Wednesday, October 17, 2012

Equivalency of Pleasure from Social Interaction and Eating and the role of dopamine system in attention and addiction

A 62 year old man, who is moderately overweight, reported that when he is not around people he eats. He  recently had ended an unhappy marriage, the last twenty years of which were quite loveless. He was overeating even while married, but, after the divorce, the problem had worsened.
Then he met someone, started a satisfying relationship and his mood improved. An interesting side-benefit of this companionship was that he did not compulsively eat when she was around. This led him to make a further observation that it was not just his girlfriend's company, but others' too, that kept his mind away from  food.
In therapy he remarked, "I got to be doing something pleasurable all the time. That is my nature. I am in horse business - and as you know how passionate I am about it - where if I make a deal, and it does not matter whether buying or selling, it gives me great pleasure. And greater the margin of profit, say if I make a steal, getting a 500-dollar horse for just 300, and then turning around and selling it for 2000 instead of  a 1000, then I am like in heaven. But coming to think of it, it is not just horses. This sense of pleasure extends to a lot of other things, like helping others. The other day when the hurricane went through Dexter, and knocked down those houses, I was the first one on the spot with my tractor, helping people sort through their rubble. And it gave me so much joy being a rescuer. It made me feel like a winner. And it is this feeling of being a winner that generates the sensation of pleasure. And if nothing else is going on which affirms this belief in my superiority then I am there eating. I guess it has to do with one's childhood when if you were into something good like eating an ice cream, while your siblings and playmates were not then you were like ahead of them."
Now we know that whenever something pleasurable happens to us, the brain immediately secretes the neurotransmitter dopamine. Why does this happen?  And is it the sensation of pleasure that causes dopamine release or is it dopamine release that stimulates some reward center in the brain which creates the sensation of pleasure?  But does it make sense for the brain to have developed a whole neurotransmitter system and a reward center just to give the subjective feeling of pleasure? And finally it raises the question as to what in the world is pleasure and why the brain needs that sensation for its functioning, and how dopamine release generates the subjective feeling of pleasure in the consciousness?
Sensation of pleasure -it is actually signal to the subjective consciousness of a relief from sensations - happens when the level of tension or stimulation in the brain goes down. Less the brain is bombarded with stimuli, whether arriving from inside the organism - hunger, thirst, sexual needs, pain - or from the external world - heat, cold, competition for food, attack from predators, pain - or from its own reflective activities  (reactivation of the past experiences as a preparation for future), the more at ease it becomes.
Brain appears to have evolved as a means to keep the level of stimulation in the whole organism at the minimum possible without the organism dying. It should not surprise us that what humans prize more than anything else in the world, more than gold, silver, and sex, is to have the deepest sleep possible; sleep free of any disturbance; sleep free of even the pleasantest dream; sleep that is just one step this side of death. No wonder narcotic addicts sometimes actually die trying to get the greatest peace/pleasure/high of their life through creating near death experience.
As to how this toning down of the brain activity creates subjective feeling of pleasure in the consciousness is beyond the scope of human understanding, at least at present, perhaps it will remain so forever. We do know that more active the brain is greater is the feeling of unpleasure, unless of course that activity is being undertaken to lessen the rising stimulation at some other point. 
And here lies the reason why people are constantly doing something. They are constantly preparing themselves to avert a more massive increase of tension in the future. This gives an illusion that we actively seek stimulation.
If we take my patient's case it can be seen that his interaction with his girlfriend and other people while raising the tension at one level also promises of lesser stimulation and thus lesser tension in the future. Interactions with girl friend are pleasurable in that they assure that the dreaded unmanageable rise in sexual tensions will not become a reality with her being around and permitting their periodic release. Helping hurricane victims is assurance that such a good deed will be noticed by the heavenly father, or whichever authority now substitutes for the parents, and he will either not be subjected to similar disaster as a reward, or if similar disaster strikes him people will come to his rescue as a payback.
How does the brain learn not to run away from these humps of increase stimulation and correctly evaluate them as unpleasant necessities that must be faced to avoid over-stimulation in the long run? In other words what mechanism the brain utilizes to override one's natural inclination to immediately avoid any overstimulation. The mechanism lies in the love that we received from our parents when we undertook painful tasks that promised future pleasure. It is  for the sake of parental love - and fear of punishment in their hands that would have caused greater increase in tensions that the unpleasant task itself - that we learn to become stoical towards the difficulties of life.  The pleasure that was generated from the love and attention given by the parents outweighed the unpleasure that arose from undertaking the tasks.
And the earliest and most momentous token of that love was being fed.
While eating is a pleasure in its own right - it brings relief from the tension of hunger  - it is also the first and the most important means to reward the child when he does not run away from mastering exigencies of life.  Promise of food - promise of parental love - can lead humans to bear great amounts of suffering.
Thus eating becomes the most important methods to tolerate suffering. It is in fact the first addiction of humans. Our first experience of satisfaction occurs on mother's breast. Even after nutritional need is taken care of, the child will keep sucking upon the pacifier, and later the thumb, to recreate this experience of pleasure, and through it, when under stress, the illusion of parental protection. This first experience of satisfaction is the prototype of all later addictions. Later when thumb sucking is no longer permissible under the critical and forbidding eyes of society, munching of food substitutes it. Other addictions may follow, but their nature is basically the same. They are all undertaken to produce pleasure at one point of the brain so it will distract the attention away from anxiety, tension and pain happening at another region.
A patient of mine recently confirmed this viewpoint with the following statement:
"I am an emotional eater. When I am in pain I eat bowls after bowls of cereals. It eases the pain. It is similar to cutting that I use to do. When the emotional pain from the molestation [which I was subjected to from the age of 7 to 14] would get overbearing I would cut myself. The physical pain would take away the emotional pain. In fact I would not even feel the physical pain, just relief from the emotional one."
So eating by producing pleasure from the positive sensations occurring at the taste buds in the mouth, feeling of fullness in the stomach, and the muscle movements of the mouth and the gullet takes away the pain happening at some other spot, just like cutting oneself physically at the wrist takes away the emotional pain that one feels inside. One of my patients stated that when the memory of molestation grips her the pain is so severe that she feels that her chest is going to cave in and she cannot even breath, and only cutting herself allows her system to breath and live again.
Fortunately most people do not have to cut themselves to generate enough counter/irritant/counter-pleasure  to combat the internal pain, they just have to reach out and eat something. And while the food is in the mouth or traveling down the gullet, and muscles of mastication and swallowing are active, the pleasure generated takes away the attention from emotional pain.
And so was the case in my horse trader patient. As long as he could drown out the unhappiness of his life by finding pleasure in making deals on buying and selling horses, or in socializing with his girlfriend, or with other people he was fond of, or helping those who he hoped would help him in return in his hour of need, he would not think of food. But when nothing else was happening and all his unfulfilled needs and ambitions would start clamoring for expression and stimulate his brain to do something worthwhile - which his age, circumstances and abilities precluded him from undertaking - then the only recourse left for him to do something meaningful was to eat.
How does the attention shift from the painful stimuli to areas which are producing pleasurable sensation?
Here comes the role of dopamine. Whichever behavior decreases overall brain activity - that is overall level of mental stimulation/tension - that behavior is strengthened - given more attention - through dopamine input. Dopamine's function appears to be to further charge/cathect/facilitate the neuronal circuitry that underlies pleasure giving behavior. Dopamine-producing neuronal circuits are not activated as a reward when something pleasurable happens. Pleasure happens when there is decrease in mental activity and dopamine is secreted to give attention to all those environmental factors and one's motor actions that brought about the pleasure. This increased attention makes the memory traces of these environmental factors and actions stronger. It is a kind of error to look upon the neuronal circuits that produce dopamine as reward circuits. They should be looked upon as attention producing circuits which make the perceptions and behaviors existing at that point of time more vivid and consequently their memory traces stronger.
At this point a few words on Attention Deficit Disorder (ADD) are in order. This malady appears to emerge as a response to some inner turmoil. As if the child is running away from some revved up inner neuronal circuits - in most boys it is running away from turmoil of the Oedipal Conflict which did not come to quiescence/dissolution with beginning of the latency period - seeking pleasure to distract attention from the tension. If this running away cannot be undertaken in motor movements, it is in racing thoughts or in daydreams. All these motor movements/racing thoughts/daydreams occur to seek winnings which will reverse the memory of the Oedipal defeat and having to give up the mother as love object out of fear of father. This fear of the father underlies the constant anxiety that is the substratum of ADD and which drives the boy to keep running and running. As the child matures, obsessive thinking and motor rituals emerge to control the anxiety and hyperactivity (running).
Careful examination of these ADD children shows that all their motor hyperactivity and day dreaming are an attempt at winning either in real life or in imagination to lessen the fear of  and to come even with "the Oedipal father". And through winning produce a decrease in level of tension, which is same as production of pleasure, and which results in secretion of dopamine from attention producing circuits. Stimulants - dopamine enhancing drugs - work in ADD because they boost dopamine and thus attention to whatever is going on in the environment. Here the dopamine is secreted not because some winning has occurred and therefore there is decrease in tension but by the means of drug. Nevertheless the release of dopamine temporarily takes away the child's attention from his revved up painful neuronal circuits and focuses upon what is happening in his environment then and there. As one of my ADHD patient remarked,"Whenever I take Ritalin all my thinking becomes immediate, current. All the past hurts and memories that rob me of my present vanish. My mind instead of being all over the place from the past are now focused in what is happening here and now."
It may not be totally out of the way to make couple of remarks on the distractibiliy/hyperactivity that occurs  due to lack of sleep and which we try to rectify by various means the most favored of which is munching upon food through the day. The purpose of sleep is to bring down the level of excitation of the revved up neuronal circuits that had occurred as a response to day's challenges so they can start afresh the next day. If this cannot be accomplished by simple withdrawal of cathexis/activation from the cares of the day dreams are generated that show the happenings of day in more favorable light allowing the vigilant and tense neuronal circuits that were on guard to discharge and become ready to undertake fresh responsiibilities the next day.  If their discharge cannot take place even in dreams because the distortion of real life circumstances in dream would have been too great to bear, leading to waking out of the dream/nightmare or unable to fall asleep in the first place out of fear of dreaming dreadful dreams, then during the day one would go around still preoccupied with the affairs of the past, unable to pay proper attention to the present. And to bring back the attention from these internal conflicts to the real world one would eat. For the pleasure generated from eating releases dopamine and draws back the attention to food and the real world from where the food is coming.
The question naturally arises that if pleasure (reduction in tensions) causes dopamine release which in turn stimulates the attention and there certainly could not be any pleasure arising from inner turmoil why the mind pays any attention to the latter in the first place. And there is little doubt that when something is bothering us  we have no interest in the affairs of the world and all our attention is to keep mulling over the painful inner turmoil. Why would one want to focus upon painful happenings? This is a tricky issue. We know that whatever causes pain we want to run away from it. And if we cannot physically run away from it then we at least don't want to look at it, think of it or pay attention to it. But this cannot be entirely true. If something painful strikes us, our first inclination is to run but if we cannot then we are forced to pay attention to it. Something gnawing inside, we may ignore it in the beginning, but finally if it does not go away by distracting ourselves with other things, we are forced in to dealing with and yanking it out of our vicinity and our system if its source is within the body.
Let us try to make some headway into the mechanisms behind this attentiveness to pain. The first and the oldest must be the reflex attention. Its evolution had to be before the emergence of Central Nervous System when the brain was multilocular, spread all over the body, and each sensory modality (taste, sound, touch) brought its own independent motor response through ganglionic cluster of neurons. This reflex attention must have evolved as a biological necessity at the discovery that by not paying attention to whatever is bothering oneself the trouble does not go away, especially if the source of stimulation is from within the organism as hunger and thirst, and the way to deal with it is not through creating a distance from it but paying attention to what is causing the excessive stimulation and taking steps to eliminate it. Perhaps release of endorphins and other anti-pain chemicals in the brain, and also at the body site from where the pain was arising, was a necessary step in the development of this mechanism of generating attention. With further development of the brain the dopamine system must have also come into play. Once endorphins would have brought about the cessation of pain and thus decrease of tension, dopamine would have been secreted to enhance attention. High addiction potential of narcotics appears to be based upon not just their ability to stop pain, but their ability to generate high level of attention; at least in some addicts. There is no doubt that some ADHD patients prefer narcotics over stimulants as a attention generating chemical.
The other mechanism behind the paying of attention to painful things has already been discussed at some length above. In the earliest years of our life when we were in pain and required relief from it, but did not have ability nor the experience to do so, it was our parents who paid attention to our needs and came to our rescue. Over time this behavior becomes internalized, and we took over the actions of our parents who instead of running away from painful situation paid attention, took cognizance and got rid of it for our sake.
Finally, we must try to answer as to why attention is generated whenever there is reduction in tension.
This requires examining as to what life itself is. An organism is alive as long as it is indulging in give and take with other organic entities. It is this exchange which bring reduction in tension. When a desirable thing like food is ingressed and added to the organism or an unwanted part of oneself like feces is extruded there is reduction of tension. Higher this rate of  exchange with the outer world more alive is the organism.. As one of my patient put it, "When I was healthy I was into everything and everybody, so full of life. Now that I am bogged down with stress, everything has ceased. Even my intestines have gone in a shutdown mode, and I get constipated for days. Last thing I want to do is to deal with people. And I am gaining weight and my cholesterol is shooting up, because even my metabolism has slowed down, refusing to burn the calories I take in."
Attention, with the aid of dopamine secretion, is an additional attempt to enhance life processes. Whatever perceptions and behaviors enable life's give and take, attention is paid to them so they have higher priority in getting activated when similar situation arises in future.