We are honoured.
No, really, we are.
When we first launched back in Spring 2018 we were privileged to feature some work by the one and only Amy Dresner. Whoop!!
Fast forward twelve months and Amy has been kind enough to allow me to republish an article that she wrote for The Fix last year.
In “Depression in Recovery”Amy takes an irreverent view on addiction, recovery, the brain reward system and, erm, dopamine.
Screw the Kombucha. Get the kettle on!
NB: This article has been published with permission of the author. Opinions expressed are her own. Also, neither Recovery.Wrx or The Fix provide medical advice, diagnosis, or treatment, nor does anything on this website create a physician/patient relationship. If you require medical advice, diagnosis, or treatment, please consult your doctor or local service.
Amy – thanks for sharing with us, you totally rock!
Depression in Recovery:
Do You Have Low Dopamine Tone?
by Amy Dresner
I just felt like shit and slept as much as I could. I showed up to work. I kept my commitments. I spoke when asked to, but I felt more than unhappy. I felt like I just didn’t care.
What really annoys me was that some people think at five and a half years of sobriety, you shouldn’t feel depressed.
I just came out of a six-week depression. That might not sound very long, but when you’re in hell it feels like forever. Good news: I didn’t bone any 25-year-old strangers; I didn’t cut myself; I didn’t get loaded; I didn’t smoke or vape although I really, really wanted to. I didn’t even eat pints of Ben and Jerry’s while binge-watching I Am A Killer. I just felt like shit and slept as much as I could. I showed up to work. I kept my commitments. I spoke when asked to, but I felt more than unhappy. I felt like I just didn’t care. I didn’t return phone calls. I didn’t wash my hair. Suicidal thoughts bounced around my head, but I ignored them like I do those annoying dudes with clipboards outside Whole Foods.
I’ve suffered from symptoms of depression since I was 19, so it’s an old, old friend. What really annoys me was that some (dare I say many?) people think at five and a half years of sobriety, you shouldn’t feel depressed. What I kept hearing from AA fundamentalists was:
“It’s your untreated alcoholism.”
“Listen to these tapes about prayer and meditation.”
“You’re not connected enough to your Higher Power.”
“You’re not going to enough meetings.”
“You need to do more service.”
Thankfully my sponsor, who has a foot in the medical world, did not say something along those lines.
One of my big problems with AA is that it looks at every mental problem through the paradigm of your “alcoholism.” If you’re suffering, you should look to the program for relief. Nobody would tell you to “drive around newcomers!” more if you had diabetes or kidney failure, but if you’re feeling down, that’s what you’re told to do. As it turns out, AA is not completely off the mark: “Addiction is a not a spiritually caused malady but a chemically based malady with spiritual symptoms,” addictionologist and psychiatrist Dr. Howard Wetsman told me. “When some people start working a 12-step program, they perceive a spiritual event but their midbrain is experiencing an anatomical event. When they’re working a program, they’re no longer isolated and they no longer feel ‘less than,’ so their dopamine receptor density goes back up [and they experience contentment],” he explained.
But what if your program hasn’t changed or feels sufficient and you still feel depressed? What if you’re working your ass off in your steps and helping others and you still feel like shit?
“Well, low dopamine tone experienced as low mood can be brought on by fear and low self-esteem (the untreated spiritual malady part of alcoholism/addiction) but it can also be brought on by biochemical issues,” Wetsman added.
So was I experiencing the chemical part of my “addiction” or was I having a depressive episode? Perhaps my whole life I’d been confusing the two. Of course, all I wanted, like a typical addict, was a pill to fix it. But as I’ve done the medication merry-go-round (and around and around) with mild to moderate success, I was hesitant to start messing with meds again. I didn’t have a terrific psychiatrist, and SSRI’s can really screw with my epilepsy. And Wetsman was talking about dopamine here, not serotonin. Hmmm…
Dr. Wetsman has some interesting stuff about brain chemistry and addiction on his vlog. He mentions something called “dopamine tone” which is a combination of how much dopamine your VTA (Ventral Tegmental Area) releases, how many dopamine receptors you have on your NA (Nucleus Accumbens), and how long your dopamine is there and available to those receptors. Stress can cause you to have fewer dopamine receptors and fewer receptors equals lower dopamine tone.
He’d explained to me in previous conversations how almost all of the people with addiction he’d treated had what he described as “low dopamine tone.” When you have low dopamine tone, you don’t care about anything, have no motivation, can’t feel pleasure, can’t connect to others. In addition, low dopamine tone can affect how much serotonin is being released in the cortex. Low midbrain dopamine tone can lead to low serotonin which means, in addition to not giving a shit about anything, you also have no sense of well-being.
Well, that certainly sounded familiar.
Dr. Wetsman has a very convincing but still somewhat controversial theory that addiction is completely a brain disease and that using drugs is the result, not the cause. I really suggest you get his book, Questions and Answers on Addiction. It’s 90 pages — you could read half of it on the john and half of it while waiting at the carwash. It explains in detail why most of us addicts felt weird and off before we picked up and why we finally felt normal when we used. Again, it’s all about dopamine, and it’s fucking fascinating. No joke.
In his vlog, he explains that dopamine production requires folic acid which you can get from green leafy veggies (which I admittedly don’t eat enough of) but it also requires an enzyme (called methylenetetrahydrofolate reductase or MTHFR for short) to convert folate into l-methylfolate. Certain people have a mutation in the gene that makes MTHFR, so they can’t turn folate into l-methylfolate as effectively, and those people are kind of fucked no matter how many kale smoothies they drink.
But it’s not hopeless. If people with this genetic mutation take a supplement of l-methylfolate, their brain can make enough dopamine naturally. Of course once you have enough dopamine, you’ve got to make sure you release enough (but there’s medication for that) and that you have enough receptors and that it sits in the receptors long enough (and there’s meds for that too).
So this all got me wondering if maybe my MTHFR enzyme was wonky or completely AWOL. Dr. Wetsman urged me to find a good psychiatrist (since I’m on Prozac and two epileptic medications) or a local addictionologist in addition to taking a genetic test for this mutation. In his experience, patients who had a strong reaction to taking the l-methylfolate supplement were frequently also on SSRIs. They either felt much better right away or really really shitty. But if they felt even shittier (because the higher serotonin levels work on a receptor on the VTA which then lowers dopamine), he would just lower their SSRI or sometimes even titrate them off it completely. And voila. Success.
It’s all very complicated, and this whole brain reward system is a feedback loop and interconnected with all kinds of stuff like Gaba and Enkephalins (the brain’s opioids) and Glutamate. But you guys don’t read me for a neuroscience lesson so I’m trying to keep it simple.
The basics: how do you know if you have too little dopamine?
You have urges to use whatever you can to spike your dopamine: sex, food, gambling, drugs, smoking, and so on. What about too much dopamine? OCD, tics, stuttering, mental obsession and eventually psychosis. Too little serotonin? Anxiety and the symptoms of too high dopamine tone. Too much serotonin? The same thing as too little dopamine tone. Everything is intricately connected, not to mention confusing as all hell.
Being broke and lazy and having had decades of shitty psychiatrists, I decided to go rogue on this whole mission (not recommended). I mean I used to shoot stuff into my arm that some stranger would hand me through the window of their 87 Honda Accord so why be uber careful now? This l-methylfolate supplement didn’t require a prescription anymore anyway. What did I have to lose? I did however run it by my sponsor whose response was: “I’m no doctor, honey, but it sounds benign. Go ahead.”
I ordered a bottle.
A few days later I heard the UPS guy drop the packet into my mail slot. I got out of bed, tore open the envelope and popped one of these bad boys. A few hours later I started to feel that dark cloud lift a little. Gotta be a placebo effect, right? The next day I felt even better. And the next day better still. I didn’t feel high or manic. I just felt “normal.” Whoa. It’s been weeks now and the change has been noticeable to friends and family.
Normal. That’s all I ever really wanted to feel. And the first time I felt normal was when I tried methamphetamine at 24. It did what I wanted all those anti-depressants to do. It made me feel like I knew other people felt: not starting every day already 20 feet underwater. I found out later that my mother and uncle were also addicted to amphetamines which further corroborates my belief that there is some genetic anomaly in my inherited reward system.
When I emailed Dr. Wetsman to tell him how miraculously better I felt, his first response was “Great. I’m glad. The key thing is to take the energy and put it into recovery. People go two ways when they feel amazingly better. One: ‘Oh, this is all I ever needed. I can stop all this recovery stuff.’ Or two: ‘Wow, I feel better. Who can I help?’ Helping others in recovery will actually increase your dopamine receptors and make this last. Not helping people will lead to shame, lowered dopamine receptors and it stops being so great.”
So no, I’m not going to stop going to meetings or doing my steps or working with my sponsor and sponsees. Being part of a group, feeling included and accepted, even those things can create more dopamine receptors.Amy Dresner
But sadly I’m still an addict at heart and I want all the dopamine and dopamine receptors I can get.
However, I also know that enough dopamine alone isn’t going to keep me from being a selfish asshole…. But maybe, just maybe, having sufficient dopamine tone and working a program will.
About the author.
Amy Dresner is a recovering drug addict and “all around fuck up” (Her words, not ours).
Growing up in Beverly Hills, Amy Dresner had it all: a top-notch private school education, the most expensive summer camps and even a weekly clothing allowance. But at 24, she started dabbling in meth in San Francisco and unleashed a fiending addiction monster. Soon, if you could snort it, smoke it, or have sex with, she did. Smart and charming, with daddy’s money to fall back on, she sort of managed to keep it all together. But on Christmas Eve of 2011, all of that changed when, high on Oxycontin, she stupidly “brandished” a bread knife on her husband and was promptly arrested for “felony domestic violence with a deadly weapon.” Within months, she found herself in the psych ward–and then penniless, divorced and looking out on a court-ordered 240 hours of community service. For the next two years, assigned to a Hollywood Boulevard “chain gang,” she would sweep up syringes (and worse) on Hollywood Boulevard as she bounced from rehabs to halfway houses, all while struggling with sobriety, sex addiction, and starting over in her 40s.
She’s been regularly writing for The Fix since 2012. When she isn’t humorously chronicling her epic ups and downs for us, she’s freelancing for Refinery 29, Alternet, After Party Chat, Salon, The Frisky, Cosmo Latina, Unbound Box, Addiction.com and Psychology Today. Her first book, My Fair Junkie: A Memoir of Getting Dirty and Staying Clean is published by Hachette Books.
You can follow her on Twitter @amydresner.