Synthesis The 4 definitions and descriptions of addiction have much in common. Items such as tolerance and withdrawal (Table 1, items 1 and 2) reflect neuroadaptation and are accepted as occuring in individuals who are not addicted. Several items that are used to diagnose addiction are merely observations of negatively valued behaviour of the addicted individual and thus are merely descriptive (Table 1, items 3 and 4). Other items (Table 1, items 5 to 10) suggest that an illogical or irra- tional behaviour is present—one that allows the addictive behaviour to continue, despite negative consequences.
Conation and Addiction The present conceptualization of addiction inadequately explains addiction as an entity unto itself and does not provide any understanding of the relation between the substance and behavioural addictions. For this reason, in 1994, Goodman suggested that a classification called “addictive disorder” be added to the DSM (15). Addictive disorder includes psycho- active substance dependence, pathological gambling, bulimia, and kleptomania—behaviours associated with rewards, appetites, and emotions, or with conative acts. Conation is described as “an inclination (as an instinct, a drive, a wish, or a craving) to act purposefully” (16) or to act with the faculty of volition and desire (17).
Craving and Addiction “To practicing clinicians, the topic of craving seems so self-evident; patients often report wanting or craving alcohol when they are abstinent or as a reason for relapse” (18). The accepted view is that craving causes the addict to act. However, if craving were causal to addiction, when the absti- nent addict experienced severe craving, the addict would always relapse. Although relapse is common, recovery can and does occur, and addicts do stop addictive behaviour. Alcoholics Anonymous noted that craving did not cause relapse and that the alcoholic had “no more idea than you have” why relapse occurred (6). At times, even the active addict who experiences severe craving can stop. Thus, crav- ing is not necessarily a causal part of the etiology of addiction.
Reasons for Action To address illogical actions, the reasons for any actions— normal and abnormal—should be considered. Illogical rea- sons for action may be due to mistakes, errors, accidents, poor judgement, organic disease (18), or intoxication. The active addict does illogical things repeatedly, and this addictive behaviour is not an error in judgement, a mistake, or an acci- dent, but a pathological behaviour. As Socrates suggested, normal individuals with a healthy mind will not deliberately behave illogically. Healthy individuals will not deliberately repeat actions with negative consequences. Instead, they
Can J Psychiatry, Vol 48, No 10, November 2003
Addiction: A Disease of Volition Caused by a Cognitive Impairment
attempt to learn from mistakes, errors, accidents, and poor judgement, such that, if consequences of the actions are nega- tive, the actions are not repeated. The addict appears unable to learn from or remember previous negative experiences asso- ciated with addictive behaviour. From an objective point of view, learning appears impaired as the addict repeats behav- iours that produce negative consequences. Recognizing the importance of the mental state just prior to the relapse, Alco- holics Anonymous notes, “So we shall describe some of the mental states that precede a relapse into drinking, for obvi- ously this is the crux of the problem” (6).
Faulty Volition Caused by Impaired Cognition as Causal for Addiction
Addicts are aware that the results of the addiction will be harmful, yet they act addictively, with subsequent negative consequences. When discussing the effects of their addiction, addicts may seem cognitively healthy in all ways, do not appear to suffer from akrasia in other life domains, and ver- balize their understanding of the potential negative conse- quences of beginning the addictive behaviour, recognizing that the addiction has caused harm. Addicts appear to be act- ing at various times on the basis of 2 different belief systems. The first belief is that the addictive behaviour is harmful and produces negative consequences. The second belief is an untrue belief (the disease of addiction), apparently that the addictive behaviour will not result in negative outcomes. On the basis of this belief, addicts appear to act deliberately. They act as if the addictive behaviour will not cause negative conse- quences. Once again, the addict begins the addictive cycle of behaviour and the ensuing negatively valued consequences continue.
Believing something that is not true is a cognitive impairment; the reason that those with a cognitive impairment act with apparent illogical volition must be that their reason for acting is faulty or false (11). The addict appears to act on the basis of faulty reasoning, and the actions are such that cognition does not appear to consider the previous negative consequences of the addiction. The memory of these negative experiences is ignored or does not appear to be considered in the decision to act. Although the action of addictive behaviour is volitional, it must be based on faulty reasoning—a reasoning that forgets why the action must not take place. This faulty reasoning is caused by a cognitive defect that must impair access to the memory that, in a normally functioning brain, would prevent the addictive action from occurring.
How Does the Volitional Disorder Develop?
When a substance or behaviour reproduces the positive feel- ing associated with a conative desire or behaviour, the indi- vidual, addicted or not, will experience an intention to act to