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The hidden island of addiction: the insula
Open accessAbstract
Most prior research on the neurobiology of addiction has focused on the role of subcortical systems, such as the amygdala, the ventral striatum and mesolimbic dopamine system, in promoting the motivation to seek drugs. Recent evidence indicates that a largely overlooked structure, the insula, plays a crucial part in conscious urges to take drugs. The insula has been highlighted as a region that integrates interoceptive (i.e. bodily) states into conscious feelings and into decision-making processes that involve uncertain risk and reward. Here, we propose a model in which the processing of the interoceptive effects of drug use by the insula contributes to conscious drug urges and to decision-making processes that precipitate relapse.
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“Consistent with this hypothesis, imaging studies have reported differential activation of the insula during craving, possibly reflecting interoceptive cues and hypothesised to involve CRF activation (table 2, circuit 18).54,117,118”
From Neurobiology of addiction: a neurocircuitry analysis (2016) · cites this paper as [54]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The insula has long been implicated in drug cravings, the maintenance of drug-seeking behavior, and the regulation of distress during withdrawal [1,6,71].”
From The Insular Cortex: An Interface Between Sensation, Emotion and Cognition (2024) · cites this paper as [6]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Dysfunction of interoception is increasingly recognized as an important component of different mental health conditions, including anxiety disorders, mood disorders, eating disorders, addictive disorders, and somatic symptom disorders.”
From Interoception and Mental Health: A Roadmap. (2018) · cites this paper as [102]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Drug addiction, another condition marked by interoceptive disturbances, has an overlapping neural circuitry and abnormal responses to interoceptive cues (101–104).”
From Interoception and Mental Health: A Roadmap. (2018) · cites this paper as [102]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“The insula appears to have an interoceptive function that integrates autonomic and visceral information with emotion and motivation, thus providing conscious awareness of these urges.54”
From Neurobiology of addiction: a neurocircuitry analysis (2016) · cites this paper as [54]
In the citing paper
“For one, the AI, dACC and dlPFC activate synchronously in response to uncertainty in the environment; these regions overlap with areas implicated in negative mood states (Feinstein et al., 2006; Naqvi and Bechara, 2009; Davis and Hasson, 2016).”
From Cortico-striatal-thalamic loop circuits of the salience network: A central pathway in psychiatric disease and treatment (2016) · cites this paper as Naqvi and Bechara, 2009
In the citing paper
“It has also been associated with depression, anxiety or substance abuse (for reviews cf. Craig, 2009; Naqvi and Bechara, 2009).”
From Cognitive flexibility in adolescence: Neural and behavioral mechanisms of reward prediction error processing in adaptive decision making during development (2015) · cites this paper as Naqvi and Bechara, 2009
In the citing paper
“The insula, particularly its more anterior regions, is reciprocally connected to several limbic regions (e.g. ventromedial prefrontal cortex, amygdala, and ventral striatum) and appears to have an interoceptive function, integrating the autonomic and visceral information with emotion and motivation, thus providing conscious awareness of these urges (135).”
From Obesity and addiction: Neurobiological overlaps (2013) · cites this paper as [135]
In the citing paper
“The insula, particularly its more anterior regions, is reciprocally connected to several limbic regions (e.g. ventromedial prefrontal cortex, amygdala, and ventral striatum) and appears to have an interoceptive function, integrating the autonomic and visceral information with emotion and motivation, thus providing conscious awareness of these urges (135).”
From Obesity and addiction: Neurobiological overlaps (2013) · cites this paper as [135]
In the citing paper
“Consistent with this hypothesis, many imaging studies show differential activation of the insula during craving (135).”
From Obesity and addiction: Neurobiological overlaps (2013) · cites this paper as [135]
In the citing paper
“Consistent with this hypothesis, many imaging studies show differential activation of the insula during craving (95).”
From The Addictive Dimensionality of Obesity (2013) · cites this paper as [95]
In the citing paper
“The insula, particularly its more anterior regions, is reciprocally connected to several limbic regions and supports interoceptive functions, integrating the autonomic and visceral information with emotion and motivation and providing conscious awareness of these urges (95).”
From The Addictive Dimensionality of Obesity (2013) · cites this paper as [95]
In the citing paper
“Consistent with this hypothesis, many imaging studies show differential activation in the insula during craving (Naqvi and Bechara 2009).”
From Food and Drug Reward: Overlapping Circuits in Human Obesity and Addiction (2011) · cites this paper as Naqvi and Bechara 2009
In the citing paper
“The insula, particularly its more anterior regions, is reciprocally connected to several limbic regions (e.g., ventromedial prefrontal cortex, amygdala, and ventral striatum) and appears to have an interoceptive function, integrating the autonomic and visceral information with emotion and motivation, thus providing conscious awareness of these urges (Naqvi and Bechara 2009).”
From Food and Drug Reward: Overlapping Circuits in Human Obesity and Addiction (2011) · cites this paper as Naqvi and Bechara 2009
In the citing paper
“Moreover, the insula integrates emotional information to and from limbic and cortical areas and is involved in the representation of interoceptive responses to emotionally salient and rewarding stimuli, such as drug craving, urgency, and impulsivity (Bonson et al., 2002; Naqvi and Bechara, 2009; Villafuerte et al., 2011).”
From The effects of poor quality sleep on brain function and risk taking in adolescence (2013) · cites this paper as Naqvi and Bechara, 2009
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“This is in line with theories proposing that brain areas involved in somatic affective representations are causally responsible for making a choice (Jones et al., 2010; Naqvi and Bechara, 2009; Craig, 2003).”
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“It has also been associated with depression, anxiety or substance abuse (for reviews cf. Craig, 2009; Naqvi and Bechara, 2009).”
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“The anterior insula integrates autonomic and visceral signals into motivational and emotional functions, whereas the posterior insula is thought to underlie somatosensory, vestibular and motor integration as well as monitoring bodily states [53].”
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“Naqvi and Bechara (2009) proposed that the insula is a region able to integrate bodily states into conscious feelings and into decision-making processes.”
BackgroundInfluentialUnbalanced neuronal circuits in addiction
Volkow, N. D., Wang, G.-J., Tomasi, D. G., & Baler, R. (2013) · Current Opinion in Neurobiology · doi:10.1016/j.conb.2013.01.002 · Cited by 234
“In fact, many imaging studies show differential activation of the insula during craving [56], which has been suggested to serve as a biomarker to predict relapse [57 ].”
Smoking, nicotine and neuropsychiatric disorders
Döme, P., Lazáry, J., Kalapos, M. P., & Rihmer, Z. (2009) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2009.07.013 · Cited by 227
“associated with impaired amphetamine-conditioned place-preference (Contreras et al., 2007; Naqvi and Bechara, 2009).”
BackgroundNeuroscience of Behavioral and Pharmacological Treatments for Addictions
Potenza, M. N., Sofuoglu, M., Carroll, K. M., & Rounsaville, B. J. (2011) · Neuron · doi:10.1016/j.neuron.2011.02.009 · Cited by 220
“Other brain regions and circuits contribute importantly to motivational behaviors, with regions like the amygdala providing important affective information, the hippocampus important contextual memory information, the hypothalamus and septum important homeostatic information, and the insula important information relat…”
Translational and reverse translational research on the role of stress in drug craving and relapse
Sinha, R., Shaham, Y., & Heilig, M. A. (2011) · Psychopharmacology · doi:10.1007/s00213-011-2263-y · Cited by 218
“These data suggest that guanfacine’s positive effects may include reversing the previously documented hypofrontality and insula deficits in drug addicts (Goldstein and Volkow 2002; Naqvi and Bechara 2009).”
Resting-State Functional Connectivity of the Medial Superior Frontal Cortex
Zhang, S., Ide, J. S., & Li, C. R. (2011) · Cerebral Cortex · doi:10.1093/cercor/bhr088 · Cited by 212
“We also examined the connectivity between the medial SFC and insula, which is implicated in many psychological processes such as emotion, somatomotor integration, and cognitive control (Naqvi and Bechara 2009; Taylor et al. 2009; Menon and Uddin 2010; Nelson et al. 2010).”
BackgroundA Triadic Neurocognitive Approach to Addiction for Clinical Interventions
Noël, X., Brevers, D., & Bechara, A. (2013) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2013.00179 · Cited by 210
“The insular cortex has recently emerged as a key neural structure that plays a key role in the formation of interoceptive representation, which is crucial for subjective emotional feelings (5, 13, 91).”
BackgroundInfluentialSelf-citationRegulation of nausea and vomiting by cannabinoids and the endocannabinoid system
Sharkey, K. A., Darmani, N. A., & Parker, L. A. (2013) · European Journal of Pharmacology · doi:10.1016/j.ejphar.2013.09.068 · Cited by 204
“(2007) suggested that this region of the insular cortex (which is also involved in craving for drugs; Naqvi and Bechara, 2009; Forget et al., 2010) may be responsible for sensing strong deviations from a “well-being state” (e.”
BackgroundAddiction science: Uncovering neurobiological complexity
Volkow, N. D., & Baler, R. (2013) · Neuropharmacology · doi:10.1016/j.neuropharm.2013.05.007 · Cited by 205
“Consistent with this hypothesis, imaging studies show differential activation of the insula during craving (Brody et al., 2009; Goudriaan et al., 2010; Naqvi and Bechara, 2009; Wang et al.,1999).”
BackgroundResultAltered prefrontal and insular cortical thickness in adolescent marijuana users
Lopez-Larson, M. P., Bogorodzki, P., Rogowska, J., McGlade, E., King, J. B., Terry, J., & Yurgelun-Todd, D. (2011) · Behavioural Brain Research · doi:10.1016/j.bbr.2011.02.001 · Cited by 187
“Moreover, numerous functional imaging studies have found both prefrontal and insular activation during conscious drug urges [38–42].”
BackgroundResultA neurocomputational account of how inflammation enhances sensitivity to punishments versus rewards
Harrison, N. A., Voon, V., Cercignani, M., Cooper, E. A., Pessiglione, M., & Critchley, H. D. (2016) · Biological Psychiatry · doi:10.1016/j.biopsych.2015.07.018 · Cited by 185
Subcortical structural connectivity of insular subregions
Ghaziri, J., Tucholka, A., Girard, G., Boucher, O., Houde, J., Descoteaux, M., Obaïd, S., Gilbert, G., Rouleau, I., & Nguyen, D. K. (2018) · Scientific Reports · doi:10.1038/s41598-018-26995-0 · Cited by 204
Nature's clocks and human mood: the circadian system modulates reward motivation
Murray, G., Nicholas, C. L., Kleiman, J., Dwyer, R., Carrington, M. J., Allen, N. B., & Trinder, J. (2009) · Emotion · doi:10.1037/a0017080 · Cited by 185
“There is no agreed multilevel measure of human reward activation (e.g., Carlezon & Thomas, 2009; Naqvi & Bechara, 2009), but measurement of left frontal asymmetry would address concerns about the reward specificity of the objective findings here (e.g., Amodio, Master, Yee, & Taylor, 2008).”
BackgroundPando‐Naude, V., Toxto, S., Fernandez‐Lozano, S., Parsons, C. E., Alcauter, S., & Garza‐Villarreal, E. A. (2021) · Translational Psychiatry · doi:10.1038/s41398-020-01128-2 · Cited by 195
Garavan, H. (2010) · Brain Structure and Function · doi:10.1007/s00429-010-0259-8 · Cited by 181
Is Our Self Nothing but Reward?
Northoff, G., & Hayes, D. J. (2011) · Biological Psychiatry · doi:10.1016/j.biopsych.2010.12.014 · Cited by 185
Atypical interoception as a common risk factor for psychopathology: A review
Brewer, R., Murphy, J., & Bird, G. (2021) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2021.07.036 · Cited by 180
Andrews, M. M., Meda, S. A., Thomas, A. D., Potenza, M. N., Krystal, J. H., Worhunsky, P., Stevens, M. C., O'Malley, S., Book, G. A., Reynolds, B., et al. (2011) · Biological Psychiatry · doi:10.1016/j.biopsych.2010.09.049 · Cited by 181
Villafuerte, S., Heitzeg, M. M., Foley, S., Yau, W.-Y. W., Majczenko, K., Zubieta, J., Zucker, R. A., & Burmeister, M. (2011) · Molecular Psychiatry · doi:10.1038/mp.2011.33 · Cited by 182
Perry, J. L., Joseph, J. E., Jiang, Y., Zimmerman, R. S., Kelly, T. H., Darna, M., Huettl, P., Dwoskin, L. P., & Bardo, M. T. (2011) · Brain Research Reviews · doi:10.1016/j.brainresrev.2010.09.001 · Cited by 180
Waiting to perceive: Reward or punishment?
Brunia, C. H. M., Hackley, S. A., van Boxtel, G. J. M., Kotani, Y., & Ohgami, Y. (2011) · Clinical Neurophysiology · doi:10.1016/j.clinph.2010.12.039 · Cited by 176
“Naqvi and Bechara (2009) argue, for example, that the insula has a role in the generation of conscious feeling of drug urge.”
BackgroundCho, Y. T., Fromm, S., Guyer, A. E., Detloff, A., Pine, D. S., Fudge, J. L., & Ernst, M. (2013) · NeuroImage · doi:10.1016/j.neuroimage.2012.10.013 · Cited by 173
“Therefore, the projections from the insula to theNAc are expected to critically influencemotivated behavior, particularly decision-making (Clark et al., 2008; Damasio, 1999; Naqvi and Bechara, 2009).”
Schwartz, D. L., Mitchell, A. D., Lahna, D. L., Luber, H. S., Huckans, M. S., Mitchell, S. H., & Hoffman, W. F. (2010) · NeuroImage · doi:10.1016/j.neuroimage.2010.01.056 · Cited by 178
“The INS may mediate withdrawal phenomena through translation of physiological symptoms into conscious dysphoria (Naqvi and Bechara, 2009).”
BackgroundInfluentialSocial touch modulates endogenous μ-opioid system activity in humans
Nummenmaa, L., Tuominen, L. J., Dunbar, R., Hirvonen, J., Manninen, S., Arponen, E., Machin, A., Hari, R., Jääskeläinen, I. P., & Sams, M. E. (2016) · NeuroImage · doi:10.1016/j.neuroimage.2016.05.063 · Cited by 170
“Given the proposed lateralization of affective processing and anterior–posterior organization of emotional versus somatosensory and interoceptive processing in the insula (Duerden et al. 2013; Naqvi and Bechara 2009), we also analyzed the insular responses using hemisphere-specific anterior and posterior insular ROIs.”
MethodThe role of interoception and alliesthesia in addiction
Paulus, M. P., Tapert, S. F., & Schulteis, G. (2009) · Pharmacology Biochemistry and Behavior · doi:10.1016/j.pbb.2009.08.005 · Cited by 176
“However, we (Paulus, 2007), Craig (Craig, 2007), and Naqvi and Bechara (Naqvi and Bechara, 2008) argue that both approach behaviors to positive hedonic stimuli and avoidance of negative hedonic stimuli are regulated by interoceptive input provided by the insula, and our model allows for both…”
BackgroundInfluentialLee, W., & Reeve, J. (2012) · Social Cognitive and Affective Neuroscience · doi:10.1093/scan/nss029 · Cited by 177
“, 2004), cravings from bodily addictions (Naqvi et al., 2007; Goldstein et al., 2009; Naqvi and Bechara, 2009), and so on.”
BackgroundOn the functional anatomy of the urge-for-action
Jackson, S. R., Parkinson, A., Kim, S. Y., Schüermann, M., & Eickhoff, S. B. (2011) · Cognitive Neuroscience · doi:10.1080/17588928.2011.604717 · Cited by 158
“The proposal that the insular and cingulate cortices are associated with the uncomfortable feelings associated with the urge to tic in TS is consistent with the putative role of these areas in the neural representation of bodily states more generally (interoception), and the initiation of behaviors associated with the…”
ResultAnterior insula degeneration in frontotemporal dementia
Seeley, W. W. (2010) · Brain Structure and Function · doi:10.1007/s00429-010-0263-z · Cited by 162
“These approaches could, in turn, elucidate key aspects of other common neuropsychiatric disorders, such as schizophrenia, anxiety states, autism, eating disorders, and substance abuse (to name a few) whose pathophysiologies seem embedded within the insula and its core network affiliates (Di Martino et al. 2009; Fornit…”
BackgroundDual role of nicotine in addiction and cognition: A review of neuroimaging studies in humans
Jasinska, A. J., Zorick, T. S., Brody, A. L., & Stein, E. A. (2013) · Neuropharmacology · doi:10.1016/j.neuropharm.2013.02.015 · Cited by 170
“In addition, smokers showed higher gray matter density in left insular cortex (Zhang et al., 2011), consistent with previous evidence of the role of the insula in supporting tobacco dependence (Naqvi and Bechara, 2009; Naqvi et al., 2007).”
Current smoking and reduced gray matter volume - a voxel-based morphometry study
Fritz, H.-C., Wittfeld, K., Schmidt, C. O., Domin, M., Grabe, H. J., Hegenscheid, K., Hosten, N., & Lotze, M. (2014) · Neuropsychopharmacology · doi:10.1038/npp.2014.112 · Cited by 160
The Insular Cortex: An Interface Between Sensation, Emotion and Cognition
Zhang, R., Deng, H., & Xiao, X. (2024) · Neuroscience Bulletin · doi:10.1007/s12264-024-01211-4 · Cited by 158
“The insula has long been implicated in drug cravings, the maintenance of drug-seeking behavior, and the regulation of distress during withdrawal [1, 6, 71].”
Gray matter and white matter abnormalities in online game addiction
Weng, C.-B., Qian, R.-B., Fu, X.-M., Lin, B., Han, X.-P., Niu, C.-S., & Wang, Y.-H. (2013) · European Journal of Radiology · doi:10.1016/j.ejrad.2013.01.031 · Cited by 158
Dopaminergic Modulation of Risky Decision-Making
Simon, N. W., Montgomery, K. S., Beas, B. S., Mitchell, M. R., LaSarge, C. L., Mendez, I. A., Bañuelos, C., Vokes, C. M., Taylor, A. B., Haberman, R. P., et al. (2011) · Journal of Neuroscience · doi:10.1523/jneurosci.3772-11.2011 · Cited by 157
“These data suggest that D1 receptors within this system (Reynolds and Zahm, 2005) may be involved in valuation of risky versus safe outcomes (or perhaps valuation of differing reward magnitudes), consistent with a role for this system in cost-benefit decision-making (Cardinal, 2006; Naqvi and Bechara, 2009).”
MethodResultIdentifying the neural substrates of intrinsic motivation during task performance
Lee, W., & Reeve, J. (2017) · Cognitive Affective & Behavioral Neuroscience · doi:10.3758/s13415-017-0524-x · Cited by 170
A review of gambling disorder and substance use disorders
Rash, C. J., Weinstock, J., & Patten, R. V. (2016) · Substance Abuse and Rehabilitation · doi:10.2147/sar.s83460 · Cited by 171
Granular insular cortex inactivation as a novel therapeutic strategy for nicotine addiction
Forget, B., Pushparaj, A., & Le Foll, B. (2010) · Biological Psychiatry · doi:10.1016/j.biopsych.2010.01.029 · Cited by 153
The neuropsychological impact of insular cortex lesions
Jones, C. L., Ward, J., & Critchley, H. D. (2010) · Journal of Neurology, Neurosurgery & Psychiatry · doi:10.1136/jnnp.2009.193672 · Cited by 158
“This finding is also in line with a Somatic Marker model of addictive behaviour in which exposure to or recollection of an experience associated with a drug can reactivate this ‘interoceptive memory ’ state.(7) Future patient studies will establish how general the effects of insula lesions are on other forms of addict…”
ResultNestor, L. J., Ghahremani, D. G., Monterosso, J. R., & London, E. D. (2011) · Psychiatry Research Neuroimaging · doi:10.1016/j.pscychresns.2011.04.010 · Cited by 160
“Research suggests that the insular cortex and interoceptive awareness are critical to drug craving and dependence (Gray and Critchley, 2007; Naqvi et al., 2007; Paulus, 2007; Naqvi and Bechara, 2009) whereby this region monitors interoceptive “urges” for rewarding stimuli such as drugs.”
BackgroundZhu, X., Cortes, C. R., Mathur, K., Tomasi, D. G., & Momenan, R. (2015) · Addiction Biology · doi:10.1111/adb.12272 · Cited by 159
“Thus, insula causes a severe imbalance between the impulsive and reflective systems (Naqvi & Bechara 2009; Noel et al. 2013; Lu & Stein 2014).”
BackgroundDevoto, F., Zapparoli, L., Bonandrini, R., Berlingeri, M., Ferrulli, A., Luzi, L., Banfi, G., & Paulesu, E. (2018) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2018.07.017 · Cited by 140
“…et al., 1997; Bonson et al., 2002) and even for air (Liotti et al., 2001); more importantly, lesions to the insula disrupt addiction to cigarettes smoking (Naqvi et al., 2007; Naqvi and Bechara, 2009), thus suggesting that the region plays a pivotal role in craving and in addiction-like behaviors.”
Jia, Z., Worhunsky, P. D., Carroll, K. M., Rounsaville, B. J., Stevens, M. C., Pearlson, G. D., & Potenza, M. N. (2011) · Biological Psychiatry · doi:10.1016/j.biopsych.2011.05.008 · Cited by 147
A Motivational Model of Alcohol Use: Determinants of Use and Change
Cox, W. M., & Klinger, E. (2011) · Wiley eBooks · doi:10.1002/9780470979952.ch6 · Cited by 150
Food cravings in food addiction: The distinct role of positive reinforcement
Meule, A., & Kübler, A. (2012) · Eating Behaviors · doi:10.1016/j.eatbeh.2012.02.001 · Cited by 144
“This area has also been recognized as a crucial part in urges to take drugs (Naqvi & Bechara, 2009).”
Background
Metadata
- Authors
- Naqvi, N. H., & Bechara, A.
- Affiliations
- New York State Psychiatric Institute (US)
- University of Southern California (US)
- Corresponding author
- Bechara, Antoine
- ORCID
- Bechara, Antoine
- Venue
- Trends in Neurosciences
- Publisher
- Elsevier BV
- Published
- 2009-01
- Volume
- 32
- Issue
- 1
- Pages
- 56-67
- ISSN
- 0166-2236 (ISSN-L)
- PMC
- PMC3698860
- OpenAlex
- W2036074427
- Semantic Scholar
- 2c3d49d333514ca29ffa128dca631e5f5cfbfe5b
- Cited by
- 833
- References
- 148
- Citations by year
- 2026: 29 · 2025: 26 · 2024: 32 · 2023: 45 · 2022: 58 · 2021: 44 · 2020: 107 · 2019: 38 · 2018: 37 · 2017: 42 · 2016: 53 · 2015: 48 · 2014: 49 · 2013: 60 · 2012: 52
- FWCI
- 3.11
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Trends in Neurosciences (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Drug Abuse (R01DA023051)
- National Institute of General Medical Sciences (T32GM007337)
- Topics
- Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Neurotransmitter Receptor Influence on Behavior
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Life Sciences › Neuroscience › Cognitive Neuroscience › Neural and Behavioral Psychology Studies
- Keywords
- insula, addiction, drug craving, interoception, relapse, decision-making, risk and reward, neurobiology of addiction
- MeSH terms
- Animals, Cerebral Cortex, Humans, Models, Biological, Neural Pathways, Substance-Related Disorders
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