Book Review: Dopamine Nation by Anna Lembke, MD

Dopamine Nation: Finding Balance in the Age of Indulgence (2021)

By Anna Lembke

291 pages

INTRODUCTION

I like popular-level psychology books written by scholars. They transcend the books by pop psychologists who often provide cliches and platitudes than psychology. Popular books by scholars are often well-written and more readily digestible than the author’s scholarly articles and books. Also, they usually bring together scholarly research, a cumulative presentation of their own research, and permission to speculate a little more than scholarly literature will allow. This book is no exception. Lembke brings together scholarly research and intuitions with her clinical experience into a single, readable volume in this book.

Dopamine Nation is engaging and interesting. This book deals with enough neuroscience and psychological research to make it incredibly dry if not well-written. Lembke both communicates scholarly research on the topic as well as brings to life the material with her personal experiences and case illustrations. This book is both accessible and thought-provoking.

PERSONAL DISCOVERY AND INTEREST

Among my college courses, I teach the Psychology of Addictions and have dealt with addictions on a personal and professional level. A student (Fall 2022) recommended that I read Dopamine Nation, and after watching a few interviews with Anna Lembke, I purchased the book. I found this book very good at exploring the implications of our current knowledge of dopamine and addiction.

As a college professor, each year I try to read at least one, usually recent, related book to my courses. If I discover an older book that is important to my topic, I will go back and read it. Generally, I attempt to stay up-to-date with the research in my courses, in this case, addictions. Just to provide a little more background, I earned advanced degrees in clinical mental health and an ABD in clinical psychology. I have counseled people with various addictions over the years.

CONTENTS

Here is a rundown of the sections and chapters. Each section contains three chapters. The Introduction is entitled, “The Problem.” What is this book about? Lembke states, “This book is about pleasure. It is also about pain. Most important, it’s about the relationship between pleasure and pain, and how understanding that relationship has become essential for a life well lived” (1). In our contemporary Western society, we have offered ourselves up to the many pleasures of this world and lost the ability to live a life well lived.

Lembke's purpose in writing this book is to "offer practical solutions for how to manage compulsive overconsumption in a world where consumption has become the all-encompassing motive of our lives" (3). She does this by educating us on the basic mechanisms that cause us to be susceptible to addictions, case studies that illustrate others' struggles and recovery, and practical suggestions for overcoming these compulsions ourselves. 

Part I: The Pursuit of Pleasure

Part I explores the reasons for our compulsive overconsumption. The three chapters for this section are Chapter One: Our Masturbation Machines, Chapter Two: Running from Pain, and Chapter Three: The Pleasure-Pain Balance. In chapter one, Lembke gives a general definition of addiction as "the continued and compulsive consumption of a substance or behavior (gambling, gaming, sex) despite its harm to self and/or others" (16). With the advent of the internet, we have easy access to addictive drugs. These "digital drugs" (23) possess "increased potency and availability" (23). The internet not only acts as a dealer but a tempter to new behaviors (27).

Continuing with chapter two, Lembke notes that the more we attempt to pursue pleasure and avoid pain; the more we experience pain. This is true for physical and psychological pain. The highest rates of anxiety and depression in the world are found among the richest countries of the world (44-45). The same is true with physical pain (45).

In chapter three, Lembke explains the pleasure-pain balance. She does an excellent job explaining in understandable terms the basics of neurotransmitters, specifically dopamine (47-50). The basic principle of addiction is that the more dopamine, plus the quicker release of dopamine, equals a greater chance of addiction. But that’s not all.

Pleasure and pain from an opponent-process mechanism (52-58). When one experiences pleasure, dopamine is released and the balance tips to the pleasure side, but this does not last. This system is self-regulating and moves us back to a balance of pain and pleasure (homeostasis). After experiencing the pleasure, we then experience the pain to bring balance back to the system (withdrawal). We desire to avoid the pain, so we attempt to avoid it by continuing to consume, but there is a problem with this approach. Repeated exposure to the pleasure-causing stimulus produces less pleasure each time we engage it (tolerance).

Our capacity to experience pleasure decreases and our vulnerability to pain increases. Ultimately, seeking pleasure leads to a loss of pleasure (57). A curious note here is that once you have indulged in a pleasure-seeking behavior or substance long enough, it will reset your pleasure setpoint, and you must continue engaging it to feel normal. The good news is that this setpoint can be “reset” to a lower level, even with severe addictions and permanent damage, new neural pathways can circumvent the old ones with healthy behaviors (64). Part II begins to explore these practical suggestions for recovery.

Part II: Self-Binding

Part II covers a concept called self-binding in three chapters. These three chapters are Chapter Four: Dopamine Fasting, Chapter Five: Space, Time, and Meaning, and Chapter Six: A Broken Balance? Chapter Four sets the foundation for this reset. Lembke provides an acrostic that she uses for working with addictions, D.O.P.A.M.I.N.E. The central emphasis is abstinence for one month (76-81). For most drugs and behaviors one month is enough for people to restore balance. The first two weeks are the most difficult because of getting through the withdrawal, but the next two weeks usually show improvement. If there is no improvement, then something else that requires treatment may be going on.

An interesting study of men with comorbidity of alcohol use disorder and major depressive disorder (MDD) showed that 80% of patients no longer met the criteria for MDD after they quit drinking (78-80). The point is that substance use often causes the issue, not the other way around. This challenges a major assumption that people are self-medicating.

Negative emotions often arise during the abstinence month. The practice of mindfulness (M.) can help with managing withdrawal and accompanying negative emotions. Lembke defines mindfulness as "simply the ability to observe what our brain is doing while it is doing it without judgment" (82). It helps one tolerate negative emotions.

Chapter five continues with a concept called, "self-binding" (91). Self-binding is a way of "intentionally and willingly creating barriers between ourselves and our drug of choice to mitigate compulsive overconsumption" (91). Willpower is not enough to stop. There are three types of self-binding.

There is physical self-binding which creates a physical and/or geographical barrier. Examples could be putting a TV in the closet or only using cash instead of credit cards. Various medications are used for it, such as naltrexone for alcohol and opioids, and various weight-loss surgeries for eating issues. A second type of self-binding is chronological. This is restricting consumption to specific times, milestones, or accomplishments. We over-value short-term rewards over long-term rewards (102-103). This is especially true of addictions (103-104). Chronological self-binding addresses this. Categorical self-binding is the third type (110ff.). This means eliminating triggers for our behavior or substance. With each of these self-binding strategies, Lembke discusses how to do it, gives examples, and considers why each may fail.

Chapter Six discusses the use of medications to restore the pain-pleasure balance. We do not know why some people require medication to accomplish this restoration, and there are problems with using medications (128-129). Medications may limit the range of emotional expression and long-term effects are still being studied. These should at least cause us to pause and attempt other approaches first.

Part III: The Pursuit of Pain

Part III discusses the pursuit of pain in three chapters. The chapters are Chapter Seven: Pressing on the Pain Side, Chapter Eight: Radical Honesty, and Chapter Nine: Prosocial Shame. Chapter Seven explores pain-seeking treatments to restore balance. While it sounds strange, several of these treatments have been used for centuries such as cold-water therapy and intermittent fasting. Exercise and electro-convulsive therapy are versions of this as well. It is counter-intuitive. Pain leads to pleasure. The science of “hormesis” studies “the beneficial effects of administering small to moderate doses of noxious and/or painful stimuli…” (148). The key is to find the right level of pain for the experience of pleasure so that it is not destructive.  Lembke considers both the benefits and dangers of this approach.

Chapter Eight investigates “radical honesty” (171). It can be painful, yet radical honesty is critical to recovery (173). Radical honesty “is essential…for all of us trying to live a more balanced life in our reward-saturated ecosystem" (176). She discusses it in terms of promoting awareness of our actions, fostering intimate human connections, a truthful and accountable autobiography, and the contagious and preventative effects (176). From these, here are some principles. Truth-telling can be transformative. Exposing vulnerabilities attracts rather than repels people. Responsibility must be taken. Radical honesty can move you from your false self to your authentic self. Truth-telling encourages an abundance mindset.

Lastly, chapter 9 analyzes prosocial shame. Lembke sees the experience of guilt and shame as the same and goes on to discuss destructive and prosocial shame. She says, "Prosocial shame mitigates the emotional experience of shame and helps us stop or reduce the shameful behavior" (208). The cycle of destructive shame moves from overconsumption to shame to lying to isolation and continues. The cycle of prosocial shame moves from overconsumption (same starting place) to shame (same experience) to radical honesty (the change) to acceptance which results in belonging and decreased consumption. Twelve-step programs provide this type of prosocial shame that helps people to recover. Lembke further surveys the mechanisms of its effectiveness and how it can work in family life.

Finally, the conclusion provides ten Lessons of the Balance (234). Here they are:

1.       The relentless pursuit of pleasure (and avoidance of pain) leads to pain.

2.       Recovery begins with abstinence.

3.       Abstinence rests the brain’s reward pathway and with it our capacity to take joy in simpler pleasures.

4.       Self-binding creates literal and metacognitive space between desire and consumption, a modern necessity in our dopamine-overloaded world.

5.       Medications can restore homeostasis, but consider what we lose by medicating away our pain.

6.       Pressing on the pain side resets our balance to the side of pleasure.

7.       Beware of getting addicted to pain.

8.       Radical honesty promotes awareness, enhances intimacy, and fosters a plenty mindset.

9.       Prosocial shame affirms that we belong to the human tribe.

10.   Instead of running away from the world, we can find escape by immersing ourselves in it.

FURTHER THOUGHTS

I covered the information in Dopamine Nation, not the illustrations. But it is the case studies and practical suggestions that really bring this book to life. This book is worth the purchase. I have told people that this book is life-changing! That is not a statement that I make very often. It builds on the material that I have been teaching for almost a decade in my psychology courses and demonstrates its application to contemporary living in Western society. I believe that we could live more fully if we implement the suggestions within this book.

Recommendation

I highly recommend reading this book! Those who live in the abundant West should especially read this book. It is written for a popular audience and I believe that it does an extraordinary job addressing that audience. While she deals with some complex topics; she does it in an accessible way. If you are struggling with a substance or behavioral addiction, or know someone who is, this book could provide the help you have been looking for.

I would also suggest that people-helpers in various vocations read it. Obviously, clinicians would benefit from it, but also, many other vocations which work with people would as well. There are many clinical tips in this book. Her interactions with patients are instructive in doing therapy. I picked up many helpful approaches for my clinical work.

When it comes to writing, the book that immediately comes to mind for me is GRIT by Angela Duckworth. Duckworth is a scholar but communicates in a very engaging narrative form. Even among the popular psychology books written by scholars, her book stands out in terms of writing. This book similarly stands out. I would still rate GRIT over Dopamine Nation in terms of the writing, but it is close. Not many scholars can write engaging popular-level psychology books like this one.  

Links

Book

Anna Lembke, Dopamine Nation: Finding Balance in the Age of Indulgence (paperback, 2023): https://amzn.to/3PEvrQP