Book Review: Dopamine Nation

  

Dopamine Nation is a 2021 book written by Anna Lembke. Dr. Lembke is a psychiatrist and the medical director of Stanford Addiction Medicine.

The book, with its catchy subtitle "Finding Balance in the Age of Indulgence", focuses on modern trends of overconsumption, specifically in American society.

To understand the book, we need to put some contemporary social pathologies into context. Princeton economists reported shorter life expectancy among white Americans without a college degree. The morbid findings of midlife mortality among caucasians were mostly attributed to three major causes: substance abuse, alcohol-related liver disease, and suicide. (The term "Death of Despair" was coined by Anne Case and Angus Deaton, and the phenomenon is discussed in their book Deaths of Despair and the Future of Capitalism.)

The book oscillates between patients and personal memories, and scientific rationale backed by some evidence-based material. Most cases are clinical cases of high-end drug abuse or other types of addiction. To tackle the goliath of addiction, it is inevitable to (at least) touch on a few domains beyond the narrow scope of psychiatry. Education, pop culture, sociology, economy, internet, and information technology are the key players in this problem, and accordingly must be addressed as components of any proposed solution.

A part of the psychology of addiction is rooted in education and the current education system. As an example, in Chapter 2 (Running From Pain), the author questions some approaches to modern treatment of children:

"... I worry that we oversanitized or overpathologized childhood, raising our children in the equivalent of a padded cell, with no way to injure themselves but also no means to ready themselves for the world."

Later in the same chapter, the book quotes Neil Postman (American media theorist and cultural critic:

"... Americans no longer talk to each other, they entertain each other. They do not exchange ideas, they exchange images. They do not argue propositions; they argue with good looks, celebrities, and commercials."

These self-deceptive behaviors, norms, or traits divert attention and insulate us from pain. As mentioned earlier, this book is founded on American psychology. The book reports that pain perception is higher among Americans compared to other nations.

An interesting part of the book explains the physiology of pleasure, anticipation, action, reward, and ultimately pain. The brain's reward pathway involves the ventral tegmental area, the nucleus accumbens, and the prefrontal cortex. While dopamine plays the key role in the sensation of pleasure, its role is even more potent in the motivation to get a reward (Wanting over Liking!).

Chapter 3 (The Pleasure-Pain Balance) introduces the concept of dopamine-deficit state: a neurological process that occurs as a result of overconsumption of dopamine substances. This overexposure disturbs the dopamine release as well as the expression of dopamine receptor (D2), bringing about a full reversal from hedonism to anhedonia.

In Part II (Chapter 4 onwards), the book shifts gears towards solutions and management strategies. Chapter 4 introduces four weeks of Dopamine Fasting for starters. The point is that we need to embrace the pain and acknowledge the suffering instead of escaping from it. The critique should target escapism rather than the pain (This section of the book is in accordance with Susan David's Emotional Agility.)

In Chapter 5 (Space, Time, and Meaning), the Self-binding is defined as the method we intentionally and willingly create barriers between ourselves and our drug of choice to mitigate compulsive overconsumption. Later in this chapter, the book criticizes some aspects of current practice where pharmacotherapy alone is applied without understanding the patient and targeting the underlying behaviors. These lopsided approaches have usually proven futile.

As the study by Warren Bickel revealed, the addicted have a different perspective on the future. The compromised abstract thinking and planning lead to shrinking temporal horizons. One consequence of repeated overconsumptive behaviors, which are modulated through reward pathways, is the atrophy of the prefrontal cortex. For the addicted, the concept of "Future" is shrunken to next week, whereas a normal person looks at a more expansive horizon, years ahead. Fixing this perception should be stressed as a key task in any treatment regime.

Further, the applied medical treatment is not impeccable. Chapter 6 (Broken Balance?) underlines some wrong medical modalities in the prescription of psychotropic medications. The new role has been assigned to psychiatrists to replace the missing chemicals in patients' brains to enable them to work normally. This idea has been welcomed by the pharmaceutical companies, doctors, and patient consumers. The trend becomes more alarming when we notice the disparity in the administration of narcotics between lower and higher socioeconomic classes. Americans on federally funded Medicaid are prescribed opioid painkillers at twice the rate of non-Medicaid patients.

In Part III (Pressing on the Pain Side), the book enters a debate about pain-pleasure management, suggesting pressing on the pain side of the equilibrium can lead to a better and more enduring pleasure. The pain here is grossly used as any type of stress induced under control. The book claims repetitive exposure to pain stimuli leads to shorter initial responses and builds an afterresponse of pleasure, which grows over time. As a result of the fight-or-flight mechanism in our neuroendocrinology, pain morphs into hypervigilance and then morphs into a fit of joy. This part of the book is sensitive and subject to misunderstanding, and in my opinion, requires better structure. The idea as the author mentions, is counterintuitive and against dogma in the field. There are references to studies linking stress to increased dopamine release in the brain's reward pathway. Also, the administration of opioid receptor blocker (naloxone) is shown to block the ameliorative effect of repetitive pain stimuli (suggestive of increased endogenous opioid release in response to pain). These concepts may be labelled as hormetic healing. Overall, I agree with the concept of carefully dosed "pain" stimulus as a method to bring back balance to the flawed pleasure-pain equilibrium. Here, the term "pain" warrants careful definition and a precision medicine approach tailored to each individual's psychosomatic profile.

The next chapter (Chapter 8: Radical Honesty) also explores the means to break the cycle of addiction and overconsumption by opting for a Radical Honesty attitude and utilizing Prosocial Shame.

Prosocial shame is the term used in contrast with a second (and morbid) type of shame called "Destructive Shame". The prosocial shame theory is predicated on the idea that shame can be harnessed as a constructive force through "acceptance" of the defect, flaw, or any transgressive behavior. This interaction and constructive behavior result in a sense of belonging and reduced consumption. 

These chapters stress the importance of prosocial shame in the management of addiction and beyond, for example, in parenting. The personal example from Dr. Lembke's family explains that the concept of perfection is a misleading goal to base a family upon. Instead, an open-hearted willingness to work in collaboration to rectify our mistakes is the way to create true intimacy. 

Truthfulness and honesty encourage a mindset called "Sense of Plenty" (opposed to "Sense of Scarcity"), which enhances the delayed gratification pathway.

Maybe a combination of these methods, applying measured pain stimuli, being radically honest, and being willing to work together (as an individual, a family, or a society/nation) can remedy the maladies of today's hypermedicated, overstimulated, pleasure-saturated world.