The Paradox of Pleasure  ## Document Notes ## Highlights - **Doctor's Descent Into Sports Betting** - A young physician became addicted to sports betting and gambled away his trust fund and loans within months. - His smartphone accessibility and secrecy accelerated weekly losses into daily devastation. Transcript: Shankar Vedantam You first met him? Anna Lembke, MD Delightful young man, handsome, kind, thoughtful, considerate. He came to me, in fact, because he got a DUI. He was driving under the influence. But as it turned out, alcohol was not his primary problem. Once he was in my office, he revealed to me that he did in fact have an addiction problem, but it wasn't addiction to alcohol. It was an addiction to online gambling, sports betting. And his story went like this. He was a very successful high school and collegiate athlete, Division I, all kinds of accolades, really a remarkable athlete. And that cycle of engagement in high-level athletics, the adrenaline that goes along with high-level competition, the wins, the losses, that absolutely was his jam, right? It kept him busy and engaged and really, really happy. But when that career came to its natural end, like so many high-level athletes, there was a sort of a free-falling disappointment, a kind of an existential, profound disappointment, A bit of an identity crisis. And although he was headed to medical school, which, you know, gave him kind of a new identity to latch on to, he really missed that cycle of intensity that he got through participation In sports. And then he was invited by his collegiate buddies to participate in fantasy football, in a fantasy football league. And, you know, they all get together and they choose their teams. And then there was, you know, minor money involved in that. But he got really, really into it, more so than his buddies from college. And that was really almost the spark for him then to begin to want to engage athletically through sports betting and sports gambling. And, you know, it started with 50 bucks, 100 bucks. And at this time, he's now started medical school. He's doing his pre-med courses. You know, he's getting ready for his clinical years. He had this phone. He could pull it out during grand rounds, you know, when he was supposed to be listening to the speaker and scroll through, you know, results of all the different sports. And then he could place a bet. And that accessibility just absolutely ensnared him. And he found himself completely caught up in it to the point where he was now spending not hundreds of dollars, but thousands of dollars, not monthly, but weekly, and eventually daily. And in about six months, he completely spent the trust fund that he had inherited from his parents in order to pay for medical school. And he was so ashamed that he didn't tell anybody. And he thought to himself, well, if I can just win, then I can get all the money back, and then I'll be fine. He took out an enormous loan without telling anybody to pay for medical school. And he thought, okay, I'm going to put it in the bank. You know, I'm going to pay it back. And instead he gambled that away too. ([Time 0:06:12](https://share.snipd.com/snip/516c1975-b249-409d-8a9c-e49ea9c74fb0)) - **Compulsive Online Shopping Spiral** - A patient became a chain online shopper who filled rooms with unwanted items and amassed tens of thousands in credit card debt. - He resorted to buying cheap items and returning them because the shopping cycle had become irresistible. Transcript: Anna Lembke, MD So this was somebody who just found himself really getting intense pleasure out of the cycle of shopping online. He would spend quite a bit of time searching for different items that he was interested in buying. And the process of kind of like the treasure hunting was very entrancing and rewarding for him. All kind of building up slowly to the point where he would choose the item that he would buy and then buy it. And then he would be waiting in anticipation for it to be delivered to his home. And all of that was very pleasurable. And then it would be delivered and he would open it and take it out. And it was the thing that he wanted and it felt so good. And it was just, you know, wonderfulness for him. So because that cycle was so entrancing for him, he started to do it more and more. And And he kind of came to rely on it as a physiologic crutch for managing his mood. But over time, what he found was that the cycle got shorter and shorter and the anticipation and pleasure that he got from it got less and less to the point where as soon as he opened the Box and got what he had ordered, it was over. And then he'd be online again trying to buy the next thing. And eventually he ended up with rooms in his house full of stuff that he didn't need or want and tens of thousands of dollars of credit card debt. And yet even then he couldn't stop. So what he started to do as kind of a last resort is he bought like these cheap items, key chains, mugs, caps, cheap sunglasses, things he didn't need or want. And then as soon as he got them, he would return them. Wow. Because he didn't have any money, but he couldn't break the shopping cycle. ([Time 0:09:49](https://share.snipd.com/snip/339ec24f-7e53-44af-8df6-e5d5d4ce7361)) - **Porn Addiction That Escalated To Crisis** - Jacob used pornography increasingly after smartphones arrived, escalating to live shows and dangerous chat-room behavior that destroyed his marriage. - He contemplated suicide as his life unraveled under compulsive sexual behavior. Transcript: Anna Lembke, MD Scientist. And by the way, let me just emphasize that I got permission from my patients to relay their stories, and I used pseudonyms and hide other identifying features. So Jacob was a Stanford scientist who came to me seeking help specifically for a severe sex addiction, so sex, pornography, compulsive masturbation. And what he described was in the 90s, he used pornography and he masturbated, you know, as much as daily, but it was never unmanageable. He was still able to function as a father, as a husband. He was successful in his profession. But with the advent of the internet, and especially in the early 2000s, the smartphone, he found that this pursuit of his became unmanageable, which is to say that he was using more and More pornography for more hours every day late into the night, not showing up at a conference that he was supposed to speak at, prepared to give that speech because he had been up the entire Night before watching pornography, repeatedly masturbating. And over time, he needed more and more potent forms to get the same effect. So he escalated from sort of vanilla toast pornography to more deviant forms of pornography. And then pornography itself wasn't adequate. So then he was going to live shows and meeting up with prostitutes. And eventually, you know, his addiction progressed to the point where he was going into chat rooms, doing dangerous things with other people in chat rooms, spending all of his available Time engaged in this activity to the point that essentially his life completely fell apart. His wife left him. And he was thinking about ending his life and even found a spot near his office where he thought about hanging himself. ([Time 0:12:10](https://share.snipd.com/snip/9c971cea-afd2-4bce-84ce-e65d9ed58a6a)) - **Pleasure And Pain Share One Seesaw** - Pleasure and pain share brain regions and act like a seesaw, seeking homeostasis. - After pleasure hits, the brain mounts an opposite pain response that drives craving and withdrawal. Transcript: Anna Lembke, MD Discovery was the fact that pain and pleasure are co-located in the brain. So the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance. So almost like a seesaw? Exactly, like a seesaw or a teeter-totter in a kid's playground. And when that teeter-totter or that beam on a central fulcrum is level with the ground, it's at rest, or what neuroscientists call homeostasis. And when we experience pleasure, it tips one way, and when we experience pain, it tips in the opposite direction. And there are certain rules governing this balance. And the first and most important rule is that the balance wants to remain level, that is, at homeostasis. And our brains will work very hard to restore a level balance after any deviation from neutrality. Shankar Vedantam So when we reach for things that are pleasurable, when I bite into a delicious dessert, for example, I'm imagining that I'm essentially pressing down on the pleasure side of that seesaw. Anna Lembke, MD That's right. So when we do something that's pleasurable and we release dopamine, the reward pathway, and the balance tilts to the side of pleasure, no sooner has that happened than our brains will Work very hard to restore a level balance. And they do that first by tilting an equal and opposite amount to the side of pain before going back to the level position. ([Time 0:32:17](https://share.snipd.com/snip/739e9b46-50f9-435f-9148-2c277fd4d06a)) - **Dopamine Drives Motivation Not Just Pleasure** - Dopamine fuels motivation as much as pleasure; rats without dopamine ate but wouldn't work to get food. - Dopamine creates a deficit state that compels effort to obtain rewards. Transcript: Anna Lembke, MD So there's a very famous experiment in which rats were bioengineered to not have dopamine receptors in the reward pathway of the brain. And what the scientists discovered was that if they put food into the rat's mouth, the rat would eat the food and seem to get pleasure from the food. But if they put the food even, you know, a single body length away, the rat would starve to death. In other words, we need dopamine not just for the experience of pleasure, but also for the motivation to do the work to go get the reward. ([Time 0:35:59](https://share.snipd.com/snip/2a2ae742-cf5a-4637-bae6-91870dbc527b)) - **The Plenty Paradox Of Modern Life** - Our ancient reward wiring is mismatched to modern abundance, creating a 'plenty paradox.' - Constant access to high-reward stimuli down-regulates dopamine and increases anxiety, depression, and craving. Transcript: Anna Lembke, MD This ancient wiring that has us experiencing pain in the immediate aftermath of pleasure is woefully mismatched for our modern ecosystem. Why? Because we are surrounded by pleasure. We have more access to more reinforcing drugs and behaviors than at any point in human history. Even things that previously you could have thought of as healthy, like reading or exercise or playing games, become drugified, has been turned into a drug in some way, making us all More vulnerable to the problem of addiction and also making us more vulnerable to the problem of this dopamine deficit state whereby our brains try to compensate for this excess of Pleasure by down-regulating our own dopamine production and transmission, not just a baseline, but below baseline, creating this constant physiologic craving for more pleasure, But also the things that go along with craving, which are anxiety, irritability, and depression. ([Time 0:36:54](https://share.snipd.com/snip/985ef6d5-f421-47b9-a12b-7c0476616101)) - **Delay The Next Hit To Reduce Escalation** - Pause before reaching for the next quick reward; waiting lets homeostasis restore without another hit. - Choose to delay consumption to avoid escalating the reward–tolerance cycle. Transcript: Anna Lembke, MD And what is the easiest way to do that? Well, you could wait until the gremlins hop off because if you wait long enough, they will hop off and homeostasis will be restored. Or you could eat another date. And if you eat another date, there's a whole crate of dates right in front of you, that would work faster, right? And maybe you'll eat two this time because then that'll level your balance, but also get you over to the pleasure side. And pretty soon you've eaten the whole crate of dates. And now you're essentially at war with those neuroadaptation gremlins. ([Time 0:41:02](https://share.snipd.com/snip/1b2988ea-c0a6-44a6-a37b-beb511d37f81)) - **How Everyday Things Become Addictive** - Normal human rewards get 'drugified' by four changes: quantity, access, potency, and novelty. - Smartphones and supply chains amplified these factors, turning everyday activities into addictive inputs. Transcript: Anna Lembke, MD The way that our modern society has drugified these things that used to be normal and healthy, like having sex or eating food or playing games, is essentially by increasing four factors, Quantity, access, potency, and novelty. Because our incredible manufacturing system has allowed us to make these reinforcing substances in enormous quantities, and our amazing supply chain allows us to ship them all over The world. You know, one of my favorite sort of anecdotes is that in the 1880s, the cigarette rolling machine was invented, allowing manufacturers of cigarettes to go from manufacturing for Cigarettes, you know, a minute to 20,000 cigarettes a minute. And that's just one example of what we've done all around. And my, you know, my own romance novel reading addiction that developed. And one of the things that I discovered when I went looking for other romance novels is that there's a whole universe of romance novels out there. There was no, it was really a never ending quantity and quantity really matters because the more we use our drug of choice, our substance or behavior that's reinforcing, the more of It we expose our brains to. And the more often, the more likely we are to change our brains to this addicted kind of circuitry. Shankar Vedantam So quantity is the first driver. What are the others? Anna Lembke, MD Yeah. So quantity is the first one. Availability or access is huge. So if you grow up in a neighborhood where drugs are sold on the street corner, we have lots of epidemiologic data showing that you're more likely to try drugs and more likely to get addicted To them. And now we live in a world where we all have more access to our substance or behavior of choice, whether it's vampire romance novels or potato chips or games or pornography or, you know, Old fashioned drugs like alcohol, cannabis and nicotine. And of course, the smartphone is essentially the equivalent of the hypodermic syringe delivering digital dopamine 24-7 for our wired generation. And that's really what it is. The smartphone totally changed things. ([Time 0:45:24](https://share.snipd.com/snip/47fabbeb-26a9-4cf5-8c44-65d0f0fa95ff)) - **Limit Access And Potency Of Rewards** - Limit quantity and accessibility of high-reward stimuli, especially digital ones on smartphones. - Reduce exposure to novelty and potency to protect dopamine balance and mood. Transcript: Anna Lembke, MD Yeah, availability, accessibility. And the other one is potency. So one of the ways to overcome these gremlins on the pain side of the balance, or what's often referred to as tolerance, is to either use more of the drug or use more potent forms or have A more potent drug delivery mechanism. So for example, with opioids, someone might start out using opium, but eventually go to heroin, which is about 10 times more potent, and then eventually progress to fentanyl, which Is 50 to 100 times more potent. And this would allow them to at least temporarily win that battle with their gremlins and get the feeling that they're looking for. But another way to achieve potency is to combine two drugs to make yet a third more novel drug. And this is done all the time. For example, people combining opioids with things like benzodiazepines, or now this new veterinary sedative TRANQ, which people are sadly using. By combining two distinct drugs together, we get a new novel drug, which then changes it up for our brain receptors and allows us to overcome tolerance. Shankar Vedantam And in the realm of non-illegal substances, you can also have combinations like French toast ice cream. Anna Lembke, MD Exactly. Or, you know, I very easily get hooked on YouTube videos, especially outtakes of American Idol. And when I think about why on earth is American Idol so entrancing for me, well, they've figured it out, right? They've taken music, which is already reinforcing for most people's brains, releases dopamine, feels good. And then they've combined that with gaming and they've turned it into a competition and thereby, you know, really made a very potent drug. Shankar Vedantam Can you talk a moment about the factor that's known as novelty? This is true in drugs of abuse, but it's also true for many of the other things that, you know, previously we might not have thought as being problematic. Anna Lembke, MD Yeah, so dopamine is extremely sensitive to novelty, which is why, for example, people can get addicted to things like the news. That's the definition of news. It's new stuff coming your way. But what's become so toxic about the modern world is that in order to maintain customers and keep them coming back, you've got to take the thing that they liked before and then package It as slightly new or different or better. And the internet has absolutely mastered that, right? These AI algorithms learn us, figure out where we've spent time before, what we've liked before, and then proffer or suggest to us things that are similar, but a little bit different. And that absolutely engages this treasure seekingseeking function where we keep going because we're hoping that the next hit will be something that's just a little bit better, but Similar to what we had before. ([Time 0:48:06](https://share.snipd.com/snip/e8d14218-bbff-4033-9653-3d2134e0b905))