Dopamine Nation: Finding Balance in the Age of Indulgence

Dopamine Nation: Finding Balance in the Age of Indulgence is a 2021 book by Dr. Anna Lembke, a clinical psychiatrist and professor of psychiatry at Stanford University School of Medicine. In the book, Lembke explores the biological processes behind addictive behaviors and conditions. Using patient anecdotes from her clinical practice, Lembke examines the significant role of the neurotransmitter dopamine in addiction. While the book offers informative reading, Lembke’s ultimate purpose is to persuade people to take stock of their own behaviors and become more aware of their pleasure-seeking patterns. Significantly, Lembke includes personal anecdotes, illustrating that even renowned experts aren’t immune from the forces that lead one into addictive behaviors or conditions.

This guide uses the 2021 Kindle edition by Dutton.

Content Warning: The book (and this guide) details addictive and compulsive behaviors and refers to mental health conditions and death by suicide.

Plot Summary

The book has three parts, framed by an introduction and a conclusion. Part 1, “The Pursuit of Pleasure,” has three chapters, the first of which has the attention-grabbing title “Our Masturbation Machines.” Lembke shares the story of a patient, Jacob, a man in his sixties who sought her help to overcome a masturbation addiction. Interestingly, Lembke’s use of the third-person possessive pronoun “our” in the title frames Jacob’s story as one that could happen to anyone. As she describes the circumstances that led Jacob to seek her counsel, her tone is objective and scientific yet compassionate, and she emphasizes that the biological process of dopamine release and reward-seeking behavior is universal: All people are subject to the same kind of risk as Jacob. Chapter 2 tells the story of David, a college student who developed an addiction to Adderall, a stimulant used to treat attention deficit/hyperactivity disorder (ADHD). As Lembke does often in the book, she begins David’s story with his seeking help for the condition—in this case, social anxiety associated with ADHD. He soon found himself taking more Adderall than prescribed, developed a disorder, and eventually began taking psychotropic drugs and sleep medicine to help balance the effects of Adderall. Astonishingly, David was initially prescribed Adderall after only a 45-minute consultation, which weighted the diagnosis primarily according to his answers on a questionnaire. David’s story is among the most shocking ones in the book because those who should have looked out for his best interests—doctors—led him astray. Other stories in the book are similar to David’s and usually follow a similar pattern. A person develops a substance use disorder after seeking help for a condition. This anecdote and others lead into Chapter 3, which depicts in detail what dopamine is and how it works in the brain. She uses a baseball analogy to visually represent this. The presynaptic neuron is the pitcher, and the postsynaptic neuron is the catcher. Between them is a space called the synaptic cleft, where dopamine and other neurotransmitters (the baseballs) carry the signals from one neuron to the next. To depict the important concept of the pleasure-pain balance, Lembke uses an illustration of a teeter-totter to show how pleasure throws the body out of balance. Because the body seeks equilibrium through a process known as homeostasis, the pain side of the teeter-totter eventually rises past this level. This explains why a person who experiences a dopamine high usually feels worse the next day. It offers a great visual for what really causes a hangover. In concluding Part 1, Lembke discusses the science behind the pleasure-pain balance in the brain. She explores not only what dopamine is but also how it functions in our brains. When she introduces complex scientific concepts and processes, she uses various narrative techniques, such as analogy, to help make the information understandable for those who aren’t well versed in psychology.

In Part 2, “Self-Binding,” Lembke transitions away from examining the science behind pleasure-seeking tendencies to discussing how people who have substance use disorders successfully recover from them. Self-binding is a process whereby those who experience substance misuse remove from their environment any temptations that might lead them to break their sobriety. In Chapter 4, Lembke discusses the concept of “dopamine fasting,” which she recommends to all her patients as the first step in breaking use of a substance. This fasting period is usually difficult and includes some level of physical discomfort and pain (which varies depending on the severity of the use) as symptoms of withdrawal manifest. Lembke again uses analogy, this time alluding to Homer’s Odyssey (in which Odysseus demands to be bound to his ship to keep him from the Sirens’ allure) to illustrate her point about self-binding. Chapter 5 extends the discussion of self-binding, showing how people who have addiction must often disassociate themselves from places, people, and things that can trigger them to partake in the drug on which they use. As an example, she brings Jacob back into the story and discusses how he experienced a recurrence of his addiction while staying in a hotel that provided access to explicit sexual content on TV. Jacob’s recurring actions highlights that for people with compulsive behavior and addictions, recovery isn’t a final destination; instead, they must always be on guard against the triggers that can send them back to addictive behaviors. Chapter 6 focuses on pharmaceutical interventions for treating addiction. Lembke introduces a patient named Chris, who was recovering from heroin use by taking a medicine called buprenorphine, a synthetic opioid used to treat heroin withdrawal. He believed that saved his life, and when asked if he’d ever abstain from the drug, he said never. Lembke discusses how modern medicine seeks to treat almost everything with pharmaceutical remedies and ruminates on the potential risks through stops short of openly criticizing pharmaceutical companies. She mentions that when she was in residency in the 1990s, the prevailing sentiment was that a psychiatrist’s job was to diagnose and prescribe medicine, rather than first provide a more comprehensive therapeutic approach and then, if needed, provide medicinal remedies.

Part 3, “The Pursuit of Pain,” counterintuitively examines how intentionally seeking discomfort and pain can increase sensations of pleasure. Lembke begins Chapter 7 with an example known as cold-water immersion therapy. The discomfort of cold water causes the body to seek a means of balancing the discomfort, resulting in the release of dopamine. This pain-seeking is the inverse of the pleasure-pain balance that Lembke discusses in Part 1. When one partakes in a behavior or ingests a substance that releases dopamine, the body recalibrates to the side of pain, which creates the coming-down effect that one experiences after high levels of pleasure. Lembke shows how the inverse is also true. However, the intentional pursuit of pain has a cost: Too much pain, like substance misuse, can throw the body out of balance and in extreme cases prevent one from feeling pleasure unless pain precipitates it. The threshold increases the more one engages in the pursuit, much as it does when a person seeks pleasure first and experiences pain afterward. Near the end of the book, Lembke lists 10 “lessons of the balance,” which summarize the book’s main points in an easily digestible and memorable way. Her strategy to close with these lessons provides a clear sense of how to proceed once one is more aware of the dangers of relentless pleasure seeking.