What does it mean to be normal? And what does it mean to be sick? I've asked myself this question from the time I was about seven, when I was diagnosed with Tourette syndrome. Tourette's is a neurological disorder characterized by stereotyped movements I perform against my will, called tics. Now, tics are technically involuntary, in the sense that they occur without any conscious attention or intention on my part.
But there's a funny thing about how I experience tics. They feel more unvoluntary than involuntary, because I still feel like it's me moving my shoulder, not some external force. Also, I get this uncomfortable sensation, called premonitory urge, right before tics happen, and particularly when I'm trying to resist them. Now, I imagine most of you out there understand what I'm saying, but unless you have Tourette's, you probably think you can't relate. But I bet you can. So, let's try a little experiment here and see if I can give you a taste of what my experience feels like. Alright, ready?
Don't blink. No, really, don't blink. And besides dry eyes, what do you feel? Phantom pressure? Eyelids tingling? A need? Are you holding your breath?
That's approximately what my tics feels like. Now, tics and blinking, neurologically speaking, are not the same, but my point is that you don't have to have Tourette's to be able to relate to my experience of my premonitory urges, because your brain can give you similar experiences and feelings.
So, let's shift the conversation from what it means to be normal versus sick to what it means that a majority of us are both normal and sick. Because in the final analysis, we're all humans whose brains provide for a spectrum of experiences. And everything on that spectrum of human experiences is ultimately produced by brain systems that assume a spectrum of different states. So again, what does it mean to be normal, and what does it mean to be sick, when sickness exists on the extreme end of a spectrum of normal?
As both a researcher who studies differences in how individuals' brains wire and rewire themselves, and as a Touretter with other related diagnoses, I have long been fascinated by failures of self-regulation on the impulsive and compulsive behavioral spectrums. Because so much of my own experience of my own body and my own behavior has existed all over that map.
So with the spotlight on the opioid crisis, I've really found myself wondering lately: Where on the spectrum of unvoluntary behavior do we put something like abusing opioid painkillers or heroin? By now, we all know that the opioid crisis and epidemic is out of control. Ninety-one people die every day in this country from overdose. And between 2002 and 2015, the number of deaths from heroin increased by a factor of six. And something about the way that we treat addiction isn't working, at least not for everyone. It is a fact that people suffering from addiction have lost free will when it comes to their behavior around drugs, alcohol, food or other reward-system stimulating behaviors. That addiction is a brain-based disease state is a medical, neurobiological reality. But how we relate to that disease — indeed, how we relate to the concept of disease when it comes to addiction — makes an enormous difference for how we treat people with addictions.
So, we tend to think of pretty much everything we do as entirely voluntary. But it turns out that the brain's default state is really more like a car idling in drive than a car in park. Some of what we think we choose to do is actually things that we have become programmed to do when the brakes are released. Have you ever joked that your brain was running on autopilot? Guess what? It probably was. OK? And the brain's autopilot is in a structure called the striatum. So the striatum detects emotional and sensory motor conditions and it knows to trigger whatever behavior you have done most often in the past under those same conditions.
Do you know why I became a neuroscientist? Because I wanted to learn what made me tick.
Thank you, thank you.
I've been wanting to use that one in front of an audience for years.
So in graduate school, I studied genetic factors that orchestrate wiring to the striatum during development. And yes, that is my former license plate.
And for the record, I don't recommend any PhD student get a license plate with their thesis topic printed on it, unless they're prepared for their experiments not to work for the next two years.
I eventually did figure it out. So, my experiments were exploring how miswiring in the striatum relates to compulsive behaviors. Meaning, behaviors that are coerced by uncomfortable urges you can't consciously resist. So I was really excited when my mice developed this compulsive behavior, where they were rubbing their faces and they couldn't seem to stop, even when they were wounding themselves. OK, excited is the wrong word, I actually felt terrible for them. I thought that they had tics, evidence of striatal miswiring. And they were compulsive, but it turned out, on further testing, that these mice showed an aversion to interacting and getting to know other unfamiliar mice. Which was unusual, it was unexpected. The results implied that the striatum, which, for sure, is involved in compulsive-spectrum disorders, is also involved in human social connection and our ability to — not human social connection, but our ability to connect.
So I delved deeper, into a field called social neuroscience. And that is a newer, interdisciplinary field, and there I found reports that linked the striatum not just to social anomalies in mice, but also in people. As it turns out, the social neurochemistry in the striatum is linked to things you've probably already heard of. Like oxytocin, which is that hormone that makes cuddling feel all warm and fuzzy. But it also implicates signaling at opioid receptors. There are naturally occurring opioids in your brain that are deeply linked to social processes.
Experiments with naloxone, which blocks opioid receptors, show us just how essential this opioid-receptor signaling is to social interaction. When people are given naloxone — it's an ingredient in Narcan, that reverses opioid overdoses to save lives. But when it's given to healthy people, it actually interfered with their ability to feel connected to people they already knew and cared about. So, something about not having opioid-receptor binding makes it difficult for us to feel the rewards of social interaction.
Now, for the interest of time, I've necessarily gotten rid of some of the scientific details, but briefly, here's where we're at. The effects of social disconnection through opioid receptors, the effects of addictive drugs and the effects of abnormal neurotransmission on involuntary movements and compulsive behaviors all converge in the striatum. And the striatum and opioid signaling in it has been deeply linked with loneliness.
When we don't have enough signaling at opioid receptors, we can feel alone in a room full of people we care about and love, who love us. Social neuroscientists, like Dr. Cacioppo at the University of Chicago, have discovered that loneliness is very dangerous. And it predisposes people to entire spectrums of physical and mental illnesses.
Think of it like this: when you're at your hungriest, pretty much any food tastes amazing, right? So similarly, loneliness creates a hunger in the brain which neurochemically hypersensitizes our reward system. And social isolation acts through receptors for these naturally occurring opioids and other social neurotransmitters to leave the striatum in a state where its response to things that signal reward and pleasure is completely, completely over the top. And in this state of hypersensitivity, our brains signal deep dissatisfaction. We become restless, irritable and impulsive. And that's pretty much when I want you to keep the bowl of Halloween chocolate entirely across the room for me, because I will eat it all. I will.
And that brings up another thing that makes social disconnection so dangerous. If we don't have the ability to connect socially, we are so ravenous for our social neurochemistry to be rebalanced, we're likely to seek relief from anywhere. And if that anywhere is opioid painkillers or heroin, it is going to be a heat-seeking missile for our social reward system. Is it any wonder people in today's world are becoming addicted so easily? Social isolation — excuse me — contributes to relapse.
Studies have shown that people who tend to avoid relapse tend to be people who have broad, reciprocal social relationships where they can be of service to each other, where they can be helpful. Being of service lets people connect. So — if we don't have the ability to authentically connect, our society increasingly lacks this ability to authentically connect and experience things that are transcendent and beyond ourselves. We used to get this transcendence from a feeling of belonging to our families and our communities. But everywhere, communities are changing. And social and economic disintegration is making this harder and harder.
I'm not the only person to point out that the areas in the country most economically hard hit, where people feel most desolate about their life's meaning, are also the places where there have been communities most ravaged by opioids. Social isolation acts through the brain's reward system to make this state of affairs literally painful. So perhaps it's this pain, this loneliness, this despondence that's driving so many of us to connect with whatever we can. Like food. Like handheld electronics. And for too many people, to drugs like heroin and fentanyl.
I know someone who overdosed, who was revived by Narcan, and she was mostly angry that she wasn't simply allowed to die. Imagine for a second how that feels, that state of hopelessness, OK? But the striatum is also a source of hope. Because the striatum gives us a clue of how to bring people back. So, remember that the striatum is our autopilot, running our behaviors on habit, and it's possible to rewire, to reprogram that autopilot, but it involves neuroplasticity. So, neuroplasticity is the ability of brains to reprogram themselves, and rewire themselves, so we can learn new things. And maybe you've heard the classic adage of plasticity: neurons that fire together, wire together. Right?
So we need to practice social connective behaviors instead of compulsive behaviors, when we're lonely, when we are cued to remember our drug. We need neuronally firing repeated experiences in order for the striatum to undergo that necessary neuroplasticity that allows it to take that "go find heroin" autopilot offline. And what the convergence of social neuroscience, addiction and compulsive-spectrum disorders in the striatum suggests is that it's not simply enough to teach the striatum healthier responses to compulsive urges. We need social impulses to replace drug-cued compulsive behaviors, because we need to rebalance, neurochemically, our social reward system. And unless that happens, we're going to be left in a state of craving. No matter what besides our drug we repeatedly practice doing.
I believe that the solution to the opioid crisis is to explore how social and psychospiritual interventions can act as neurotechnologies in circuits that process social and drug-induced rewards. One possibility is to create and study scalable tools for people to connect with one another over a mutual interest in recovery through psychospiritual practices. And as such, psychospiritual practice could involve anything from people getting together as megafans of touring jam bands, or parkour jams, featuring shared experiences of vulnerability and personal growth, or more conventional things, like recovery yoga meetups, or meetings centered around more traditional conceptions of spiritual experiences.
But whatever it is, it needs to activate all of the neurotransmitter systems in the striatum that are involved in processing social connection. Social media can't go deep enough for this. Social media doesn't so much encourage us to share, as it does to compare. It's the difference between having superficial small talk with someone and authentic, deeply connected conversation with eye contact. And stigma also keeps us separate. There's a lot of evidence that it keeps us sick. And stigma often makes it safer for addicts to connect with other addicts. But recovery groups centered around reestablishing social connections could certainly be inclusive of people who are seeking recovery for a range of mental health problems.
My point is, when we connect around what's broken, we connect as human beings. We heal ourselves from the compulsive self-destruction that was our response to the pain of disconnection. When we think of neuropsychiatric illnesses as a spectrum of phenomenon that are part of what make us human, then we remove the otherness of people who struggle with self-destruction. We remove the stigma between doctors and patients and caregivers. We put the question of what it means to be normal versus sick back on the spectrum of the human condition. And it is on that spectrum where we can all connect and seek healing together, for all of our struggles with humanness. Thank you for letting me share.