Transcript: Are our hormones being hijacked by technology?

Dr. Anna Lembke, MD

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Anna Lembke

Hi, I’m Professor Ana Lembke and this is my Garden talk today.

Sophie Adelman

We’re continuing our theory of happiness collection with a talk from Professor Anna Lembke about the world of our happiness hormone dopamine and how the relentless pursuit of pleasure it can take us on can actually lead to pain. Anna Lembke is a professor of psychiatry at Stanford University School of Medicine and a best selling author of a number of books, including drug dealer MD, which looked at the opioid epidemic in the US, the subject of actually another recent Garden talk which you should check out.

And she also published Dopamine Nation, an instant new york Times bestseller which explores the personal and societal price of being ruled by the dopamine hit, which is going to talk about today. Now in today’s talk, Anna will share her thoughts and research on the modern addictions we face, such as social media and the effect this has on us. And importantly, I guess what we can all do about it. Anna, it’s great to have you here in The Garden today. Welcome.

Anna Lembke

Thank you for inviting me. I’m excited to be here.

Sophie Adelman

Now before I hand over to you for your Garden talk, I know you’ve studied addiction from many different angles for a long time now. What made you want to focus your career on psychiatry and the study of addiction in particular?

Anna Lembke

Well, my interest in psychiatry came out of just by enduring fascination with the human brain emotion behavior. Um I also have a sister with bipolar disorder and her disease really made me very conscious of how the brain is an organ like any other and it can go wrong and you know what that looks like and the importance of trying to help people with mental illness in terms of treating addiction, I went into that very reluctantly when I graduated from medical school and started in my practice um I actually didn’t want to see people with addiction.

I had been taught that it was not a mental illness, but rather a willpower problem or a social problem. And it really was a very tragic situation of a patient of mine who had been using heroin and I was completely ignorant of that fact until her brother called me and told me that she had been in a very serious car accident and had almost died. And then when I asked him, you know what had gone wrong, he said, oh she’s been using again, I said using what he said, she’s been using heroin, didn’t didn’t you know that isn’t that what you’ve been treating her for? And there was this moment of profound shame for me because I had not a single time asked her about drug or alcohol use.

So I had a really kind of an awakening that I was a bad psychiatrist, in fact in ignoring um addiction and substance use problems more broadly. And so I really shifted my practice um and became very focused on that and that has essentially become my career,

Sophie Adelman

Thank you so much for sharing that. It’s it’s amazing how these sort of, these moments really shape the directions of our lives and it sounds like finding out that that moment really gave you this opportunity to make such a difference to so many people’s lives and I know we’re going to hear so much about amazing the amazing work you’ve done on addiction today.

So with that it’s time for me to hand over to Professor ANna Lembke for her Garden talk. Are we being hijacked by our happiness hormone?

Anna Lembke

To begin? I’d like to share a story with you of a patient of mine who I first met two or three years ago. He has given me permission to tell you his story anonymously. This was a young man about 19 or 20 years old who came to my office to see me for debilitating depression and anxiety. Um he was also playing video games most of his waking hours and late into every night I met his parents, they were wonderful, caring loving people.

Um he had grown up in privilege. He had gone to excellent private schools, there had been no history of significant trauma or deprivation and yet he really didn’t see a reason to keep living. When I asked him how his um depression and anxiety began. What he described is that he went off to college with the highest of hopes. He was going to be a computer science major and you know, do great things and um he found that he was very anxious once he got to school, he didn’t know anybody. He felt awkward meeting people.

And so he started playing video games in the evenings with his friends from high school. Um, and that was a way to sort of keep himself company and not feel so alone. But when his friends would sign off of the video games and go to sleep, he kept playing with strangers all over the world as you can do now. Um, and what he found was that he just got progressively more isolated, depressed and anxious and to kind of cope with that he played more video games until he got to the point where he was up all night playing video games, sleeping during the day, not going to class, getting more anxious about the fact that he was falling behind in his grades, then playing more video games and on and on went this vicious cycle until he was suicidal, told somebody his parents were called and they essentially came to pick him up and brought him home back to California.

So when he came to see me, um, you know, he was looking for some help with his depression and anxiety and um, he was hoping that I would either prescribe him a pill or do some sort of talk therapy that would make him realize, you know, the root of his his problems. But instead what I suggested to him is something that I suggest to many of my patients now, when they first come to see me, if I detect that there may be a problem of compulsive over consumption of highly reinforcing drugs and behaviors and when I use that word drug, I’m using it very broadly.

I’m really using it not just to encompass traditional drugs like cannabis, cocaine, alcohol, but really any reinforcing substance that we ingest or behavior that we do that keeps us in that moment feeling euphoric or exhilarated or numbed or whatever it is that we’re looking for. Um and And and when I see that in a patient and I see that they’re engaging in that behavior repeatedly in a way that suggests addiction. The first thing that I will suggest to them is to stop using that drug or stop that behavior for 30 days.

So when I suggested that to him that that I thought maybe the first thing that we should do was that he should stop playing video games for 30 days, he said to me, that doesn’t make any sense to me playing video games is the only thing that gives me relief from my depression and anxiety, it’s the only time when I’m not absolutely objectively in despair. So I said to him, I hear you, which is what I say to, you know, all of my patients, that in the moment it feels like the video games are relieving your anxiety and depression.

But I have a hypothesis and that hypothesis is that it’s actually the video games that are making you depressed and anxious. And in order for me to explain to you why that is, let me explain to you something about recent discoveries in the neuroscience of pleasure and pain. So then I proceeded to explain to him A truncated version of some of the exciting discoveries in addiction neuroscience in the last 75 years, which I’m going to explain to you now. One of the most interesting findings in neuroscience in the last 50-75 years is that pleasure and pain are co located in the brain.

So what that means is that the same parts of the brain that process pleasure also process pain and they work like opposite sides of a balance. So, imagine that in your brain, that part of our brain called the reward pathway, which has been conserved over millions of years of evolution and is essentially preserved identically across species. Imagine that there’s a balance like a beam on a fulcrum, sort of like a teeter totter in a kid’s playground, that balance represents our pleasure, Pain balance and how pleasure and pain are processed in the brain.

When we do something pleasurable, that balance tips one way, when we do something or experience something painful, that balance tips the other. But one of the overarching rules governing this balance is that it wants to remain level, it doesn’t want to be tipped for very long to the side of pleasure or pain. And our brains will work very hard to restore a level balance or what neuroscientists call homeostasis. So for example, when I eat a piece of chocolate because I love chocolate, I get a little release of dopamine our reward neurotransmitter in that part of the brain called the reward pathway.

And my balance tips slightly to the side of pleasure. But no sooner has that happened. And my brain will adapt to that experience of pleasure by down regulating my own dopamine production and my own dopamine receptors. And I imagine that is these little neuro adaptation. Gremlins hopping on the pain side of the balance to bring it level again. But here’s the thing about those gremlins, they really love it on the balance so they don’t get off as soon as the balances level they stay on until it’s tipped an equal and opposite amount to the side of pain.

That’s the come down, the aftereffect hangover or in my case, that moment of wanting a second piece of chocolate. Now, if I wait long enough, the gremlins hop off and balance is restored and that feeling passes. But the lesson here is that it really is true that when it comes to pleasure and pain, what goes up must come down and for every pleasurable experience that we have, the brain adapts to that pleasurable experience, not merely by restoring a level balance, but first by tipping an equal and opposite amount to the side of pain before going back to the level condition.

So here’s the second rule governing this balance, which is which is essential for understanding how people progress from recreational use to addictive use with repeated exposure to the same or similar stimulus. That initial response to pleasure gets weaker and shorter and that after response to pain gets stronger and longer. So, if I were to eat a second piece of chocolate and a third and eventually the whole box, I accumulate more and more gremlins on the pain side of my balance, trying to compensate such that I get to a place eventually where I don’t get any pleasure at all from eating that piece of chocolate, but the come down or the after effect is profound.

That feeling of irritability, anxiety, restlessness, intrusive thoughts of wanting that piece of chocolate and those, by the way, are the universal symptoms of withdrawal from any addictive substance. And this is what happens when people become addicted. They end up with enough gremlins on the paint side of their balance to fill this whole room. And those gremlins are camped out, their barbecues and tents included, which means that even after a sustained period of abstinence, people with addiction don’t operate with a level balance there tipped to the side of pain.

They’re experiencing anxiety irritability, insomnia dysphoria craving. They’re very narrowly focused on getting that drug and using that drug, not to feel good, but just to restore a level balance and feel normal and importantly, when they’re not using their walking around with the balance tipped to the side of pain and nothing else is enjoyable. They have this very narrowed focus. So this is really essential to understanding what happens when we repeatedly use highly reinforcing drugs and behaviors which by the way, come in many guises today.

And what I explained to my patient was that in the moment it felt to him like playing video games was self medicating his depression, but really all it was doing was momentarily giving him some relief from pain and ultimately adding more neuro adaptation. Gremlins to the pain side of the balance and putting him in this dopamine deficit state. So what is the solution to that problem? Well, the initial intervention has to be that we abstain for long enough from our drug of choice for those neuro adaptation.

Gremlins to hop off and for our balance to be restored. Because with enough neural plasticity and enough time, almost every brain can restore homeostasis. And so that’s what I suggested to him to do. But I warned him that in those first two weeks he would feel worse before he felt better because all he would be doing was taking away the pleasure from that side of the balance. But those gremlins, they like it there and they will take a while to re adapt, which is again why people with addiction will relapse.

But I said if you just hang in there, you know, and if you can just get through, especially those first two weeks, by the time you get two weeks three and four, you really you will see the sun start to come out and those gremlins will start to hop off and you will have a restored balance. So he looked at me very skeptically and he said, you know what, I don’t actually think that that you’re right. I think that my depression is related to something else and that the video games are, you know, kind of a solution for me.

But I’m willing to give this a try, which I thought was super brave of him. I said I’m willing to give it a try. I’m willing to abstain from video games for a month. But he was a really smart kid and he said, but you know what, I’m pretty sure that if I have my smartphone that’s gonna pull me and I’m not gonna be able to do it because as soon as I get an alert about somebody playing a video game or watch a Youtube video game, Youtube of other people playing video games. Um I’m I’m gonna want to play a video game.

So I think I probably can’t even have my phone for that month. So that was really brilliant that he hit on that because that’s what the neuroscience tells us. So if you stick a probe that measures dopamine levels in a rat’s brain and then you basically get that rat addicted to something like cocaine by having the rat know that when it presses a lever it will get a shot of cocaine right into its blood system. That rat will essentially press that lever until it dies. And if you then train the rats to know that when it sees a light or hears a bell that will tell it that cocaine will be available from pressing with the lever.

What the dopamine levels show is that even when that rat just sees the light or get some other trigger, letting it know that the reward is coming. There is a slight increase in dopamine levels just by being reminded which is to say that a trigger alone can actually release dopamine and give pleasure. And many, many people with addiction will talk about euphoric recall where they’ll look back and remember using and get like this little moment of euphoria or this little bump, but here’s something really fascinating that we found is that not only does dopamine slow, slowly rise above baseline levels in response to something like a trigger, but it’s immediately followed by dopamine going not just to baseline levels but below baseline levels.

Again that balance being tipped to the side of pain that dopamine deficit state. And of course that’s craving. So even being reminded of using our drug of choice can send us in this little pleasure, pain balance kind of loop where we end up in this dopamine deficit state after the reminder. And of course that’s a state of craving that then drives us to want to seek out our drug of choice. So he very astutely observed that he would have to not have any kind of screens if he was going to be able to make it a whole month with without video games.

And since he had stopped out of school at that point and was living at home with his parents and his all of his friends were at school. He figured ok I can do as he put everything away, his screens, his gaming console went in the garage, his phone got taken away. And um when he came back in a month I said well you know how was it, how did how did it go? And he said I am really, really surprised, I feel a lot better. And of course I was thrilled and I said tell me tell me what happened. He said I just he said you were right.

Initially I felt more anxious, more depressed, Really, really bored. I had a ton of time, I didn’t know what to do with that time. But you know I after about two weeks of feeling restless and anxious, I just started to notice it going away and by the time I got two weeks three and weeks four um I just felt I felt less depressed, I felt less anxious. I feel better. He said that I have in a very long time. The reason I’m telling you this story is because I’ve been treating all forms of mental illness, including addiction for more than 25 years.

And over that time period I have vastly changed my practice such that my prescription pad is not my first go to and even psychotherapy isn’t necessarily the thing I will do first. Instead, what I will ask of my patients who are immersed in this kind of um sort of tsunami of dopamine. I’ll ask them to do a dopamine fast or an abstinence trial in order to reset reward pathways. I’ll warn them that they’ll feel worse before they feel better. But that in doing a dopamine fast, that alone may actually treat Their anxiety and depression without us having to do any other intervention.

And I also say to them, but if you come back in 30 days and you’re still depressed, that’s also really useful information because what it means is that it’s not your video games or your cannabis use or the alcohol that’s driving it. It’s something else going on. So either way, it’s a really useful experiment, it forces folks to also tolerate the discomfort of not reaching for their drug of choice. And so I will always say to patients, I’m really, really important to know that this is gonna be really tough.

You’re not gonna be able to kind of reach for that thing that that gives you comfort. Um what I love to ask of my patients after they’ve done this experiment is sort of how they coped or what what kinds of things, you know, they did with all that time and what he said was he spent a lot more time with his dog, he spent a lot more time reading and then he found himself leaving his room kind of going to look for people because he was lonely because he wasn’t on the internet and he said I spent a lot of time in the kitchen talking with my mom, I had a lot of conversations with my dad, so of course this is all, you know, wonderful to hear, especially, you know, when I think about this this younger generation and the ways in which they’re spending so much time on the internet and increasingly divesting their energies from their their relationships and their activities uh in real life and in my book, Dopamine Nathan Nation, what I hypothesize is in fact that this kind of dopamine overload, which leads to anxiety and depression in many individual patients that I see and which is understandable from the perspective of the neuroscience may also be explaining, it may explain why we’re seeing collectively an increase in anxiety, depression, suicide and addiction across the world, but especially in Rich nations, one of the things that’s so powerful and also um you know, Sort of paradoxical is that when you look at rates of depression, anxiety, suicide and addiction over the past 30 years, they’ve been going up all over the globe.

But especially in wealthy nations where people have incredible access to all kinds of luxuries, they have access to mental healthcare treatment, they have access to psychotropic medications and psychotherapy. And yet it doesn’t seem to be collectively reducing the number of people struggling with anxiety and depression. And yes, there are horrible things going on in the world and there’s trauma and there’s all kinds of badness. But I really do believe that one of the major sources of our increasing despair is that we have too much of the wrong kinds of rewards.

And that in fact if we want to get to a place of wellness, we have to recognize how this pleasure pain balance works and indeed begin to eliminate the frequency and quantity of these highly reinforcing drugs and behaviors which are essentially ubiquitous today in the world. And I would even go further and suggest that we need to invite difficult, uh even painful things into our lives. So if you remember this balance, um with that initial stimulus on the pleasure side, we get this neural adaptation or this compensation on the pain side, when the gremlins hop on there in order to restore homeostasis, it turns out the same thing is true when that initial stimulus is pain.

So when we take an ice cold water bath or when we exercise, we tilt our pleasure pain balance to the side of pain. And then those neural adaptation, gremlins actually hop on the pain side of the balance to bring it level again. But again, with that opponent process, they tipped to the side of pleasure. And of course that’s the dopamine or that euphoria or that feel good, those feel good hormones that we get after we exercise or after we take an ice cold water bath. And they’re really fascinating data to show that for example, if you immerse yourself in an ice cold water bath for those of you who are able to tolerate that what you see is a slow and gradual increase in dopamine levels over the course of that first hour of being in an ice cold water bath.

And then interestingly those levels remain elevated for a good 2-6 hours after that. The same thing has been shown with exercise that dopamine levels rise slowly over the course of exercise and then remain elevated for hours afterwards. So in fact pressing on the pain side of the balance is a much better way to get your dopamine than that initial intoxicating stimulus because again, the intoxicating stimulus we get a sudden spike in dopamine, followed by a plummeting of dopamine, not just the baseline levels, but below baseline levels before returning to baseline and with repeated exposure, that initial amount of dopamine gets less, but that plummeting gets deeper and stays there longer and effectively changes our set point for experiencing pleasure and pain, making it that much harder to experience pleasure and making us more and more vulnerable to pain.

Whereas if we press on the pain side of the balance initially, what we’re doing is essentially telling our bodies, oh boy, there’s an injury here, we need to start up regulating are feel good hormones and neurotransmitters like serotonin, like dopamine, like our endocannabinoid system are endo opioid system and then ultimately that can lead us to effectively change our set point to the side of pleasure. So um having said that um you know, for those of you who have in your own lives experienced addiction, I hope that this, you know, resonates and makes sense.

Um for those of you who haven’t and are kind of thinking, I’m not sure, you know, that that that I can really relate to, that what I Challenge you to consider doing is to put away your smartphone for 24 hours now. 24 hours probably isn’t enough time to restore fully restored dopamine reward pathways, but it certainly is enough time to challenge us and to make us aware of the kind of the kind of compulsive overuse of this device which is inherently addictive, you know, the device itself kind of speaks to our age old urges to sort of tap and swipe, it’s almost like a living organism the way it responds to us.

And then of course it’s a portal to all of these reinforcing drugs and behaviors including things like social media, which is essentially a way to drug defy human connection. We do know that when we make human connection we release oxytocin which has recently been discovered to bind to dopamine releasing neurons in the reward pathway. So it’s all connected. But social media is essentially a way to take something that’s very healthy and adaptive like human connection and drug if I it if we overuse it or if we use certain kinds of apps in a way that’s ultimately just about chasing that feeling and not any longer really about connecting to other people.

So I challenge you to put away all devices for 24 hours. Um I warn you that in the first part of it, you know, maybe that first half of the day you will have intrusive thoughts of wanting to check your phone. That’s a really powerful moment to mindfully observe how much of our mental real estate has been taken over by our devices. And you should think of those intrusive thoughts about using your phone as as a kind of a hijacking of your brain. The ways in which we are no longer free to have other thoughts, um more expansive thoughts in many ways.

More creative thoughts because we’re obsessively wanting to react to the stimulus that is our phone. But if you can just hang in there and resist that urge, I promise you that you will get to a place where those sorts of intrusive thoughts of wanting to use will get less and you will find that you’re certainly board in some ways, maybe even anxious, maybe even sort of existentially aware and depressed and terrified, because in so many ways these devices now have become sort of who we are. But again, if you can just mindfully observe, stay curious, not run away from that feeling.

I believe that you will get to a place where you experience real relief, this sense that you are no longer being ruled by by this device and that you’re able to be really fully more present in the moment. And to take in sensory experiences that you otherwise may not be observing. Or even to begin to notice the bubbling up of your own thoughts, which is importantly, the beginning of creativity. Right? If we’re constantly reacting to external stimuli, we don’t have the opportunity to really see what our own minds will produce.

And granted there’s a lot of stuff our own minds produce that we don’t want to look at or hear. And it’s a lot of repetitive stuff and ruminative stuff. But again, it’s important to let ourselves just sort of experience that in order to really get to this place where where we’re free, which I think is what we all want. So that’s my challenge to you. Um I would love to hear, you know, how it goes for you. If you if you consider um doing it and I’m really looking forward to your questions. Thank you.

That’s my Garden talk.

Sophie Adelman

Thank you so much for sharing that challenge with us. I think we need a hashtag for the challenge or something because I think it’s good for all of us. I think you’re absolutely right that many of us, myself included, struggle with not getting that kick of checking social media or email every morning when we wake up and I will take you up on that challenge. I’m going to try not to I’m not going to try not to check my phone quite as much and maybe abstain in order to see whether or not I’m also addicted.

So thank you for that. I’ve got lots of questions for you, but I can see that we’ve got lots of questions from our members. So I’m going to go to the first question and the first question comes from laura and laura says, “where is the line between something you enjoy doing? So you do it a lot and addiction? What are the triggers that move you from one point to another”

Anna Lembke

Laura Thank you. That’s a great question. So addiction is a spectrum disorder. You know, we have sort of mild moderate and severe ways to grade it based on the number of criteria that somebody meets in our, in our sort of checklist, they don’t need to meet all the criteria in the checklist.

The more they meet, you know, the more significant. But your question is really important. It sort of says, well what is the point when we cross from recreational use or just a passion or something that gives us pleasure to more addictive use. And really there are a couple of things to look for. First there’s the four seas, so the C stands for control, compulsion, consequences and craving. So if we find that we only plan to use our drug of choice a certain amount or for a certain time period, but we keep exceeding that.

That suggests we have out of control use, compulsive use means there’s a level of automaticity to it, even outside of conscious awareness. I find myself going to get my drug or I find myself reaching for my phone. Um Craving can be psychological or physical, but essentially it’s the intrusive desire or urge to use, especially in the context where we had promised ourselves that we would abstain. Um and then finally consequences, consequences is really the senior quantum of addiction. It’s that continued use despite consequences and consequences can be really subtle to just not being fully present for the people that we care about.

To very serious consequences like legal consequences, health consequences, professional consequences. In addition to those forces to look for as a signal for transitioning into addictive compulsive pathological use. You want to look for something called tolerance and tolerance means needing more and more of a certain drug to get the same effect or more potent forms of that drug to get the same effect. Because tolerance will really tell you that you’re starting to accumulate those neural adaptation.

Gremlins on the pain side of the balance. For example, I see a lot of people with sex and pornography addiction and what they will very classically described as they start out looking at sort of vanilla pornography. But over the course of their addiction, they look at more and more deviant forms of pornography because they have to have more potent stimuli in order to be able to get the desired effect. So that’s something to look for. And then also physiologically look for withdrawal. Right? Look for that.

When you’re not using your drug, your irritable, you’re anxious, you’re depressed, you’re very focused on it and importantly, you’re not able to enjoy other things and more modest rewards. One of the things I talk about in the book is my romance reading addiction, which people often laugh at, but it actually did get to a point where it was interfering with my life. I was using escape fantasy um to sort of um in a way that became compulsive, I needed more and more potent forms of um erotica to get the same effect.

I got to a point where I was not spending time with my kids or my husband because I prefer to be reading. I took it to work and I was reading between patients just wanting to be in this place where I didn’t have to be me really, but also as a result, um you know, finding that um I enjoyed the things that I used to enjoy less. So this is a really key point because um you know, we often will write a story about why we use and we’ll sort of say, well, you know, my my husband doesn’t do X, Y or Z, let’s say in my case, or um I don’t like my job anymore.

But what happens when we engage in these repeated high dopamine drugs and behaviors is that essentially those things that we used to enjoy are no longer enjoyable because we’ve hijacked our reward pathway, not because we’ve intrinsically changed what we like, or because those things have gotten worse. In other words, I wasn’t able to enjoy my kids and my husband, not because I don’t enjoy my kids and my husband because getting lost in fantasy had tipped my scale to the side of pain. Such that natural rewards were no longer reinforcing.

Sophie Adelman

Thank you for explaining that with lisa has a question about phone addiction, and she says with a phone addiction, would you always recommend total abstinence or would you recommend maybe a more gradual withdrawal?

Anna Lembke

Great lisa, thank you for saying that it reminds me that I meant to tell a part of my patient’s story that that I that I didn’t tell you. But essentially um you know, we live in a world in which we have to be interacting with this technology is simply not possible for most of us not to have a phone.

So the idea is to have a relationship with this technology that is adaptive and healthy and productive and not self and other destructive, which is essentially the definition of addiction, continued compulsive use of a substance or behavior despite harm to self and others. So I recommend with the phone that you do a dopamine fast With the activity on the phone that is your clamped activity right? The one that kind of like you keep getting sucked down the rabbit hole. So maybe deleting that app um and not necessarily putting your entire phone away.

Although I do think the 24 hour no phone is a good mental exercise for all of us. So it’s more about like oh it’s that video game or oh it’s that app or that’s the one I always get lost in it and instead deleting that for a month and not necessarily you know, not using your phone at all but trying to figure out how the phone is good and helpful and productive and what things we do on the phone that actually make us feel worse either because you know of the incredible come down afterwards or there’s the sheer quantity of time we spent using it um in my in my book, what I talk a lot about actually is moderation and how to achieve moderation and in my work I found that it’s much easier to achieve moderation by first quitting completely for a period of time and then going back to using rather than just trying to cut back slowly.

Generally we are not good at cutting, cutting back slowly. And the other thing is that cutting back slowly doesn’t restore a level balance. Whereas if we stop those gremlins hop off, we were we reset our reward pathways and then we can go into using our device in more moderation with barriers in place. Right? So self binding strategies and self finding strategies um fall into three basic categories. Space, time and category. So space means that we like have rules about not bringing our phone into certain spaces in our home for example, or we literally shut off the phone when we put it into our bag.

Those are little things we can do that. Just press the pause button between our desire to go on the phone and actually acting on it. Time is another one. So maybe saying I’m only gonna use a certain number of hours a day or I’m only going to use on this day of the week or on the weekend. I’m gonna treat myself to two hours of Youtube but I’m not gonna use it other times. So using time as a binding strategy and then categorical binding strategies is just simply what I said before. You know, I’m not going to go on on that, you know, social media app or I’m, I’m not going to, you know, watch that kind of youtube video or I’m not going to play, which is why patient did.

He came up with lots of good self binding strategies when he eventually went back to playing video games, he decided he was not going to play League of Legends because whenever he played League of Legends, he just couldn’t stop. He decided he was going to only play with friends and never with strangers because once he started playing with strangers that took him to a place where he had difficulty extracting himself. He actually got two separate um, ipads, one was for school and one was for video games and never the twain shall meet and that was really useful, especially when he went back to school during covid times.

Um so little little tricks like that.

Sophie Adelman

That’s some great advice and actually it’s a great bounce off to the question from Tim, who wants to know about how how do you recommend that? We manage a teenager’s phone usage that may be judged as say an addiction to using their phone when they actually need to use it for school and for homework and I’m sure that also translates into adults who need to use it for work as well.

Anna Lembke

Yeah, so I mean with what I recommend in general with kids is that they did not have their own devices until at least age 12 or 13.

Um and the reason for that is because it is in fact very difficult to um control and manage what our kids have access to and kids have access to a whole lot of stuff. So my advice for younger Children is no personal devices and essentially no unsupervised screen time. I know that might sound drastic, but um I really do believe that it’s essential that in that first decade we don’t have our kids um building a lot of mental machinery that’s solely focused on consuming these products online. Now, once kids get to be teenagers, we essentially have limited control, even if we don’t give them the device, they will go out and get their own, which is what happened in our family with our teenagers.

And then I think it’s really a matter of having a lot of informed discussions about um what I’ve just been talking about about, you know, how these can be drugs, how they’re potentially addictive to have teenagers really try to self observe how they feel when they’re on a social media app and then also how they feel afterwards, um when, when it’s over, so that they can begin to see that pleasure pain balance and how potentially their irritability, their insomnia, their sadness might be actually caused by their engagement online.

Also as parents, we can reflect back to them what we observe, we can say, you know, when I, when you’ve been playing video games for four hours or if you’ve been on Snapchat for four or five hours, you’re really grumpy after that. You’re really selfish after that. You know, I noticed that you don’t really care about what’s happening in the family or about your chores, that kind of actually a slight bit of sociopathy that happens in teenagers, um, sort of anyway, can really be exacerbated by them spending enormous amounts of time just consuming these products online.

So reflecting that back to them and then I will say that I think in a small subset of teenagers who are really vulnerable to the problem of tech addiction and or developing serious signs and symptoms of addiction. I would urge you to um really get professional help and or take it on yourself to remove that device, for example. And I, my kids know I often use them as example, but our three older Children really ultimately have been able to manage their lives alongside having their phones. And by the way, they all went out and bought their own phones and paid for their own plans.

And there was nothing that we could do to stop them by the time they got to be about 14. But our youngest child clearly could not handle it. And this past fall, he was failing out of his classes and the teacher told us he’s on his phone, um, you know, all through class. So we took the phone away and we explained to him why and as soon as we did that, he seemed like a happier kid. Of course, initially he was an angrier kid, but then he really was a happier kid and his grades went up and I don’t even really think on some level he wants the phone back, we give it back to him occasionally and intermittently so he can do some video games and talked with his friends on discord.

But it’s really only about one or two hours a week because he’s a kid who just he couldn’t balance.

Sophie Adelman

I’m going to move to a question from Usma and also one from Susan because they are two sides of the same coin. So the question is is it possible to have a lack of dopamine and also do some people have more happiness hormones than others.

Anna Lembke

Yeah, so this is a great question. There is a little bit of science around this looking at sort of baseline dopamine levels across different people. And there is a suggestion that people with depression actually may have lower baseline dopamine firing.

And of course, so that suggests that this metaphor, the extended metaphor of the pleasure, pain balance. It means that not everybody necessarily starts out with a level balance right. Some people are starting out tilted to the side of pain and indeed we do know that people with depression and other mental illnesses um that is a risk factor for addiction. Those individuals are probably more likely to try substances and behaviors to change the way they feel and and being exposed to a substance is a risk is one of the main risk factors for getting addicted to that substance, but the thing to keep in mind is that even if that’s true, the balance still works in the same way.

So even if you start out here, kind of dislike manic or depressed and you use a substance or behavior to try to level it out, you’re still going to get those neural adaptation gremlins on the pain side, which will ultimately depress your move further with repeated exposure. So again, the antidote to that is to intentionally do things that are um you know, difficult or uncomfortable or even painful in order to try to um hore medically get your body to start to up regulate its own dopamine.

Sophie Adelman

Nicholas has a similar question.He says, what can we do intentionally to trigger our hormones to motivate us to have healthier habits in our work leisure time and our relationships, can we use dopamine to do that?

Anna Lembke

Yeah, yeah, great, great question. And and yes, the answer is yes, you can and I recommend that you do. And the first thing again is to abstain from highly reinforcing substances or behaviors for about a month. That alone will reset reward pathways because those neural adaptation Gremlins will hop off the pain side of the balance and you will restore healthier baseline dopamine levels.

But the other thing that you can do is intentionally do things that are uncomfortable or painful. For example, exercise, we know that exercise is actually toxic at the cellular level, but what it does is it tells the body oh, I’m experiencing injury, you need to make more dopamine and serotonin and norepinephrine, so that really what it effectively does is resets our balance to the side of pleasure. Um and that’s a really, really effective way to combat um dysphoria, anxiety or even just, you know, general, you know, the sort of general suffering of everyday life.

The problem is that we’re incredibly amnestic for the gremlins. So we have an incredible memory for what gives us initial pleasure and we also have a vivid memory for what gives us initial pain. What we seem to not remember is the opponent process mechanism. So for example, patients with severe addictions say I can you instantly and easily euphorically recall the great parts about using drugs and somehow not remember all of the terrible things that happened afterwards. And likewise, every day when I get up, like even just this morning, I was lying in my bed saying you should get up and go for a walk, you should get up and go for a walk, you should get up and go for a walk and yet all I could think of was how I didn’t want to get out of bed and go for a walk.

It’s like we forget every day that we feel so much better after we go for the walk, I did finally drag myself out of bed. I went for my walk, I felt better afterwards, but it’s really, really hard to get ourselves to do those things and I will say, you know, with with many people that I see in my practice now, you know, just getting up off the couch and going outside and interacting with a person in real life is hugely challenging for them. Just not being plugged in and constantly listening to music or listening to a voice.

It’s hugely challenging for them. So the bar is pretty low for a lot of modern people.

Sophie Adelman

Well unfortunately we’ve probably only got time for one more question. So I’m going to end with julie’s question because julie has the question. I think we’re all wanting to know the answer to what’s the ending to the story. Do you have any update on your patient in terms of their, their, you know, their addiction and their withdrawal from, from their phone addiction.

Anna Lembke

Yeah, so as I said, he came back a month later, he was feeling so much better. Normally my patients want to go back to using immediately, but they want to use differently, they want to use less. They want to use a more moderation and he very interesting said, you know what? This has been such a good month for me. I don’t, I don’t want to have any screens. I think I want to do this again. And he did it again for another month and then a month after that. And every month I kept asking, what do you want to do, you want to continue? And it was just amazing. He just kept getting feeling better and better and better with the passage of time.

And then about six months into it. He said to me, you know, I do, I do want to have my phone again. I’m feeling it’s like a socially disconnected and I want to have my phone again. So he got his phone back. But he was very intentional about his use, right? And really circumscribed. It’s important that we write it down and plan it out how we’re going to use. Um and so he did that. And then eventually he said, you know, I do want to go back to playing video games. But then as I told you, he put all these wonderful things in place, Oh, I forgot to tell you to.

One of the things that made me so happy is he eventually went back to school by the time he was back in school, Covid had landed. So everything was online. But he said to me, you know, it’s so amazing. I had thought that I just didn’t like computer science and that I would have to find something else to major in. But now that I’m not playing video games, my classes are great. Like I’m really interested in them. So that’s so wonderful because what it means is when we’re not constantly bombarding our reward pathway with these instant feel good drugs and behaviors, other things become interesting again and that’s exactly what happened to him and he continues to do very well to this day.

Sophie Adelman

Ana thank you so much for joining us today and for that absolutely fascinating Garden talk. I think we’ve all learned a huge amount and hopefully we’ve all taken up your challenge to abstain from our phones for at least 24 hours. Thank you for joining us in The Garden . I hope you’ll join us again very soon.

Anna Lembke

Thank you.

Sophie Adelman

And thank you to you, our members for joining us here today and for your great questions. Don’t forget to save your seat at your next Garden talk and until we see you again, stay curious.

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