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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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“The insula has been implicated in interoceptive effects of drug-taking, and its contribution to drug-related responses has been demonstrated both in humans and animal models including the AA line (Contreras et al., 2007; Naqvi and Bechara, 2009; Droutman et al., 2015; Haaranen et al., 2020).”
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“…Pelchat et al., 2004), dysfunctions of the insular cortex are related to abnormal cravings, such as addicted behaviors (Goldstein et al., 2009; Naqvi & Bechara, 2009), and people having addicted behaviors quit their addicted behaviors after incurring damage to the insular cortex (Naqvi et…”
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Farb, N. A. S. (2012) · TSpace (University of Toronto) · Cited by 2
Yu, J., Fiore, V. G., Briggs, R. W., Braud, J., Rubia, K., Adinoff, B. H., & Gu, X. (2020) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2020.04.08.031757 · Cited by 2
Surgical treatment of glial tumors of the paralimbic system
Dimertsev, A. V., & Зуев, А. А. (2022) · Burdenko s Journal of Neurosurgery · doi:10.17116/neiro20228605137 · Cited by 1
Köhler, R., Zhornitsky, S., Potenza, M. N., Yip, S. W., Worhunsky, P. D., & Angarita, G. A. (2024) · The American Journal of Drug and Alcohol Abuse · doi:10.1080/00952990.2024.2318585 · Cited by 1
“The significant III-by-dose interaction we observed when insular thickness was included in the model (see Supplemental Material for details) may relate to the insula’s role in the interoception of subjective drug effects (66).”
Mukherjee, A., Gilles‐Thomas, E. A., Kwok, H. Y., Shorter, C. E., Sontate, K. V., McSain, S. L., Honeycutt, S. C., & Loney, G. C. (2024) · Alcoholism Clinical and Experimental Research · doi:10.1111/acer.15383 · Cited by 1
Tang, V. M., & Blumberger, D. M. (2024) · Expert Review of Medical Devices · doi:10.1080/17434440.2024.2404962 · Cited by 1
“The insula has long been an area of interest in addiction, with early studies showing that lesions to this area due to neurological damage seemed to be associated with spontaneous remission of substance use in patients [36].”
Theory-based strategies to enhance interventions for smoking: Relevance to a digital intervention
Baker, T. B., Kaye, J. T., & Piasecki, T. M. (2025) · Behaviour Research and Therapy · doi:10.1016/j.brat.2025.104812 · Cited by 2
Ethier-Gagnon, M. A., DeGrace, S., Romero‐Sanchiz, P., Helmick, C. A., Tibbo, P. G., Crocker, C. E., Good, K., Rudnick, A., Cosman, T., Barrett, S. P., et al. (2025) · Journal of Psychiatry and Neuroscience · doi:10.1503/jpn.250064 · Cited by 1
A Tragedy of Errors: The State of Psychedelic Research in the Treatment of Alcohol Use Disorder
Srivastava, A. B., & Gold, M. S. (2025) · Brain Sciences · doi:10.3390/brainsci15111190 · Cited by 3
“However, in this same dataset, connectivity changes between the anterior MFG/area 9–46 and anterior insula (AI), a region proposed to be involved in the regulation of craving and withdrawal [131,132], were associated, at a trend level, with reductions in drinking [133].”
Kunzmann, T., Behrendt, C., & Lepach-Engelhardt, A. C. (2025) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.70183 · Cited by 2
Hu, M., Song, K. S., Choi, J.-Y., Pyeon, A., Cho, H., Choi, J.-S., Choi, I., Chun, J.-W., & Kim, D.-J. (2025) · Life · doi:10.3390/life15121899 · Cited by 2
“In addition, the insula plays a significant role in behavioral and substance addiction, like internet gaming disorder and drug addiction [65,66].”
Clarke, R. E., Pagoota, B. E., Dinu, I. E., Paniccia, J. E., Tsyrulnikov, A., Westphal, A. M., Baek, J., Scofield, M. D., & Otis, J. M. (2026) · Addiction Biology · doi:10.1111/adb.70118 · Cited by 1
Dampuré, J., Agudelo-Orjuela, P., van der Meij, M., Barber, H. A., & Belin, D. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1743972 · Cited by 1
“These behavioural manifestations reflect impairments in insula-dependent interoceptive insight (Naqvi and Bechara, 2009; Belin et al., 2011; Goldstein et al., 2009), otherwise necessary for the accurate integration and monitoring of bodily signals to guide adaptive behaviour (Bechara and Damasio,…”
Lu, G., Guo, Y., Ma, L., Wang, X., Zhang, H., Zhang, M., Wang, W., Han, S., & Zhang, Y. (2026) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2026.111726 · Cited by 1
Albert, O. M. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1819543 · Cited by 4
“Lesion-network evidence provides causal-strength support: Naqvi and colleagues showed that focal insular damage can disrupt cigarette addiction (31, 56), and Joutsa and colleagues subsequently demonstrated that lesions associated with addiction remission map to a distributed insula – anterior…”
Common Mechanisms of Addiction
Reissner, K. J., & Kalivas, P. W. (2013) · Elsevier eBooks · doi:10.1016/b978-0-12-398335-0.00017-0 · Cited by 1
Insula, a “mysterious” island in our brain – minireview
Palkovits, M. (2010) · Orvosi Hetilap · doi:10.1556/oh.2010.29004 · Cited by 1
Neurobiologische und kognitive Grundlagen der Sucht
Yalachkov, Y., Kaiser, J., Roeper, J., & Naumer, M. J. (2012) · Zeitschrift für Psychiatrie Psychologie und Psychotherapie · doi:10.1024/1661-4747/a000118 · Cited by 1
“Bei abhängigen Personen aktivieren Drogenreize auch sensorische Areale in okzipitalen, temporalen und parieta-len Hirnbereichen (Yalachkov, Kaiser & Naumer, 2010).”
BackgroundUTICAJ DOPAMINERGIČKOG SISTEMA NA ZAVISNOST OD INTERNETA
Jović, J., & Đinđić, N. (2011) · Acta Medica Medianae · doi:10.5633/amm.2011.0112s · Cited by 1
Sutherland, M. T., Ray, K. L., Riedel, M. C., Yanes, J. A., Stein, E. A., & Laird, A. R. (2014) · Cited by 1
Madras, B. K. (2014) · Elsevier eBooks · doi:10.1016/b978-0-12-418679-8.00001-0 · Cited by 1
The Neuroanatomy of Addictive Processes
Rogers, S. W., & Gahring, L. C. (2011) · Elsevier eBooks · doi:10.1016/b978-0-12-369497-3.10033-0 · Cited by 1
Impulse Control Disorders in Neurological Settings
Bechara, A. (2012) · Oxford University Press eBooks · doi:10.1093/oxfordhb/9780195389715.013.0126 · Cited by 1
Self-citationDisrupted Resting-State Brain Functional Architecture in Amphetamine-Type Stimulant Abusers
Chen, Q., Zheng, D., Cui, S., Yan, K. J., Fan, C. X., Zhang, G. F., Xiao, L., Li, Y., Yuan, X., Xie, K., et al. (2018) · Neuropsychiatry · doi:10.4172/neuropsychiatry.1000346 · Cited by 1
Prevention and Treatment of Work Addiction
Quiñones, C., & Griffiths, M. D. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108632591.028 · Cited by 2
Sussman, S. Y. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108632591.003 · Cited by 1
Hippocampal fear engrams modulate ethanol‐induced maladaptive contextual generalization in mice
Cincotta, C., Ruesch, E. A., Senne, R. A., & Ramirez, S. (2022) · Hippocampus · doi:10.1002/hipo.23463 · Cited by 2
Hua, C. (2023) · Frontiers in clinical drug research. CNS and neurological disorders · doi:10.2174/9789815123319123110004 · Cited by 1
Transcranial Direct Current Stimulation in Nicotine Use
Gwon, S. H., Lee, H., & Ahn, H. B. (2023) · Journal of Addictions Nursing · doi:10.1097/jan.0000000000000542 · Cited by 1
“…(ECN) in the dorsolateral prefrontal cortex, orbitofrontal cortex, and anterior cingulate cortex plays a central role in the regulation of cognition and behavior (Boettiger et al., 2013; Miller & Cohen, 2001; Wu et al., 2014), including craving control (Fedota & Stein, 2015; Naqvi & Bechara, 2009).”
Structural and Functional Imaging of Alcohol’s Effects on the Brain
Gowin, J. L., Kirk‐Provencher, K. T., Karoly, H. C., & Schacht, J. P. (2023) · Springer eBooks · doi:10.1007/978-3-031-32483-3_26 · Cited by 3
Non-local diffusion-based biomarkers in patients with cocaine use disorder
Estudillo-Romero, A., Migliaccio, R., Batrancourt, B. M., Jannin, P., & Baxter, J. S. H. (2024) · Neuroimage Reports · doi:10.1016/j.ynirp.2024.100202 · Cited by 1
The Role of Implicit Associations in Alcohol and Substance Use Disorders
Chatard, A., Zerhouni, O., Solinas, M., & Noël, X. (2024) · Springer eBooks · doi:10.1007/978-3-031-55889-4_12 · Cited by 1
Namkung, H. (2024) · Journal of Neuroscience · doi:10.1523/jneurosci.0318-24.2024 · Cited by 1
Koob, G. F., Kandel, D. B., Baler, R., & Volkow, N. D. (2024) · Springer eBooks · doi:10.1007/978-3-030-51366-5_29 · Cited by 1
Zhou, Y., Liu, Y., Yang, C., Zhang, X., Liu, R., & Chen, H. (2024) · Brain Imaging and Behavior · doi:10.1007/s11682-024-00932-4 · Cited by 1
“Moreover, as insular lesions have been linked to spontaneous smoking cessation, it has been proposed that the insula plays a causal role in the generation of smoking urges (Garavan, 2010; Naqvi & Bechara, 2009; Naqvi et al., 2007).”
Almada, L. F. (2010) · Psicologia em Revista · doi:10.5752/p.1678-9563.2010v16n1p199 · Cited by 1
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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