Functional, structural, and emotional correlates of impaired insight in cocaine addiction

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 studywas 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).