The Role of Disappointment in Chronic Illness and Modern Society

The Habenula, a Very Small, Little Known Part of the Brain with Massive Implications

Introduction

In a recent podcast interview, Prof. Andrew Huberman provides some further pragmatic advice for how to increase and maintain healthy baseline levels of dopamine, following on from Dr Anna Lembke’s work on dopamine, as covered in her book Dopamine Nation.

Here is what I gleaned from the interview:

• dopamine is involved in both motivation (effort, striving, seeking) and reward (achieving a goal, winning);

• the problem is that "reward"-type pleasure (quick dopamine hits) without prior requirement for pursuit (effort, seeking, striving) is terrible for us, examples include food at our fingertips without the need to farm, hunt or gather, sex without the romantic courtship, instant knowledge without the need to actively learn;

• the reward version of pleasure has a more opioid bliss character;

• celebrating the win (a big, quick peak in dopamine) more than the pursuit rebounds into the pain side of the pleasure-pain balance system, and too much of this will lower baseline levels of dopamine, as per Dr Lembke's research;

• we have some control over what we attach dopamine and pleasure to;

• to maintain and increase baseline levels of dopamine, we need to learn to take pleasure in the motivating part, in the effort, the seeking and striving;

• if addiction is a progressive narrowing of the things that bring pleasure, the alternative is a progressive expansion of the things that bring pleasure, and includes pleasure in the effort part, not just in the win;

• restraint or resistance is a practice which can be done daily, by mindfully resisting cravings or impulses, e.g. not checking the smartphone when you have an urge to do so, or not reaching for snacks, even if this resistance is only for a few minutes at first;

• like most things, the "no go", or restraint, circuits of the brain need to be used often in order to maintain and strengthen them;

I am reminded by this of my own workaholic behaviours in the years prior to my diagnosis. I was always working flat out, to the exclusion of all else, to complete a task or reach a target, such as the next academic paper, grant application or promotion, whilst never really taking pleasure in the work itself.

In fact, I was feeling [self-]stressed and angry with my work most of the time. The result would be a very brief win when a target was achieved, followed by a crash into feeling flat and disappointed, and then straight on to the next task or target without pause.

I see now I was never present to what I was doing, always looking to a future that never realized. So for me, there is much to what Prof. Huberman is saying here, and I do believe my workaholism fed my descent into disease.

I think there is also much we can say about how this applies to how we go about chasing healing too. Perhaps healing can only really happen if we learn to enjoy the healing process itself.

Synchronously, I read an article by Dr Iain McGilchrist, which included the following:

"According to the philosopher James Carse, there are at least two kinds of games. One could be called finite, the other infinite. A finite game is played for the purpose of winning, an infinite game for the purpose of continuing the play."

I think reframing many things in life as infinite games would be in-keeping with what Prof. Huberman is recommending.

The Habenula

In the above mentioned interview with Prof. Huberman, he also mentions an area of the brain called the “habenula” as being involved. I had never heard of this before, but on researching it, it quickly became apparent to me that this part of the brain is vital to any discussions about chronic illness and trauma, and indeed may be involved in mediating the freeze stress response. Here is what I learned.

The habenula is a very small area of the brain which neighbours the pineal gland. It receives information from the limbic system and basal ganglia, and sends information to the substantia nigra and the ventral tegmental area, which are both involved with dopamine release. Recall that in the classical view of Parkinson’s Disease, it is dopamine cell death in this substantia nigra area which is the proposed mechanism of the disease.

So the habenula is a part of the brain which can exert a large and wide influence on dopamine producing cells in the brain.

Indeed, the activation of the habenula inhibits or deactivates the dopamine neurons in the substantia nigra and ventral tegmental area, and, conversely excites or activates them when it is deactivated. This has profound implications for chronic conditions.

For example, this points to the possibility that it is not cell death which causes the issues in PD, but chronic activation of the habenula permanently switching off the cells in the substantia nigra from producing dopamine. This is a more hopeful hypothesis, as it means the cells are just dormant, not dead. If we can figure out how to deactivate the habenula, this should provide significant symptom reduction.

Similarly, if acute activation of the habenula can temporarily switch off dopamine production in the substantia nigra part of the brain, this would cause temporary immobilization, and hence the habenula might be the mechanism by which the Nervous System creates the freeze or “playing dead” stress response, which folks with chronic conditions or trauma tend to get stuck in.

The habenula also seems to be responsible for the pain part of the pleasure-pain balance of dopamine release highlighted be Dr Lembke, and hence has a vital role in addiction too. After a peak in dopamine, the habenula gets activated and dopamine crashes until the baseline is restored.

Thus it is very important to understand what can activate the habenula. A very informative article on the habenula reveals that:

“... the habenula is involved in encoding information about disappointing (or missing) rewards. The habenula has also been found to be activated in response to punishment and stimuli that we have previously associated with negative experiences. Based on all of this information, it is thought the habenula plays an important role in learning from aversive experiences and in making decisions so as to avoid such unpleasant experiences in the future.”

So perhaps the habenula “switch” gets stuck on, and hence chronic freeze starts manifesting, when one has built up too many negative experiences.

Furthermore:

“… when the reward is smaller than we expected [i.e. disappointment]… dopamine activity in the substantia nigra and ventral tegmental area is inhibited. Smaller-than-expected rewards, however, cause increased activity in the habenula, while larger rewards lead to an inhibition of activity there… when the reward is smaller than we expected, dopamine activity in the substantia nigra and ventral tegmental area is inhibited… thus, it has been hypothesized that the habenula is involved in encoding information about disappointing (or missing) rewards."

Prof. Huberman refers to this as “reward prediction error”. My disappointment, and feeling flat, after the completion of a task at work, which I described above, is, I think, a good example of this. It is interesting to conjecture how my mindset and behaviours generating a lifetime of disappointments may also have contributed to my PD diagnosis.

Also, people with chronic issues tend to become pessimistic, and this may actually be a learned adaptive response to avoid disappointments and hence to offset even further activation of the habenula! Similarly, folks with chronic conditions tend to have a very strong negative inner voice, or inner critic. Such a well developed inner critic may again be there as an over-compensation in order to avoid further disappointment.

“The habenular nuclei are involved in pain processing, reproductive behavior, nutrition, sleep-wake cycles, stress responses, and learning... the function of the lateral habenula with reward processing, in particular with regard to encoding negative feedback or negative rewards.”

These are all things strongly related to chronic illness symptoms too, and hence habenula activation explains why these tend to cluster together.

I wonder if it is possible to create targeted visualization, meditations or hypnotherapy scripts to inform the habenula to deactivate?

The Habenula and Behavior

The following is a contribution by my friend Xisca Nicolas, a person with Asperger's who likes to relate different fields for provoking thought, to open new ways to connect the dots, and take into account more parameters at the same time. She uses her dog behaviorist and clicker (additive reinforcement) training, Somatic Experiencing and Transformational Social Therapy training, and anthropology.

“The habenula is part of the interface between the limbic brain and the brain stem and activated by what we can group under the word ‘trauma’. It links with dopamine and serotonin release, and it is activated by the addition of unpleasant events and the reduction of pleasant events.

It could thus be related to the freeze response because it inhibits dopamine, the neurotransmitter that gives motivation for action as long as we still have hope to be successful. The habenula seems to play a role when the balance falls too much on the side of "it is not worth to invest more energy", or giving up.

As we know in behaviorism, behaviors are either reinforced or dissuaded through experiences and how much energy we can invest before dopamine drops (in order to not insist in a useless behavior). It happens that the habenula could be the physiological switch on or off involved in immobilization, through the release or inhibition of dopamine.

So the physiology suggests that some behavior tools could help build up a tolerance to how much stress we can stand before dopamine is turned off which creates discouragement, helplessness, procrastination...

My training in behaviorism and clicker training, using additive reinforcement in balance with subtractive reinforcement (removing pain or unpleasant things) shows we can indeed reinforce the resistance to discouragement, while also avoiding that the additive reinforcement becomes addictive reinforcement.

Emotions and behaviors are both part of the SIBAM (Somatic Experiencing list of tools where we search for under- and over-couplings : Sensations - Images - Behaviours - Affects - Meanings), so we might benefit from behavior tools that help to change the habits ingrained in the limbic system. Children's motivation system is culturally not at all well taken care of currently, and we cannot pass on easily what we have not experienced properly either.

It is necessary that the path becomes a form of reward, so that we can stand failing to reach the treat. Then we can manage better our path to increase our resilience, we can increase the time lapse between the effort and the result, we can accept to receive smaller rewards than what we expected.

When we fail at those points, the habenula activates and shuts down dopamine, producing at least the partial freeze responses, the ones that are less obvious than passing out or fainting, for example.

I feel quite confident to say that our modern way of living favors a quite high incidence of procrastination, going unnoticed because we replace dopamine by cortisol. So the energy of joy and motivation is too often replaced by a pressure to perform and reach a goal, with an emphasis on result more than on the path. This lowers dopamine even more, because the path is not rewarding, and the effect of isolated victories does not last. We need to treat ourselves better instead of relying too much on treats. Is it what "the journey is the goal" really means.”

The Habenula in the Modern World

This is Gary writing again now. From the above, I propose the key to happiness is to take pleasure in the pursuit of happiness itself, and that a good life is when we live in alignment with minimizing the time in which our habenula is activated. Meditations which de-activate the habenula, re-framing our goals and purpose from trying to win the finite games to playing the infinite games to the best of our ability, developing a growth mindset, changing negative habits and beliefs, may all help (I provide a complete list of suggestions of changes we can make, that I believe all help to de-activate the habenula, in my first ever substack article).

Conversely, the modern society we have created for ourselves seems almost to be designed to cause chronic disappointment, and hence habenula over-activation. It is finite games all the way down!

The politicians who never deliver on their promises; the news media which constantly tell us situations are going from bad to worse; the bombardment by adverts for products and services which never live up the hype or the marketing; the anti-meritocracy in which we are seldom recognized for our achievements; the daily grind for no or little or reward; the consumerism in which we can never have enough; the lure of a cure for cancer or chronic illnesses which never arrive; the tease of the virality of our social media posts that go nowhere; the lottery tickets which never bring us fortune; the hunt for fame which, even if it we find it, turns out to be more a curse than a blessing; the travesties of justice and obvious unfairness, the sports teams who lose a lot; the abundance of junk food which we crave but make us feel sick; …

It also seems likely to me that the control mechanisms which the powers-that-be and our traumatized institutions employ against us implicitly exploit habenula activation. After all, what better way to control the population and prevent us taking action or rising up, than by making us freeze up instead?

The good news is that now we know about the role of the habenula, its profound links to dopamine, and we aware of the things which tend activate it, and practices which can help to deactivate it, we can avoid the pitfalls and traps. Hence we can now add this pragmatic knowledge to our anti-dystopia toolbox.

I have created a online course called “The Nervous System in Chronic Illness”, in which I am amassing all the practical knowledge I have gleaned along the way of my own journey of recovery, for folks with chronic conditions, caregivers and therapists: