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

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.