The Canadian Journal of Psychiatry—Review Paper
achieve that feeling. The individual needs to decide whether to act or not to act. In individuals who have a predisposition to become addicted, this intention to act will, at the same time, impair the ability to access memory of any previous negative consequence associated with the use of the substance or the behaviour. Because the addict is unable to recall the negative consequences of acting on this feeling, there is no reason to control this behaviour. This cognitive impairment of incom- plete memory access is the common denominator of all addictions.
When first exposed to an addicting substance or behaviour, the potential addict will not have a memory of negative conse- quences. As the negative memories accumulate, however, the impaired access to memory will allow the addictive behaviour to continue; that is, volitional decisions are increasingly based on access to a memory that does not provide the necessary information to allow the addict to recognize the need not to act addictively. Externally, this would appear to be akrasia, or weak will. However, this is actually a faulty volitional process caused by a cognitive impairment that prevents the addict from making volitional decisions on the basis of all necessary memory. This impaired access to negative memory is not present in nonaddicted individuals. Instead, they make deci- sions that are based on both negative and positive memories of the results of the conative desires and actions. Thus, nonaddicted individuals control their actions when exposed to potential addicting substances and behaviours.
The cognitive impairment for each addiction must be behav- iour- or substance-specific: it emerges only when a specific addiction associated with harmful consequences produces a simultaneous positive emotional response. To allow addictive behaviour to be initiated and to continue, the resulting cogni- tive impairment must minimize the memory of the previous negative consequences. For this reason, when exposed again, depending on social and environmental cues, the addict is unable to recall the previous negative consequences. Left with only reasons to act and unable to access reasons not to act, the addict once again resumes the addictive behaviour, with nega- tive consequences. Orford did show that “toxic and short-term drawbacks of heavy drinking were more salient than longer- term illness effects” (9). This suggests that a more recent or readily accessible memory of negative consequences decreases the cognitive impairment, which impedes the return to addictive behaviour. Because the act of addiction appears to produce a cognitive impairment that results in faulty volition with negatively valued behaviour, it follows that continued addictive behaviour would increase the strength of the cogni- tive impairment. This process produces a vicious regress, with the life-threatening consequences associated with addictive diseases.
Addiction is a disease of faulty volition, caused by a cognitive impairment that results in negatively valued actions or conse- quences. The negative actions are those associated with the conative desires, or the appetitive behaviours, in otherwise healthy individuals. This cognitive impairment minimizes or negates the memory, or access to aversive memory, of the negative effects or consequences of previous addictive behav- iour. The cognitive impairment can vary in strength, and once the behaviour begins, the addictive behaviour increases the impairment. To be expressed, an addiction requires both a genetic predisposition and exposure to behaviour or an addict- ing substance that triggers a conative drive.
This definition provides an etiology that allows an explana- tion for all addictive behaviour. It explains the results from existing empirical data and is in accordance with clinical experience. Further, it explains that the signs and symptoms of addiction are the result of impaired volition, or the inability to choose to act appropriately despite negative consequences. This deranged volition results from a cognitive impairment that minimizes the appreciation of the negative effects of the addictive behaviour. The cognitive impairment will vary, depending on social and environmental cues that affect the strength of the desire. This explains periods of time when con- trol of the addictive behaviour is observed. The definition that the disease of addiction is produced by cognitive impairment, resulting in abnormal volition, explains the varying rates and frequency that occur with environmental, social, economic, and other factors. Further, it explains the genetic disposition for the disease to appear as an individual-specific disposition to develop a cognitive impairment, resulting in faulty volition with ensuing negative consequences, with cultural or social exposure to the addicting substance or behaviour.
Difficulties in classifying and defining addiction can be un- derstood in terms of form and content. The specific cognitive impairment (minimizing or negating the memory or access to the memory of negative consequences) would be considered the form of the disease. The various types of addictions would be considered the content. Comorbid conditions can be under- stood to increase faulty reasoning and resultant faulty action when a preexisting cognitive impairment or emotional dis- tress is added to the one causing the addiction. Cross-cultural addictions and differences may be understood in terms of en- vironmental interactions and expressions that affect the cog- nitive impairment and resultant faulty volitional acts, which are judged by cultural norms. The record of poor treatment outcomes and treatment resistance is similar to problems that exist with treating other mental disorders; they are difficult to
Can J Psychiatry, Vol 48, No 10, November 2003