Richer than ever, miserable anyway: Stanford’s Anna Lembke on today’s pain epidemic

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Humankind is in a deep funk.?

Despite the global declines in poverty, increases in literacy and growing access to health care we have seen over the past several decades, the world is in immense pain. You can see this in the disconcerting upticks in addiction, depression and suicide, particularly in wealthier nations. These challenges have only been exacerbated by the pandemic.?

What’s driving this misery mismatch? That’s the key question driving Stanford psychiatry professor Anna Lembke’s latest book, “Dopamine Nation: Finding Balance in the Age of Indulgence.”?

“Why, in a time of unprecedented wealth, freedom, technological progress, and medical advancement, do we appear to be unhappier and in more pain than ever?” Lembke writes.

In a bitter twist of fate, our wealth, technology and other advances may be aiding and abetting our suffering. “The reason we're all so miserable may be because we're working so hard to avoid being miserable,” argues Lembke.?

Our ready access to instant gratification -- via technology, food and drugs, among other things -- may be causing us more pain than we realize. That’s because the human brain is a balance-seeking machine. When we overindulge in something that gives us pleasure, our brain works hard to bring us back down to Earth, triggering feelings of pain, which then sends us back for more pleasure. It’s a vicious cycle.

In the following conversation, which has been edited for length and clarity, Lembke discusses the roots of this pleasure-pain imbalance and what might help people find relief.?

Scott Olster: Your book starts off with some harsh news. You lay out the sobering stats on the rising rates of depression, the rates of anxiety, of loneliness in the U.S and beyond. And the populations that you're discussing are people who live in wealthy nations. What's going on?

Anna Lembke: It's precisely our wealth and our abundance that's making us so unhappy. You know, traditional narratives have been that people nowadays living in rich nations are unhappy because of trauma or because of social dislocation or because of brain chemistry problems creating mental illness or because of wealth inequality. And it's certainly true that all of those things contribute to our suffering. But what I think is an under-appreciated aspect of why we suffer is precisely because we are constantly ingesting all of these high reward, high dopamine substances and behaviors, which is causing our brains to essentially reset our pleasure pain balance, such that we're made more unhappy, precisely because we are sort of relentlessly seeking pleasure.

How does that work??

It's basically a mismatch, our primitive brains and our modern ecosystem. Our brains were evolutionarily designed for a world of scarcity. We process pleasure and pain by trying to preserve a level balance, or homeostasis, which means any time we experience pleasure, our brain will work very hard to down-regulate our own dopamine to make it level again. But to do that, it tips it in [an] equal and opposite amount to the side of pain.?

With repeated ingestion of these very high dopamine rewards, the homeostatic response is a very strong tilt to the side of pain. And with repeated exposure, our pleasure pain balance gets chronically tilted to the side of pain.?

We end up more unhappy than when we started and we can't figure out why, because we have all these great things. And so then we keep trying to make ourselves more comfortable and ingest more pleasure, and it results in the pleasure pain balance being even more tipped to the side of pain.?

We're victims of our abundance.

Definitely.?

What are the key culprits in the dopamine overload?

Well, I mean the most obvious one right now is screens, right? Ingestion of screens in almost any form. And now we have all these digital products, from pornography to video games. It's also exacerbated existing vulnerability to things like gambling and shopping, which are also drugs.?

I think technology is a huge part of this, the industrial revolution and the amazing social communications revolution. The way that even just chemistry has advanced to go from opium to the current day fentanyl lollipop. I mean, all of this technology, the dark side is that we're using it to deliver digital dopamine sort of 24/7.

The thing is we're taught to avoid pain and suffering by all means necessary.

Yeah, exactly. This idea that we should constantly seek out relief from our suffering is not going to make us happy in the end. And instead, what we need to do is intentionally invite pain and discomfort into our lives, and also just become more accepting and settled with the fact that life is hard and that most of us struggle on any given day. And that it's okay to be unhappy and it's normal.

As long as people are taught that they should be ecstatically happy 24/7 or something is wrong with them — with their brain chemistry, with their relationship, with their job — people are constantly going to be looking for ways to change it up, which won't necessarily solve the problem.?

And when something is wrong, many turn to medication, whether it’s the kind we’re prescribed or not.?

Basically, an antidepressant or a benzodiazepine like Xanax, essentially presses on the pleasure side of the balance. And, so, initially that works great. But the same homeostatic mechanisms that come into play for alcohol or cannabis or pornography also, ultimately, over time, can affect the efficacy of those drugs, such that over time they stop working and in some cases may even lead to their opposite. Some patients, for example, on opioids long-term for chronic pain will actually end up with more pain than they started with. Some people who take benzodiazepines, like Xanax for anxiety can actually get to a point where they have more anxiety ... through this reregulating process. This process is called neuroadaptation.

What we're not adequately recognizing is that much of our suffering comes from trying to avoid suffering.?

How does our relationship with work play into all of this??

It's definitely a part of the cycle. We all have this mindset of, “Well, as soon as I get through this, then I'm going to reward myself.” So, then these intoxicants become a way that we shape our day and bookend our lives. You can get into this work hard, play hard mentality where you're pressing really hard on the pain side, and then you're pressing really hard on the pleasure side. And every time that pleasure-pain balance deviates from neutrality, it's a stressor on the system.?

What’s the first step to level-setting this pleasure-pain balance, whether in our personal or professional lives??

Try to find that balance, which includes setting limits. I engage in intermittent fasting with food. I also engage in intermittent fasting with my work. I can't always do this, but I try for [work] to not be the very first thing that I do when I get up in the morning. I try to first make my bed, exercise, eat some breakfast, talk with my kids. And then I try to put a stopping point at the end of the day and instead try to be present for my family or just for myself, allow myself to be bored a little bit, anxious a little bit.?

It's not like you're going to go to this wonderful nirvana place where you figured it all out and you're present in the moment. To the contrary, what happens when we turn off our screens is the pleasure-pain balance tips to the side of pain. And we're restless, bored, wondering what we're missing, anxious. But that is exactly what we need to embrace, because otherwise we get into this really vicious cycle of compulsive over-consumption.

It sounds like we need to recognize that pain's okay.

Not just okay, but good, probably good. In this dopamine environment, we need to invite all kinds of different discomfort into our lives and allow ourselves to just sit with it.