There is a narrative wave in popular psychology and neuroscience that has taken a small amount of very basic science and twisted it into a fantastic narrative of feast and famine. Its central character is dopamine. The Dopamine Detox also known as dopamine fasting is a pseudoscientific treatment that at best illustrates how magnificently strange and evidence-less some claims about dopamine can be.
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Welcome to PsyDactic Residency Edition. Today is May 3, 2023. I am Dr. O’Leary a 3rd year psychiatry resident in the National Capital Region…
A while ago a patient came into my office and reported to me that one of the symptoms he noticed after discontinuing his escitalopram was “an increase in impulsive behaviors.” When I asked him to explain, he reported that he does things that “bring me excess amounts of pleasure.” I was intrigued, thinking that he might tell me something that would raise my suspicion for a bipolar type disorder. “What kinds of things?” I asked. “Oh, I masterbate and look at pornography.” Does he do this excessively, like many times a day. No. Does he frequently seek out new sexual partners? No. After pressing him for something that might make me concerned for pathological impulsivity, he reported that he believes when he masterbates, this results in a huge load of dopamine being released into his brain, so much so that for the next day or two, he cannot feel as much other kinds of pleasure like “watching movies and stuff.”
It was then that I asked him, “Have you ever read about the Dopamine Detox?”
Today I want to talk about dopamine. I’ve mentioned monoamines before. They are psychoactive players in many of the drugs that psychiatrists give patients. Dopamine is unique among them for having taken on an almost mythical status in our culture as a bringer of pleasure and doom. Dopamine could be loosely compared with Harvey Dent in Batman, that good and benevolent district attorney turned Gotham supervillain. The pleasure he once received by doing good for his community is replaced by a desire for mischief, chaos, and revenge. There is a similar narrative wave in popular psychology and neuroscience that has taken a small amount of very basic science and twisted it into a fantastic narrative of feast and famine. Its central character is dopamine. The Dopamine Detox also known as dopamine fasting is a pseudoscientific treatment that at best illustrates how magnificently strange and evidenceless some claims about dopamine can be.
One of my fears is that psychiatrists and psychotherapists will use pseudoscience to inspire patients to either believe in bogus treatments or to assign disturbing significance to benign actions. Take the example of masterbation. If you were taught by your therapist to believe that masturbating at night after work is going to result in a large dopamine dump that will delete your ability to feel pleasure for the next two days, then your therapist is causing unnecessary distress by spreading fake science. First, do no harm. If your patient is masterbating in the bathroom at work on their lunch break, this should be addressed, but if they do it a couple times a week in the privacy of their home, this is healthy and normal and no cause for shame. Your patient doesn’t need the burden of blaming last night’s masterbatory session on their current day’s malaise. If they do, then that is something to explore.
There is a purportedly science-based idea that engaging in pleasurable activities will somehow either deplete your brain of dopamine of raise the bar in your brain for what it considers pleasurable, resulting in the need to do pleasurable things for longer periods of time or with more intensity than you did before in order to receive the same satisfaction. This actually pseudoscientific idea is often explained by comparing pleasurable acts to addictive substances or impulsive behaviors. The idea is that if there are people who use substances like methamphetamine or do things like play video games or scroll through TikTok to get pleasure and abstinence from these substances or acts cause dysphoria, that this means they have either depleted their dopamine stores or increased their tolerance to dopamine in their brains. The solution, then, is a dopamine fast or dopamin detox.
Let me read you something I encountered from an article called “How to do a dopamin detox” from gamequitters.com. “Instead of getting enough dopamine from everyday activities, individuals suffering from addiction rely on receiving dopamine from drugs, alcohol, video games, or other external stimuli instead.” They go on to claim, “The side effects of too much dopamine include: ADHD, Addictions, Binge-eating and other binging behaviors, Gambling, Obesity.” I have no idea how ADHD got into that mix, being a neurodevelopmental disorder and not something that you develop by doing drugs or playing video games. I imagine they are mistaking the appearance of ADHD that might arise when someone has poor organization skills because they have never learned how to exist in a structured work environment with the actual disorder.
The idea that we should take a break from things that have taken undue control over our lives is not new, and when done intentionally can be an effective way to combat certain addictions or compulsive behaviors, but to convince someone that dopamine needs to be precisely conserved lest you become an a joyless zombie is completely out of touch with the science of dopamine.
Had gamequitters.com been the authoritative source on dopamine in our lives, I would probably not have even bothered to do an episode on this. Then I listened to multiple podcasts, both featuring Stanford faculty, one a psychiatrist and the other a neuroscientist. I have included links at the end of the show transcript at psydactic.buzzsprout.com. It may not surprise you that these Standford experts are either selling books or a plethora of supplements in order to support the good work of spreading their message to the masses. I will avoid giving names in the episode because I don’t sell supplements or books to anyone and so don’t really have the monetary resources to engage in a prolonged legal battle if someone decides to try to silence me by filing a predatory lawsuit. I am also not suggesting that they would, just that I’m not in the position to test that hypothesis.
What I am going to say doesn’t depend on the identity or even the credentials of an individual. I am trying to promote healthy skepticism of what people claim is “science based information.” I think I have a more rigid definition of science than many other people. I should also say that I was impressed with the amount of actual scientific information that people promoting their dopamine narratives include. I should mention that many popularizers of dopamine fasts or dopamine detoxes do not present their opinions as mere hypotheses, but as facts. They do include many facts. Many, many facts.
In some ways listening to them was a good review for me, and I probably learned something, though I am not sure I can trust what I learned. For example, one of the hosts reported that we can increase our available dopamine by sitting in a cold water tank up to the neck for up to an hour. This was confirmed by peripheral blood draws. On the surface, it sounds impressive, but dopamine does not readily cross the blood brain barrier. That is why, when we give dopamine to Parkinson's patients, it is in the form of Levodopa, which can cross the blood-brain barrier and then be converted into dopamine and we give this along with carbidopa, which does not cross the blood-brain barrier, to prevent peripheral tissues from converting the levodopa into dopamine outside of the brain, because this can result in a lot of unwanted side effects. A peripheral blood draw doesn’t tell us much about what dopamine levels are in the brain, and it also doesn’t tell us what else is going on that we didn’t measure. Even if we did do a spinal tap, we still wouldn’t know where in the brain dopamine was most available and active.
What separates pseudoscience and the fringes of “evidence-based medicine” from actual science and science-based medicine is the extent that the purveyor makes unsupported claims based on either preliminary or basic scientific findings. Often this basic science is included in a shot-gun fashion, quoting fact after fact in an attempt to overwhelm the listener with so much information that they are left with no choice but to think that the speaker is on to something.
Searching for facts that appear to be consistent with a preconceived notion is called, “cherry picking,” and just because your bucket is full of cherries, it doesn’t mean there is actual evidence for the claim being proposed. In fact, the exact opposite is true. A bucket-full of cherries is most likely to result in a rotten mess. Each of those facts independently has a level of uncertainty associated with it, and adding more uncertain facts does not add to the certainty, it multiplies the uncertainty.
Basic science answers very specific questions and hints at other possible areas of research. Science is painfully slow, but when it progresses it produces durable results. Pseudoscience takes very specific answers and builds a giant web of illusory knowledge around it. The link between each of the nodes is weak, and when tugged at, the whole web comes tumbling down. Pseudoscience is fast, and it produces misleading results that have unpredictable consequences. The tell-tale sign of an illusory web of facts is when the speaker is willing to sell you food products or supplements that, for example, “boost dopamine naturally” instead of the unnatural way that you are supposedly doing it now.
A name that I will now mention is Dr. Cameron Sepah, a Harvard graduate who is listed as the CEO of Maximus and Executive Psychologist and Professor at UC San Francisco Medical School. He popularized his own ideas about dopamine fasting that he termed Dopamine Fasting 2.0. He goes to lengths to try to clarify that his method is not aimed at actually reducing dopamine, but instead at regulating impulsive behaviors. The fact that he called it a dopamine fast instead of an impulse fast doesn’t help to reduce the confusion. He also wants to make it clear that his method does not discourage people from engaging in other activities that can increase their dopamine if these are healthy, like exercise and hanging out with your friends. He has to make these clarifications because he did not invent the dopamine fast (it was a trend for many years before he invented is 2.0 version) and many people who do it will limit all pleasurable activities, like eating tasty foods or talking with friends, in an attempt to reset dopamine levels in their brain. Dr. Sepah instead focuses on addictive, impulsive, and compulsive behaviors and proposes a plethora of Cognitive Behavioral Therapy based interventions such as stimulus control, exposure and response prevention therapy, and mindfulness-like methods. However, these therapies were not necessarily developed for the indications he is proposing. What makes his method something that he can actually claim some credit for is that he prescribes a schedule to abstain from unwanted behaviors that people can use to help gain more control over their lives.
This includes a dopamine fasting schedule of:
1-4 hours at the end of the day (depending on work & family demands)
1 weekend day (spent outside on a Saturday or Sunday)
1 weekend per quarter (go on a local trip).
1 week per year (go on vacation!)
If you don’t find this ground-breaking, then you are no alone. What confounds me is why Dr. Sepah seems to have thought that co-opting a pseudoscientific trend could result in anything other than more pseudoscience is beyond me. It certainly gave him and potentially his company a lot of attention. Maximus sells pharmaceuticals to me such as enclomiphene (selective estrogen receptor modulator that reportedly increases testosterone levels by increasing release of gonadotropin in the pituitary), tadalafil (that is known to treat erectile dysfunction), bremelanotide (that was approved as an subcutaneous injectable for reduced libido in women, but sold by Maximus in pill form for men). Interestingly, the Mayo clinic website states that men should not use bremelanotide, but to be fair, off-label use of medicines is a common practice. In addition, Maximus will sell you a concoction to help men regrow hair. It also contains pharmaceuticals that have an indication for hair regrowth. I should also report am not an expert in male sexual performance and this podcast is not specifically about male sexual health or hair growth. I am confident to report that some patients’ ideas as to what a dopamine fast or detox is can result in sexual shaming and maladaptive behaviors, which is not helpful.
I do want to spend an inadequate amount of time discussing some of the basic science of dopamine, though. Dopamine is a neuromodulator that is generally excitatory to neurons, which means that when it is released into synapses, it hits G-protein coupled receptors on the postsynaptic neurons and ultimately results in greater potential for signal induction. It basically makes those neurons more excitable. But just because a neuron is excitable doesn’t mean that its firing will result in a downstream excitatory effect. It could result in inhibition. In psychiatry and neurology, dopamine is probably best known for it’s role in movement disorders and in reward-based reinforcement learning and memory. It is also proposed to play a central role in mania and psychosis.
Dopamine that is produced in the substantia nigra is exported through the nigrostriatal pathways to the striatum. The striatum is involved in executing movements that are first planned in our premotor cortex and initiated in our motor cortex before being coordinated with the rest of our body in the striatum. We know that death of neurons in the substantia nigra results in a relative decrease in available dopamine, which results in difficulty suppressing and initiating movements in the striatum. Without sufficient dopamine, parts of our body move when we don’t intend them to and other parts are hard to move even when we try. Parkinson’s disease and Dementia with Lewy Bodies both often manifest in tremors and rigidity and they are both associated with death of neurons in the substantia nigra.
Dopamine is also produced in the ventral tegmental area and transported via the mesocortical pathway to the prefrontal cortex and the mesolimbic pathway to the nucleus accumbens and olfactory tubercle. These pathways are connected to our higher reasoning and more basic emotional and memory processing centers and are thought to play key roles in addiction, mania, and psychosis. Dopamine is also produced in the hypothalamus of the brain and aids in memory formation and retrieval, which is thought to reinforce novel, rewarding, and addictive behaviors by emphasizing reward-based memories. However, we know that serotonin, norepinephrine and glutamate modulators can also affect these functions profoundly. When it comes to treating addiction, I ask the psychiatry residents in the audience, “How many direct dopamine modulating agents do we have that have good evidence for treating addiction?” I’ll give you a moment to ponder that question.
Bupropion is a dopamine and norepinephrine reuptake inhibitor that has been shown to help some people with smoking cessation, but I am at a loss to find others off the top of my head. While most of our addictive drugs have a pathway that is thought at some point to lead to dopamine dysregulation, they also do so many other things. Opioids, nicotine, alcohol which are some of the most profoundly addictive substances we know have been linked to dopamine, but they do so much more and have effects on far more neuromodulators than just dopamine. Drugs like cocaine and methamphetamine have a more direct dopaminergic effect, but they represent a relative small number of our addicted patients. Maybe dopamine is not the end-all-be-all of addiction that simplistic reasoning would have us postulate. It certainly plays a role, but it is also certainly not the only master of addiction.
Psychosis or mania has been thought to be caused by excessive amounts of dopamine, but we also know that psychedelic substances can cause hallucinations and delusions, like LSD which act as a serotonin agonist. Glutamate receptor antagonists like ketamine also can cause delusions and dissociative or psychotic-like experiences. We know that excessive amounts of amphetamines (which do increase dopamine) can cause psychosis, but it normally takes a lot and often the psychosis is associated with a long period of use without much food or sleep. To lay the burden of psychosis solely on dopamine ignores the fact that many second generation antipsychotics and serotonin modulators like pimavanserin can treat many forms of psychosis. Blocking dopamine receptors may work sometimes, but not always, and come with a load of side effects, including the severe movement disorder, tardive dyskinesia, when given over a long period of time.
None of the hypotheses stating that we can fully explain addiction, or impulsivity, or psychosis, or compulsive and impulsive behaviors primarily by too much or too little dopamine or getting a spurt of dopamine at the wrong time makes any sense once you look past the surface. There are some isolated examples where pathologies obviously affect dopamine levels (like parkinsons and Lewy body dementia) and we see consequences in the brain, but our brain under anything approaching normal operating conditions, is far too complex to be so easily explained.
Let me ask you this now. If a neuroscientist who spends their life engaging in social media such as podcasts, websites, their facebook, twitter, TikTok or whatever other media is asking you to buy their sponsored natural substance that is supposed to increase or better regulate dopamine levels in your brain so that you can enjoy life without the need for what they are characterizing as unnatural or impulsive ways of doing this, is this not at some level hypocritical? Whether it is hypocritical or not, it is certain not science. It is a mythology built within a scientific landscape. It is also certainly a good way to get sponsorships and sell books or supplements.
If you don’t remember anything else from this podcast, at least remember that Doctor O begged you to please stop telling my patients to detox from dopamine or dopamine fasts. In my humble opinion, you are confusing everyone and possibly causing harm.
I am Dr. O, and this has been an episode of PsyDactic Residency Edition.