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Original Investigation |

Functional, Structural, and Emotional Correlates of Impaired Insight in Cocaine Addiction

Scott J. Moeller, PhD1; Anna B. Konova, MA1,2; Muhammad A. Parvaz, PhD1; Dardo Tomasi, PhD3; Richard D. Lane, MD, PhD4; Carolyn Fort, BA4; Rita Z. Goldstein, PhD1
[+] Author Affiliations
1Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
2Department of Psychology, Stony Brook University, Stony Brook, New York
3National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
4Department of Psychiatry, University of Arizona, Tucson
JAMA Psychiatry. 2014;71(1):61-70. doi:10.1001/jamapsychiatry.2013.2833.
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Importance  Individuals with cocaine use disorder (CUD) have difficulty monitoring ongoing behavior, possibly stemming from dysfunction of brain regions mediating insight and self-awareness.

Objective  To investigate the neural correlates of impaired insight in addiction using a combined functional magnetic resonance imaging and voxel-based morphometry approach.

Design, Setting, and Participants  This multimodal imaging study was performed at the Clinical Research Center at Brookhaven National Laboratory. The study included 33 CUD cases and 20 healthy controls.

Main Outcomes and Measures  Functional magnetic resonance imaging, voxel-based morphometry, Levels of Emotional Awareness Scale, and drug use variables.

Results  Compared with the other 2 study groups, the impaired insight CUD group had lower error-induced rostral anterior cingulate cortex (rACC) activity as associated with more frequent cocaine use, less gray matter within the rACC, and lower Levels of Emotional Awareness Scale scores.

Conclusions and Relevance  These results point to rACC functional and structural abnormalities and diminished emotional awareness in a subpopulation of CUD cases characterized by impaired insight. Because the rACC has been implicated in appraising the affective and motivational significance of errors and other types of self-referential processing, functional and structural abnormalities in this region could result in lessened concern (frequently ascribed to minimization and denial) about behavioral outcomes that could potentially culminate in increased drug use. Treatments that target this CUD subgroup could focus on enhancing the salience of errors (eg, lapses).

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Figure 1.
Brain and Levels of Emotional Awareness Scales Analyses

A, Reduced error greater than correct rostral anterior cingulate cortex (rACC) mean blood oxygenation level–dependent (BOLD) signal change in the 15 impaired insight cocaine use disorder (iCUD) cases compared with the other 2 study groups (18 unimpaired insight cocaine use disorder cases and 20 healthy controls) during the color-word Stroop task (with corresponding image, which for display purposes only was thresholded at 2.4 ≤ T ≤ 7.0 and masked by an anatomical ACC region of interest) (Pcorrected < .05 for impaired less than others). B, This reduced error-related rACC activity correlated with more frequent drug use in the last 30 days in all CUD participants (r = −0.50, P = .007). In parallel and compared with the other study groups, impaired iCUD cases had lower (C) voxel-based morphometry (VBM) gray matter volume in the same rACC region and (D) emotional awareness (Levels of Emotional Awareness Scale [LEAS] scores) (P < .05 for impaired less than others) for both (C) and (D). Error bars indicate SEs. Note that BOLD signal values below 0 do not necessarily reflect deactivations (because the contrast with error is not with a fixation baseline but rather with an implicit, active baseline of correct trials; see Methods).

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Figure 2.
Rostral Anterior Cingulate Cortex Involvement in Neuropsychiatric Illnesses Characterized by Impaired Insight

A, Current results. B, Activations during reality monitoring (the ability to distinguish internally generated information from externally generated information) in health (that do not emerge under the same task conditions in schizophrenia)74 (adapted with permission from Elsevier). C, Activity during a go/no-go task in patients with Alzheimer disease with unimpaired insight relative to those with impaired insight19 (adapted with permission from Oxford University Press). D, Activity during error on an error awareness task, which was lower during unaware errors in cannabis abusers18 (note that although peak anterior cingulate cortex activity in this cannabis study is more caudal and dorsal, the cluster indeed extends to the rostral anterior cingulate cortex) (adapted with permission from Nature Publishing Group).

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