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.

On Impact of Physician Burnout

by : Kevin Pho
I wrote last year in USA Today about the impact of physician burnout. Not only do doctors suffer, but so do their patients.

Burnout starts early in residency, with entering interns having a depression rate of 4%, similar to the general public. But after the first year of residency, that number balloons to 25%.
Now, another study adds fuel to this disturbing trend.
A paper published in the Archives of General Surgery looks at the prevalence of physician burnout in surgeons:
In a national survey, one in 16 surgeons reported contemplating suicide, researchers reported.
An increased risk of suicidal ideation was linked to three factors: depression, burnout, and the perception of having made a recent major medical error …
… But only about one in four of those who reported thinking about taking their own lives sought psychiatric or psychologic help.
The rate of suicidal ideation in surgeons, at 6.3%, was almost double of that in the general population (3.3%).
Physician burnout is a phenomenon that’s often ignored. The practice environment is deteriorating, with increasing time pressures and worsening bureaucratic burdens. Little of this is addressed in the national health conversation, or in the recently passed health reform law.
As more doctors burnout and quit medicine, patients will suffer. It’s certainly not an ideal situation as more than 30+ million newly-insured patients will be looking for physicians to care for them in the coming years.
And for the physicians who stay, burnout will impact the care they give to patients — including a decrease in empathy and an increase in medical errors.
Burnt out doctors feel they have little recourse. In the Archives study,
Only 130 surgeons — 26% of those who had recent suicidal thoughts — had sought psychiatric or psychologic help.
Among the 501 doctors who reported suicidal thoughts, 301 said they were reluctant to seek help because of worry that it could affect their medical license.
That’s unacceptable. Hospitals need to better recognize the signs of burnout and increase the support they give to depressed physicians.
Another consideration would be to better monitor work hours to ensure proper work-lifestyle balance. Today, doctors in training are strictly regulated to ensure they work no longer than 80 hours a week. Once they graduate and practice in the real world, that oversight ceases. There is nothing to prevent doctors from working days at time, which can happen at an understaffed, rural hospital, for instance.
The same zeal that goes into limiting residents’ work hours should be applied to doctors in the real world, to ensure their workload doesn’t drive them to burnout and potential suicide.

Resolving Treatment Resistant Depression

About 60% of patients suffering from depression do not find any benefit from their first antidepressant. Up to 20% of patients find depression impossible to overcome even after 1 year. Assertive treatment of depression from the get go is essential to helping recover from depression.

Psychiatrists don’t have a shared definition of treatment resistant depression. However, most would agree that your depression may be treatment resistant if it has not resolved almost completely after adequate trials of at least 2 separate treatments.
You, with your doctor and/or therapist, must then consider the following strategies to beat it :

Confirm diagnosis:
Make sure that your depression is not a phase of Bipolar disorder – it can be tricky, but must be ruled out. Co-occurring addiction, anxiety or other psychiatric illness should be diagnosed and treated. Psychiatric diagnosis still remains a subjective enterprise. Get a second opinion regarding your diagnosis. Even if you like your therapist or psychiatrist, and intend to get treatment from them forever and ever, get a second opinion from a different psychiatrist.

Follow treatment recommendations:
 Take your medicine as prescribed. Maintain your frequency of psychotherapy. These things take time to work. Don’t skip doses or sessions. And don’t give up on any treatment prematurely.

Optimizing medication:
Your dose of antidepressant may need adjusting to get better results. Some antidepressants work better at higher doses. Others have a window of dosing in which they may work the best for you while having the fewest side-effects.

Switching medication:
 There are about 30 antidepressants belonging to about 8 classes available in the US. Even among patients who have had trials of multiple medicines, most have tried only 2-3 classes. Talk to your doctor about trying medicines from classes that you have not tried yet.

Adding a medication:
 If you have partial response to a given medicine, adding another medicine that is compatible with the first medicine may allow you to build on the effectiveness of the above medicine. Talk to your doctor about this. The medicine added could be another antidepressant, or a medication that is known to help antidepressants be more effective (e.g., T3, lithium).

Talk therapy (psychotherapy, counseling):
 If you are not already in psychotherapy, you must consider adding this to your treatment regimen. Psychotherapy typically does not work as quickly as medication, but tends to have lasting benefit. Ask for a referral to a therapist who treats using one of the consistently proven therapies in depression – interpersonal therapy or cognitive behavior therapy.

TMS (Transcranial Magnetic Stimulation):
 This is a treatment that involves repeatedly delivering very, very short magnetic pulses to the part of the brain that is most believed to be involved in depression. It was cleared in 2008 by the FDA as effective in those who have failed treatment with 1 adequate trial of an antidepressant. It has few side-effects, but carries with a minuscule risk of seizures. It is an outpatient treatment that does not require sedation or anesthesia.


Electroconvulsive therapy (a.k.a. electroshock therapy):
This is probably the most effective treatment for depression, but to be effective it requires that a seizure (convulsion) be triggered. Therefore, it must be conducted in a hospital setting, using sedation and muscle relaxation. It may impair memory in a lasting manner in some patients.

Most importantly, choose treatment with a physician, psychiatrist or therapist who will systematically evaluate how any chosen treatment is working. He or she should also be willing to change the medication regimen if it does not work in adequate doses over a 3-month period.
Through all of this you must also:

Practice living well:
Eat a balanced diet. Excercise some everyday (to the extent your body allows and your physician approves). Minimize smoking, drinking. Attempt to connect with loved ones frequently. None of this may be easy when you are depressed, but overcoming treatment resistance requires you to do your part to the extent that you can.



by : Dheeraj Raina
Depression Clinic of Chicago

60 Years With One Last Breath

This story about Thomas Lynch just reminded me of the debated subject of the unknown martyrs' Burial in Tehran universities.Maybe it can shed light on the psychiatric aspect of the matter.Of course if we don't follow the decent policy of making a melancholic poet out of all students !

Born to a family who ran a funeral home in small-town Michigan, the poet Thomas Lynch began pondering aging and death at a young age, as a child leafing through the gory pages of his father’s mortician texts.

“A lot of 15-year-olds think they’re going to live forever,” he said. “But when I was 15, I sort of knew I wasn’t, because I spent a lot of time at the funeral home.”
Mr. Lynch eventually joined his father’s funeral business, and now two of his sons run it. Mr. Lynch, in his early 60s, still helps out. The day we spoke, he had spent the morning on a long drive north to pick up a friend who’d died. Mr. Lynch loaded the familiar body onto the stretcher himself.
“Making the drive, bringing him home, was good duty,” he said. “Having something to do is a blessing.”
A National Book Award finalist, for “Undertaking: Life Studies From the Dismal Trade,” and the subject of a 2007 “Frontline” documentary, Mr. Lynch has just published his fourth collection of poems, “Walking Papers.” It is a pilgrimage of sorts through growing old and facing death — subjects that caregivers know all too well. His upfront, unvarnished style is likely to resonate with many who have come face to face with life’s most important questions.
In the book’s title poem, Mr. Lynch advises an ailing friend to put aside his lab reports and explore a different type of medicine:






I say clean your plate and say your prayers,


go out for a long walk after supper


and listen for the voice that sounds like you


talking to yourself, you know the one:


contrapuntal, measured to footfall, true


to your own metabolism. Listen –


inspiration, expiration, it’s all the same,


the sigh of creation and its ceasing -


whatever’s going to happen’s going to happen.






Mr. Lynch addresses the impermanence of life, evident in everything from farm animals to his own aging body, which he imagines dead in his bed, “a little purple on the side I sleep on.” He reminds readers that enduring death requires simply being present and handling the tasks before us: baking casseroles, writing obits, digging graves.
Mr. Lynch insists that the prospect of his own death still scares him. Yet, he told me, “Mortality as a condition is one that I don’t think we should rail too much against. Living as if you’re going to be dead sometime is more sensible than living as if you’ll live forever.”
As a child, Mr. Lynch recalls, he was regularly called out of school to help out during memorial services. The constant parades of pallbearers taught him that funerals have less to do with the dead, more to do with what the living do about the fact that loved ones have died.
Grief is the price we pay for being close to one another, Mr. Lynch believes. “If we want to avoid our grief,” he said, “we simply avoid each other.”
Mr. Lynch writes that we’re “born with our last breath in us.” “Walking Papers” brings us up against this fact and, through the simple rhythms of small town life, tells us that’s O.K.

@nytimes
by : Mary Plummer

Activation vs Blocking

Based on neurochemical and genetic evidence, Blum et al suggest that both prevention and treatment of multiple addictions, such as dependence to alcohol, nicotine and glucose, should involve a biphasic approach. Thus, acute treatment should consist of preferential blocking of postsynaptic Nucleus Accumbens (NAc) dopamine receptors (D1-D5), whereas long term activation of the mesolimbic dopaminergic system should involve activation and/or release of Dopamine (DA) at the NAc site. Failure to do so will result in abnormal mood, behavior and potential suicide ideation. Individuals possessing a paucity of serotonergic and/or dopaminergic receptors, and an increased rate of synaptic DA catabolism due to high catabolic genotype of the COMT gene, are predisposed to self-medicating any substance or behavior that will activate DA release, including alcohol, opiates, psychostimulants, nicotine, gambling, sex, and even excessive internet gaming. Acute utilization of these substances and/or stimulatory behaviors induces a feeling of well being. Unfortunately, sustained and prolonged abuse leads to a toxic" pseudo feeling" of well being resulting in tolerance and disease or discomfort. Thus, a reduced number of DA receptors, due to carrying the DRD2 A1 allelic genotype, results in excessive craving behavior; whereas a normal or sufficient amount of DA receptors results in low craving behavior. In terms of preventing substance abuse, one goal would be to induce a proliferation of DA D2 receptors in genetically prone individuals. While in vivo experiments using a typical D2 receptor agonist induce down regulation, experiments in vitro have shown that constant stimulation of the DA receptor system via a known D2 agonist results in significant proliferation of D2 receptors in spite of genetic antecedents. In essence, D2 receptor stimulation signals negative feedback mechanisms in the mesolimbic system to induce mRNA expression causing proliferation of D2 receptors.

PROPOSAL AND CONCLUSION:

The authors propose that D2 receptor stimulation can be accomplished via the use of Synapatmine, a natural but therapeutic nutraceutical formulation that potentially induces DA release, causing the same induction of D2-directed mRNA and thus proliferation of D2 receptors in the human. This proliferation of D2 receptors in turn will induce the attenuation of craving behavior. In fact as mentioned earlier, this model has been proven in research showing DNA-directed compensatory overexpression (a form of gene therapy) of the DRD2 receptors, resulting in a significant reduction in alcohol craving behavior in alcohol preferring rodents. Utilizing natural dopaminergic repletion therapy to promote long term dopaminergic activation will ultimately lead to a common, safe and effective modality to treat Reward Deficiency Syndrome (RDS) behaviors including Substance Use Disorders (SUD), Attention Deficit Hyperactivity Disorder (ADHD), Obesity and other reward deficient aberrant behaviors. This concept is further supported by the more comprehensive understanding of the role of dopamine in the NAc as a "wanting" messenger in the meso-limbic DA system.


published@ theoretical biology & medical modelling 2008

Describing the Brain in Autism in Five Dimensions

Autism spectrum disorders (ASD) are a group of biologically based neurodevelopmental disorders characterized by impairments in three major domains:

1.       socialization

2.      communication

3.       behavior

These disorders include

·         autistic disorder (classic autism, sometimes called early infantile autism, childhood autism, or Kanner's autism),

·          Rett disorder,

·          childhood disintegrative disorder,

·         pervasive developmental disorder, not otherwise specified (PDD-NOS), and

·          Asperger disorder (also known as Asperger syndrome

A recent study by Ecker et al demonstrated  how a multiparameter classification approach can be used to characterize the complex and subtle structural pattern of gray matter anatomy implicated in adults with ASD. A set of five morphological parameters including volumetric and geometric features at each spatial location on the cortical surface was used to discriminate between people with ASD and controls using a support vector machine (SVM) analytic approach and to find a spatially distributed pattern of regions with maximal classification weights.

 On the basis of these patterns, SVM was able to identify individuals with ASD at a sensitivity and specificity of up to 90% and 80%, respectively. However, the ability of individual cortical features to discriminate between groups was highly variable, and the discriminating patterns of regions varied across parameters.

Morphometric feature Correctly classified (%) Sensitivity (%) Specificity (%) p Left hemisphere     All parameters 85 90 80 0*     Cortical thickness 90 90 90 0*     Radial curvature 72.5 65 80 <0.001     Average convexity 70 75 65 <0.004     Metric distortion 80 80 80 0*     Pial area 77.5 70 85 0* Right hemisphere     All parameters 65 60 70 <0.03     Cortical thickness 60 65 55 <0.01     Radial curvature 52.5 50 55 <0.30     Average convexity 50 40 60 <0.40     Metric distortion 57.5 45 70 <0.06     Pial area 45 45 45 <0.60

 The classification was specific to ASD rather than neurodevelopmental conditions in general (e.g., attention deficit hyperactivity disorder). These results confirm the hypothesis that the neuroanatomy of autism is truly multidimensional, and affects multiple and most likely independent cortical features. The spatial patterns detected using SVM may help further exploration of the specific genetic and neuropathological underpinnings of ASD, and provide new insights into the most likely multifactorial etiology of the condition.

@The Journal of Neuroscience August 2010

One Flew Over The Cuckoo's Nest

Godfather's Marlon Brando,Forrest Gump's Tom Hanks, Scent of A Woman's Al Pacino,The Piano Teacher Isabelle Huppert, The Dark Knight's Heath Ledger and now Jack Nicholson in Milos Forman's masterpiece :

i got the whole story this way: a kind of border line personality guy is sent to mental institution with a nurse not far from dogmatic manner, in charge

Randle McMurphy (Nicholson) shows his discomfort and tries to break the routines;but he's not well supported by other patients;as it's shown McMurphy's demands are far ahead of other patients thoughts.But after a while he finds other patients' assistance,confronting the wards staff specially cotquean head-nurse...

The squence McMurphy broadcasts Baseball across the TV showing a serial( pretending to watch World Series on TV) This is the saddest scene i have ever seen;a five star Nicholson could make it a memorable and everlasting picture;a mixture of innocence and waggery;how fantastic !

I don't get the concept of the movie;i can make some assumptions;Forman shows the role of elite and genious people demolished in the cast of democracy,or regular bureaucracy

Another angle shows the head nurse didnt really respect the votes as they reach the quorom for watching baseball she refuses to accept the vote.Isn't it a similar story we have with some democracies.(how about Afganistan elections as a recent example.)

It also shows McMurphy as a loser :in the end ; he's not the one who can escape,he's the one who gets caught and sink deeper,brainwashed by harsh treatment ; it seems they blurred his sight offreedom;

eventhough he finds ample oppurtunity to run away he misses them because of his inconssistent manner based on hedonism,and sometime due to his sense of compassion for other patients.He could really find his way out of sanitarium in the interview with psychiatrist but he finds kind of entertainment living there playing a superior role . He's not a must be admitted type at the begining.

I haven't watched any other Forman's film but as i read in IMDB he's got obssessed with this rebellious type personalities .

Final Words : Jack Nicholson realy deserved Oscar prize,also; credit to Sydney Lassick

I give it a 9/10