Dopamine Nation

Ourselves to Death, wrote, “Americans no longer talk to each other, they
entertain each other. They do not exchange ideas, they exchange images. They
do not argue with propositions; they argue with good looks, celebrities, and
commercials.”
My patient Sophie, a Stanford undergraduate from South Korea, came in
seeking help for depression and anxiety. Among the many things we talked
about, she told me she spends most of her waking hours plugged into some
kind of device: Instagramming, YouTubing, listening to podcasts and
playlists.
In session with her I suggested she try walking to class without listening to
anything and just letting her own thoughts bubble to the surface.
She looked at me both incredulous and afraid.
“Why would I do that?” she asked, openmouthed.
“Well,” I ventured, “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.”
She thought about that for a moment. “But it’s so boring,” she said.
“Yes, that’s true,” I said. “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.

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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.”
The next week, Sophie experimented with walking to class without being
plugged in.
“It was hard at first,” she said. “But then I got used to it and even kind of
liked it. I started noticing the trees.”
Lack of Self-Care or Mental Illness?
Back to David, who was, in his own words, taking “Adderall around the
clock.” After he graduated from college in 2005, he moved back in with his
parents. He thought about going to law school, took the LSATs, and even did
okay, but when it came down to applying, he didn’t feel like it.
“I mostly sat on the couch and built up a lot of anger and resentment: at
myself, at the world.”
“What were you angry about?”
“I felt like I’d wasted my undergraduate education. I hadn’t studied what I
really wanted to study. My girlfriend was still back at school . . . doing great,
getting a master’s. I was wallowing at home doing nothing.”
After David’s girlfriend graduated, she landed a job in Palo Alto. He
followed her there, and in 2008 they were married. David got a job at a
technology start-up, where he interacted with young, smart engineers who
were generous with their time.
He got back into coding and learned all the stuff he had meant to study in
college but was too afraid to pursue in a room full of students. He got
promoted to software developer, was working fifteen-hour days, and ran
thirty miles a week in his spare time.
“But to make all that happen,” he said, “I was taking more Adderall, not
just in the morning, but all through the day. I’d wake up in the morning, take
Adderall. Get home, eat dinner, take more Adderall. Pills became my new
normal. I was also drinking huge amounts of caffeine. Then I’d hit the end of
the night, and I needed to go to sleep, and I’m like, Okay, what do I do now?

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So I went back to the psychiatrist and talked her into giving me Ambien. I
pretended like I didn’t know what Ambien was, but my mom had taken
Ambien for a long time, and a couple uncles too. I also talked her into a
limited prescription of Ativan for anxiety before presentations. From 2008 to
2018, I was taking up to thirty milligrams of Adderall a day, fifty milligrams
of Ambien a day, and three to six milligrams of Ativan a day. I thought, I
have anxiety and ADHD and I need this to function.”
David attributed fatigue and inattentiveness to a mental illness rather than
to sleep deprivation and overstimulation, a logic he used to justify continued
use of pills. I’ve seen a similar paradox in many of my patients over the
years: They use drugs, prescribed or otherwise, to compensate for a basic
lack of self-care, then attribute the costs to a mental illness, thus necessitating
the need for more drugs. Hence poisons become vitamins.
“You were getting your A vitamins: Adderall, Ambien, and Ativan,” I
joked.
He smiled. “I guess you could say that.”
“Did your wife or anybody else know what was going on with you?”
“No. Nobody did. My wife had no idea. Sometimes I would drink alcohol
when I ran out of Ambien, or get angry and yell at her when I took too much
Adderall. But other than that, I hid it pretty well.”
“So then what happened?”
“I got tired of it. Tired of taking uppers and downers day and night. I
started thinking about ending my life. I thought I’d be better off, and other
people would be better off. But my wife was pregnant, so I knew I needed to
make a change. I told her I needed help. I asked her to take me to the
hospital.”
“How did she react?”
“She took me to the emergency room, and when it all came out, she was
shocked.”
“What shocked her?”
“The pills. All the pills I was taking. My huge stash. And how much I had
been hiding.”

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David was admitted to the inpatient psychiatric ward and diagnosed with
stimulant and sedative addiction. He stayed in the hospital until he finished
withdrawing from Adderall, Ambien, and Ativan, and until he was no longer
suicidal. It took two weeks. He was discharged home to his pregnant wife.
—
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 ourselves. Yet all this trying to
insulate ourselves from pain seems only to have made our pain worse.
According to the World Happiness Report, which ranks 156 countries by
how happy their citizens perceive themselves to be, people living in the
United States reported being less happy in 2018 than they were in 2008.
Other countries with similar measures of wealth, social support, and life
expectancy saw similar decreases in self-reported happiness scores,
including Belgium, Canada, Denmark, France, Japan, New Zealand, and
Italy.
Researchers interviewed nearly 150,000 people in twenty-six countries to
determine the prevalence of generalized anxiety disorder, defined as
excessive and uncontrollable worry that adversely affected their life. They
found that richer countries had higher rates of anxiety than poor ones. The
authors wrote, “The disorder is significantly more prevalent and impairing in
high-income countries than in low- or middle-income countries.”
The number of new cases of depression worldwide increased 50 percent
between 1990 and 2017. The highest increases in new cases were seen in
regions with the highest sociodemographic index (income), especially North
America.
Physical pain too is increasing. Over the course of my career, I have seen
more patients, including otherwise healthy young people, presenting with full
body pain despite the absence of any identifiable disease or tissue injury.
The numbers and types of unexplained physical pain syndromes have grown:
complex regional pain syndrome, fibromyalgia, interstitial cystitis,
myofascial pain syndrome, pelvic pain syndrome, and so on.

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When researchers asked the following question to people in thirty countries
around the world—“During the past four weeks, how often have you had
bodily aches or pains? Never; seldom; sometimes; often; or very often?”—
they found that Americans reported more pain than any other country.
Thirty-four percent of Americans said they felt pain “often” or “very
often,” compared to 19 percent of people living in China, 18 percent of
people living in Japan, 13 percent of people living in Switzerland, and 11
percent of people living in South Africa.
The question is: 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?
The reason we’re all so miserable may be because we’re working so hard
to avoid being miserable.

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