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Perhaps the mystery is a little too plain. The use of language determines how we understand and evaluate the world around us. The various and complex presentations of those who bear the label “addict” have confused our ability to clarify the meaning of addiction and its etiology. The negative effects of substance use and addictive disorders are a major cause of morbidity and mortality in our society. Despite some major advances in understanding addiction and the enormous amounts of money spent on research, there has not been a proportional improvement in explaining its etiology or any significant improvement in treatment outcomes. If addiction does have a cause, it is obscure. The cause remains undiscovered, yet a large body of theories and empirical data has accumulated. Philosophy and ScienceSocrates suggested that normal individuals with healthy minds would not deliberately behave illogically or self- destructively. If they did not act in their best interest, they would not be acting deliberately, and this would be abnormal. If they acted on desires illogically, they would be exhibiting akrasia, or weakness of will (1). Yet addicts repeatedly and consistently appear to follow the worst course. They continue addictive behaviour and appear to exhibit akrasia, or weakness of will. The poet and laudanum addict Samuel Taylor Coleridge recognized the issue of will and its importance as causal to addiction when he wrote, “my case is a species of madness, only that it is a derangement of the volition, and not of the intellectual faculties” (2). In 1817, Jean Etienne Dominique Esquirol attempted to classify mental illness according to a disturbance of specific behaviours that he called “affective monomanias,” realizing that man’s reasoning ability was subservient to emotional needs (3), which in some ways is similar to Socrates’ concept that actions that do not follow a rational or the best course of action are abnormal. Proposals suggesting that addiction may be a disease appear in the literature as early as 1700, with The Mystery of Opium Revealed, by John Jones (4), followed by Benjamin Rush’s Inquiry into the Effect of Ardent Spirits (5). The dilemma of whether addiction is a disease—and if it is, what type of disease—has continued into the present, with various hypo- theses proposed. No hypothesis, however, connects the concept of the disease of addiction with a common etiology. There have been many significant premises, hypotheses, and findings with respect to addiction. In 1939, Alcoholics Anonymous showed that addiction to alcohol or alcoholism could be treated (6). In 1984, Gold (7) suggested that “cocaine must produce a state similar to a delusion in users” and that “our past failure to recognize the delusionary and addictive power of cocaine is in part responsible for the current cocaine epidemic.” The confusion and use of multiple terminologies with no common etiology of addiction are such that William Miller warned in 1993 that the current disease models were inadequate to explain or resolve the wide spectrum of alcohol- related problems (8). In 2002, Orford reported that, among a group of heavy drinkers, the perceived benefits outweighed the drawbacks “which challenges both conventional health promotion efforts and motivational models of alcohol consumption” (9). In 2002, the endogenous cannabinoid system was shown to have a central function in the extinction of aversive memories (10). Presently, no model explains the addictive behaviours in a rational, scientific manner or provides any explanation that defines a common cause for the various behaviours that are called “addictive.” It may be that what is required to expose the etiology of addiction may not be found using traditional scientific methods, for some scientific problems may not be answered empirically. In these cases—particularly with problems of conception and causality—philosophy may help analyze and define issues for examination. Linguistic analysis is a philosophical process based on the work of Ludwig Wittgenstein and described as follows:
Linguistic analysis and inductive reasoning will be used in an attempt to discover an etiology of all addictive disorders, beginning with descriptions and definitions of addiction that are in common use. Putative TermsThe analysis will look at 4 contemporary descriptions or definitions of addiction. These include the description of alcoholism by Alcoholics Anonymous (6), the definition of addiction by The American Society of Addiction Medicine (ASAM) (12), the DSM classification of substance dependence (13), and the ICD-10 Classification of Mental and Behavioural Disorders dependence syndrome (14). Table 1 lists the criteria that are associated with addiction for the descriptions or definitions being considered.
SynthesisThe 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 irrational behaviour is present—one that allows the addictive behaviour to continue, despite negative consequences. Conation and AddictionThe 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 psychoactive 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 abstinent 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, craving is not necessarily a causal part of the etiology of addiction. Reasons for ActionTo address illogical actions, the reasons for any actions— normal and abnormal—should be considered. Illogical reasons 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 accident, 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 attempt to learn from mistakes, errors, accidents, and poor judgement, such that, if consequences of the actions are negative, the actions are not repeated. The addict appears unable to learn from or remember previous negative experiences associated with addictive behaviour. From an objective point of view, learning appears impaired as the addict repeats behaviours that produce negative consequences. Recognizing the importance of the mental state just prior to the relapse, Alcoholics Anonymous notes, “So we shall describe some of the mental states that precede a relapse into drinking, for obviously this is the crux of the problem” (6). Faulty Volition Caused by Impaired Cognition as Causal for AddictionAddicts 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 verbalize their understanding of the potential negative consequences of beginning the addictive behaviour, recognizing that the addiction has caused harm. Addicts appear to be acting 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 consequences. 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 feeling associated with a conative desire or behaviour, the individual, addicted or not, will experience an intention to act to 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 incomplete 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 consequences. 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 decisions 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 behaviour- 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 cognitive 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 negative 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 cognitive impairment. This process produces a vicious regress, with the life-threatening consequences associated with addictive diseases. Proposed DefinitionAddiction is a disease of faulty volition, caused by a cognitive impairment that results in negatively valued actions or consequences. 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 behaviour. 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 addicting substance that triggers a conative drive. DiscussionThis definition provides an etiology that allows an explanation 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 control 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 understood 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 understood to increase faulty reasoning and resultant faulty action when a preexisting cognitive impairment or emotional distress is added to the one causing the addiction. Cross-cultural addictions and differences may be understood in terms of environmental interactions and expressions that affect the cognitive 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 treat, and neuroleptics provide limited help. Support groups such as Alcoholics Anonymous can successfully encourage the refusal to act on the basis of faulty reasoning and provide recurrent exposure to a process that stresses the need for continued awareness of the ever-present potential to forget negative consequences. Successful therapies, such as cognitive-behavioural therapy, promote increased awareness and vigilance about “stinking thinking” and “negative tapes,” which are metaphors for impaired cognition. Spontaneous recovery without treatment can be explained as the regaining of normal cognition and, hence, healthy volition, for any reason. Ultimately, this improves the access to memory associated with the addiction. SummaryBecause addiction has been obscured by various psychosocial and biological problems, as well as by the great variation in the types of addictions, we lack understanding of the disease. The problem of considering a volitional disorder as a disease has been a major stumbling block when studying many mental disorders. With a single etiology as the form of the disease (a volitional disorder based on impaired memory access), development of an addictive disorder can be related to the genetic background and environment of the individual and to exposure to those substances or actions that improve feelings, while at the same time, resulting in negative consequences. The concept that the etiology of addiction is volition caused by impaired access to memory suggests that addiction is a mental disease, albeit induced by the addict’s own impaired volition and behaviour. It is difficult to perceive that addicts have a disease. Acts of will or volition are usually not accepted as diseases, because volition is an act of choice or free will. Nevertheless, addicts do have a volitional disorder based on cognitive impairment caused by impaired memory access. Further, when actions and results are looked at rationally, addiction is a serious and potentially fatal problem. If there is a common etiology for addiction, it should be one that is basic and fundamental to the healthy functioning of a human being. A disorder of volition, based on impaired cognition, associated with impaired access to memory, and resulting in negatively valued actions is just that. The diagnosis of addiction is so coloured by the negative moral and social values entailed with the illness that this, unfortunately, has prevented medicine from discovering its etiology and effective treatment. Addicts always describe their problem as one in which they know that their behaviour is illogical; however, the negative social and moral overlay, combined with the complexity of the disease presentation, has obscured its underlying common etiology and resulted in a long delay in its determination. The concept that addiction is a disease of faulty volition caused by cognitive impairment should enable the medical profession to provide more effective and compassionate treatment for addicts. Rather than attempting to treat the social, personal, emotional, legal, spiritual, and physical symptoms that are the consequences of the disease, identifying the etiology of addiction will allow treatment to focus on the cause of the symptoms. Treating volitional diseases may be difficult and controversial, but until the problem of addiction is recognized as one caused by a cognitive impairment resulting in faulty volition, treatment will continue to have limited success. While the issue of whether addiction is a disease is of interest medically and philosophically, it is of vital significance for the addict or alcoholic who still suffers from the disease of addiction. Recognizing that addiction is a disease in which impaired access to memory causes faulty volition should encourage research into treatments that are effective and that address the addict’s significant brain dysfunction. This will eventually allow the addict to receive the treatment that is required from the medical community. Obscure for various reasons, the etiology of addiction is a cognitive impairment based on impaired memory access and resulting in faulty volition. This has been shown as necessary and causal to all addictions. References1. Honderich T, editor. The Oxford companion to philosophy. Oxford (UK), New York: Oxford University Press; 1995. 2. Letter to Joseph Cottle, April 26, 1814. 6 Volumes. In: Griggs EL, editor. Coleridge, Samuel Taylor, Collected letters of Samuel Taylor Coleridge. Oxford: Clarendon Press; 1956–1971. Reprint Oxford University Press; 2000. 3. Alexander FG, Selesnick ST. The history of psychiatry. London: Harper and Row. 1966. 137 p. 4. Jones J. The mysteries of opium reveal’d. In: Hunter R, Mac Alpine I, editors. Three hundred years of psychiatry 1535–1860. Oxford University Press; 1982. p 88–9. 5. Rush B. 1784. Inquiry into effects of ardent spirits on the human mind and body. Reprinted in Q J Stud Alcohol 1943;4:321–41. 6. Alcoholics Anonymous. 4th ed. New York: Alcoholics Anonymous World Services Inc; 2000. 7. Gold MS, Verebey K. The psychopharmacology of cocaine. Psychiatric Ann 1984;14:714–23. 8. Miller W. Alcoholism: toward a better disease model. Psychol Addict Behav 1993;7:129–36. 9. Orford J, Dalton S, Hartney M, Ferrins-Brown M, Kerr C, Maslin J. How is excessive drinking maintained? Untreated heavy drinkers’ experiences of the personal benefits and drawbacks of their drinking. Addiction Research and Theory 2002;10:347–72. 10. Marsicano G, Wotjak CT, Azad SC, Bisogno T, Rammes G, Cascio MG, and others. The endogenous cannabinoid system controls the extinction of aversive memories. Nature 2002;418:530–4. 11. Fulford KWM. Moral theory and medical practice. Gateshead: Athnaeum Press; 1989. p. 22–3. 12. American Society of Addiction Medicine. www.asam.org/ppol/paindef.htm. Accessed 2002 Jan 15. 13. Diagnostic and statistical manual of mental disorders. 4th ed. Text Revision. Washington (DC): American Psychiatric Association; 2000. 14. The ICD-10 Classification of mental and behavioural disorders. Geneva: World Health Organization; 1992. 15. Goodman A. Pragmatic assessment and multitheoretical classification: addictive disorder as a case example. in: sadler jz, wiggins op, schwartz ma, editors. Philosophical perspectives on psychiatric diagnostic classification. Baltimore: The Johns Hopkins University Press; 1994. p 295–311. 16. Merriam-Webster collegiate dictionary. www.m-w.com/home.htm. Accessed 2002 Feb 2. 17. The compact edition of the Oxford English dictionary. Oxford: Oxford University Press; 1979. 18. Gordis E. Craving research: implications for treatment—a commentary by NIAAA director Enoch Gordis, MD. Alcohol Alert 2001;54. 19. Austin JL. A plea for excuses. Proceedings of the Aristotelian Society 1956–57. In: White AR, editor. The philosophy of action. Oxford: Oxford University Press; 1968. p 19–42. Author(s)Manuscript received April 2002, revised and accepted August 2003. 1. Clinical Associate Professor, Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta; Consulting Physician, Addiction Centre, Foothills Medical Center, Calgary, Alberta; Fellow of The American Society of Addiction Medicine. Address for correspondence: Dr WG Campbell, Addiction Centre, Foothills Medical Center, 1403 29 Street NW, Calgary, AB T2N 2T9 e-mail: billcampbell@nucleus.com
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