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      The possible role of the insula in the epilepsy and the gambling disorder of Fyodor Dostoyevsky

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          The retrospective diagnosis of Fyodor Mikhailovich Dostoyevsky’s (1821–1881) neurological and psychiatric disease proves to be particularly interesting. Recent neurobiological data suggest a solution to the questions regarding the writer’s retrospective diagnosis, claiming the insular cortex to be the origin of the rare ecstatic seizures. Regarding Dostoyevsky’s pathological gambling, this hypothesis is consistent with another finding from recent neuroscience, namely that the malfunction of the insula could be an important underlying pathology in gambling disorder.

          Case study

          Literary and scientific overview (1928–2015) on the subjects of Dostoyevsky’s epilepsy and gambling disorder.

          Discussion and conclusion

          Taking Dostoyevsky’s neurological (ecstatic seizures) and psychiatric (pathological gambling) disease and the crossroads into consideration, these two disciplines make regarding the underlying pathology, we would like to suggest a speculative theory that these two disorders have a common insular pathomechanism, namely, the malfunctioning of the risk prediction–risk prediction error coding system. Furthermore, based on Dostoyevsky’s case, regarding gambling disorder in general, we would like to hypothesize that the three common gambling-related cognitive distortions (near-miss effect, gambler’s fallacy, and the illusion of control) can be all attributed to the impairment of the anterior insular risk prediction–risk prediction error coding system.

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          Most cited references 29

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          Damage to the insula disrupts addiction to cigarette smoking.

          A number of brain systems have been implicated in addictive behavior, but none have yet been shown to be necessary for maintaining the addiction to cigarette smoking. We found that smokers with brain damage involving the insula, a region implicated in conscious urges, were more likely than smokers with brain damage not involving the insula to undergo a disruption of smoking addiction, characterized by the ability to quit smoking easily, immediately, without relapse, and without persistence of the urge to smoke. This result suggests that the insula is a critical neural substrate in the addiction to smoking.
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            Pathological gambling is linked to reduced activation of the mesolimbic reward system.

            By analogy to drug dependence, it has been speculated that the underlying pathology in pathological gambling is a reduction in the sensitivity of the reward system. Studying pathological gamblers and controls during a guessing game using functional magnetic resonance imaging, we observed a reduction of ventral striatal and ventromedial prefrontal activation in the pathological gamblers that was negatively correlated with gambling severity, linking hypoactivation of these areas to disease severity.
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              Gambling Near-Misses Enhance Motivation to Gamble and Recruit Win-Related Brain Circuitry

              Summary “Near-miss” events, where unsuccessful outcomes are proximal to the jackpot, increase gambling propensity and may be associated with the addictiveness of gambling, but little is known about the neurocognitive mechanisms that underlie their potency. Using a simplified slot machine task, we measured behavioral and neural responses to gambling outcomes. Compared to “full-misses,” near-misses were experienced as less pleasant, but increased desire to play. This effect was restricted to trials where the subject had personal control over arranging their gamble. Near-miss outcomes recruited striatal and insula circuitry that also responded to monetary wins; in addition, near-miss-related activity in the rostral anterior cingulate cortex varied as a function of personal control. Insula activity to near-misses correlated with self-report ratings as well as a questionnaire measure of gambling propensity. These data indicate that near-misses invigorate gambling through the anomalous recruitment of reward circuitry, despite the objective lack of monetary reinforcement on these trials.

                Author and article information

                Journal of Behavioral Addictions
                J Behav Addict
                Akadémiai Kiadó (Budapest )
                24 August 2016
                September 2016
                : 5
                : 3
                : 542-547
                [ 1 ]Department of Neurology, Faculty of Medicine, University of Pécs , Pécs, Hungary
                [ 2 ]Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Pécs , Pécs, Hungary
                Author notes
                [* ]Corresponding author: Dalma Tényi, PhD student; Department of Neurology, Faculty of Medicine, University of Pécs, Rét u. 2, Pécs 7629, Hungary; Phone: +36 72 536000; Fax: +36 72 535911; E-mail: tenyidalma@
                © 2016 The Author(s)

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium for non-commercial purposes, provided the original author and source are credited.

                Page count
                Figures: 0, Tables: 1, Equations: 0, References: 30, Pages: 6
                Funding sources: The authors were supported by the National Brain Research Program under grants NAP KTIA NAP-A-II/12 and KTIA NAP-13-a-II/9.
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