-shirt. These are the pieces that make getting dressed easy, and that's what Quince does best. Quince makes elevated everyday essentials using premium materials in designs that are timeless, thoughtfully crafted, and made to be worn again and again. And when the temperatures start to drop, Quince makes it easy to build on these everyday staples with versatile layers designed to keep you warm and comfortable all season long. Find your next fall favorites at Quince. Download the Quince app for app-exclusive offers or go to quince.com. Get free shipping on your order and 365-day returns. Now available in Canada and the UK too. And when Quince asks where you heard about them, let them know it was Hidden Brain. This is Hidden Brain. I'm Shankar Vedantam. Over many years of practice at Stanford University, Psychiatrist Anna Lembke has found that lots of people living in the Bay Area, one of the wealthiest parts of the United States, were suffering from a strange malady. Despite being blessed with great success in terms of education and material wealth, many of her patients were unhappy. At one point, Anna saw something in herself that reminded her of the patients she was treating. Anna, I want to zoom into your life around the time you turned 30.

Okay.

What was going on in your life at this time?

My life was good then. You know, my marriage was fine. My kids were healthy. My work was rewarding and meaningful. I was in relatively good health for a 40-ish-year-old woman, so things were good.

Now, you've always loved reading, and around this time, you fell in love with a very popular book series. What was it?

It was the Twilight Saga.

And can you tell me a little bit about what the Twilight Saga is? I confess I have not read the books. What is their broad plot and what is it built around?

Well, you know, I was turned on to the Twilight Saga when I dropped my kids off at elementary school and there was a group of moms clustered around. Megan was one of the moms, my friend, and they were all laughing hysterically. And I went over and I said, hey, what's so funny? And Megan said, oh, I've been reading this romance novel that I absolutely love. And I went into the bookstore to try to get the sequel. And I couldn't find it. So I went up to the bookstore owner. And I said, hey, you know, where's the sequel? And he said, it's in the teenager section. Right? So all the moms started cracking up. They thought that was the funniest thing. But she said, but you guys have to read it. It's so good. So I said, okay, Megan, what is it called? Because I'm always looking for a good read, right? She said, oh, it's called The Twilight Saga. So I thought, okay, I'll give it a try. And it was absolutely mesmerizing for me. It was as if I had never read a novel in my life, and all of a sudden this novel about a bunch of teenage vampires running around biting each other on the neck just absolutely transported me. It was really weird.

So the Twilight books eventually spawned a very popular series of films. I want to play you a clip from one of those movies. In this series, a teenage girl named Bella is confronting a boy she knows, Edward, about his true nature.

I know what you are.

Say it.

Out loud.

Say it.

Vampire. Are you afraid?

No. Okay, so there are a lot of, you know, breathless pauses here, but I'm hearing, you know, fantasy, paranormal stuff. But it sounds like an innocent enough pastime, Anna.

Oh, an innocent enough pastime? Sure. It always starts out innocent. And of course, you know, it was. But what happened was it changed the way I felt in the moment in a way that resonated so deeply that I wanted to keep recreating that feeling. And what was that feeling? It was essentially a feeling of non-being.

Mm-hmm.

While I was reading the Twilight Saga, it just transported me to another time and place such that I completely forgot myself. And that self-forgetting was clearly something that I needed and wanted. You know, I read the whole saga. I think it's like 4 books. And then I wanted to recreate that feeling again. So I read the whole saga again.

Wow.

Pleasurable, but not as pleasurable as the first time around. But by then I was completely tapped into this whole genre of vampire romance novels. And so I started to invest larger and larger amounts of time, energy, and creativity into obtaining and reading vampire romance novels. You know, seemingly innocent to start with, but it became a bit of an obsession. And, and when I ran out of vampire romance novels, I moved on to werewolf Romance novels, and then there was necromancers and soothsayers and all kinds of paranormal romance novels.

Where were you procuring these books?

So I live right next to a little library which has a limited collection. So when I went through the limited collection at my local library, I either biked over to the main library or you can order through the interlibrary loan. And, you know, some of these romance novels have very revealing covers. Like, it was some bodice ripper with some hunk on the COVID you know, at the prow of a ship or something. Like, I wouldn't want to be seen reading that anywhere.

So Anna came up with a way to hide what she was reading from her family and friends.

I haven't revealed this to anybody. This is terrible. But I would actually put the book inside another book. So that if one of my kids came by or my husband came by, I could look like I was reading the other book.

Wow, like a medical journal or something.

Except that might not really trick them because, like, you know, they would know that I wouldn't spend that much time reading a medical journal.

I mean, I used to do this in 8th grade, Anna. I felt like, you know, the trick of the book inside the book was something I had perfected in 8th grade.

I know, I know. And I discovered it in my 40s. What can I tell you? I was a late bloomer.

So, at one point, Anna, your love of this literature received a turbocharge when you moved from the printed page to the electronic domain. Tell me how that happened.

Well, my friend Susan said, Anna, you should get a Kindle because then you don't have to, you know, be carrying these books around. Kindles had just come out then. And, of course, that was very— I liked that idea because it would be easy access. But pretty soon, I also started regularly going going on Amazon and looking for things that were similar to the Twilight Saga. And guess what? Amazon will suggest those to you, as we all know now. And so Amazon did the work for me. All I had to do was look in my feed and say, oh, they're telling me I should read this one, they're telling me I should read that one. And like later on in the process, I also discovered that you can get free books on Amazon. So anything that was free that was in the romance category, I would download and read. And that was really the beginning of the end for me, because once that electronic reader, I essentially became a chain reader. Like, as soon as I finished one book, I would either borrow from the local library or buy on Amazon another book. These were all romance novels. And I got to a point where whenever I wasn't doing something that I absolutely had to do, like for my work or my family, I was reading romance novels.

Wow.

And then it got to where, like, That's all I wanted to do, and I didn't enjoy anything else. I didn't even really want to, like, be with my kids or my husband, right? I just wanted those times to rush through them so that I could go back to reading romance novels. The other thing that I only realized in retrospect was that these sort of tamer versions of romance where, you know, the sex scenes aren't super graphic Well, those stopped working for me. And now I needed ever more graphic types of romance novels in order to get that zing that I was looking for.

So this was no longer about the pleasure of reading at this point or your love of language. It had become something else.

Oh, it had absolutely become something else. And of course, it was rooted in the pleasure of reading and the pleasure that I I've always gotten from fiction. But what happened was I got to a point where I really didn't care if it was badly written or badly plotted or the characters were uninteresting. I would just flip through to the climax, pun intended. So then I got to where I was like reading really graphic erotica, and the more graphic the better, the more sex scenes the better. But it was all about It's about getting to that moment and getting a certain, very specific feeling.

Yeah.

And I became the possessor of the knowledge that if you take any romance novel and you open it up to 2/3 or 3/4 of the way through, you'll get right to the point, which is to say these romance novels are engineered. They're written according to a recipe.

So at this point, you're a respected researcher and psychiatrist at Stanford University. You have a great family.

But no longer. Soon to be no longer. Okay.

But that's what I want to ask you about. You know, you have— you know, what you are doing in some ways must have felt at odds with your public persona, the sense that you had that you were a mom, that you had a great family. Were you embarrassed by your newfound love of steamy literature?

First of all, I didn't really see what was happening as it was happening. I would occasionally joke to friends, oh, I'm so addicted to vampire romance novels, or romance novels in general. But just by being able to joke about it, I felt that that must mean I'm really not addicted to it or it's not really a problem. The other thing was that because of the technology in large part, I could do the behavior secretly. Once I got the Kindle, you know, I could be reading something on that Kindle that nobody else knew what I was reading, whereas before I wouldn't want to be seen reading that anywhere. That would just be really embarrassing. But on a Kindle, like, it was anonymous.

How did this affect your patient care? Because presumably through all of this, you were still treating other patients and helping people with their addictions.

Right. As it was happening, I didn't really see it happening, and I didn't relate it as being similar to what my patients were going through. That I really only saw in retrospect. But I started to be less interested in my work. Like, again, the work that had given me meaning and purpose and joy started to be dull and gray and boring. And I found myself less engaged and more just wanting to rush through the work so that I could go home and read romance novels.

So you weren't reading these at work. You reserved the reading at home.

Well, there was one day, and this was sort of near the sort of culmination of this behavior, Time is weird for me then, but I think it developed over the course of about a year or two. But I did bring a romance novel to work and was reading in the 10 minutes between patients.

So I don't want to play armchair psychiatrist, but it seems that you were—

That's okay.

You were using your immersion in these books as a kind of escape. What do you think you were escaping from?

Well, that's what's so fascinating. I really didn't have anything to escape from. I have a great husband. I have got these great kids. I have work that I adore. My patients are just so fantastic. There was nothing wrong. I was really just escaping to. And the thing that I was escaping to was just not having to be in my body, not having to think, being able to experience this kind of intense Euphoria, you know, this other place, which was very, very pleasant for me. It just felt good.

The other thing I just want to flag here is that the pattern we've seen over and over again, which is that something starts out being pleasurable. So your friend tells you about this romance novel. You read the Twilight Saga. You find it fun. You find it enjoyable. And so you go back for more. But somewhere along this process, sort of the balance shifts, and now you're no longer actually reading these things because they're giving you pleasure. It's that, you know, you're reading them almost to avoid pain. Does that sound right?

That's really the key, that we start out doing whatever the behavior is for, you know, rational reasons, and it succeeds in achieving what we're trying to achieve, either to give us pleasure or Or to accomplish some other goal. But if it then hijacks our brain's reward pathway, it gets a life of its own. And then even when it stops doing what we want it to do, we can't stop. And that's really the hallmark of addiction.

When we come back, the brain science behind an increasingly global malady. You're listening to Hidden Brain. I'm Shankar Vedantam. Support for Hidden Brain comes from Instagram. Instagram Teen Accounts' automatic protections limit who can contact teens, the content they can see, and the time they spend on the app. Teens are automatically placed into Teen Accounts. Teens under 16 Your teen will need a parent's permission to change any of those settings to be less strict. Learn more about teen accounts and Instagram's ongoing work to protect teens online at instagram.com/teenaccounts. Working as a dedicated Fidelity advisor, I always ask, what's important to you? I'll look at those priorities and goals alongside your full financial picture to build a comprehensive A comprehensive plan designed to help grow and protect your wealth. With proactive portfolio insights and an eye on taxes, I'm here to help you make the most of your money. I'm Laura Maxwell, and I'm a dedicated Fidelity advisor.

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Fidelity Brokerage Services, LLC, member NYSE SIPC. Support for Hidden Brain comes from Air France. Air France business cabin offers comfort throughout the journey, With priority check-in, boarding, and lounge access. Onboard, enjoy menus from renowned French chefs, wines and champagne selected by a sommelier, and free high-speed Wi-Fi. When it's time to rest, settle into a fully adjustable lie-flat bed with added mattress comfort. The art of travel, elevated, because Air France Business Cabin goes further in every detail to make your journey exceptional. This is Hidden Brain. I'm Shankar Vedantam. Anna Lembke is a psychiatrist and researcher in the behavioral sciences at Stanford University. She's the author of Dopamine Nation: Finding Balance in the Age of Indulgence. Anna, many of your patients suffer from problems related to compulsive overconsumption, and you experienced some of this yourself, but you had a big You had a unique advantage over your patients. You were a researcher and a scientist who studies the brain, and you knew about a very important discovery in neuroscience that has to do with the relationship between pain and pleasure inside the brain. What was this discovery?

This discovery was the fact that pain and pleasure are co-located in the brain. So the same parts of the brain that process pleasure also process pain. And they work like opposite sides of a balance.

So almost like a seesaw?

Exactly, like a seesaw or a teeter-totter in a kid's playground. And when that teeter-totter or that beam on a central fulcrum is level with the ground, it's at rest, or what neuroscientists call homeostasis. And when we experience pleasure, it tips one way, and when we experience pain, it tips in the opposite direction. And there are certain rules governing this balance. And the first and most important rule is that the balance wants to remain level, that is, at homeostasis. And our brains will work very hard to restore a level balance after any deviation from neutrality.

So when we reach for things that are pleasurable, when I bite into a delicious dessert, for example, I'm imagining that I'm essentially pressing down On the pleasure side of that seesaw.

That's right. So when we do something that's pleasurable and we release dopamine in the reward pathway and the balance tilts to the side of pleasure, no sooner has that happened than our brains will work very hard to restore a level balance. And they do that first by tilting an equal and opposite amount to the side of pain before going back to the level position. And I like to imagine that as these little neuroadaptation gremlins hopping on the pain side of the balance, and that's the comedown, the hangover, the aftereffect. And it often happens even while we're still experiencing the dopamine hit, and it often happens outside of conscious awareness.

So if I have this image here about pressing down on one side of the seesaw and these gremlins are jumping on the other side, why is it they want to press down on the side of pain? Why not just try and get to, you know, equilibrium? Why press down so much that it tips over in the other direction?

That's a great question, and I don't exactly know why the mechanism is built like that, why we pay a price for every pleasure. But I suspect it has to do with the fact that that kind of mechanism makes us the ultimate seekers, never satisfied with what we have, always looking for more. And if you think about it, we are evolved over millions of years of evolution to approach pleasure And avoid pain. And then on top of that, you have this pleasure-pain balance whereby as soon as we get whatever reward we're looking for, we experience pleasure, we immediately remember where and how that happened, and we want to recreate it. And that recreation is accelerated by the fact that as soon as we get that hit of dopamine, we essentially go into dopamine freefall. That's those gremlins on the pain side of the balance. And now we're in a dopamine deficit state and we feel this overwhelming motivation to do the work it takes to get the next reward, which, you know, for most of human existence has meant walking tens of kilometers every day, you know, has involved doing enormous work in order to get just a little bit of reward. So it's not that dopamine is good or bad, it's that dopamine's essential for survival and it keeps us moving.

So dopamine is not involved only in feeling pleasure. Perhaps more importantly, it's also involved in motivation, which is, of course, what you're talking about just now. Can you explain that connection between dopamine as a messenger of pleasure, but also dopamine as the architect for motivation?

Yeah. So there's a very famous experiment in which rats were bioengineered to not have dopamine receptors in the reward pathway of the brain. And what the scientists discovered was that if they put food into the rat's mouth, the rat would eat the food and seem to get pleasure from the food. But if they put the food even, you know, a single body length away, the rat would starve to death. In other words, we need dopamine not just for the experience of pleasure but also for the motivation to do the work to go get the reward.

And probably the way that dopamine makes us motivated is to create this dopamine deficit state or those gremlins So what happens when we transport this brain that evolved, you know, over millions of years into the modern environment where everything is now available at the touch of a button?

This ancient wiring that has us experiencing pain in the immediate aftermath of pleasure is woefully mismatched for our modern ecosystem. Why? Because we are surrounded by pleasure. We have more access to more reinforcing drugs and behaviors than at any point in human history. Even things that previously, you know, you could have thought of as healthy, like reading or exercise or playing games, has become drugified, has been turned into a drug in some way, making us all more vulnerable to the problem of addiction and also making us more vulnerable to the problem of this dopamine deficit state whereby our brains try to compensate for this excess of pleasure by downregulating our own dopamine production and transmission, not just to baseline but below baseline, creating this constant physiologic craving for more pleasure, but also the things that go along with craving, which are anxiety, irritability, and depression.

So the mechanisms in our brain that compel us to approach pleasure and avoid pain, you say, were evolved over millions of years for a world of scarcity. Whereas today, because we're surrounded by so much stuff, we're sort of drinking from a fire hose of dopamine, as you put it.

Yeah. This is the plenty paradox, right? It's the literal physiologic stress of overabundance.

Walk me through the same seesaw analogy that we talked about earlier. Again, 100,000 years ago, I found a date tree and the date tree had delicious dates and it made my brain very happy to eat some of those dates, but there were not very many dates on that one tree. I had to find the next tree and the next tree might have been, as you say, 3 miles away, and so it required a huge amount of effort to get to that next date tree. What's happening with that seesaw? How does that seesaw now in the world in which we live where things are in fact available at the touch of a button?

Yeah, well, let's go back for a second and talk about what's happening with the seesaw when you're looking for the date tree. Because what happens as you're scouring your environment to try to find, you know, one date tree with a couple of dates on it is that your pleasure-pain balance goes onto the pain side, right? Because you're hungry and you're walking and you're tired. And then finally you find this date tree and you're ecstatic and you eat this date and your balance, your pleasure-pain balance goes back to the level position, which feels like euphoria because part of the key here is the directionality of the pleasure-pain balance. So if I'm in pain because I'm hungry and then I find something to eat and it moves me in the direction of pleasure, that's as pleasurable. As if I start out with a level balance and I use an intoxicant and I get high.

Interesting. And so now the same pain-pleasure balance, now what happens now?

Yeah, so now in the modern world, let's say, yeah, take Silicon Valley because it's a prime example, but it's also true all over the world now. You go and you're hungry, right? And you're looking for a date tree, and all of a sudden, you know, you've got like a whole crate of dates shipped to you from Amazon right on your kitchen table, right? And by the way, they're giant, like they're like, like abnormally giant dates, right? So you eat a giant date from Amazon and, you know, it releases dopamine in your reward pathway because they've also added sugar and salt and fat and flavorings. You know, it's like coffee dates or something, who knows? And you get the release of dopamine and wow, that feels great because like, wow, who's ever had a date like that in the history of humans? And then, you know, as soon as it's over, your pleasure-pain balance tips to the side of pain because those gremlins are trying to compensate for all that dopamine. And as soon as you're in that dopamine deficit state with the gremlins on the pain side of the balance, you want to restore a level balance. And what is the easiest way to do that? Well, you could wait till the gremlins hop off, because if you wait long enough, they will hop off and homeostasis will be restored. Or you could eat another date. And if you eat another date because there's a whole crate of dates right in front of you, that would work faster, right? And maybe you'll eat 2 this time because then that'll level your balance but also get you over to the pleasure side. And pretty soon you've eaten the whole crate of dates, and now you're essentially at war with those neuroadaptation gremlins.

And the more we then try and press down on the pleasure side of the seesaw, and the more the gremlins try and press down on the other side to achieve homeostasis, You make the case that over time, the gremlins start to push down on the opposite side of the seesaw, and then we end up depressed and anxious. Explain how this happens, Anna.

Well, what happens as we continually bombard our reward pathway with highly reinforcing substances and behaviors is that we accumulate more and more gremlins on the pain side of the balance. They're just doing their job, you know, trying to restore homeostasis, and over time, You know, those gremlins essentially are camped out on the pain side of the balance, tents and barbecues in tow. And now we're in addicted brain. We've changed our hedonic or joy set point such that now we need more of our drug quantity-wise and more potent forms of our drug, not to get high, but just to level the balance and feel normal. And most importantly, when we're not using, we're walking around with a pleasure-pain balance Tilted to the side of pain, which means we are experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and craving.

I mean, you're an addiction psychiatrist and you treat many patients who are dependent on drugs. So drugs in the conventional sense of a chemical that is swallowed or smoked or snorted or ingested, and obviously that is a very big problem, but, you know, you're making a much more radical claim here. You're saying that our problem with addiction is not just limited to nicotine and cocaine and heroin.

You're absolutely right. What I am saying is that science, technology, and innovation has allowed us to drugify almost every human behavior. If you're not addicted yet, it's coming soon to a website near you. And my bigger claim is that the rising rates of depression, anxiety, and suicide, which by the way are rising fastest in the richest nations in the world, are due in part to the fact that we are overloading our brain's reward pathway with too much dopamine. And that in our brain's effort to compensate for too much pleasure, We are essentially individually and collectively downregulating our own dopamine production and transmission, not just to baseline levels but actually below baseline levels. So we are in a dopamine deficit state. Which means that we're all unhappier, more anxious, more depressed, more irritable, less able to take joy in the things that used to give us joy or that have given people joy for generations. And also more susceptible to pain, right? Even the merest slight now can make us pain. And that we're not— this isn't happening because somehow we're spoiled or our values have changed. It's because we've literally physiologically changed our brains as a result of constantly bombarding them with these high-reward substances and behaviors.

So in some ways, this feels really mind-bending to me, Anna, because I can see how nicotine and alcohol and marijuana or heroin or cocaine, I can see how these could be addictive. But many of the things you're talking about, food or social connection or sexual intimacy, these are not things that are inherently problems. In fact, many of them are part of what it means to be human. Talk about how our modern societies have taken these normal, healthy things and in effect, as you would put it, druggify them.

So the way that our modern society has druggified these things that used to be normal and healthy, like having sex or eating food or playing games, is essentially by increasing 4 factors: quantity, access, potency, and novelty because our incredible manufacturing system has allowed us to make these reinforcing substances in enormous quantities, and our amazing supply chain allows us to ship them all over the world. You know, one of my favorite sort of anecdotes is that the— in the 1880s, the cigarette rolling machine was invented, allowing manufacturers of cigarettes to go from manufacturing 4 cigarettes Wow. And that's just one example of what we've done all around. And my, you know, my own romance novel reading addiction that developed, and one of the things that I discovered when I went looking for other romance novels is that there's a whole universe of romance novels out there. There was no— it was really a never-ending quantity. And quantity really matters because the more we use our drug of choice, our substance or behavior that's reinforcing, the more that we expose our brains to and the more often, the more likely we are to change our brains to this addicted kind of circuitry.

So quantity is the first driver. What are the others?

Yeah, so quantity is the first one. Availability or access is huge. So if you grow up in a neighborhood where drugs are sold on the street corner, we have lots of epidemiological data showing that you're more likely to try drugs and more likely to get addicted to them. And now we live in a world where we all have more access to our substance or behavior of choice, whether it's vampire romance novels or potato chips or games or pornography or, you know, old-fashioned drugs like alcohol, cannabis, and nicotine. And of course the smartphone is essentially the equivalent of the hypodermic syringe delivering digital dopamine 24/7 for our wired generation. And that's really what it is. The smartphone totally changed things when people could carry in their pocket this device that gave them access to digital media and digital content 24/7. We all essentially became more addicted to these kinds of digital drugs.

All right, so we've talked about quantity and we've talked about accessibility. What's next?

Yeah, availability, accessibility, and the other one is potency. So one of the ways to overcome these gremlins on the pain side of the balance, or what's often referred to as tolerance, is to either use more of the drug or use more potent forms. Or have a more potent drug delivery mechanism. So for example, with opioids, someone might start out using opium but eventually go to heroin, which is about 10 times more potent, and then eventually progress to fentanyl, which is 50 to 100 times more potent. And this would allow them to at least temporarily win that battle with their gremlins and get the, the feeling that they're looking for. But another way to achieve potency is to combine 2 drugs to make yet a 3rd, more novel drug. And this is done all the time. For example, people combining opioids with things like benzodiazepines, or now this new veterinary sedative, tranq, which people are sadly using. By combining 2 distinct drugs together, we get a new novel drug, which then Changes it up for our brain receptors and allows us to overcome tolerance.

And in the realm of non-illegal substances, you can also have combinations like French toast ice cream.

Exactly. Or, you know, I very easily get hooked on YouTube videos, especially outtakes of American Idol. And when I think about why on earth is American Idol so entrancing for me, well, they've figured it out, right? They've taken music, which is already reinforcing for most people's brains, releases dopamine, feels good. And then they've combined that with gaming and they've turned it into a competition and thereby, you know, really made a very potent drug.

Can you talk a moment about the factor that's known as novelty? This is true in drugs of abuse, but it's also true for many of the other things that, you know, previously we might not have thought as being problematic.

Yeah, so dopamine is extremely sensitive to novelty, which is why, for example, people can get addicted to things like the news. That's the definition of news. It's new stuff coming your way. But what's become so, so toxic about the modern world is that, you know, in order to maintain customers and keep them coming back, you've got to take the thing that they liked before and then package it as slightly new or different or better. And the internet has absolutely mastered that, right? These AI algorithms learn us, figure out where we've spent time before, what we've liked before, And then proffer or suggest to us things that are similar but a little bit different. And that absolutely engages this treasure-seeking function where we keep going because we're hoping that the next hit will be something that's just a little bit better but similar to what we had before.

You know, I remember when I was in 8th grade or maybe 7th grade, Anna, teachers would tell me, you know, to avoid a local park, me and all of my classmates, because the rumor was that drugs were being bought and sold and used at this park. park. But if everything can be drugified, if addictions can be beamed and streamed and Wi-Fi'd into our living rooms and bedrooms, it becomes really now very hard to put a fence around it and say, avoid going to this park, because the problem is no longer just with one park.

That's the problem we're all facing as individuals, as parents, as schools. I mean, I don't know about you, but when I walk around and see the way that people are just glued to their phones. It just makes me really sad. And yet I totally get it. Um, I mean, these things are— they're literally mesmerizing. We are put in a trance by these devices. They're highly reinforcing for our very fragile little human brains.

When we combine the ancient pleasure-pain seesaw in the brain With a modern world that is ready to push hard and often on the pleasure side of the balance, we get trouble. We end up with compulsive overconsumption and all the associated problems it causes for people's health, well-being, and relationships. We also end up with a plague of depression and anxiety. In the second part of our story, coming up in the next episode, how to reset our relationship with a world of plenty and turn unhappiness into thriving. Anna Lembke, thank you for joining me today on Hidden Brain.

Oh, you're very welcome.

If you have follow-up questions that you'd like to ask Anna and that you'd be comfortable sharing with the larger Hidden Brain audience, please send a voice memo to ideas@hiddenbrain.org. Use the subject line, That email address again is ideas@hiddenbrain.org. 60 seconds is plenty, and please be sure to include your name and phone number. Hidden Brain is produced by Hidden Brain Media. Our audio production team includes Bridget McCarthy, Annie Murphy-Paul, Kristen Wong, Laura Querelle, Ryan Katz, Autumn Barnes, and Andrew Chadwick. Tara Boyle is our executive producer. I'm Hidden Brain's executive editor. Our unsung hero this week is Angelica, or Jelly, Monteros. Jelly works on the podcast operations team at Apple, and she played an essential role in the launch of our new podcast subscription, Hidden Brain Plus. Jelly is the type of person who seems to know everything, the person that others turn to for She's always there to help when there's a question or issue to troubleshoot. She knows how to get things done, and we're so grateful for all her help. If you would like to help us build more stories like this, please consider joining Hidden Brain Plus. It's where you'll find even more of the ideas and insights that you love from the show, plus you'll have the chance to have your questions answered by researchers we feature on the show. Apple Podcasts app or at apple.co/hiddenbrain. I'm Shankar Vedantam. See you soon.

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