Notes from Dopamine Nation

This article will contain my notes that I took while reading the book Dopamine Nation. I definitely enjoyed reading the book and taking notes for it. I believe I now have a proper guideline to resrort to, whenever I'm exibhiting behaviors of addiction. Hope you enjoy reading the notes below!

The Problem

As humans, we've transformed the world from a place of scarcity to a place of overwhelming abundance. It becomes extremely easy to get that dopamine hit from a large variety of highly rewarding stimuli.

Neuroscientists rely on measuring dopamine to measure addictive potential of any experience. The more dopamine in the reward pathway(it is the pathway in brain which is connected to areas of control and memory) in brain, the more addictive the experience.

One of the remarkable neuro-scientific findings is that pleasure and pain are processed in the same place in the brain. Pleasure and pain work like opposite sides of a balance. When we crave or want something, the brain's pleasure balance is tipped to the side of pain. When we indulge, the pleasure balance is tipped to the side of pleasure.

The book aims to unpack the neuroscience of reward to enable us to find healthier, better balance between pleasure and pain. It also includes true stories from people who fell prey to addiction and looking to recover. The purpose is to learn how to overcome compulsive overconsumption.

"Persons with severe addictions are among those contemporary prophets that we ignore to our own demise, for they show us who we truly are."

- Philosopher Kent Dunnington

The secret to finding balance is combining the science of desire wit the wisdom of recovery.

Part 1: The Pursuit of Pleasure

Chapter 1: Our Masturbation Machines

Jacob was a patient author Anna. He struggled with a masturbation addiction. So much so that built a machine to maintain preorgasm state for hours.

He masturbated for several hours a day with. his machine. He tried to stop masturbating.. He had hid the machine high up in a closet or dismantled it completely and threw away the parts some times. But a day or two later, he was pulling the parts down from the closet or out of the trash can, only to reassemble them and start again.

As readers, this story about Jacob might be regarded as a kind of extreme perversion that is beyond everyday experience, with little or no relevance to you and your life. But the truth is that, we're all engaged with our own masturbation machines.

Addiction can be broadly defined as the continued and compulsive consumption of a substance or behavior (gambling, gaming, sex) despite its harm to self and/or others. We don't necessarily need trauma, social dislocation, poverty, unemployment, or other risk factors for addiction.

One of the biggest factors for getting addicted to any drug is easy access to that drug. When it's easier to get a drug, we're more likely to try it. In trying it, we're more likely to get addicted to it. The US banned production, import, transportation and sale of alcoholic beverages from 1920 to 1933. The prohibition led to sharp decline in the number of people consuming and becoming addicted to alcohol. This proves the fact that when we don't have access to the drug, it is not likely to get addicted.

If we have a biological parent or grandparent with addiction, even when we're raised outside the addicted home , we have a risk of addiction. Mental illness is also a risk factor, but the relationship between the two risks are unclear: Does the mental illness lead to drug use, does drug use cause or unmask mental illness, or is it somewhere in between?

Trauma, social upheaval, poverty contribute to addiction risks, as drugs become a means of coping and lead to epigenetic changes—heritable changes to the strands of DNA outside of inherited base pairs—affecting gene expression in both an individual and their offspring.

Chapter 2: Running from Pain

The practice of medicine has been transformed by our striving for a pain-free world. Doctors today are expected to eliminate all pain or else they fail in their role as common passionate healers. Today, more than 1 in 4 American adults- and more than 1-20 American children takes a psychiatric drug on a daily basis.

We've lost the ability to tolerate even minor forms of discomfort. We're constantly seeking to distract ourselves from the present moment, to be entertained.

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

- Neil Postman - Author of 1980s classic Amusing Ourselves to Death

Sophie, one of Anna's patients, seeking help from depression and anxiety told her that she spends most of her waking hours plugged into some kind of device: Instagramming, Youtubing, listening to podcasts and playlists. Anna suggested that she tried walking to the class without listening to anything and just let her thoughts bubble to the surface. This is what she spoke to Sophie:

Well, it’s a way of becoming familiar with yourself. Of letting your experience unfold without trying to control it or run away from it. All that distracting yourself with devices may be contributing to your depression and anxiety. It’s pretty exhausting avoiding yourself all the time. I wonder if experiencing yourself in a different way might give you access to new thoughts and feelings, and help you feel more connected to yourself, to others, and to the world.

Boredom is not just boring. It can also be terrifying. It forces us to come face-to-face with bigger questions of meaning and purpose. But boredom is also an opportunity for discovery and invention. It creates the space necessary for a new thought to form, without which we’re endlessly reacting to stimuli around us, rather than allowing ourselves to be within our lived experience.

Eventually, Sophie got used to and also began to like after experimenting not being plugged in.

We're all running from pain. Some of us take pills. Some of us couch surf while binge-watching Netflix. Some of us read romance novels. We'll do almost anything to distract ourselves from our selves. Yet all this trying to insulate ourselves from pain seems only to have made our pain worse.

Chapter 3: The Pleasure-Pain Balance

Neurotransmitters are like baseballs. The pitcher is the presynaptic neuron. The catcher is the postsynaptic neuron. The space between pitcher and catcher is the synaptic cleft. Just as the ball is thrown between pitcher and catcher, neurotransmitters bridge the distance between neurons: chemical messengers regulating electrical signals in the brain.

Dopamine is the most important neurotransmitter in reward processing. Dopamine may play a bigger role in the motivation to to get a reward than the pleasure of the reward itself. Genetically engineered mice unable to make dopamine will not seek out food, and will starve to death even when food is placed just inches from their mouth. Yet if food is put directly into their mouth, they will chew and eat the food, and seem to enjoy it.

The more dopamine a drug releases in the brain’s reward pathway, and the faster it releases dopamine, the more addictive the drug. High-dopamine substances do not literally contain dopamine. Rather, they trigger the release of dopamine in our brain's reward pathway.

Below is a small pictographic representation of the increase in through various things. Note: Amphetamine is the active ingredient used in medications like Adderal.

Neuroscientists have determined that pleasure and pain are processed in overlapping brain. Both of them contribute to certain balance. The easiest way to think of that balance is to imagine a seesaw with pleasure on one side and pain on the other side. The balance is the scale on the fulcrum in the center. When nothing is on the balance, it’s level with the ground. When we experience pleasure, dopamine is released in our reward pathway and the balance tips to the side of pleasure. The more our balance tips, and the faster it tips, the more pleasure we feel.

The balance was to remain level in equilibrium. It does not want to be tipped for very long to one side. Hence, every time the balance tips toward pleasure, powerful self-regulating mechanisms kick into action (without out our conscious thought or an act of will) to bring it level again.

Once the balance is level, the see saw keeps going, tipping an equal amount to the side of pain as pleasure.

We've all experienced cravings. Whether it’s reaching for a second potato chip or clicking the link for another round of video games, it’s natural to want to re-create those good feelings or try not to let them fade away. The simple solution is to give into the cravings. But there's a problem with that.

With repeated exposure to the same or similar pleasure stimulus, the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain gets stronger and longer, a process scientists call neuroadaptation. That is, with repetition, our gremlins get bigger, faster, and more numerous, and we need more of our drug of choice to get the same effect.

Needing more of a substance to feel pleasure, or experiencing less pleasure at a given dose, is called tolerance. Tolerance is an important factor in the development of addiction.

Neuroscientist Nora Volkow and colleagues have shown that heavy, prolonged consumption of high-dopamine substances eventually leads to a dopamine deficit state. That is, when we become tolerant to a substance or behavior (drugs, gambling, gaming, sex), it drains the dopamine activity in our brain.

The universal symptoms of withdrawal from any addictive substances are anxiety, irritability, insomnia, and dysphoria(a state of general dissatisfaction in our life). It is one of the reasons why people continue to take their drug even if the drug stops working for them and they don't get high anymore.

A phenomenon described by neuroscientist George Koob as dysphoria driven relapse, where people return to substance use to alleviate physical and psychological suffering caused by prolonged withdrawal, rather than seeking pleasure. Basically, even during sustained periods of abstinence, the drive to relapse occurs when our balance is tilted to the pain side, we crave our drug just to feel normal (a level balance).

The good news is that if we wait long enough, our brains usually readapt to the absence of the drug and re-establish our baseline dopamine activity. This allows us the take pleasure in everyday, simple rewards.

The pleasure-pain balance is triggered not only by reexposure to the drug itself but also by exposure to cues associated with drug use. In Alcoholics Anonymous, the catchphrase to describe this phenomenon is people, places, and things. In the world of neuroscience, this is called cue-dependant learning

Below is a pictograph of an experiment which demonstrates that dopamine is released in the brain in response to the conditioned (e.g., a buzzer, metronome, light) well before the reward itself is ingested.

Right after the conditioned cue, brain dopamine firing decreases not just to baseline levels (the brain has a tonic level of dopamine firing even in the absence of rewards), but below baseline levels. This transient dopamine mini-deficit state is what motivates us to seek out our reward. Dopamine levels below baseline drive craving. Craving translates into purposeful activity to obtain the drug. Once we get the anticipated reward, brain dopamine firing increases well above baseline. But if the reward we anticipated doesn’t materialize, dopamine levels fall well below baseline The dopamine deficit is craving and drives drug-seeking behavior.

My personal opinion or finding: This probably explains why people need a smoke right after they are angry

In a 2010 study, Jakob Linnet and his colleagues measured the dopamine release in people addicted to gambling and in healthy controls while winning and losing money. There were no distinct differences between the two groups when they won money; however, when compared to the control group, the pathological gamblers showed a marked increase in dopamine levels when they lost money. The amount of dopamine released in the reward pathway was at its highest when the probability of losing and winning was nearly identical (50 percent)—representing maximum uncertainty.

The author's patients with a gambling addiction told her that a par of them wants to lose when gamlingh. The more they lose, the stronger the urge to continue gambling, and the stronger the rush when they win -- a phenomenon described as loss chasing. She also suspects that something simlar is going on with the social media apps, where there's the uncertainty of getting a like.

The brain encodes memories of reward and their associated cues by changing the shape and size of dopamine-producing neurons. There was an experiment where researchers injected cocaine for successive days for a week and measured how much they ran after each injection. On the last day, it had run frenzily compared to a slow jog on the first day. After a year, the rat stopped running. But when they were again injected, it again started to run frenzily as the last day of the week. A lot of people who struggle with severe addiction slipping right back into compulsive use with a single exposure, even after years of abstinence. This may occur because of persistent sensitization to the drug of choice, the distant echoes of earlier drug use.

Learning also increases dopamine firing in the brain. Female rats housed for three months in a diverse, novel, and stimulating environment shows a high dopamine activity compared to rats housed in standard laboratory cages. The brain changes that occur in response to a stimulating and novel environment are similar to those seen with high-dopamine (addictive) drugs.

But if the rats are addicted with meth before entering into a novel environment, they fail to show the dopamine activity. These findings suggest that meth limits a rat's ability to learn. Some brain changes due to addiction are irreversible, but it is possible to detour around these damaged areas by creating neural networks to create healthy behaviors. The future holds tantalizing possibilities for ways to reverse the scars of addiction.

Pleasure and pain can occur simultaneously. For example, we can experience both pleasure and pain when eating spicy food.

Not everyone starts out with a level balance: People with depression, anxiety, and chronic pain start with a balance tipped to the side of pain, which may explain why people with psychiatric disorders are more vulnerable to addiction.

Our sensory perception of pain and pleasure is heavily described by the meaning we ascribe to it. There was a study taken by military doctor Henry Knowles Beecher during World War 2. He studied only people with severe wounds such as pound fracture of a log bone, a penetrated head, etc... who were mentally clear and not in shock at the time of questioning. Three quaters of these badly injured soldiers reported little or no pain in the immediate aftermath of their wounds. The physical pain was was tempered by the emotional relief of escaping from an exceedingly dangerous environment filled with fatigue, discomfort, anxiety, fear and real death of pain. Their pain, such as it was, gave them "a ticket to the safety of the hospital".

My personal opinion or finding: A contrast is me. I'd report pain even if there's no fracture and is small wound.

With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and out threshold for experiencing pleasure increases. It is perfectly adapted for a world of scarcity. Without pleasure we wouldn’t eat, drink, or reproduce. Without pain we wouldn’t protect ourselves from injury and death. By raising our neural set point with repeated pleasures, we become endless strivers, never satisfied with what we have, always looking for more.

The pain that follows pleasure is longer lasting and more intense than the pleasure that gave rise to it. The problem is that human beings, the ultimate seekers have responded too well to the challenge of pursuing pleasure and avoiding pain. As a result, we’ve transformed the world from a place of scarcity to a place of overwhelming abundance. Our brains are not evolved for this world of plenty. We're cacti in the rain forest drowning in dopamine.

Part 2: Self-Binding

Chapter 4: Dopamine Fasting

Delliah was a patient of Anna(the author). She was struggling with anxiety which as effect triggers her pot addition. Hitting her wax pen is the only thing that gets her out of the bed. Anna then guided the conversation guided by the framework she developed which be easily be remembered by the acronym DOPAMINE. It applies not just to conventional drugs like alcohol and nicotine but also to any high-dopamine substance or behavior we ingest too much of for too long, or simply wish we had a slightly less tortured relationship with.

The D in DOPAMINE stands for data. She begins by gathering the simple facts of consumption. In Delilah’s case, she explored what she was using, how much, and how often.

The O in DOPAMINE stands for objectives for using. Even seemingly irrational behavior is rooted in some personal logic. People use high-dopamine substances and behaviors for all kinds of reasons: to have fun, to fit in, to relieve boredom, to manage fear, anger, anxiety, insomnia, depression, inattention, pain, social phobia . . . the list goes on.

The P in DOPAMINE stands for problems. The only problem Delliah said is that "her parents are always on my back. If they'd just leave me aline, there wouldn't be any downsides". She was the picture of health even though she was ingesting so much cannabis. Youth compensates for so much. Most of us are unable to see the full extent of the consequences of our drug use while we're still using. High dopamine substances and behaviors cloud our ability to accurately assess cause and affect. Most of Anna's patients are patients who come voluntarily for treatment as they've reached a tipping point where the downsides outweigh the upsides. As teenagers are so full of energy and youth, they don't get sick nor tired. Even so, getting teenagers to see some negative consequences, can be point of leverage for getting them to stop. And stopping, even just for a period of time, is essential for getting them to see true cause and effect.

"The world is sensory rich and causal poor"

- Neuroscientist - Daniel Friedman - Author of 1980s classic Amusing Ourselves to Death

The A in DOPAMINE stands for abstinence. Abstinence is necessary to restore our baseline dopamine activity, and with it our ability to see the true cause and effect between our substance use and the way we're feeling. Fasting from dopamine allows sufficient time for the gremlins to hope off the seesaw for it to go back to the level position.

2 weeks of abstinence is not enough. At two weeks, patients are usually still experiencing withdrawal and in dopamine deficit state. Four weeks is often sufficient. But Anna has seen patients less that four week to reset their reward pathway, and others who need far longer. Those who have been using more potent drugs in larger quantities for longer duration will typically need more time. Younger people recalibrate faster than older people, their brains being more plastic. Furthermore, physical withdrawal varies drug to drug. It can be minor for some drugs like video games but potentially life-threatening for others, like alcohol and benzodiazepines.

Anna never suggest a dopamine fast to individuals who might be at risk to suffer life-threatening withdrawal if they were to quit all of a sudden, as in cases of severe alcohol, benzodiazepine. For those patients, medically monitored tapering is necessary. 20% of Anna's patients don't feel better after the dopamine fast. It is because the patient likely has a co-occurring psychiatric disorder that requires its own treatment. Dopamine fast is very beneficial even then as it help psychiatrists observe the relationship between substance use and the psychiatric symptoms.

The M in DOPAMINE stands for mindfulness. Mindfulness is simply the ability to observe what our brain is doing while it’s doing it, without judgment. Reserving judgment is important to the practice of mindfulness because as soon as we start condemning what our brain is doing—Ewww! Why would I be thinking about that? I’m a loser. I’m a freak—we stop being able to observe. Mindfulness practices are especially important in the early days of abstinence. Many of us use high-dopamine substances and behaviors to distract ourselves from our own thoughts. When we first stop using dopamine to escape, those painful thoughts, emotions, and sensations come crashing down on us.

The I in DOPAMINE stands for insight. After the dopamine fast, Delliah came back to Anna to tell Anna that she was very happy that her anxiety is gone. She never thought weed was a problem but after experiencing withdrawal, it motivated her to continue with the dopamine fast. She is not putting a lot of time and mental effort to organize the next high. She had so many insights that were just not possible to see during substance use.

The N in DOPAMINE stands for next steps. Anna would ask her patients what they want to do after their month ob abstinence. The vast majority of the patients was to use substance differently than they were using before. The overarching theme is that they want to use less. An ongoing controversy in the field of addiction medicine is whether people who have been using drugs in an addictive way can return to moderate, non-risky use. For decades, AA dictated abstinence is the only option for people with addiction However, emerging evidence suggests that some people who have met criteria for addiction in the past, especially those with less severe forms of addiction, can return to using their drug of choice in a controlled way

The E in experiment stands for experiment. This is where patients go back into the world armed with a pleasure-pain balance and a plan for hout to maintain it. Whether the goal is continued abstinence or moderation, like Delilah’s, we strategize together for how to achieve it. Through a gradual process of trial and error, we figure out what works and what doesn’t. The goal of moderation can backfire, especially for people with severe addiction, contributing to a dangerously high escalation in use after a period of abstinence, it is also referred as abstinence violation effect.

Chapter 5: Space, Time and Meaning

Jacob(from the first chapter) relapsed again after a year of abstaining from compulsive sexual behaviors. He was feeling depressed and was thinking about his family. Then, the trigger was somehow seeing naked woman on TV. He started about thinking his old habits. He purchased the parts to make the masturbation machine again. He masturbated for 20 hours without stopping. After 2 days with the machine, he threw all the parts away in the garbage only to take out and repair them after a day. He wanted to stop but couldn't.

Anna suggested to Jacob to dump the parts of the machine in a place where it is impossible to retrieve it. She also suggested to kneel down, pray for god to help if he has the urge or craving to use. Generallly doctors don't talk about god but she believed that this would resonate with Jacob as he was raised a roman catholic.

The act of Jacob throwing his machine away can be described as self binding. It is the way we intentionally and willingly create barriers between ourselves and our drug of choice in order to mitigate compulsive overconsumption. If we wait until we feel the compulsion to use, the reflexive pull of seeking pleasure and/or avoiding pain is nearly impossible to resist. In the throes of desire, there’s no deciding. By creating tangible barriers between ourselves and our drug of choice, we press the pause button between desire and action.

Self binding can be organized into three broad categories:

1. Physical strategies
2. Chronological strategies
3. Categorical strategies

Here are some physical barriers that Anna's patients have told her about: “I unplugged my TV and put it in my closet.” “I banished my game console to the garage.” “I don’t use credit cards. Only cash.” “I call hotels beforehand to ask them to remove the minibar.” “I call hotels beforehand to ask them to remove the minibar and the television.” “I put my iPad in a safety deposit box at Bank of America.”

Self-binding is not failsafe and there is no guarantee. Sometimes the barrier itself becomes an invitation to a challenge. Solving the puzzle of how to get our drug of choice becomes part of its appeal.

Physical self-binding is now available from local pharmacies. The medication naltrexone is used to treat alcohol and opioid addiction, and is being used for a variety of other addictions as well, from gambling to overeating to shopping. Naltrexone blocks the opioid receptor, which in turn diminishes the reinforcing effects of different types of rewarding behavior. Some of her patients do report a flatlining of pleasure with naltrexone.

Chronological self-binding is the use of time limits and finish lines. By restricting consumption to certain times of the day, week, month, or year, we narrow our window of consumption and thereby limit our use. Sometimes, we can bind ourselves based on milestones or accomplishments. When the clock has run down, or we've crossed a self-designated finish line, the drug is our reward.

A study by Neuroscientists S. H. Ahmed and George Koob have shown that when the rats were given unlimited access to cocaine which they get after pressing a lever, they gradually increased their level pressing to the point of physical exhaustion and death. But, when the access was restricted to only 1 hour, they had steady amounts of cocaine over many consecutive days.

This study suggests that by restricting drug consumption to a narrow window of time, we may be able to moderate our use and avoid the compulsive and escalating consumption that comes with unlimited access.

High dopamine goods mess with our ability to delay gratification, a phenomenon called delay discounting. It refers to the fact that the value of a reward goes down the longer we have to wait for it. Opioid-addicted study participants referred to a future that was on average nine days long. Healthy controls referred to a future that was on average 4.7 years long. This striking difference illustrates how “temporal horizons” shrink when we’re under the sway of an addictive drug.

In a study by neuroscientists Samuel McClure and colleagues which examined what parts of the brain involved in choosing immediate versus delayed rewards, they found that when participants chose immediate rewards, emotion- and reward-processing parts of the brain lit up. when participants delayed their reward, the prefrontal cortex-- the part of the brain involved in planning and abstract thinking became active.

Categorical self-binding limits consumption by sorting dopamine into different categories: those subtypes we allow ourselves to consume, and those we do not. This method helps us to avoid not only our drug of choice but also the triggers that lead to craving for our drug. One of Anna's patients Mitch, who was addicted to sports betting, learnt through Gamblers Anonymous that it was important for him to abstain from sports-related sites, newspapers and sports radio. This helped him mitigate the risk of relapse to sports betting.

Categorical self-binding fails when we inadvertently include a trigger in our list of acceptable activities. We can then correct mistakes like these with a mental shifting process based on experience. But this is tricky when the categories themself change due to market forces. There are many other modern examples of previously taboo drugs being transformed into socially acceptable commodities, often in the guise of medicines. Cigarettes became vape pens and ZYN pouches. Heroin became OxyContin. Cannabis became medical marijuana.

A patient of Anna named Jasmine was seeking help for excessive alcohol consumption. Anna suggested that she remove all alcohol from her home as a self-binding strategy. Jasmine did that but she kept only one bottle in her fridge. She regarded it as the symbol of her choice not to drink. This is also a form of self-binding as well and this has worked for her as well.

"When we realize that we are capable of this inner legislation, the (natural) man feels himself compelled to reverence for the moral man in his own person"

- As Immunel Kant wrote in The Metaphysics of Morals

Binding ourselves is a way to be free.

Chapter 6: A broken balance?

Research suggests that the usage of psychiatric medications like antidepressants, anxiolytics(to treat anxiety), and hypnotics in four high-resourced countries, has not decreased the prevalence of mood and anxiety symptoms in people who were administered doses.

Patients with anxiety and insomnia who take benzodiazepines (Xanax and Klonopin) and other sedative-hypnotics daily for more than a month may experience worsened anxiety and insomnia. Patients with pain who take opioids daily for more than a month are at increased risk not only for opioid addiction but also for worsened pain.

Anna(the author) in her childhood was very cranky and was irritable. So much so that her mom preferred her brother over her. She was diagnosed with atypical depression. She then started taking Prozaz and it helped. She was feeling less cranky and less irritable. So much so that, she bonded with her mother. Years later, in anticipation to get pregnant, she went off Prozac. She reverted back to her old self: restless and cranky. Then, immediately, her mother and Anna was against the odds. She says “My non-Prozac personality, although not a good fit for my mom, has allowed me to do things I never would have done otherwise. Today, I’m finally okay with being a somewhat anxious, slightly depressed skeptic. I’m a person who needs friction, a challenge, something to work for or fight against. I won’t whittle myself down to fit the world. Should any of us?”

Part 3: The pursuit of pain

Chapter 7: Pressing on the pain side

A study was undertaken by the scientists at Charles f in Prague consisted of 10 men in cold water(14 degree celicus) for 1 hour. Using blood samples, the researchers showed that blood dopamine concentrations increased 250% and blood noradrenaline concentrations increased 530% as a result of cold-water immersion.

Dopamine rose gradually and steadily over the course of the cold bath and remained elevated for an hour afterward. Noradrenaline rose precipitously in the first thirty minutes, plateaued in the latter thirty minutes, and dropped by about a third in the hour afterward, but it remained elevated well above baseline even into the second hour after the bath. Dopamine and noradrenaline levels endured well beyond the painful stimulus itself.

This study is an example of how pressing on the side of balance can lead to its opposite - pleasure. Unlike pressing on the pleasure side, the dopamine that comes from pain is indirect and potentially more enduring.

The initial pain stimulus is followed by gremlins hopping on the pleasure side of the balance. And it eventually leads to a a balance.

With intermittent exposure to pain, our natural hedonic set point gets weighted to the side of pleasure, such that we become less vulnerable to pain and more able to feel pleasure over time. Just as pain is the price we pay for pleasure, so too is pleasure our reward for pain.

Hormesis is the branch of science that studies the beneficial effects of administering small to moderate doses of noxious and/or painful stimuli, such as cold, heat, gravitational changes, radiation, food restriction and exercise. Edward J. Calabrese describes hormesisas the "adpative responses of biological systems to moderate environmental or self imposed challenges through which the system improves it functionality and/or tolerance to more severe challenges".

Exercise is immediately toxic to cells, leading to increased temperatures, noxious oxidants, and oxygen and glucose deprivation. Yet, the evidence is overwhelming that exercise is health promoting. It's the reason there's a high after an exercise or a run. Exercise reduces the likelihood of using and getting addicted to drugs. High levels of physical activity in junior high, high school, and early adulthood predict lower levels of drug use. Exercise has also been shown to help those already addicted to stop or cut back.

But pursuing pain is harder than pursuing pleasure. It goes against our innate reflex to avoid pain and pursue pleasure. It adds to our cognitive load: We have to remember that we will feel pleasure after pain.

"Of two pains occuring together, not in the same part of the body, the stronger weakens the other"

- As Hippocrates in Aphorisms

The intentional application of pain to treat pain has been been around a long time. The history of medicine is fully of example using painful stimuli to treat painful disease states. they were someimtes called heroic therapies - which included cupping, blisters.. These kinds of painful remedies were practiced a lot prior to 1900 until the advent of drug therapy.

It is also one of the reasons why shock therapy is very useful. Nietzsche once said that "What doesn't kill me makes me stronger". If one gets very anxious to talk to people, one could plan to get exposed in escalating increments - being in crowds, talking a few words to the Barista, small talk with co-workers, etc.. It is very helpful to also quantify these things as a method of self awareness. For example, they could see track and record their anxiety levels before and after the exposure.

Alex Honnold, a famours personality for climbing the face of Yosemite's El Capitan. The researchers who studied Honnold’s brain speculated that he was born with less innate fear than others, which in turn allowed him, they hypothesized, to accomplish superhuman climbing feats. But, he disagreed: “I’ve done so much soloing, and worked on my climbing skills so much that my comfort zone is quite large. So these things that I’m doing that look pretty outrageous, to me they seem normal.”

He had basically trained through years of climbing not to be fearful of death defying feats. Of note, Honnold nearly had a panic attack when he went inside the fMRI machine to get pictures taken of his “fearless brain,” which also tells us that fear tolerance doesn’t necessarily translate across all experiences.

Stress alone can increase the release of dopamine in the brain's reward pathway, leading to the same brain changes seen with addictive drugs like cocaine and meth.

That is why extreme sports—skydiving, kitesurfing, hang gliding, bobsledding, downhill skiing/snowboarding, waterfall kayaking, ice climbing, mountain biking, canyon swinging, bungee jumping, base jumping, wingsuit flying—slam down hard and fast on the pain side of the pleasure-pain balance. Intense pain/fear plus a shot of adrenaline creates a potent drug.

Just as we become tolerant to pleasure stimuli with repeated exposure, so too can we become tolerant to painful stimuli, resetting our brains to the side of pain. A study of skydivers compared to a control group (rowers) found that repeat skydivers were more likely to experience anhedonia, a lack of joy, in the rest of their lives.

Chapter 8: Radical honesty

All of Anna's patients who have achieved long term recovery have relied on truth-telling as critical for sustained mental and physical health. Telling the truth is painful. We're wired from the earliest ages to lie, and we all do it, whether or not we care to admit it. Children begin lying as early as age two. The smarter the kid, the more likely they are to lie, and the better they are at it. Lying tends to decrease between ages three and fourteen, possibly because children become more aware of how lying harms other people.

The average adult tells between 0.59 and 1.56 lies daily. Lies arguably have some adaptive advantage when it comes to competing for scarce resources. But lying in a world of plenty risks isolation, craving, and pathological overconsumption. We all engage in regular lying, most of the time without realizing it. Our lies are so small and imperceptible that we convince ourselves we’re telling the truth. Or that it doesn’t matter, even if we know we’re lying.

Radical honesty promotes awareness of our actions. It fosters intimate human connections. It will hold us accountable not just to our present selves but also to our future selves. Telling the truth might even prevent development of future addiction.

Recounting our experiences give us mastery of over them. Whether in the context of psychotherapy, talking to an AA sponsor, confessing to a priest, confiding in a friend, or writing in a journal, our honest disclosure brings our behavior into relief, allowing us in some cases to see it for the first time. This is especially true for behaviors that involve a level of automaticity outside of conscious awareness.

Denial is when we're aware of the behavior, but not aware at same time as well. It is a kind of a half-conscious state akin to a waking dream. Denial is likely mediated by a disconnect between the reward pathway part of our brain the higher cortical brain regions that allow us to narrate the events of our lives, appreciate consequences, and plan for the future. Many forms of addiction treatment involve strengthening and renewing connections between these parts of the brain. Practicing radical honesty can stimulate prefrontal cortex. It is the frontmost part of our brain, just behind the forehead, and is involved in decision-making, emotion regulation, and future planning, among many other complex processes. It’s also a key area involved in storytelling.

Telling the truth draws people in, especially when we're willing to expose our own vulnerabilities. It logically makes sense that people would distance themselves when they learn about our character flaws and transgressions. In fact, the opposite happens. People come closer. They see in our brokenness their own vulnerability and humanity. They are reassured that they are not alone in their doubts, fears, and weaknesses.

But, there is something called disclosure porn that has become prevalent in modern culture, where revealing intimate aspects of our lives becomes a way to manipulate others for a certain type of selfish gratification rather than to foster intimacy through a moment of shared humanity.

In Anna's two decades of being a psychiatrist, she is convinced that the way we tell our personal stories is a marker and predictor of mental health. Patients who tell stories in which they are frequently the victim, seldom bearing responsibility for bad outcomes, are often unwell and remain unwell. By contrast, patients who tell stories that accurately portray their responsibility, get better.

The victim narrative reflects a wider societal trend in which we’re all prone to seeing ourselves as the victims of circumstance and deserving of compensation or reward for our suffering. Even if patients are victims, if the narrative doesn't move beyond victimhood, it's difficult for healing to occur. One of the jobs of good psychotherapy is to help people tell healing stories.

When our lived experience diverges from our projected image(who we show ourselves to be aka false self), we are prone to feel detached and unreal, as fake as the false images we’ve created. Psychiatrists call this feeling derealization and depersonalization. It’s a terrifying feeling, which commonly contributes to thoughts of suicide. After all, if we don’t feel real, ending our lives feels inconsequential.

The antidote to the false self is the authentic self. Radical honesty is a way to get there. It tethers us to our existence and makes us feel real in the world. It also lessens the cognitive load required to maintain all those lies, freeing up mental energy to live more spontaneously in the moment. When we’re no longer working to present a false self, we’re more open to ourselves and others.

Truth-telling engenders a plenty mindset. Lying engenders a scarcity mindset. When people around us reliable which includes keeping promises. We're confident about the world and our future. We feel we can rely not just on them but also on the world to be an orderly, predictable, safe kind of a place. This is the plenty mindset. With the case of scarcity mindset, it is the exact opposite. We feel less confident about future and the world around us. We go into competitive survival mode and favor short-term gains over long-term ones, independent of actual material wealth.

Dopamine overload impairs our ability to delay gratification. Social media exaggeration and post-truth politics amplify our sense of scarcity. The result is that even amidst plenty, we feel impoverished. Just as it is possible to have a scarcity mindset amidst plenty, it is also possible to have a plenty mindset amidst scarcity. The feeling of plenty comes from a source beyond the material world. Believing in or working toward something outside ourselves, and fostering a life rich in human connectedness and meaning.

Chapter 9: Prosocial shame

When it comes to compulsive overconsumption, shame is an inherently tricky concept. It can be the vehicle for perpetuating the behavior as well as the impetus for stopping it. Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self.

The author shares that, experientially, shame and guilt are identical. The difference is not in how we experience the emotion, but how others respond to our transgression. If others respond my rejecting, condemning, or shinning us, we enter the cycle of destructive shame. Destructive shame deepens the emotional experience of shame and sets us up to perpetuate the behavior that led to feeling shame in the first place. If others respond by holding us closer and providing clear guidance for redemption/recovery, we enter the cycle of prosocial shame. Prosocial shame mitigates the emotional experience of shame and helps us stop or reduce the shameful behavior.

Here's an illustration of destructive shame:

The antidote to destructive shame is prosocial shame. Prosocial shame is predicated on the idea that shame is useful and important for communities. It accepts that we're all flawed, capable of making mistakes, and in need of forgiveness. Here's an illustration for prosocial shame:

The author has established radical honesty as a core family value. Sometimes as parents we think that by hiding our mistakes and imperfections and only revealing our best selves, we’ll teach our children what is right. But this can have the opposite effect, leading children to feel they must be perfect to be lovable. As parents, she says that, we must be open and honest about our struggles and create a space for them to be open and honest about their own. When we are radically honest and and form intimacy in our relationships, the rush we get is adaptive, rejuvenating and health promoting.

Lessons of the balance - The final section

The author suggests that we find a way to immerse yourself fully in the life that we’ve been given. To stop running from whatever we’re trying to escape, and instead to stop, and turn, and face whatever it is. In this way, the world may reveal itself to you as something magical and awe-inspiring that does not require escape. Instead, the world may become something worth paying attention to.

The rewards of finding and maintaining balance are neither immediate nor permanent. They require patience and maintenance. We must be willing to move forward despite being uncertain of what lies ahead. We must have faith that actions today that seem to have no impact in the present moment are in fact accumulating in a positive direction, which will be revealed to us only at some unknown time in the future. Healthy practices happen day by day.

Here's a quick summary that we've learned about balance:

1. The relentless pursuit of pleasure (and avoidance of pain) leads to pain
2. Recovery beings with abstinence
3. Abstinence resets the brain's reward pathway and with it our capacity to take joy in simpler pleasures
4. Self-binding creates literal and metacognitive space between desire and consumption, a modern necessity in our dopamine overloaded world
5. Medications can restore our homeostasis(our baseline dopamine level), but consider what we lose by medicating away our pain
6. Pressing on the pain side resets our balance to the side of pleasure
7. Beware of getting addicted to pain
8. Radical honesty promotes awareness, enhances intimacy, and fosters a plenty mindset
9. Prosocial shame affirms that we belong to the human tribe
10. Instead of running away from the world, we can find escape by immersing ourselves in it