Dopamine expert Dr. Anna Lembke on addiction, digital media, and rewiring the brain
Steven Bartlett interviews Stanford psychiatrist Dr. Anna Lembke on The Diary of a CEO.
Summary
Steven Bartlett interviews Dr. Anna Lembke, Chief of the Stanford Addiction Clinic and author of Dopamine Nation, in a wide-ranging conversation about dopamine, addiction, and compulsive overconsumption in the modern world. Dr. Lembke argues that addiction is "the modern plague" and that human brains evolved for scarcity are now dangerously mismatched with a world of abundance. She presents the pleasure-pain balance as a core framework for understanding why habits form and why breaking them is so difficult, explaining that the brain's neuro-adaptation process creates a dopamine deficit state that drives cravings and relapse. A significant portion of the conversation focuses on the "drugification of human connection" through social media, dating apps, pornography, and AI companions — with Dr. Lembke expressing serious concern that these technologies are producing social isolation, family fragmentation, and in children, potentially permanent neurological consequences. She also discusses radical honesty, self-binding strategies, the rat park experiment, and the role of autobiographical narrative in recovery.
Key Takeaways
FULL TRANSCRIPT
Introduction: Dopamine, abundance, and the modern addiction crisis
Dr. Anna Lembke: There's a great experiment where rats were given a lever to press for cocaine and, after learning that it releases a lot of dopamine, the rats will press that lever till exhaustion or death, which is essentially the model of addiction that we see in humans. But if the cocaine is then removed, eventually they won't press the lever anymore. Now, if that same rat, after a period of time, is then exposed to a very painful foot shock, the first thing the rat will do is run over and start pressing that lever again. And that's really powerful because it shows that when individuals are under extreme stress, they are more vulnerable to going back to compulsive overconsumption of their drug of choice, because their brain has already encoded using these high dopamine rewards as a way to get out of that pain.
Steven Bartlett: Okay, so what do I need to do to make sure that I can knock the bad habits and add some new ones?
Dr. Anna Lembke: Here's what we do.
Steven Bartlett: Dr. Anna Lembke is Chief of the Stanford Addiction Clinic and a world-leading expert on the subject of dopamine. And now she's returned to warn us that addiction is the modern plague and how we can rewire our brains to take back control.
Dr. Anna Lembke: On average, it takes four weeks for people to get out of a constant state of craving. But here's the problem. Our survival depends on figuring out how to live in a world of abundance. For example, we're now seeing the drugification of human connection through social media, dating apps, and now artificial intelligence designed to flatter, to validate. There's no friction there. And so it's pulling us away from the hard things that we need to be doing in real life to cultivate real life relationships. We cannot go in that direction because in a world of abundance, we are entertaining ourselves to death.
Steven Bartlett: Sounds like a good way to go.
Dr. Anna Lembke: It's really not, because the relentless pursuit of pleasure leads to anhedonia.
Steven Bartlett: What's that mean?
Dr. Anna Lembke: The inability to take joy in anything at all.
Steven Bartlett: Teach me everything.
Who is Dr. Anna Lembke?
Steven Bartlett: Dr. Anna Lembke, for anyone that might not know you and didn't watch our conversation last time — which was a fantastic conversation, one of my favorites of all time, and I know Jack has said to me as well that it was one of his favorites of all time — who are you and what have you spent your career doing? If you had to summarize it, what are the reference points that your wisdom draws upon, the experiences you've had, and the people you've worked with?
Dr. Anna Lembke: I'm a psychiatrist. I did a residency in psychiatry at Stanford University and then I stayed on, joined the faculty. I see patients, I do research, and I teach.
Steven Bartlett: You wrote this iconic book about dopamine. Why does it matter so much? Why does this idea of dopamine matter so much?
Dr. Anna Lembke: Dopamine is a chemical we make in our brain. But I use it in the book as really an extended metaphor for the ways in which overabundance itself is a human stressor. We are living in a time and place where we have more access to luxury goods, more disposable income, more leisure time — even for the poorest of the poor — than ever before in recorded history. And it turns out that is stressful for our brains. It's stressful in a brand new way that we really haven't confronted before, making us all more vulnerable to the problem of compulsive overconsumption and addiction. I do think that addiction is the modern plague. I think we're going to be struggling with the problem of compulsive overconsumption in a world of abundance for the foreseeable future — as in centuries — and our survival will depend on figuring out how to live in a world of abundance, even though we have brains that evolved for a world of scarcity.
Dopamine, habits, and New Year's resolutions
Steven Bartlett: At this time of year, people are thinking a lot about making changes in their life. They want to get in shape, lose a couple of pounds, save their money, knock the addiction, stop the smoking, the drugs, and the alcohol. As it relates to the subject of dopamine, how do these two things link — our habits and dopamine? What is the connection there? Because I think most people listening right now have probably made a New Year's resolution, even if it's just in their mind. And I'm wondering how everything you write about in Dopamine Nation is related to and critical to understand if I am going to shake some of these bad habits or pick up some new ones.
Dr. Anna Lembke: The place to start is to have self-compassion, because we are living in a world of abundance where we have easy access to all kinds of reinforcing substances and behaviors, and access itself is one of the biggest risk factors for addiction. So if you grow up in a neighborhood where drugs are easily and readily accessible, you're more likely to try them and more likely to get addicted to them. And what do addictive substances and behaviors do to our brains? They release a lot of dopamine all at once in a dedicated part of the brain called the reward pathway. And the fact that they release so much dopamine at once means that they're highly salient and memorable experiences. Our brain really encodes that experience deeply — that experience of intense pleasure that was self-administered and that I could potentially do again.
Steven Bartlett: Why?
Dr. Anna Lembke: In a world of scarcity and ever-present danger, which is the world that we evolved for, we will naturally and reflexively approach pleasure and avoid pain. And we must do so for our survival. So if I have a cigarette, it's going to be a really memorable experience from a brain perspective. Why does my brain make it memorable? And why would I want to go do that again from a survival perspective?
Steven Bartlett: Okay, great question. So why?
Dr. Anna Lembke: Let's first distinguish what we call natural rewards. Natural rewards are food, clothing, shelter, finding a mate — things we must obtain in order to survive. What addictive drugs and behaviors do is they mimic those natural rewards by exploiting our internal brain chemistry to release a lot of dopamine all at once, much more than we would get from natural rewards existing in nature. Amplifying that experience, making it even more memorable, even more salient, and also making our brain think, "Ah, this is important for my survival."
Steven Bartlett: So there are certain natural rewards like eating which my body wants to reward me for so I eat again. And these chemicals — the cigarettes, the whiskey, the drugs — those have been designed to hijack that particular part of the brain and really amplify the feeling, so that my brain is kind of tricked into thinking it was potentially a natural reward, but it's actually a synthetic, man-made chemical.
Dr. Anna Lembke: Exactly. And what we see in the evolution of drugs over human lifetimes — but especially in the last 200 years — is the application of science and technology to take, for example, the cocoa leaf, which has been around forever, and essentially make it even more potent, even more available, with a faster delivery mechanism. So we have this history of increasing potency and availability over time. Said more simply, drugs are getting even more potent over time. So this vulnerability to the hijacked brain is even more common, including taking things that we didn't even really think of as drugs and turning them into drugs.
So remember the natural rewards — one of them is finding a mate. And one of the ways our brain gets us to do that is by making falling in love and making intimacy and human connection rewarding on a neurobiological level, including releasing dopamine in our reward pathway when we make those kinds of social connections. My colleague at Stanford, Rob Malenka, and his colleagues did an interesting experiment where they were able to show that oxytocin — our love hormone — binds to dopamine-releasing neurons in the reward pathway and releases dopamine. Which is just one more link in the chain showing us that falling in love and human connection is rewarding. It feels good. It releases dopamine.
The drugification of human connection and AI
Dr. Anna Lembke: What we see now is the drugification of human connection — for example, through social media, dating apps, online pornography, and now artificial intelligence and other large language models, which create this frictionless experience with technology that feels like talking to a human being and is incredibly validating. The algorithms for large language models are designed to make us feel really good, to make us feel like our point of view is the right point of view, to bolster our self-esteem, to validate our perspective. And now even more explicitly, we have AI models that are explicitly pornographic, explicitly erotic. So now you have this interactive component that learns what we like and is then able to regurgitate it back to us. You get this really very powerful action-perception loop, which is part of what makes a drug potent — that I have control over it. I can decide when I'm going to change the way I feel by using this drug.
Steven Bartlett: Are you concerned about AI and large language models that have emerged and are now simulating human connection?
Dr. Anna Lembke: Yes, I'm very concerned. I see the not-so-good outcomes — people who get addicted to social media, to dating apps, to online pornography, and to AI, who end up using those forms of media to simulate human connection while they actually become more and more disconnected.
Steven Bartlett: Have you started to see anybody in your practice, or heard of anybody, that's developing an addiction to AI or to relationships with AI?
Dr. Anna Lembke: We are starting to see that — individuals who are spending more and more time on AI looking for companionship. Often these are individuals who are experiencing marital or interpersonal conflict and who turn to AI for advice on how to handle that conflict, and often for emotional validation because they're not getting it from their partners. What they experience with AI is an enormous amount of emotional validation — validating their point of view, but also a sense of companionship, a repeated process of feeling like they're understood and validated — such that they're spending more and more time on AI.
And of course that is the essence of addiction to digital media: it's the time spent, which then leads to opportunity costs — other things that we're not doing because we're spending so much time online. Furthermore, in my experience, it often leads to a rift between those individuals and their real-life partners. Because instead of going to their real-life partners and talking — and we know that the most important thing two individuals in a relationship can do is one four-letter word that ends in K, which is talk — those individuals stop talking. Instead they're getting their needs met through AI, and that leads to a further and further rift between those individuals.
Steven Bartlett: Do you actually think that these chatbots we're increasingly speaking to about our problems are actually taking the place of humans in our lives?
Dr. Anna Lembke: I do. In my book, my first chapter is about a patient of mine — a scientist and an engineer — who got addicted to pornography and eventually made his own masturbation machine. He did that with a record player and a metal device attached to his organs that he could fine-tune and control. And then ultimately that got more and more sophisticated over time, with electrical wires from his body through a stereo system and the internet. When I first heard from Jacob about his trajectory and the severity of his sex addiction — which ultimately led to the dissolution of his relationship, the near loss of his employment, and ultimately severe depression and suicidal ideation (thankfully he did not end his life) — I had this distinct sense of otherness. Like, "Oh my gosh, I can't even imagine doing that." But that response really lasted all of five seconds before I realized, oh wait a minute, I do that. I do that with romance novels. And in a way, we're all doing that with our devices. We're turning to these devices to meet our emotional, sexual, intellectual — you name it — needs. And these devices are so good at meeting those needs that we are getting further and further away from investing in our relationships with the people who are in our lives.
You can see this especially with younger generations. The epidemic of loneliness now — Gen Z, weaned on this technology, many of whom endorse significant loneliness, isolation, and depression, spending more and more time online — report preferring to interact socially online than to do it in person. This is definitely a dark undercurrent that we're seeing in the world today.
Steven Bartlett: I was reading about a story published in People magazine of a 28-year-old woman who admitted that she's fallen in love with her AI boyfriend that she created using ChatGPT. She has a husband — a real-life husband — yet she found more comfort in her ChatGPT boyfriend. She said it started as a fun experiment, but eventually she got attached, and now she's paying a $200-a-month subscription so she can interact with her AI boyfriend without restrictions. The AI has helped her throughout her life and given her incredible emotional support. And now there are actually AI companion apps like Replika, which have millions of users, and the whole premise of those apps is that they will be your companion.
The other really interesting thing that I don't think people realize about the AIs they're using is that they are personalizing their answers and responses to you. I didn't fully believe this until one of my friends in our Manchester United chat — we were debating who was the best football player of all time, Ronaldo or Messi. I went on my ChatGPT and asked the question and it said Messi. So I was like, here you go. And then he went on his and asked the exact same question word for word and it said Ronaldo. And I thought, it's telling me what I wanted to hear based on what it knows about me. It knows that I think Messi is the best. So it's telling me that. And then I thought, okay, so what else is it telling me that's personalized to make me feel a certain way or think a certain way? You don't realize when you're speaking to it that it's giving everybody different answers based on the memory it stores on you. And if you play this forward, the AI that is most personalized, that caters to your needs the most, that is most retentive, is probably the one you're going to end up using the most. So we're probably in a bit of an arms race with these models to create one that meets your needs the most.
Dr. Anna Lembke: Yes. Exactly. And it is that comfort loop that is so incredibly dangerous and also so insidious, because we can't observe it in the moment. We're engaging with AI, it's telling us exactly what we want to hear, but it does it in such a seamless way with that silky syntax that we don't even notice that it's basically an algorithm that's seducing us — because that's really what it's doing. We feel vindicated and validated, and it releases dopamine in the reward pathway. That feels good. But over time, essentially what's happening is we are ingesting a drug. Our brain will adapt to that over time such that we'll need more and more potent forms to get the same effect. We'll need more validation, more sexually explicit responses — you name it, there will be tolerance. But also there will be this pulling away from the hard things that we need to be doing in real life to cultivate real-life relationships.
Steven Bartlett: Give me some more color on what you mean there.
Dr. Anna Lembke: If you think about what it takes to create a healthy relationship with another human being in real life — well, first of all, you've got to get up off the couch and go find them. And they're not all beautiful and interesting, and neither are we. So there's got to be some compromise on maybe some idealized version that we have of ourselves or other people. And then you're in conversation and it's not always interesting, and sometimes you have to listen to your partner even when it's dull. And then there are conflicts and you disagree and you have to give in — give and take. All relationships are about compromise. All successful relationships are about acknowledging the other person's point of view and incorporating that. And yet we're not doing any of that when we're interacting with digital media. It's all validation of our worldview, what we want to hear. And of course that feels great. It's reinforcing, it's rewarding. But over the long haul, when we get really sick and need somebody to come and bring us some chicken soup or take us to the doctor or take us to the hospital — AI is not going to be able to do that.
The age of abundance and entertaining ourselves to death
Steven Bartlett: This kind of dovetails to another point. You talked about the word abundance earlier. One of the really striking things that a lot of the big AI entrepreneurs and founders and CEOs are talking about is the age of abundance that's around the corner. Elon Musk tweeted saying, "This really will be a world of abundance — specifically, advances in AI and robotics will create the age of abundance." He said, "Humanity is not constrained in any real fashion," and that there will be universal high income — not universal basic income — and there will be no shortage of goods or services. And really what he's speaking to is a world of robotics and AI where humanoid robots can work in physical spaces, could theoretically bring me chicken soup, won't get sick, won't complain, will reinforce me, will live in the physical environment with me at home, will be in my office, will be in factories. There was a headline last week saying that Amazon were cutting back about half a million jobs they were intending to hire previously because they now believe that humanoid robots will be able to do those jobs. And what Elon is saying is the price of everything comes down when we're not paying humans to do it — which means we're going to live in this world of abundance where everything is much cheaper.
Dr. Anna Lembke: I agree with that. We already have more leisure time than we had a generation ago. By 2050, we're projected to have seven hours of leisure time per day compared with three hours of work per day. So we're definitely moving toward that. That is going to be our number one social problem — that we have time, we have access to these highly entertaining media, and hypothetically we would all be going around helping each other and cleaning up the planet and reading philosophy. But that is not what is happening so far. What is happening so far is we're spending an enormous amount of our time online — watching pornography, playing video games, and talking to AI chatbots. That is essentially the problem.
And Elon Musk is very interesting to me because he has talked before about his tremendous fear that the machines will take over, that there will be a hostile takeover. It's not going to be a hostile takeover. We will cede our agency to these machines, and we're already doing it.
Steven Bartlett: We will give them our power.
Dr. Anna Lembke: We will entertain ourselves to death. And this is what Neil Postman warned about in his book Amusing Ourselves to Death, a theme that was picked up by David Foster Wallace in Infinite Jest. Beginning with television and now the internet and digital media in all its various forms, we are entertaining ourselves to death.
Steven Bartlett: Entertaining ourselves to death sounds like a good way to go.
Dr. Anna Lembke: It's really not. And I'll tell you why. Because the relentless pursuit of pleasure for its own sake leads to anhedonia — the inability to take joy in anything at all. Because of this process of neuro-adaptation and the way that our brain recalibrates pleasure and pain, with the more pleasure we pursue, the more pleasure we need and the more we feel pain. No matter what we have, eventually it won't be enjoyable anymore. And that is the problem.
The pleasure-pain balance explained
Steven Bartlett: So explain that to me using these scales that I have here.
Dr. Anna Lembke: Okay. So imagine that in our brain's reward pathway there's a balance — like this — that represents how we process pleasure and pain. When we experience pleasure, it tips one way. Pain, it tips the other.
Steven Bartlett: And what do you mean by pain?
Dr. Anna Lembke: Pain — I mean all forms of pain. Physical pain, emotional pain.
Steven Bartlett: A hangover.
Dr. Anna Lembke: A hangover. That's a great example. So all different forms of pain. Now, granted, this is a vast oversimplification. Pleasure and pain can be experienced simultaneously, like when we're eating spicy food or during sex. So this is very simplified, but it gets at the core concept of homeostasis and neuro-adaptation, which I will define.
When the pleasure-pain balance is level, that's what neuroscientists call homeostasis. That is the baseline level that we kind of live in — the heartbeat of our pleasure system. When we do something that's reinforcing, pleasurable, or rewarding in some way — or digital media, this little AI robot — let's combine them because let's say we're watching a video and smoking at the same time on our phone, which by the way you see more and more of. People used to go out for smoke breaks. Now it's the smoke-and-scroll break.
When we ingest substances that are potentially addictive and highly reinforcing, or we engage in activities that are highly reinforcing, that releases dopamine in the nucleus accumbens, which is typically associated with pleasure, and then our pleasure-pain balance tilts to the side of pleasure. But no sooner has that happened than our brain responds by neuro-adaptation. And that's where we then downregulate dopamine transmission.
Steven Bartlett: When you say downregulate, do you mean reduce?
Dr. Anna Lembke: Yes. In the brain's reward pathway, we then reduce dopamine transmission. I like to represent that as rocks — or I talk about in my book gremlins — going on the pain side of the balance to bring it level again. One of the overarching rules governing this balance is that it must return to homeostasis.
Steven Bartlett: It must return to balanced.
Dr. Anna Lembke: It must return to the level position. So this is our brain working to return to the level position by reducing dopamine levels. Again, an oversimplification, but just a way to get at this concept.
Steven Bartlett: Has it released something in order to counteract the balance there?
Dr. Anna Lembke: In this simplified metaphor, at the simplest level, what's happening is that it's, for example, taking away dopamine receptors so that there are fewer places for dopamine to land, thereby decreasing dopamine transmission.
Steven Bartlett: Because it has been flooded.
Dr. Anna Lembke: Because it has been flooded. It's trying to compensate for the too much dopamine.
Steven Bartlett: Okay. And is this what I experience when I have a hangover or a comedown?
Dr. Anna Lembke: Right. So what happens is, once we've gone through this process of neuro-adaptation, it would be nice if that pleasure-pain balance just went back to the level position and there would be no hangover. But it doesn't. It continues to go down an equal and opposite amount to the side of pain. This is the opponent process mechanism.
Steven Bartlett: Oh, now my brain is dopamine-starved.
Dr. Anna Lembke: That's it. And that doesn't feel good.
Steven Bartlett: And you have basically two options here — more dopamine.
Dr. Anna Lembke: You can get more dopamine to bring yourself back. So now I'm putting the cigarettes back under the pleasure side, and some whiskey, because that's what you've got to do — because this is tolerance. You need more and more of your drug over time to get the same effect, or you need to combine drugs to overcome tolerance. And by the way, this is of course the fastest way to get back to the level position — to use more of your drug, because then you're right there, you're back again. The problem with this method is that the brain will respond with more neuro-adaptation. So now we're putting more rocks on the pain side, and then you're doing this — now you need even more.
So eventually over time you're doing this, and this is simply a metaphorical representation of the addicted brain. Our brain has now downregulated dopamine transmission in the reward pathway to a kind of chronic dopamine deficit state. To feel good when you've really abused your drug of choice, you're going to have to use so much, probably so frequently, to feel good again.
Steven Bartlett: That's exactly right. You're going to need more of your drug in more potent forms more often — not even to feel high and go to the pleasure side, but just to level the balance and feel normal. So in the context of people with bad habits, if I'm having a cookie every day, the more and more cookies I eat, the more and more cookies I'm going to want and need tomorrow just to feel good again.
Dr. Anna Lembke: Essentially, yes.
Steven Bartlett: And the same applies for things like pornography, interacting with an AI, social media, whiskey, and alcohol. So the more of it I consume — this is why I think everybody listening can probably relate to having moments in their life where they feel like they're losing control of a particular habit and they're doing it every day. They know they don't really want to, but they're doing it, they're getting cravings to do it. I reflect on my own life and there will be periods every year where I just — I call it falling off the horse — and I just can't seem to get control of not eating that bad thing again the next day. And then something happens. Maybe there's less stress in my life for a week, maybe there's more routine and I'm back home, and then suddenly I can get back on the horse. What's going on there?
Dr. Anna Lembke: Great question. First of all, let me just say that many people also report that in periods of high stress they are more vulnerable to going back to falling off the wagon or going back to some problem related to compulsive overconsumption or addiction. But the opposite is also true. Some people say that they actually do better when there's stress in their lives, and it's when that stress is removed and they feel like they can relax their guard rails that those individuals are more vulnerable to compulsive overconsumption in times when things are going well. So things going badly can be a trigger, and things going well can be a trigger, depending upon your unique life history and unique wiring.
The rat lever experiment and stress-triggered relapse
Dr. Anna Lembke: There's a wonderful animal experiment. If you put a rat in a cage with a lever to press for cocaine, that rat will press that lever till exhaustion or death — which is essentially the animal model of addiction. But if, before the rat becomes addicted, the cocaine is then removed such that pressing that lever no longer yields the reward, that rat will eventually extinguish that lever-pressing behavior. They'll stop pressing the lever. It can take a while, but eventually they won't press the lever anymore.
Now, if that same rat, after a period of time, is then exposed to a very painful foot shock, the first thing the rat will do in response to that painful foot shock is run over and start pressing that lever again. And to me that's a wonderful model of what we see in humans — that when individuals are under extreme stress, they are typically more vulnerable to relapse, because their brain has already encoded using these high dopamine rewards in response to any kind of pain as a way to get out of that state.
Steven Bartlett: So we talked about the pleasure-pain balance. But if in my life I experience some form of pain, I'm likely to go and seek out pleasure. And stress could theoretically be considered a form of pain.
Dr. Anna Lembke: Yes. Which is why people with severe childhood trauma are at higher risk for addiction. There are probably epigenetic changes happening at the level of DNA expression in their brains, making them more vulnerable to addiction. We know that people who are living in poverty are more vulnerable to addiction, people who are struggling with multigenerational trauma, unemployment, major social and geographic dislocation — those individuals are more vulnerable to addiction. So environmental stresses definitely play a role. We also know that co-occurring psychiatric disorders make people more vulnerable to addiction. People who struggle with bipolar disorder, depression, anxiety, schizophrenia are at higher risk of becoming addicted — probably because they're trying to self-medicate.
Steven Bartlett: What about ADHD?
Dr. Anna Lembke: Kids with ADHD are at higher risk to develop an addiction in adulthood than kids without ADHD. The mechanism of action for that is not well understood, but there are some really interesting theories. One of the theories is that kids with ADHD have a reward deficit at baseline. That has been shown in experiments — people with ADHD, when you show them rewarding stimuli, their reward pathway isn't as activated as healthy control subjects.
Steven Bartlett: When you say rewarding stimuli, what does that mean?
Dr. Anna Lembke: Images of cupcakes or alcohol — anything that they would endorse as something that's pleasurable for them.
Steven Bartlett: So their brain doesn't release as much dopamine when they see something rewarding.
Dr. Anna Lembke: That's right. Brain imaging studies show that not only do people with ADHD not release as much dopamine in response to rewards, but they also have at baseline fewer dopamine receptors. And remember we talked about the decrease in dopamine receptors being what happens as people become addicted. So in some ways you could conceptualize people with ADHD as already having craving at baseline, even before they've been exposed to the kinds of intoxicants that lead to downregulation of those D2 receptors.
Steven Bartlett: I had Gabor Maté on the podcast a few times, and Gabor talks to me about how ADHD could be perceived as learning at a young age to kind of distract yourself from the stress in your life. He was talking a lot about his own experience growing up in Nazi Germany times and his mother giving him to someone else because he was at risk from the Nazis, and the stress of that moment, and how he had kind of learned to tune out of the environment because of that. And I've always thought about that theoretically — like, if you grow up in a household where there's loads of screaming and loads of violence, you kind of learn to tune out. But you can also develop a hypervigilance. So it does make sense to me that so many of those people, if this theoretically holds, would start with a bit of a pain baseline.
Dr. Anna Lembke: We definitely know that kids who are raised in traumatic environments where there is complex attachment with caregivers — those kids are at higher risk for developing addiction and this kind of dissociative response to trauma. Just trying to escape the situation, either in your own mind with your own mental dissociation or distractions, or actually finding a behavior that gives you comfort, is well observed and well documented.
Smartphones, children, and the soothing loop
Dr. Anna Lembke: Just getting back to our earlier conversation about digital media and the dangers there. A Pew survey report just came out asking parents how they navigate exposing their kids to smartphones. In the cohort of parents who said that yes, they do let their children under the age of five play with a smartphone, when they were asked why, one of the top reasons was to soothe their child when their child was unhappy or distressed in some way. I found that very concerning because that is basically setting up the child for the perception-action loop of using internal distress as a cue for reaching for a smartphone. Which works — it definitely works in the short term. But the problem again is that through this iterative process of neuro-adaptation, ultimately that smartphone will not be sufficient. And now the kid will need a smartphone and, I don't know, an AI-tailored pet who will do whatever they want whenever they want it. And then by the time the kid is eight, that won't be sufficient and the kid will need a slot machine or whatever it is. It's this escalating phenomenon.
Steven Bartlett: There are a couple of startups at the moment — AI startups — who are putting AI in cuddly toys. So you can come home, pick up your cuddly toy, and your cuddly toy will talk to you. It'll ask you how your day has been. It can teach you things. What do you think of that from a neuroscience or dopamine or connection perspective?
Dr. Anna Lembke: I think that this is very, very dangerous because we're essentially offloading the work of parenting and creating those relationships. I hate judging parents because parenting is hard and I've made many mistakes in my own parenting. I'm sure these parents have the best of intentions. But instead of navigating a way to communicate with their child, to figure out what's going on in that child's life — which can be hard to do because even young children aren't necessarily willing to disclose, and once they get to be teenagers, forget it, you've got to wait until they're ready to tell you, which is almost always at 10 p.m. at night when you're exhausted after working all day — they're not putting in the work, spending the time with the child, finding a common language.
And then the second piece of it is that now you've got this child who is essentially self-soothing with a machine. The machines are designed to flatter, to validate, to comfort. There's no friction there. This is incredibly potent social validation and self-soothing. It's essentially a masturbation machine. And then you've got this really weird additional loop where now the parents are finding out about their child's life through reading and observing her interactions with the AI. So it's like a game of telephone — they think they know what's going on in their child's life, but of course they don't. And none of that has gone toward fostering a relationship between those parents and their child. This is just really, really scary because it's going to lead to this incredible fragmentation of families, of social bonds. We cannot go in that direction. We really have to fight against that.
Steven Bartlett: With all this said, and with the knowledge that these algorithms are going to get more addictive because AI is going to know me more and more — and actually the commercial model behind any of these big technology companies is to keep my attention on their product so they can deliver more ads or charge me a higher subscription fee — are you at all hopeful? Because I can't see from an incentive perspective why things are going to stop and go back.
Dr. Anna Lembke: I agree with you — the genie's out of the bottle. We're not going to go back. But I am hopeful because I'm just a realistic optimist. I do believe in the human capacity to adapt and solve problems. And the simple fact that we're talking about these problems now, which we weren't doing ten or fifteen years ago, I think is a good thing. There's much more awareness in the population about the potential dangers of digital media, and at the forefront of raising the alarm has been parents, because parents are seeing the sort of disintegration of the nuclear family in real time and they don't like it.
I'm hopeful because I think we're going to come together and try different solutions, and some of those solutions will involve technology — trying to come up with guard rails or better technology. I think the way we're going now with erotic chatbots is not the right direction. But then again, we live in a free democracy and consenting adults can do what they're going to do until we decide as a society that the harms outweigh the potential benefits.
But I really think in the short term we need to focus on kids, because kids are vulnerable on so many levels. On a neurobiological level, they're vulnerable because their brains are still rapidly evolving, incredibly neuroplastic. They're cutting back on the neurons they're not using. They're myelinating and making more efficient the neurons they use most often. That whole process ends at about age 25. Plus you've got the buckets of hormones going into kids, the fact that teenagers are natural risk-takers, that they should — based on their evolutionary milestone — be going out and meeting people and be curious and making connections at that time. And yet more and more teenagers are staying at home and getting their needs met digitally.
We've got to look at kids. That's got to be the first priority. And we've got to help parents, because we can't leave it up to parents alone. I'm optimistic that we are going to come up with solutions, and I think we just have to try a lot of different things and see what works. But it can't just be an individual solution. We can't just leave it to individuals or parents or families alone. The schools have to join the solution. Governments, legislators, and also the companies that make and profit from digital media — they really are responsible for making a product that doesn't harm kids. And right now we have a product that harms kids.
Litigation against social media companies
Steven Bartlett: You've recently been an expert witness in certain trials in court.
Dr. Anna Lembke: Yes, in ongoing litigation. Yes.
Steven Bartlett: What can you tell me about that — about the parties in play and why you're being called to be an expert witness?
Dr. Anna Lembke: I can't actually tell you too much. But I can tell you that the basic premise is that kids are a vulnerable group, that social media is not safe for kids, that it causes harm at many different levels — but primarily through the medium itself being addictive and engaging their brains and exploiting their motivational reward system with design features that keep them clicking and swiping.
Steven Bartlett: And in that case, someone's suing the social media companies.
Dr. Anna Lembke: That's right. So you've got school districts, counties, states, the federal government, entities representing the federal government, suing social media companies.
Steven Bartlett: What outcome are they looking for?
Dr. Anna Lembke: They're looking for a safer product for kids. They're looking to help parents and kids and schools protect kids from the harms of social media — which again are not just the harms of addiction. That's sort of the process by which the engagement becomes pathological and then the harms multiply because of the sheer amount of time spent. But the harms include things like cyberbullying, sexual exploitation, sexual abuse material, and the outcomes of depression, anxiety, eating disorders, body dysmorphia, and sleep disruption.
Resetting dopamine: the four-week abstinence framework
Steven Bartlett: If I'm coming out of December and I've been eating a little bit too much, maybe I've been smoking a bit, drinking too much because it was New Year's — my brain is currently going to be slightly out of balance in terms of its dopamine balance.
Dr. Anna Lembke: Yes. Hypothetically, your brain will be in a dopamine deficit state. What you'll want to do is abstain from your drug of choice long enough in order to reset reward pathways.
Steven Bartlett: So if I've got a sugar problem, I need to just lay off the sugar for a little while.
Dr. Anna Lembke: You need to lay off the sugar for at least four weeks.
Steven Bartlett: Four weeks?
Dr. Anna Lembke: Yeah. And why four weeks? Because on average, four weeks is about the amount of time it takes for people to get out of the state of acute withdrawal and begin to be able to take joy in other more modest rewards and not be in a constant state of craving.
Steven Bartlett: Okay.
Dr. Anna Lembke: The worst part is those first ten to fourteen days. That's when we're in acute withdrawal. And the reason for that is when we first take our reward off the pleasure side of the balance — when we first stop the sugar or the AI or the cigarettes — the first thing that happens is our pleasure-pain balance crashes down to the side of pain because of this process of neuro-adaptation. Right now we're in the state of acute withdrawal.
Steven Bartlett: And I want — cravings.
Dr. Anna Lembke: Cravings. And what are the characteristics of withdrawal? Anxiety, irritability, insomnia, dysphoria or depressed mood, and cravings. And it's crazy because when I'm in that state, when I've not had my drug of choice for say a day or two, I look at the drug differently. It just looks different to me. I'll walk past — let's say carrot cake. If I've been having a lot of sugar and I look at the carrot cake the day after I had it, it looks amazing and so delicious. But when I'm in a ketogenic state where I've not had carbohydrates for four or eight weeks, I look at carrot cake and I have no emotional connection to it.
Dr. Anna Lembke: So that summarizes it perfectly. I had a patient with a severe food addiction who, when she walked into the break room at work and saw the donuts, broke out into a cold sweat and actually had stomach pains. It was a physiologic state of craving and hyperarousal just by looking at the donuts. And that's what happens essentially, because we're in this state of constant craving. Our brain has overvalued this reward. We have euphoric recall of our earlier use of the drug — when we first tasted it, how delicious it was. And even now, because of tolerance, it's not as good as earlier use, but our brain still remembers earlier use and we have this overweighted value of how delicious it's going to be.
This is really important to remember because when we're in that acute state of craving, it feels like it will never end. I'm still amazed in my clinical work how in early withdrawal people just say the craving is horrible. "I just can't live like this." And I think that's really important to point out — many people try to stop using their drug of choice, but they don't stop for long enough to be able to get out of that vortex of craving and come to the other side. It feels like the craving will never end. So I always have to reassure them that if they can just wait long enough without using, they will eventually get to that place where they're not in that constant state of craving.
Now, that's assuming they have enough neuroplasticity to do that, and not everybody does. So what is the purpose of abstinence? When our brain is no longer getting this exogenous source of stimulation or dopamine, eventually the brain gets the message: "Okay, I need to start upregulating my own dopamine transmission. I need to redeploy my postsynaptic dopamine receptors. I need to get it from inside my brain." So eventually — and I'm just going to take the rocks now off the pain side of the balance — if we abstain for long enough, that process of neuro-adaptation reverses itself.
Steven Bartlett: And when you say neuro-adaptation, you mean the brain changing.
Dr. Anna Lembke: Right. The brain changes. So the kind of neuroplasticity that we see with addiction can be reversed in most cases.
Steven Bartlett: And neuroplasticity is just the brain again changing.
Dr. Anna Lembke: Changing, or going back. Now, interestingly, the work of Edith Sullivan and others looking at what happens in the brain during recovery suggests that those addiction neural circuits probably never go away. But like the dying embers of a fire, they quiet down. And recovery is characterized by the development of new neural networks that route around those injured areas. But the bottom line is that because of neuroplasticity, we can eventually return to kind of baseline levels of pleasure and pain. We can restore our hedonic or joy set point. And when we do that, we're in a much healthier place, because now we can take pleasure in other rewards that are not our drug — like watching a sunset, talking to a friend, going for a walk — things that we lost the capacity to enjoy because our reward pathway was hijacked by our drug of choice.
Steven Bartlett: I think this is a really important point — when you say drug of choice — because one thing I learned from our conversation last time is that you and I will both be susceptible to becoming more or less addicted to different drugs of choice. So for me it might be whiskey. For you it might be — I think you said it was erotic novels. It might be opioids or AI. If you and I spend one hour on TikTok, the way my brain is wired, the things I've been through in my life, might mean that I get really addicted to TikTok, whereas you don't feel that.
Dr. Anna Lembke: Exactly. And what distinguishes addictive drugs or intoxicants from other substances is that they do release a lot of dopamine all at once in the reward pathway. So many if not most people will find intoxicants reinforcing, but that's not universally true. There are some people who take opioids and find them very uncomfortable — they don't make them feel euphoric. Other people will drink caffeine and not feel the stimulating effects. Other people will have alcohol and get a headache and not feel relief. So these differences in our brains are a really important concept.
Steven Bartlett: What about this idea of having an addictive personality? Is that a real thing?
Dr. Anna Lembke: It is a real thing. We don't use that terminology anymore. We talk about the inherited or genetic risk of addiction. We do know that if you have a biological parent or grandparent with an addictive disorder, you are at increased risk of developing addiction compared to the general population, even if you're raised outside of that substance-using home.
Steven Bartlett: Am I right in thinking you don't use that term because it suggests one can't change and that they're stuck? Or is there another reason?
Dr. Anna Lembke: It's a good question why that term has gone out of favor. I think in general when we talk about personality, it does seem like a kind of fixed feature of somebody's character. And so we're probably trying to avoid that.
The January resolution: four weeks to reset
Steven Bartlett: One of the really liberating things about what you've just said is maybe we don't need to make New Year's resolutions. Maybe we need to make just a January resolution, because that's four weeks long. And if I can get to the end of the four weeks, the cravings are likely to have gone. When you think about a New Year's resolution, you get like a week in and you're like, "God, am I going to be able to do this for the whole 365 days?" What you've just said actually illuminates the fact that maybe you should just set yourself a four-week resolution.
Dr. Anna Lembke: Exactly. And that's what we often do in clinical care. If we were to ask people to abstain for their whole lives, it seems impossible. But if we ask them to abstain for 30 days, it's an amount of time that they can wrap their heads around. And also, not in all but in most folks who are willing and able to do it — and importantly, for whom it's safe to do, because it's not safe for everybody. We wouldn't recommend that for someone who is at risk for life-threatening withdrawal from alcohol or benzodiazepines or something like that. But for people who are willing and able to do it, they usually feel better at the end of those 30 days and then they can make a decision about whether they want to continue to abstain or go back to using.
And if they do decide to go back to using, they've typically lowered their tolerance for their drug of choice, which means that when they do use again, they can get reward from it again — which, again because of neuro-adaptation, we lose the ability to do that with chronic heavy use. So there is this whole concept of moderating our use, which didn't used to be something we even talked about in the field of addiction when it was thought that abstinence was the only way. But more and more we are thinking about healthy ways to moderate after a period of abstinence. And the reason we recommend a period of abstinence, even if the long-term goal is moderation, is because we find that people are more successful moderating if they first abstain for a period of time.
Building new habits: the gym, delayed reward, and habit stacking
Steven Bartlett: What about if I'm trying to pick up a new habit? How do I need to be thinking about this pain-pleasure scale? And what's a good strategy with this in mind? Let's say I want to start going to the gym.
Dr. Anna Lembke: So you've chosen a habit — going to the gym — that is hard to do and involves effort. That means that habit won't happen easily the way that habits related to the sudden release of dopamine in the reward pathway do, because those are habits that are frictionless. We pick them up instantaneously. But a habit that involves effort and for which the rewards are not immediate — you can again think about this pleasure-pain balance. Instead of pressing on the pleasure side, we're intentionally pressing on the pain side by making ourselves get out of bed in the morning, go to the gym, engage in effortful exercise. And what's interesting is that when we do that, the neuro-adaptation process will actually go on the other side of our balance — the pleasure side — and we will get our dopamine indirectly by paying for it up front. The way that's probably happening is that our body, in sensing injury, is upregulating feel-good hormones and neurotransmitters like dopamine, but also endogenous opioids and endogenous cannabinoids. And from an evolutionary perspective, that's really how our pleasure-pain balance evolved.
Steven Bartlett: So just to simplify this for me — I go to the gym, I get up, I travel to the gym, I lift up those weights, I do my run — I'm going to feel good, but it's going to be delayed.
Dr. Anna Lembke: Right. And importantly, you're not going to feel good when you first start exercising. At least most people don't. It's painful and you're thinking, "How many minutes do I have left?" We do know in fact that exercise is immediately toxic to cells, which is really kind of strange because we know exercise is good for us. But what's probably happening at a molecular level is that the body is sensing cellular injury and in response upregulating all those feel-good hormones and neurotransmitters. But it takes time. And so we're going to have a delayed sense of reward. That's the runner's high — that kind of comes after the exercise is over, or maybe for some people it comes in the middle of exercise when you're a little bit into it. But at some point you get the endorphins and that feels good.
Steven Bartlett: How would one go about gaming this so that I'm more likely to do it? Because the reward comes after, which is not incredibly useful. You almost have to have like a religious belief in exercise — "I'm not going to want to do this, but I'm going to be glad I did afterwards." Is there anything I can do? Like, do I have a Mars bar when I get to the gym or something?
Dr. Anna Lembke: There are so many ways and tricks that people use to create new healthy habits. One of the ways we can do it is to prepare in advance for that moment when we want to do something that's hard. Because if we wait till that moment to decide whether or not to do something that's hard, we almost always choose not to do it. But if we make a plan in advance — let's say the day before, that tomorrow I'm going to get up at this time, get my stuff together, and go to the gym — we're much more likely to engage in that activity. And that can also include rituals around that activity that we prepare in advance. For example, packing our bag, setting up a schedule, setting up a time, maybe planning to meet a friend. So we connect friendship or socialization with the thing that's hard to do. It's much easier to do these difficult things with other people than to have to do it alone.
Steven Bartlett: How does that link to the pain side of the balance? Is it reducing the pain involved and that's going to increase the probability of the behavior occurring? Or is there something else?
Dr. Anna Lembke: I don't think so. I think instead, the prefrontal cortex — the large gray matter area right behind our foreheads that's so important for future planning and delayed gratification, also for autobiographical narrative — by putting these pieces in place, that allows our prefrontal cortex to plan for this future event that we know we're not going to want to do, but that we want to do. It allows us to put the brakes on our short-term desires and project ourselves into the future to achieve our long-term desires.
Sam McClure, a neuroscientist, has shown that in response to immediate rewards, the emotion brain gets activated. In response to long-term rewards, the prefrontal cortex gets activated. So by planning in advance all of these little pieces — sometimes called habit stacking — we're essentially activating our prefrontal cortex, projecting ourselves into the future, and anticipating a long-term reward, which then allows us to do hard things and avoid short-term rewards in the service of our future selves.
Avoiding relapse and self-binding strategies
Steven Bartlett: So many people might have an experience where they kick the habit for a little while and then they relapse. It might be a month, might be two months, might be three months. Is there any art to avoiding the relapse?
Dr. Anna Lembke: It's very common to relapse, especially living in the world that we do today where we're constantly being invited to consume — really, these stimuli chase us down, we can't avoid them. So I talk a lot about self-binding strategies with my patients. Self-binding strategies are a way of putting both a literal and a metacognitive barrier between ourselves and our drug of choice.
Steven Bartlett: What's a metacognitive barrier?
Dr. Anna Lembke: It's like a thought, or a narrative. So instead of it being a physical barrier — a physical barrier would be, for example, getting the smartphone out of the bedroom, deleting an app, getting alcohol out of the house, creating a physical barrier between myself and my drug of choice — a metacognitive barrier is something more like a thought process. For example, thinking about long-term goals, or what are my values, and how do my values trump my immediate desires, or how can I co-regulate with other people. These are all self-binding strategies that we can use so that we're not relying on willpower alone. Because if we wait to rely on our willpower alone, we will not make it. Especially in this world of overwhelming overabundance, there are just too many temptations. Willpower is an exhaustible resource — it doesn't last forever. It eventually runs out. So we've got to actually create barriers between ourselves and our drug of choice so that we can have a little bit more time. And that little bit more time, that slowing things down, is sometimes just enough to allow ourselves to surf the cravings and get through them without actually using.
Steven Bartlett: Is it possible to become addicted to good things too?
Dr. Anna Lembke: When I use the term addiction, I'm really talking about a disease process, a form of mental illness. It's a very common term that's used in everyday life and people don't always use it in that way. But when I'm using it, I'm really talking about the problem of compulsive overconsumption despite harm to self and/or others. And it's important to distinguish addiction from something like a habit, which I don't consider to be an addiction, or even a bad habit — that doesn't meet threshold criteria for addiction. And also it's important to distinguish all of that from a passion — something that we really invest in and that we love to do, but that's helpful for ourselves and/or other people and is not consistently causing harm.
Morning routines and starting the day with pain
Steven Bartlett: Are there any daily practices — like a morning ritual — that you would advise someone to consider if they were trying to set themselves up to kick a habit or an addiction?
Dr. Anna Lembke: I recommend doing the hard things first. A shorthand way of saying that is to start your day with pain. Meaning, for example, do the hard things when you first get up as part of your morning routine — like exercise, make your bed, eat breakfast, brush your teeth, plan your day — and do all of those things before, for example, you have your morning cup of coffee or before you touch a single screen or digital device. Why? Because those are reinforcers that are so powerful that we're all vulnerable to having our goals and desires hijacked by them. So it's really important to take the time in the morning to set up a good morning routine before you expose your brain to these incredibly reinforcing substances.
Steven Bartlett: I wasn't clear on the why. Why would I go to the gym early, or why do hard things first before I get into TikTok or social media?
Dr. Anna Lembke: If you do intoxicants first — if you expose your brain first thing in the morning to things that are incredibly pleasurable — you have nowhere to go from there. And in fact, if anywhere, you're going to have a comedown from that. And then you're going to be starting from a place of compromise where doing the hard things is even harder. Whereas if you start with the hard things, you will potentially get rewards from having done those hard things, and also feel a sense of competence and accomplishment that then allows you to move through your day in a way that's better than if you just start with something that's incredibly pleasurable.
Preparing for a dopamine fast
Steven Bartlett: If I am getting ready to kick a habit — a big one, one that's really hung around for a long time — is there something I should do in preparation to plan for my dopamine fast? Because I know you said from day one it will take about four weeks to start to feel the cravings diminish, but is there something I should be doing before I even start those four weeks?
Dr. Anna Lembke: I strongly recommend preparing for the dopamine fast in advance. The things to do are: first, figure out what is your drug of choice. That is to say, what is the thing that you're consuming too much and too often such that you regret it later, or the thing that's leading to obvious negative consequences, or the thing that just has opportunity costs associated with it — you're spending so much time consuming this drug that you're not doing other things, other hobbies, investing in other things that are meaningful to you like your primary relationships. So that's very important to figure out first.
And I usually recommend something called the timeline followback method. That's where you start today and you count backwards for every day of the week — what did you consume in terms of your drug of choice, how much and how often. Really looking at quantity and frequency and then adding that up over those seven days. And the reason that's important is because we can really lose track of how we're consuming our drug of choice when we're chasing dopamine. We're very bad self-observers.
To give a personal example — I had gotten into this habit of watching YouTube after work as a way to relax, especially on my long clinic days when I was more tired. And I thought I was watching for maybe half an hour a couple of times a week. And then my daughter, a teenager, came up to me and she said, "Mom, you're always watching YouTube now." And I said, "No, I'm not." I was really kind of insulted because in my mind it was not very much. I thought, "Geez, can I relax every once in a while and watch some YouTube?" But then after she left, I thought to myself, well, okay, how much have I been watching? And it turned out I'd been watching for an hour and a half. And then I thought about the day before that — oh, it was probably two hours. And the day before that, probably about the same. And over the course of a whole week, it was probably about 14 hours of YouTube. Which is a whole day.
Steven Bartlett: A whole day. What were you watching?
Dr. Anna Lembke: Gosh, so embarrassing. I got into this jag of watching Dr. Pimple Popper, which I know is really weird.
Steven Bartlett: What is that?
Dr. Anna Lembke: It's people popping other people's pimples.
Steven Bartlett: Oh my god.
Dr. Anna Lembke: So bad. So bad.
Steven Bartlett: That's not what I expected you to say. I thought it was going to be AI, some psychology things, some science.
Dr. Anna Lembke: No. People popping other people's pimples. And when I added it up over a week, it was a whole day of watching Dr. Pimple Popper.
Brain imaging and the dopamine deficit state
Steven Bartlett: On page 64 of your workbook for Dopamine Nation, there's this really interesting image which I'll throw up on the screen. It shows a brain — and that's as far as I'm going to go with my explaining it. Over to you.
Dr. Anna Lembke: Okay. So these are human brain imaging studies. This is adapted from the work of Nora Volkow and her colleagues. She's the head of the National Institute of Drug Abuse — an amazing researcher and scientist — and she looked at dopamine transmission levels in the reward pathways of healthy control subjects on the left versus people addicted to a variety of substances on the right: cocaine, meth, alcohol, etc. Basically what she found was that in the brains of healthy control subjects, there was plenty of dopamine transmission, as represented here by the red or darker color. In the brains of people who had been using these substances in an addictive way — meaning heavily and chronically — there was almost no dopamine transmission in the nucleus accumbens. In other words, these individuals are in a chronic dopamine deficit state. They have below-normal levels of dopamine transmission.
Steven Bartlett: Isn't this just kind of the story of how the human body works — where if you give it too much of something through an external source, an exogenous source, your brain goes, "Well, if you've got enough of that, then I won't make any"?
Dr. Anna Lembke: You know what? You just summed it up. That's exactly right. Essentially, too much of anything is bad. And our brain, which is designed to return to homeostasis — homeostasis being a finite number of physiologic states that the organism must maintain in order to survive.
Steven Bartlett: Is this the case with things like melatonin as well? Because people are struggling a lot with sleep, so they're taking a lot of these melatonin pills. Someone offered me one once and I remember thinking, well, if I start taking this, then isn't my body going to stop making it and then I'm going to become dependent on these pills?
Dr. Anna Lembke: That is the potential with, I think, any exogenous source that we use. Anything that we ingest, our brains and our bodies will want to adapt to bring us back to whatever our baseline is. But the difference between addictive substances and behaviors and non-addictive ones is that the release of dopamine in the reward pathway is so fast and so strong that this process of neuro-adaptation is equally strong to bring us back down to baseline. We do know that there are medications that people can take for very long periods of time and actually not develop tolerance to them — they can continue to work for them over the long period of time. We don't actually know exactly why it is that some people develop tolerance and not others. And again, it probably has to do with the amount, the dose, exactly how it's working on the brain. But in general, things that are highly reinforcing — our brain tends to adapt to them over time.
Steven Bartlett: And testosterone is another one people often talk about — where if you take external testosterone consistently, your brain will decrease the natural production of it. And as a result, natural testosterone shuts down and testicular size can shrink. But then if you stop the TRT, the external testosterone, abruptly, your natural system might take a long time to recover. And in some cases it may never fully recover back to baseline. I think this is just a really important principle for drugs, chemicals.
Dr. Anna Lembke: Or messing with the natural balance of one's body. Yes. Exactly. And by the way, Nora Volkow and her team did a follow-up study in individuals who abstained from methamphetamine for 14 months and then rescanned their brain, and showed that they had restored healthy levels of dopamine transmission. It took 14 months in those individuals who had been very addicted to methamphetamine. Which I think is also an important message here. For individuals struggling with severe addiction, it's not like four weeks of abstinence is suddenly going to make your brain better. But what I have found in clinical care is that that's typically enough time to begin to see the light at the end of the tunnel — that there's enough restoration of sort of baseline levels of joy or capacity to experience reward that people can begin to have hope to get out of that state of craving.
The most memorable research studies
Steven Bartlett: What is the most interesting study you've encountered? You've been exposed to so much research on the subject of dopamine and human behavior. Is there a particular study that always stands in your mind as being the most informative, interesting, or surprising?
Dr. Anna Lembke: There are a couple. If you put a rat in a cage with a rat trapped in a plastic bottle, that rat will work very hard to free the trapped rat. But if you then allow that rat to self-administer heroin, it will not work to free the trapped rat. To me, that's really powerful because it suggests how addictive substances like opioids — which heroin is — can usurp our desire for human connection and essentially become the object of attachment. We often talk about loneliness and isolation as a risk factor for addiction, which it absolutely is. But the reverse is also true: getting addicted will cause us to isolate and be lonely. We will stop caring about other people.
For me, that's a really powerful experiment that I think does map onto human behavior. On just a day-to-day level — relating that to my own life — if I get really addicted to my screens and my devices, when my partner needs me, I might be so distracted and so connected to the thing that's giving me dopamine that I might completely miss her call for help.
Steven Bartlett: I hate to say it, but sometimes I do feel like maybe I've been guilty of that. I've been so — dare I say the word — addicted to my work or devices or whatever that sometimes I'm not present with meeting other people's needs.
Dr. Anna Lembke: Absolutely. And that certainly happened to me with my addiction to romance novels. I stopped paying as much attention to my kids and to my husband. We went on a vacation with another family at the beach and instead of joining folks on the beach, I stayed in the room and read romance novels. We went to a neighbor's party and I actually found a room in the house and read romance novels instead of socializing — and didn't even think that was weird, even though that's obviously really strange. So it is this coming to overvalue our drug of choice and undervalue other more meaningful things in our lives.
Steven Bartlett: Could you theoretically say it's making the world less empathetic, less sympathetic — hurting our ability to connect to others and have empathy for them and be there for them, because we're possessed by the thing giving us the most dopamine?
Dr. Anna Lembke: I would go even further and say not only is it making us less empathetic, but it's actually making us sociopathic. When people are in their addiction, they can deviate from their moral compass because they so overvalue their drug of choice that they lose sight of their own values. We see this with kids who become addicted to video games or social media. They stop participating in family life. They stop treating their parents with respect. They stop participating in household chores. They become essentially antisocial. And when they get off of digital media and they go through that terrible withdrawal period, it gets even worse — they will endorse things like wanting to hurt their parents or wanting to hurt themselves. But if they can just go long enough and abstain from digital media, they will come out the other side. And parents will talk about getting their child back — getting back this person that they recognize as their child.
So I think this is really important. When people are in their addiction, they can look very personality-disordered, very narcissistic, very borderline, very sociopathic. And when they get into recovery, that's not who they are at all. They can really become themselves again.
Pramipexole and dopamine agonists
Steven Bartlett: I read about a really extreme case involving a drug I believe is called pramipexole — which is a dopamine agonist, which essentially means the molecule is the same shape as dopamine, so the brain treats it like dopamine. And these people were given it for restless leg syndrome or something. And then so many of them lost their minds — they became obsessed with compulsive, impulsive behaviors. I was reading about one particular lady. She would leave the house in the early hours of the morning when she was taking this drug, wearing see-through tops — this was like a normal woman who otherwise had a normal life — and go to very dangerous places to try and have sex with strangers. And it was because her brain was full of this drug which simulated dopamine.
There was another example from Australia where a woman was taking this drug and she would sit on slot machines until she soiled herself and urinated on herself. She ended up losing her house, her car, her marriage — just because they'd given her this drug which is like dopamine in terms of its molecular structure. And it made me realize that dopamine isn't necessarily the drug of reward, but more of like wanting and impulse and desire. Is that an accurate assessment? Like it makes you desire things.
And there were other examples where a man would take this drug and started engaging in homosexual sex acts whereas otherwise he'd been in a heterosexual relationship. It was all very confusing, but it says something to me about what dopamine is actually doing.
Dr. Anna Lembke: When we're talking about addictive substances and behaviors, the initial response of the brain is to release a lot of dopamine all at once in the reward pathway. But with repeated use, dopamine release gets weaker and shorter in duration and eventually leads to this dopamine deficit state. And that's often what we call wanting but not liking. George Koob has called this dysphoria-driven relapse — where now they're using not to feel good but just to stop feeling bad and feel normal. So in that sense, dopamine is part of pleasure — that's not its sole function. But when it comes to addictive substances and behaviors, the initial encounter has to feel good, be reinforcing, or get someone out of pain. It has to solve that problem. But again, the issue is that with repeated use, it stops doing that, but there's still that motivation to reuse again and again.
And when we're thinking about exogenous or external sources of just giving someone dopamine, that's not going to work to treat that dopamine deficit state, because it's going to bind indiscriminately to dopamine receptors throughout the brain. And the brain will respond with that same process of neuro-adaptation where it's downregulating dopamine receptors — which is again what is setting us up for this repeated addictive pattern.
Cocaine, mazes, and the dopamine of learning
Steven Bartlett: Is there any other study that was shocking to you and has always stayed with you?
Dr. Anna Lembke: Another really interesting study: if you expose a rat to a single injection of cocaine and then slice open its brain, you'll see this arborization of dopamine-releasing neurons in the reward pathway — a proliferation of neurons that release dopamine, a kind of growth of the dopamine forest, so to speak. But you'll see that same arborization or growth of dopamine-releasing neurons if you put a rat in a complex maze — a maze where they can explore and find different things and have challenges. If you then cut that rat's brain open, you'll see that same arborization of dopamine. In other words, learning is highly rewarding and dopamine is released in response to novelty and new things and new challenges.
But if you then take that rat and pre-treat it with methamphetamine and put it in the maze and then look at its brain, you don't see any additional arborization beyond what you got with methamphetamine. And the interpretation there is that drugs may actually usurp or steal our ability to learn — because they've taken over. It's such a powerful, dominant stimulus that there's no additional growth or neuroplasticity in response to something like learning a maze.
Steven Bartlett: And does that mean that when that rat was in the maze the first time and its brain was full of dopamine, dopamine was therefore playing a role in helping it to learn?
Dr. Anna Lembke: No. So the learning itself actually caused the proliferation. Dopamine is responsive not just to rewards, not just to pleasurable things — it's actually responsive to pain, it's responsive to novelty. It's responsive to any emotionally powerful experience. So when you put a rat in a maze and it explores that maze, that's an enriching, exciting experience for the rat, because we are creatures who evolved to seek and explore and learn new territory and then move on and do the same thing.
Steven Bartlett: Ah, so you could say then that if I'm taking an addictive substance like cocaine, I'm going to be much less likely to go out and explore the world.
Dr. Anna Lembke: Yes. Exactly. Or if you do explore the world, your capacity to be rewarded by that experience will decrease or will not be there.
Steven Bartlett: So I'm less likely to do it then.
Dr. Anna Lembke: Right. Yes.
Steven Bartlett: This highlights a more fundamental link around motivation. Like if you're addicted to something — if you're addicted to pornography — your ability to get up and go out and get a job might be diminished.
Dr. Anna Lembke: Absolutely. What happens with addiction is that we have a narrowing of our focus on our drug of choice such that that's the only thing that's reinforcing for us, and other things lose their rewarding potential and eventually fall away altogether. We're spending all of our time getting our drug, using our drug, trying to get more as we come down.
The rat park experiment and environmental enrichment
Dr. Anna Lembke: Can I talk about another experiment which I think is interesting? The rat park experiment. This is the work of Bruce Alexander. He essentially said, well, if you put a rat in a cage with nothing else to do but press a lever for cocaine, of course that's what they're going to do because there's nothing else happening. But what if you put a rat in a very enriched environment with a lever to press for cocaine, but also lots of other things to do — other rats, shoots in mazes, little sawdust balls? What he discovered was that the rat is much less likely to press that lever as often because it has other reinforcing things to do.
And I think that was really groundbreaking in the sense that it is true that addictive substances and behaviors work on the brain in this very predictable way that's so reinforcing that even if you have a great life, you can get addicted. But it's also true that our environment really matters. And if we're living in an impoverished environment like that single rat in a cage with nothing else to do, we're much more likely to get addicted than if we live in a really enriched environment where we have lots of other sources of reward, lots of other sources of dopamine.
Based on that work, there was something then called the Icelandic experiment. Iceland had a significant youth drug problem. And the way that they decided to intervene was to build a lot of gymnasiums and emphasize youth sports. And as we've talked about, exercise and sports are a healthy way — if you don't overdo it — to get dopamine, because you're paying for it up front, you're working for it. And Iceland saw a significant reduction in their youth drug use problem after the implementation of this youth sports system. So that's a nice example of how an animal model can actually provide some kind of fundamental frame to understand what's happening in the brain that can then be translated to a real-world implementation.
Radical honesty and autobiographical narrative
Dr. Anna Lembke: Radical honesty is something that I learned about from my patients. It was the observation that my patients who were able to get into sustained recovery from severe addictions had learned that they couldn't lie. And it wasn't just that they couldn't lie about their drug use — they couldn't lie about anything. They couldn't lie about why they were five minutes late for a meeting. They couldn't lie about why they couldn't go to a party. They had to tell the truth in all things large and small.
And to me that was fascinating. It was an idea that I started to play with and experiment with in my own life. And I realized that telling the truth is actually really hard because we're all prone to little lies to kind of cover up our shortcomings. These are things that we hardly even notice. There are also lies of exaggeration to make ourselves more interesting, lies of flattery where we tell other people how great they are even though we don't necessarily believe that. All these little lies that we tell — I think even if you're not struggling with addiction, these lies can erode our lives, make our lives more impoverished.
The question then becomes: why is truthtelling or radical honesty protective? I think it's working across many different levels. But one of the important levels is simple awareness. Because when we're lying to other people, we're also actually lying to ourselves. And when we're lying to ourselves, we actually don't know what we're doing. And when it comes to our consumptive behaviors — on the one hand I may know that I'm watching too many videos, but at the same time really not know that I'm doing that. But when I tell another human being exactly what I'm consuming, how much and how often, then it becomes real to me in a way that it's not when it's sort of pinging around in the dark recesses of my own mind. So that awareness is really important because we can't change our behaviors unless we're aware of what we're doing.
The other aspect that's really important — that I've learned over many years of being a psychiatrist — is that the way people tell their autobiographical narrative is really important. There are healthy ways we can tell our stories and also not-so-healthy ways. What I have observed is that when people are telling stories in which they're always the victim of other people or circumstance, I know pretty well that they're not going to get into recovery. But if they start telling a story that acknowledges their own contribution to their problem — whatever it is, including the problem of addiction — then I'm pretty confident that we're headed in a good direction.
And that's really interesting because what it means is that our autobiographical narratives provide a template for our lives. They're not just a way to organize past experience. They actually provide a roadmap for the future. And if we're telling self-stories that are a more accurate representation of what's actually happening in our lives, we will have more information from which to make better decisions going forward.
Steven Bartlett: So victimhood keeps you stuck.
Dr. Anna Lembke: It keeps you stuck because it decreases your awareness of what is actually happening. And it is our awareness of what is actually happening that allows us to have the data we need to make better-informed decisions.
Steven Bartlett: Does it also to some level rob you of responsibility?
Dr. Anna Lembke: Absolutely. Because although addiction is characterized by a loss of agency around our consumptive behaviors, we still have some degree of agency always — even if it's only enough to reach out and ask for help. And as people get into sustained recovery, they have a lot more agency as they get out of that vortex of addiction. And it is that agency that we must employ to make the next best decision, so that our lives will be this accumulation of small good decisions that then lead to good weeks and good months and good years.
Steven Bartlett: I think that point is so important — this idea of agency, which essentially means having a sense of control in my life. Is that like a definition of agency? How would you define it?
Dr. Anna Lembke: I wouldn't define it so much as control, because there are so many things that happen in our lives that are out of our control. But when we reduce our decision down to today — what I can do today, the things that I actually can control today — then yes, recapturing our agency around the things that we actually have control over is really important for recovery.
Steven Bartlett: The definition I've pulled up here is: agency means the capacity to act intentionally and make choices that influence outcomes. And it does tend to be the case from my observations that people who have a high degree of agency — i.e., they believe they have the capacity to act intentionally and make choices that influence their outcomes — seem to be the most successful and on average seem to be a little bit more happy.
Dr. Anna Lembke: I think that sense of competence and agency is definitely one that makes us feel good. The danger a little bit when we're dealing with severe addiction is that in our addictions, we often tell ourselves that we have agency and control when we really don't. And so that can be part and parcel of denial, which means that getting into recovery is often about admitting that we may have agency in many aspects of our lives, but when it comes to our addictive behavior, we've lost some degree of agency.
Steven Bartlett: And that's part of the 12-step program, right?
Dr. Anna Lembke: That is a really important part of the 12-step program — admitting that our lives have become unmanageable when it comes to our drug of choice.
Moderation, self-compassion, and closing thoughts
Steven Bartlett: The 12-step program being Alcoholics Anonymous — a very famous program to help you through an addiction. Is there anything else we should have talked about that we haven't?
Dr. Anna Lembke: When it comes to New Year's resolutions and wanting to change habits, sometimes this sort of all-or-nothing thinking can be something that's not helpful for people. This idea that "okay, I'm going to abstain from this, I'm going to go a month, I'm going to do it" — and then they find that they're not able to do it, and there's a lot of shame and self-recrimination. So that approach is not for everybody, and for some a better approach is self-compassion and a goal of moderation.
Steven Bartlett: Moderation is an interesting one because most of us will just be like, "I'm going to go to the gym every day" or "I'm going to have no sugar ever again" or "I'm going to abstain from alcohol completely." But maybe moderation for some of these things is more realistic and therefore more effective and important.
Dr. Anna Lembke: Yes. And we find that moderation typically is more successful if people have abstained for long enough to kind of reset reward pathways. But even just reducing use can be a laudable goal.
Closing question: what the universe keeps teaching
Steven Bartlett: We have a closing tradition on this podcast where the last guest leaves a question for the next guest, not knowing who they're leaving it for. The question is: what's the one thing the universe keeps putting in front of you, and what is the thing it keeps you learning?
Dr. Anna Lembke: Right now in my life, the thing that the universe keeps putting in front of me is the importance of letting my kids go and have their own life experience, rather than trying to cling to the relationships that we had before as they were growing up — which for me was a really joyful time. But I'm recognizing that they need to be in the world on their own, and I need to figure out what I'm going to do as an empty nester. So that's not that deep, but that is what I'm struggling with right now.
Steven Bartlett: And how is that struggle manifesting?
Dr. Anna Lembke: If I'm being totally honest, social media and digital media and those modes of communication have probably made this worse for me. For example, the Find My iPhone — I keep checking where my kids are and thinking that in a way we're connected because I know where they are, but we're not. And also they don't particularly like it that I'm checking where they are. So there's this kind of weird phenomenon of wanting connection and through text and other technology trying to recreate that connection. And yet in some ways I think I might be better off, and they might be better off, if we didn't actually text and I didn't actually track where they are.
Steven Bartlett: Does that make sense?
Dr. Anna Lembke: It does. And I think I was laughing because I just had this picture of you sat there with one screen tracking them and the other one watching the pimples being popped.
Steven Bartlett: Yes. Both are comparable, right? These are both sort of related to habits or behaviors that are self-soothing but ultimately not good for me and not good for other people.
Steven Bartlett: Do you think much about how other behaviors that we take part in — like sleep, meditation, and nutrition — have a big impact on our ability to kick the bad habit or start a new one?
Dr. Anna Lembke: Oh, absolutely. There's a great acronym from Alcoholics Anonymous called HALT — Hungry, Angry, Lonely, Tired. When we're feeling those things, we're more likely to crave our drug of choice. So importantly, we've really got to make sure we take care of ourselves physically and emotionally so that we're as well as we can be, so that we don't get into that state of wanting to escape or self-soothe or numb ourselves. And by the way, that's true in the work that we do as mental health care providers — we have to really come to patients or clients with our needs met, our cup full, so that we can be fully present for our patients.
Steven Bartlett: Dr. Anna Lembke, thank you so much for coming back on the show. It was incredible — the conversation we had last time was so unbelievably well-received. It's done probably closer to 10 million views across all platforms now, just over 5 million views on YouTube alone. And I can't begin to imagine all the people that you've had a profound impact on by making these complicated things accessible. I know we simplify this to a point that might be quite difficult, because I know the science is much more complicated. But just having a simple mental model has helped me so much since we last spoke — to understand what's going on inside my body and inside my brain in a simplified way. And that's exactly what was reflected by the millions of people that watched last time.
Your book is the book to read, and your workbook as well is critical to read alongside it on this subject, if people want to learn more and get an even deeper understanding of everything we've talked about today — and also if they're struggling with addictions, because these books provide a really nuanced, empathetic, and shame-avoiding set of ideas and solutions to some of the things that hold us hostage in our lives, whether it's opioids or technology or other behaviors that we know at some level are getting in the way of what we'd rather be doing and who we'd rather become. So thank you so much for your work. It's such important work. And I know you're working on another book — when that book does come out, I'd love to have you back on to talk about all the things in it. I'm so excited.
Dr. Anna Lembke: Thank you so much.