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What does it mean to be normal?

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And what does it mean to be sick?

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I've asked myself this question
from the time I was about seven,

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when I was diagnosed
with Tourette syndrome.

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Tourette's is a neurological disorder

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characterized by stereotyped movements
I perform against my will, called tics.

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Now, tics are technically involuntary,

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in the sense that they occur
without any conscious attention

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or intention on my part.

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But there's a funny thing
about how I experience tics.

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They feel more unvoluntary
than involuntary,

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because I still feel like it's me
moving my shoulder,

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not some external force.

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Also, I get this uncomfortable sensation,
called premonitory urge,

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right before tics happen,

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and particularly
when I'm trying to resist them.

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Now, I imagine most of you out there
understand what I'm saying,

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but unless you have Tourette's,
you probably think you can't relate.

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But I bet you can.

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So, let's try a little experiment here
and see if I can give you

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a taste of what my experience feels like.

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Alright, ready?

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Don't blink.

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No, really, don't blink.

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And besides dry eyes, what do you feel?

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Phantom pressure?

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Eyelids tingling?

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A need?

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Are you holding your breath?

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(Laughter)

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Aha.

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(Laughter)

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That's approximately
what my tics feels like.

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Now, tics and blinking,
neurologically speaking, are not the same,

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but my point is that you
don't have to have Tourette's

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to be able to relate to my experience
of my premonitory urges,

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because your brain can give you
similar experiences and feelings.

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So, let's shift the conversation from
what it means to be normal versus sick

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to what it means that a majority of us
are both normal and sick.

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Because in the final analysis,
we're all humans

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whose brains provide
for a spectrum of experiences.

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And everything on that spectrum
of human experiences

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is ultimately produced by brain systems

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that assume a spectrum
of different states.

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So again, what does it mean to be normal,

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and what does it mean to be sick,

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when sickness exists on the extreme end
of a spectrum of normal?

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As both a researcher who studies
differences in how individuals' brains

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wire and rewire themselves,

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and as a Touretter
with other related diagnoses,

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I have long been fascinated
by failures of self-regulation

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on the impulsive and compulsive
behavioral spectrums.

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Because so much of my own
experience of my own body

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and my own behavior

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has existed all over that map.

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So with the spotlight
on the opioid crisis,

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I've really found myself
wondering lately:

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Where on the spectrum
of unvoluntary behavior

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do we put something like abusing
opioid painkillers or heroin?

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By now, we all know that the opioid crisis
and epidemic is out of control.

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Ninety-one people die every day
in this country from overdose.

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And between 2002 and 2015,

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the number of deaths from heroin
increased by a factor of six.

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And something about the way
that we treat addiction isn't working,

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at least not for everyone.

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It is a fact that people
suffering from addiction

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have lost free will

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when it comes to their behavior
around drugs, alcohol, food

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or other reward-system
stimulating behaviors.

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That addiction is a brain-based
disease state

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is a medical, neurobiological reality.

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But how we relate to that disease --

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indeed, how we relate to the concept
of disease when it comes to addiction --

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makes an enormous difference
for how we treat people with addictions.

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So, we tend to think of pretty much
everything we do as entirely voluntary.

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But it turns out
that the brain's default state

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is really more like a car
idling in drive than a car in park.

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Some of what we think we choose to do

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is actually things that we
have become programmed to do

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when the brakes are released.

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Have you ever joked that your brain
was running on autopilot?

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Guess what?

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It probably was.

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OK?

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And the brain's autopilot
is in a structure called the striatum.

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So the striatum detects
emotional and sensory motor conditions

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and it knows to trigger
whatever behavior you have done most often

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in the past under those same conditions.

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Do you know why I became a neuroscientist?

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Because I wanted to learn
what made me tick.

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(Laughter)

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Thank you, thank you.

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(Laughter)

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I've been wanting to use that one
in front of an audience for years.

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(Applause)

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So in graduate school,
I studied genetic factors

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that orchestrate wiring
to the striatum during development.

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And yes, that is my former license plate.

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(Laughter)

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And for the record, I don't recommend

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any PhD student get a license plate
with their thesis topic printed on it,

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unless they're prepared
for their experiments not to work

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for the next two years.

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(Laughter)

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I eventually did figure it out.

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So, my experiments were exploring
how miswiring in the striatum

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relates to compulsive behaviors.

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Meaning, behaviors that are coerced

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by uncomfortable urges
you can't consciously resist.

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So I was really excited
when my mice developed

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this compulsive behavior,

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where they were rubbing their faces
and they couldn't seem to stop,

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even when they were wounding themselves.

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OK, excited is the wrong word,

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I actually felt terrible for them.

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I thought that they had tics,
evidence of striatal miswiring.

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And they were compulsive,

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but it turned out, on further testing,

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that these mice showed
an aversion to interacting

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and getting to know other unfamiliar mice.

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Which was unusual, it was unexpected.

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The results implied that the striatum,

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which, for sure, is involved
in compulsive-spectrum disorders,

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is also involved in human
social connection and our ability to --

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not human social connection,
but our ability to connect.

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So I delved deeper,

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into a field called social neuroscience.

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And that is a newer,
interdisciplinary field,

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and there I found reports
that linked the striatum

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not just to social anomalies in mice,

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but also in people.

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As it turns out, the social
neurochemistry in the striatum

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is linked to things
you've probably already heard of.

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Like oxytocin,

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which is that hormone that makes
cuddling feel all warm and fuzzy.

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But it also implicates
signaling at opioid receptors.

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There are naturally occurring
opioids in your brain

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that are deeply linked
to social processes.

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Experiments with naloxone,
which blocks opioid receptors,

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show us just how essential
this opioid-receptor signaling is

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to social interaction.

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When people are given naloxone --
it's an ingredient in Narcan,

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that reverses opioid overdoses
to save lives.

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But when it's given to healthy people,

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it actually interfered
with their ability to feel connected

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to people they already knew
and cared about.

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So, something about not having
opioid-receptor binding

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makes it difficult for us to feel
the rewards of social interaction.

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Now, for the interest of time,

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I've necessarily gotten rid
of some of the scientific details,

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but briefly, here's where we're at.

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The effects of social disconnection
through opioid receptors,

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the effects of addictive drugs

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and the effects of abnormal
neurotransmission

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on involuntary movements
and compulsive behaviors

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all converge in the striatum.

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And the striatum
and opioid signaling in it

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has been deeply linked with loneliness.

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When we don't have enough signaling
at opioid receptors,

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we can feel alone in a room full of people
we care about and love, who love us.

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Social neuroscientists, like Dr. Cacioppo
at the University of Chicago,

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have discovered that loneliness
is very dangerous.

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And it predisposes people

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to entire spectrums
of physical and mental illnesses.

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Think of it like this:
when you're at your hungriest,

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pretty much any food
tastes amazing, right?

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So similarly, loneliness
creates a hunger in the brain

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which neurochemically hypersensitizes
our reward system.

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And social isolation
acts through receptors

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for these naturally occurring opioids
and other social neurotransmitters

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to leave the striatum in a state

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where its response to things
that signal reward and pleasure

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is completely, completely over the top.

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And in this state of hypersensitivity,

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our brains signal deep dissatisfaction.

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We become restless,
irritable and impulsive.

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And that's pretty much when I want you
to keep the bowl of Halloween chocolate

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entirely across the room for me,
because I will eat it all.

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I will.

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And that brings up another thing
that makes social disconnection

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so dangerous.

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If we don't have the ability
to connect socially,

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we are so ravenous for our social
neurochemistry to be rebalanced,

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we're likely to seek relief from anywhere.

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And if that anywhere
is opioid painkillers or heroin,

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it is going to be a heat-seeking missile
for our social reward system.

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Is it any wonder people in today's world
are becoming addicted so easily?

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Social isolation --

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excuse me --

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contributes to relapse.

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Studies have shown that people
who tend to avoid relapse

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tend to be people who have broad,
reciprocal social relationships

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where they can be
of service to each other,

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where they can be helpful.

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Being of service lets people connect.

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So --

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if we don't have the ability
to authentically connect,

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our society increasingly lacks
this ability to authentically connect

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and experience things that
are transcendent and beyond ourselves.

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We used to get this transcendence

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from a feeling of belonging
to our families and our communities.

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But everywhere, communities are changing.

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And social and economic disintegration
is making this harder and harder.

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I'm not the only person to point out

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that the areas in the country
most economically hard hit,

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where people feel most desolate
about their life's meaning,

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are also the places

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where there have been communities
most ravaged by opioids.

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Social isolation acts
through the brain's reward system

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to make this state of affairs
literally painful.

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So perhaps it's this pain,
this loneliness,

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this despondence

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that's driving so many of us
to connect with whatever we can.

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Like food.

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Like handheld electronics.

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And for too many people,
to drugs like heroin and fentanyl.

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I know someone who overdosed,
who was revived by Narcan,

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and she was mostly angry
that she wasn't simply allowed to die.

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Imagine for a second how that feels,
that state of hopelessness, OK?

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But the striatum is also a source of hope.

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Because the striatum gives us a clue
of how to bring people back.

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So, remember that the striatum
is our autopilot,

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running our behaviors on habit,

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and it's possible to rewire,
to reprogram that autopilot,

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but it involves neuroplasticity.

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So, neuroplasticity
is the ability of brains

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to reprogram themselves,

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and rewire themselves,
so we can learn new things.

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And maybe you've heard the classic
adage of plasticity:

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neurons that fire together, wire together.

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Right?

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So we need to practice social
connective behaviors

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instead of compulsive behaviors,
when we're lonely,

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when we are cued to remember our drug.

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We need neuronally firing
repeated experiences

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in order for the striatum to undergo
that necessary neuroplasticity

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that allows it to take
that "go find heroin" autopilot offline.

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And what the convergence
of social neuroscience, addiction

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and compulsive-spectrum disorders
in the striatum suggests

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is that it's not simply enough

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to teach the striatum healthier
responses to compulsive urges.

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We need social impulses
to replace drug-cued compulsive behaviors,

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because we need to rebalance,
neurochemically, our social reward system.

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And unless that happens,

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we're going to be left
in a state of craving.

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No matter what besides our drug
we repeatedly practice doing.

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I believe that the solution
to the opioid crisis

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is to explore how social
and psychospiritual interventions

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can act as neurotechnologies in circuits

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that process social
and drug-induced rewards.

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One possibility is to create
and study scalable tools

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for people to connect with one another

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over a mutual interest

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in recovery through
psychospiritual practices.

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And as such, psychospiritual practice
could involve anything

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from people getting together
as megafans of touring jam bands,

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or parkour jams, featuring
shared experiences of vulnerability

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and personal growth,

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or more conventional things,
like recovery yoga meetups,

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or meetings centered
around more traditional conceptions

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of spiritual experiences.

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But whatever it is,

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it needs to activate

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all of the neurotransmitter
systems in the striatum

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that are involved
in processing social connection.

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Social media can't go
deep enough for this.

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Social media doesn't so much
encourage us to share,

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as it does to compare.

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It's the difference between having
superficial small talk with someone

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and authentic, deeply connected
conversation with eye contact.

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And stigma also keeps us separate.

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There's a lot of evidence
that it keeps us sick.

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And stigma often makes it safer
for addicts to connect with other addicts.

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But recovery groups centered around
reestablishing social connections

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could certainly be inclusive
of people who are seeking recovery

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for a range of mental health problems.

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My point is, when we connect
around what's broken,

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we connect as human beings.

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We heal ourselves
from the compulsive self-destruction

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that was our response
to the pain of disconnection.

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When we think of neuropsychiatric
illnesses as a spectrum of phenomenon

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that are part of what make us human,

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then we remove the otherness of people
who struggle with self-destruction.

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We remove the stigma

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between doctors and patients
and caregivers.

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We put the question of what it means
to be normal versus sick

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back on the spectrum
of the human condition.

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And it is on that spectrum
where we can all connect

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and seek healing together,
for all of our struggles with humanness.

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Thank you for letting me share.

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(Applause)