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PSYCHIATRIKI 21 (4), 2010 Cognitive theories of addiction: a narrative review 321ments of previous theories that proven to be validand useful under one theoretical common framework.The levels of motivation are hierarchical fromlow levels of responses that involve reflexes and automaticbehaviours to the higher ones that of evaluationsand plans that involve expectancies and theconcept of identity.The theory proposed that there are three typesof abnormalities that underlie addiction: (i) abnormalitiesof the motivational system that exist independentlyof the addictive behaviour, such as propensityto anxiety or depression; (ii) abnormalitiesof the motivational system that stem from the addictivebehaviour itself, such as the acquisition ofa strongly entrenched habit or an acquired drive;and (iii) abnormalities in the individual’s socialor physical environment, such as the presence ofstrong social or other pressures to engage in theactivity”. That means that an activity becomes addictiveif it affects an already unbalanced system(co-morbid anxiety, traits of impulsivity), whichoperates within an unbalanced environment (belongingto a social group in which the particularactivity is considered normal), in such a way ofundermining the normal checks and balances thatoperate to prevent undesirable behaviour (activitybecoming continuously rewarding).The theory is based on the principles of Chaostheory. This means that the motivational system isinheritably unstable in the sense that it is susceptibleto continuous influence of smaller or bigger internaland external stimuli. This can explain both the developmentof an addictive behaviour and the needfor change. Therefore an event that could be seenas significant or insignificant can send an individualdown to a specific path (use) or could set up susceptibilityso other triggers are needed for the addictivebehaviour to develop. The theory also accounts forthe co-occurrence of addictive behaviours as long asthey are mutually reinforcing in terms of their effecton the balance of the motivational system or the individual’senvironment.DiscussionThe theories and models discussed above, considersubstance abuse as a decision making process.The cognitive elements involved are or can beconscious and therefore modifiable. Overall theycan be considered as cognitive theories and assuch, discussed under a common framework, canbe compared and combined in order to contributeto a better understanding of the phenomenon.Psychoanalytic theories or models are not discussedin this paper. These theories and associatedresearch need to be reviewed separately.Some of the theories discussed above focus on understandingthe mechanisms involved in the developmentand maintenance of substance use (biological,psychological, social or even spiritual). Othersexplore the interrelationship between the differentmechanisms involved. Others attempt to combinemethods of investigation. Research on substanceuse aimed on understanding the different facets ofthe addiction phenomenon too, with more attentionthough on the change of the established addictivebehaviour, the developing and evaluating clinicalinterventions (pharmacological, psychological orsocial) for the person and the family involved, ratherthan understanding the underpinning mechanismsand concepts involved in the process of change duringtreatment.Most of the evidence on treatment interventionsfor all substance groups is coming from the USA. Ithas been argued that there are differences in philosophyand orientation of treatment services betweenUSA, UK and other countries, therefore interventionseffective in one country should not be assumed apriori as effective in other countries. 30,31The application of theories into models, measurementof relevant concepts, generation and testingof hypothesis, and outcome and process clinical researchare the main steps involved in the scientificstudy and testing of theories. A scientific study that isnecessary in order to maintain a coherent approachinto the development of science.Psychological interventions are the main approachfor most substances as stand alone or incombination with other interventions. Withinpsychological interventions Cognitive BehaviourTherapy (CBT) or related models based on theabove discussed theories have had considerableevidence supporting their effectiveness. 32,33 Thoseclinical models and interventions need to be reviewedseparately.