Addiction, Compulsion, and Persistent Temptation

Impaired control in addiction involves cognitive distortions and unreliable self-control, not compulsive desires and overwhelmed self-control

Impaired control in addiction involves a characteristic but obscure kind of partial control. Certain aspects of control over drug use are clearly reduced, reflected in difficulty cutting back and relapse. However, other aspects of control are clearly preserved, as reflected in substantial sensitivity to situational incentives-for example, the ability to defer use when needed. This juxtaposition is puzzling, and a clear mechanistically precise understanding of impaired control has yet to emerge. In this article, a Distortion model of impaired control is put forward. The key insight of the model is that the puzzling pattern of partial control seen in addiction can be understood in terms of unreliable control. The model posits large populations of distorted automatic thoughts (e.g., about drugs, one's self, one's circumstances, and one's abilities to cope), coupled with unreliable control over these distorted thoughts. These distorted thoughts, typically gradually and cumulatively, lead to illusion-like misvaluation of costs and benefits of drug use, in turn eventually leading to decisions to use. The model captures an elusive middle ground in addiction in which substantially preserved control over drug use for briefer intervals coexists with difficulty maintaining sobriety over the long-term. Moreover, the model explains a range of clinical findings in addiction that are not easily accommodated on leading alternative views.

Is the concept of compulsion useful in the explanation or description of addictive behaviour and experience?

The concept of compulsion, in which addictive behaviour is said to be carried out against the will, is central to the disease theory of addiction and ubiquitous in modern definitions. The aims of this article are: (i) to describe various meanings of compulsion in the literature; (ii) to compare the part thought to be played by compulsion in addiction with its suggested role in obsessive-compulsive disorder; (iii) to critically examine the place of compulsion in influential neurobiological accounts of addiction; (iv) to summarise the empirical evidence bearing on the usefulness of the compulsion concept, evidence that seems at first sight incompatible with the notion of compulsion. This is followed by a discussion of which possible meanings of compulsion can survive an empirical test and what role they might play in understanding addiction, paying particular attention to a distinction between strong and weak senses of compulsion. A conclusion is that addictive behaviour cannot be considered compulsive at the time it is carried out, though other possible meanings of compulsion as an explanation or description of addictive behaviour and experience are discussed. Among other conclusions, it is suggested that, although in some senses of the term it may seem arbitrary whether or not 'compulsion' should be retained, its use has important consequences for the public understanding of addiction, and is likely to deter people's attempts to overcome their addictions and their chances of success.