Transpassing to the psychiatric aspects of Dostoyevsky’s pathology gambling disorder has to be taken into consideration. The Russian novelist struggled with pathological gambling nearly throughout his adult life: his biography researchers usually refer to the fact that he lost all his money on roulette several times. Interesting literary historical fact that one of his famous short novels, The Gambler (a story, inspired by his own gambling addiction), was written under strict pressure in order to be able to pay off his gambling debt. The well-known gambling disorder-related pathological cognitive and behavioral patterns can be recognized in the following letter written to his brother by Dostoyevsky:

“…in Wiesbaden I invented a system, actually tried it out, and immediately won 1,000 francs. The next day I got excited and departed from the system and immediately lost. In the evening I returned to the strict letter of the system again and soon won 3,000 francs again without difficulty. […] And then to cap it all I arrived in Baden, went to the tables, and within a quarter of an hour I won 600 francs. This whetted my appetite. Suddenly I started to lose, couldn’t control myself and lost everything. After that I wrote to you from Baden, took my last money, and went to play. Starting with 4 napoleons in won 35 napoléons in half an hour. I was carried away by this unusual good fortune and I risked all 35 napoleons and lost them all.” ( Jones, 1991 , p. xvi)

The proven role of the insula in gambling disorder

Gambling disorder (previously referred to as pathological gambling and classified as “Impulse-Control Disorders Not Elsewhere Classified” in DSM-IV) has recently been reclassified in the DSM-5 under the subsection of “Non-substance-related disorders” in the category of “Addictions and Related Disorders.” This reclassification can be attributed to the significant amount of growing evidence that gambling disorder has similarities to substance use disorders in many levels (i.e., genetics, neurochemical and neurobiological mechanisms, clinical characteristics, and treatment response). In a review published in 2010, van Holst, van den Brink, Veltman, and Goudriaan (2010) identified four important cognitive–emotional processes that initiate and maintain addictive behavior, especially focusing on gambling disorder: (a) reward and punishment processing, (b) impulsivity, (c) attentional bias and cue reactivity, and (d) decision-making and executive function. The insular cortex was identified among the underlying causes in two out of four processes: attentional bias and cue reactivity and decision-making and executive function.

Analyzing reward and punishment processing, patients with gambling disorder (as well as patients with substance use disorder) have lower sensitivity for reward, thus they are more susceptible for initiating reward seeking behavior (van Holst et al., 2010). This theory is consistent with the fMRI findings that showed lower ventral striatal and ventromedial prefrontal cortex activity during monetary gains in pathological gamblers compared to controls (Reuter et al., 2005). Regarding punishment processing, patients with gambling disorder are considered to have diminished sensitivity to punishment, creating the risk for poor choices through insufficient feedback (van Holst et al., 2010).

Regarding impulsivity, neurocognitive studies indicated that the process of ignoring irrelevant information and inhibiting irrelevant behaviors is impaired in patients with gambling disorder (Goudriaan, Oosterlaan, de Beurs, & van den Brink, 2004). Impulsivity playing an important role in initiating and maintaining gambling behavior is fortified by the high comorbidity of attention deficit hyperactivity disorder with pathological gambling.

Cue reactivity in patients with gambling disorder was also analyzed with neuroimaging; however, the results of the different fMRI studies are inconsistent. Although not analyzing patients with gambling disorder, an interesting study pointed out the role of the insula in drug urges and craving: patients with damage to the insular cortex were more likely to manage to go through a disruption of smoking addiction (Naqvi, Rudrauf, Damasio, & Bechara, 2007). This interesting finding raises the hypothesis of the insular cortex playing a sufficient part in craving and drug urge, maintaining addictive behavior.

Regarding the role of the insula in gambling disorder, the processes of decision-making and executive function are the most relevant. As the Iowa Gambling Test indicates, patients with gambling disorder ignore long-term consequences to obtain fast short-term gratification – in other words, they are “myopic for the future” (Bechara, Dolan, & Hindes, 2002). In patients with gambling disorder, impaired decision-making is attributed to three main cognitive distortions: the “near-miss effect,” the “gambler’s fallacy,” and the “illusion of control.” Insular involvement in all of these three cognitive impairments has been indicated in separate neuroimaging and lesion-control investigations.

The first distorted construct is the “near-miss effect,” a belief that the outcome of “almost winning” is closer to winning than losing. This effect can be best demonstrated with the slot machine game, in which case – after pressing the “start” button – win occurs when three identical figures show up in the same row (i.e., apple–apple–apple). However, a result with “apple–apple–orange” does not win, the patient with gambling disorder do not identify it as a pure loss but claims it to be closer to winning. The results of neuroimaging studies gave explanation to the near-miss effect showing that near-misses show overlapping activation with wins in the bilateral insula, ventral striatum, and medial prefrontal cortex in patients with gambling disorder (Chase & Clark, 2010; Clark, Lawrence, Astley-Jones, & Gray, 2009; Dymond et al., 2014). The second cognitive distortion that is commonly observable in gambling disorder is the “gambler’s fallacy” (also known as Monte Carlo fallacy): a belief that the chance of an outcome (e.g., heads or tails) is not independent from the previous outcomes but rather depends on them. For example in the case of playing heads or tails, after a row of 34 heads (which is statistically rare but can happen), the gambler thinks that the outcome of the next throw will more likely be tails than heads (however, the next outcome’s chance is still fifty-fifty percent theoretically). In a lesion-control study Clark, Studer, Bruss, Tranel, and Bechara (2014) found that patients with damage to the insular cortex (n = 8) are no longer susceptible to the “gambler’s fallacy” and the “near-miss effect” – giving evidence that the insula may be the underlying pathology in these cognitive distortions. The third cognitive distortion patients with gambling disorder are more susceptible to the “illusion of control”: the misbelief that personal participation in the gambling process has a positive effect on the outcome. The belief of the significant positive effect of pressing the “start” button personally rather than leaving it up to a computer is commonly observable in slot machine players. Significantly enhanced connectivity between the insula and the ventral striatum was detected in the “illusion of control” contrast during gambling in an fMRI investigation (van Holst, Chase, & Clark, 2014). The authors hypothesized excessive insular recruitment during illusion of control to be a risk factor in maintaining gambling behavior.