Craig How Do You Feel Now

PErsPECTIvEs
OpInIOn
How do you feel now? The anterior insula and human awareness
A. D. (Bud) Craig
Abstract | The anterior insular cortex (AIC) is implicated in a wide range of conditions and behaviours, from bowel distension and orgasm, to cigarette craving and maternal love, to decision making and sudden insight. Its function in the re-representation of interoception offers one possible basis for its involvement in all subjective feelings. New findings suggest a fundamental role for the AIC (and the von Economo neurons it contains) in awareness, and thus it needs to be considered as a potential neural correlate of consciousness.
In a 2002 Perspective article I discussed the phylogenetically new primate lamina I spino thalamocortical pathway, which provides a primary interoceptive representation of the physiological condition of the body in the posterior insular cortex 1. The evidence at that time indicated that the anterior insular cortex (AIC) (FIG. 1) contains interoceptive re representations that substantialize (that is, provide the basis for) all subjective feel ings from the body and perhaps emotional awareness, consistent with the essence of the JamesLange theory of emotion and Damasios somatic marker hypothesis. Studies in diverse fields now offer a wealth of convergent data that support and extend these proposals. In this Perspective, I discuss recent functionalimaging reports that describe activation of the AIC and highlight those that seem the most important for understand ing its role. The available evidence suggests strongly that the AIC has a fundamental role in human awareness. After discussing this concept, I describe a model that could explain how the AIC might play this role.
Recent findings of AIC activation The recent imaging studies that report acti vation of the AIC are here categorized in different fields of inquiry (FIG. 2). Selected studies are highlighted and others are listed in Supplementary information S1 (table). In most but not all of these studies, the AIC and the anterior cingulate cortex (ACC) are
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jointly activated, consistent with the idea that they serve as complementary limbic sensory and motor regions that work together, similar to the somatosensory and motor cortices (BOX 1). The studies that reported activation of the AIC but not the ACC are explicitly noted. In addition, activation in the AIC often spills over into the frontal operculum and the neighbouring inferior frontal gyrus (IFG), and it overlies the distribution of von Economo neurons (VENs) in this frontoinsular junction (BOX 2). Interoception. Interoceptive stimuli that have been shown to activate the AIC include thirst, dyspnea, air hunger, the Valsalva manoeuvre, sensual touch, itch, penile stim ulation, sexual arousal, coolness, warmth, exercise, heartbeat, winetasting (in sommel iers), and distension of the bladder, stomach, rectum or oesophagus (see Supplementary information S1 (table)). Our original positron emission tomography (PET) study showed that objective cool temperatures are represented linearly in the contralateral dorsal posterior insula, whereas subjective ratings of these stimuli correlate with activa tion of the contralateral midinsula and then most strongly with the AIC and the adjacent orbitofrontal cortex on the right side2, sug gestive of a posteriortomidtoanterior pattern of integration of interoceptive infor mation. Here, I highlight three reports that substantiate and expand these findings.
Critchley et al. reported functional MRI (fMRI) and morphometric data indicating a specific role for the right AIC in heart beat awareness3, an interoceptive measure that correlates with individual subjective emotional awareness4. A PET study of non painful gastric distension reported that a subjective sense of fullness was associated with activation peaks in the bilateral dorsal posterior insula, the left midinsula, the left AIC and the ACC5; these results conform to the posteriortomidtoanterior pattern of integration mentioned above, but the left sided asymmetry seems to correlate with the fact that this stimulus activates primarily vagal (parasympathetic) afferents (BOX 3). Finally, activation was observed in the bilat eral AIC (right side (R)>left side (L)) during nonpainful oesophageal distention or view ing of fearful faces, and such activation dis played synergistic enhancement when these stimuli were delivered simultaneously 6, sug gesting that emotional states are integrated with interoceptive states in the representation of the subjective feelings of the moment. Pain is a significant interoceptive feeling, and four recent pain studies are noteworthy here. One study reported that noxious heat stimulation of the left or right hand activated the contralateral dorsal posterior insula, the bilateral midinsula (R>L) and, when the subject attended to the stimulus, the right AIC (R>>L)7. Another study reported that the objective intensity of a heat pain stimulus correlated with activation in the posterior insula, whereas the subjective eval uation of heat pain correlated with activation in the bilateral AIC (R>L)8. A different study found that empathic feelings for a loved one receiving painful simulation were associated with activation of the bilateral AIC but not the posterior insula9. Finally, investigators injected volunteers with hypertonic saline in the arm and the leg to produce a painful stimulation of muscle or the overlying skin, and they observed distinct, neighbouring sites of activation in the AIC that were somatotopically arranged10. Awareness of body movement. Two reports11,12 showed that the feeling of agency or awareness of body control during hand movements is associated with activation
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PersPectives
in wellknown melodies were mistimed)16. A recent fMRI study compared activation induced by listening to pleasant and unpleas ant music that the subjects selected individu ally and found that subjectively pleasant music induced activation of the AIC that was greater on the left than on the right side17. One review presented evidence that the AIC is activated bilaterally during overt speech and singing and, strikingly, that the AIC acti vation is asymmetric during covert singing: activity in the right AIC was higher during slow tempos (<3 Hz); activity in the left AIC was higher during fast tempos (>3 Hz)18. Emotional awareness. Almost all recent imaging studies of emotion report joint acti vation of the AIC and the ACC in subjects experiencing emotional feelings, including maternal and romantic love, anger, fear, sadness, happiness, sexual arousal, disgust, aversion, unfairness, inequity, indigna tion, uncertainty, disbelief, social exclusion, trust, empathy, sculptural beauty, a state of union with God, and a hallucinogenic state (induced by ayahuasca). Thus, the AIC is activated not just in association with subjec tive feelings from the body, but apparently with all subjective feelings. One noteworthy study examined restingstate functional connectivity and found two networks: an executive control network that included the dorsolateral prefrontal cortex (DLPFC) and parietal areas, and an emotional sali ence network that included the bilateral AIC, the ACC, the amygdala and the hypo thalamus19. Significantly, small regions in the left AIC and the medial prefrontal cortex (MPFC) near the ACC were included in both networks, suggesting a basis for both emotional awareness of cognitive functions and the influence of emotion on cognition. In addition, several studies (for example, ReFs 20,21) found selective activation in overlapping regions in the AIC during an empathic feeling and a comparable subjec tive feeling (for example, seeing disgust expressed on anothers face and smelling a disgusting odour, respectively), with the former located anterior to the latter (consist ent with the posteriortoanterior gradient towards greater behavioural complexity in the frontal cortex 22). Notably, similar loca tions in the AIC may be active during quite different emotions and behaviours20,21,23; across all studies, a main determinant of location in the AIC seems to be the region of somatic association, with face representa tions located most anterior and hand and foot representations located more posterior (see also ReF. 14).
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SPS as ms ps al pl IPS H
APS
ac
Figure 1 | Anatomy of the insula. A photograph of the left insular cortex of a human patient. For a comparison with the insulae of other patients, see ReF. 114. The human insular cortex is a distinct but hidden lobe of the brain. It is disproportionately (~30%) enlarged in the human relative to Neuroscience Nature Reviews | the macaque monkey109. It has 57 oblique gyri, but its morphology is quite variable, even between the two sides114118. A comprehensive hodological description in the macaque is lacking, and few connectivity analyses of the insula have been made in humans. Primary interoceptive representations are located in the dorsal posterior insula and re-represented in a polymodal integrative zone in the mid-insula and again in the anterior insular cortex (AIC)2,7,119,120. The primary interoceptive, gustatory and vagal representations extend to the anterior limit of the insula in macaques but only to the middle of the insula in humans98,121124, which suggests that the AIC of humans has no equivalent in the monkey. The most anterior and ventral (inferior) portion of the human insula that adjoins the frontal operculum is probably the most recently evolved, because this part (as well as the anterior cingulate cortex; BOX 1) contains von Economo neurons (BOX 2). as, anterior short insular gyrus; al, anterior long insular gyrus; ac, accessory gyrus; APs, anterior peri-insular sulcus; H, Heschls gyrus; IPs, inferior peri-insular sulcus; ms, middle short insular gyrus; ps, posterior short insular gyrus; pl, posterior long insular gyrus; sPs, superior peri-insular sulcus. Photograph is courtesy of Professor Thomas P. Naidich, Mount sinai Medical Center, New York.
in the bilateral midinsula. Another study reported activation in the right midinsula during the rubberhand illusion, in which the subject was not actually moving but felt like the moving hand was their own13. The authors suggested that the midinsula activa tion during movement might represent a sense of body ownership rather than agency. No activation was observed in the ACC in these studies. Finally, a recent study reported that simply hearing the piano notes that a subject has just learned to play activates the same midinsular region14. Based on a meta analysis that they performed of prior studies, the authors proposed that the insula contains a sensorimotor map that represents move ments. My interpretation of these studies is that the insular cortex contains a somatotopic representation of the subjective feelings of ones current movements as part of a representation of all feelings from the body. Self-recognition. The imaging studies cited in Supplementary information S1 (table) reported that the act of seeing ones own image produced activation in the AIC. The
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most recent study 15 contrasted brain activa tion in subjects viewing photos of their own face or body with activation when these subjects viewed photos of a close colleague or scrambled images. During both types of visual selfrecognition the authors found selective activation of the AIC and the adja cent IFG and ACC, all on the right side. They suggested that the right AIC and ACC could give rise to an abstract representation of oneself that could possibly participate in maintaining a sense of self . Vocalization and music. There are differing views on the involvement of the insula in speech (some authors include the insula in Brocas area), as summarized in the reviews cited in Supplementary information S1 (table), but there is consistent evidence for the involvement of the AIC in music. Of note, a PET study reported findings that differenti ated brain regions associated with familiarity, pitch, rhythm and timbre in music listening; the authors reported robust activation spe cifically in the left AIC (not the ACC) during the rhythm task (in which occasional notes
PersPectives
Error awareness Feeling of knowing Subjective cooling Pleasant music
Free wont
Attention to heat pain
Rhythm
Heartbeat awareness Moment of recognition Inspection time Maternal affiliation
Learned pain now
Happy voices Decision making
ACC Anterior insula
Self recognition
Seeing or making a smile
Anterior insula
Time perception
Figure 2 | Activation of the Aic. A summary of imaging results showing activation of the anterior insular cortex (AIC) during particular tasks and emotions highlighted in the text. The two right-hand columns contain images from different studies that found predominantly unilateral activation; images in the two left-hand columns show mostly bilateral activation. stimuli that activate the right AIC are generally arousing to the body (for example, pain). The left AIC is activated mainly by positive and affiliative emotional feelings (BOX 3). For example, activation of the left AIC was reported in mothers viewing photos of their own child125; greater activation of the left than of the right AIC was associated with both maternal and romantic love126; activation of the left AIC was reported while subjects were either seeing or making a smile21; activation of the left AIC was found while subjects attended to happy voices127; activation of the left AIC was associated with hearing pleasant music17; selective
activation of the left AIC was observed in subjects experiencing joy128; and selective activation of the left AIC in females was found that correlated with self-reported orgasm ratings129. ACC, anterior cingulate cortex. Images are Nature top to bottom and left reproduced, with permission, from (in order fromReviews | Neuroscience to right): (first column) ReF. 23 (2007) Elsevier, ReF. 45 (2007) society for Neuroscience, ReF. 39 (2007) society for Neuroscience, ReF. 40 (2007) society for Neuroscience; (second column), ReF. 41 (2002) Cell Press, ReF. 31 (2004) Elsevier, ReF. 34 (2007) Elsevier; (third column) ReF. 2 (2000) Macmillan Publishers Ltd (all rights reserved), ReF. 7 (2002) Elsevier, ReF. 3 (2004) Macmillan Publishers Ltd (all rights reserved), ReF. 24 (2004) Macmillan Publishers Ltd (all rights reserved), ReF. 15 (2007) Elsevier; (fourth column) ReF. 17 (2006) Wiley, ReF. 16 (1997) Oxford Journals, ReF. 125 (2004) Elsevier, ReF. 127 (2006) Oxford Journals, ReF. 20 (2005) Elsevier.
PersPectives
Box 1 | The co-activation of the AIC and the ACC
It is understandably mystifying that a region of the ventrolateral prefrontal cortex (the anterior insular cortex (AIC)) and a region of the medial prefrontal cortex (the anterior cingulate cortex (ACC)) are co-active in so many behaviours, because such widely separated regions in the cortex generally have distinct roles. The insular cortex was long regarded simply as a visceral sensory region, based on findings by Penfield, Mesulam and Saper8486, whereas the medial prefrontal cortex has been associated with conflict responses, impulsive behaviour and autonomic activity. In an earlier article I suggested that the insula and the ACC be regarded as limbic sensory and motor cortices that respectively engender the feeling and the motivation (agency) that constitute any emotion1. This suggestion was based on the dual lamina I spinothalamocortical projection to both the insula and the ACC, the co-activation of these areas in virtually all studies of emotion, their respective descending projections to sensory (parabrachial nucleus) and motor (periaqueductal grey) brainstem regions, the overall anatomical organization of the frontal cortex into sensory and motor networks, and the evolutionarily ancient limbic role of the cingulate cortex in integrated behavioural control. I regarded the AIC as the probable site for awareness on the basis of its afferent representation of the feelings from the body, and the ACC as the probable site for the initiation of behaviours. A recent review87 offered support for this view and an explanation for the anatomical separation of the insula and the ACC. The ACC evolved first as a motor-control region aligned with the sensory integration, in the hippocampus and the amygdala, of olfactory-guided group behaviour in mammals. The insula evolved later for cortical processing of homeostatic sensory activity in the individual animal. The two regions naturally became linked for integrative autonomic control, and in mammalian evolution the insula grew as limbic behavioural activity became aligned more with autonomic activity than with olfactory activity. This anatomical perspective87 is illustrated in the ventral view of the brain in the figure, which reveals the common relationship of these structures to the olfactory epithelium. Figure is reproduced, with permission, from ReF. 87 (1999) Elsevier.
Cingulate sulcus
Hippocampus Rhinal sulcus Collateral sulcus Laterobasal cortical amygdala
Olfactory bulb Olfactory peduncle Insula Olfactory cortex Olfactory tract Anterior olfactory nucleus Diagonal band Basolateral amygdala Hippocampus Entorhinal area
Risk, uncertainty and anticipation. Of the articles listed in Supplementary information S1 (table), I note particularly one report that emotional value in the immediate present, as specified in a secondorder temporal difference model of learning, correlated selectively with activity in the right AIC24; another study (in which this learning model was adapted for neuroeconomic studies) reported that both the riskprediction signals
and the riskprediction error signals speci fied in the model were present only in the bilateral AIC25. No activation was observed in the ACC in this study. Activation in the AIC is also correlated with feelings of anticipated value during purchase and sales decisions26. Visual and auditory awareness of the moment. Several reports that associated acti vation in the AIC with awareness of sensory
bistable percepts Naturebe explicitly noted must Reviews | Neuroscience 2729 here , but I highlight three additional studies. The first is a PET study which found that the right AIC and the ACC are sensitive to crossmodal sensory time synchroniza tion and display a graded response to a mismatch in timing between auditory and visual stimuli that should normally be syn chronous (for example, a speaking mouth)30. The second is an fMRI study that examined
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PersPectives
Box 2 | VEns and awareness
An extraordinary morphological characteristic of the anterior insular cortex (AIC) and the anterior cingulate cortex (ACC) in hominoid primates is the unique concentration of clusters of large spindle-shaped neurons among the pyramidal neurons in layer 5, called von Economo neurons (VENs) after an early neuroanatomist88,89. Their connections are not known, but I have proposed78 that VENs are the substrate for fast interconnections between the physically separated advanced limbic sensory (the AIC) and motor (the ACC) cortices. Analogous to the tight interconnections between the contiguous somatosensory and motor cortices (so-called U-fibres) needed for manual dexterity (for example, for playing a musical instrument), the VENs might enable fast, highly integrated representations of emotional moments and behaviours. They may underlie the joint activity in the AIC and the ACC reported in most studies. The loss of emotional awareness and self-conscious behaviours in patients with frontotemporal dementia that correlates with the degeneration of VENs directly supports this notion75,76,90,91. Hof, Allman and colleagues reported that many VENs are present in aged humans, but progressively fewer are found in infants, gorillas, bonobos and chimpanzees, and they are not present at all in macaque monkeys88,89. This clear phylogenetic progression parallels the results of the mirror test for self-awareness2,55. VENs have recently been reported in elephants92 and whales93. The possibility that this implies sentience in these animals received support recently when elephants were reported to pass the mirror test94. Interestingly, there are reports that elephants sing or make music communally (as captured in a film on the National Geographic website), which would be consistent with the present model for awareness, in which music (viewed as a rhythmic temporal progression of emotionally laden moments) is an emergent property of awareness. By contrast, although most people feel that particular dogs and cats have some sense of awareness, the cortex of these animals receives an integrated brainstem homeostatic pathway and only a primordial homologue of the ascending lamina I pathway that underlies the emergence of interoceptive re-representations in the AIC of humanoid primates1. Whether that is a sufficient basis for sentience is unresolved: cats and dogs do not pass the mirror test, and a lesion of the presumptive homologous pathway in cats does not produce the same devastating effects on interoception that it produces in humans1. Rats and lizards apparently do not have a homologous anatomical substrate at all1.
inspection time using a briefly displayed asymmetric visual test stimulus (a onesided fork) followed immediately by an ambiguous stimulus (socalled backward masking)31. The authors reported that subjects perform ance in detecting the asymmetry decreased progressively from 100% to chance levels for presentation times shorter than 150 ms, yet activation in the AIC and the ACC selectively and progressively increased with shorter presentation times. The authors inferred from these data an effortrelated process that guides goaldirected attention, which they related to psychometric intelli gence; however, this observation can also be interpreted as evidence for a role for the AIC and ACC in heightened awareness of the immediate moment. The third study 32 used the attentionalblink paradigm, in which a second target cannot be perceived if it occurs too soon after a primary target in a rapid series of visual stimuli. The authors reported joint activation of the AIC/IFG and the ACC (plus activation of the DLPFC and parietal regions) when the second target was correctly detected at the shortest intervals (100200 ms) but not when it was not per ceived. They suggested that the AIC/IFG and the ACC might contain a conceptual short term memory buffer prone to decay and replacement by other stimuli that receives
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processed input from a parietal network and requires a finite period of time to transfer information into working memory (in the DLPFC). Time perception. Joint activation of the AIC and the ACC or nearby areas has been reported in many studies of mental time keeping and interval estimation across the range of seconds to subseconds, but little explanation has been given for this activity (for example, see ReF. 33). In a recent report, task difficulty was manipulated in order to isolate time estimation from other task related cognitive demands34. The authors found three small regions that seem to be crucial for time perception: one in the dorsal putamen (bilaterally), another in the left inferior parietal cortex and another at the junction of the AIC and the IFG bilaterally (with no ACC activation). They suggested that the AIC/IFG focus must be of central importance in time perception. Attention. Activation of the AIC (and the ACC) is reported by most studies of goal directed attention, but these studies often lack comments regarding the role of this activation. One influential model for the neural correlates of the executive control of attention does not include the insula (for
example, see ReF. 35), and some have argued that attention and consciousness must be different processes36. Nevertheless, two recent studies of attention described activa tion in the AIC/IFG37,38. The authors of one study reported decreased activation in the right IFG, ACC and middle frontal gyrus (DLPFC) just before lapses of attention dur ing a monotonous selectiveattention task (in which lapses of attention were marked by increased reaction times), and they observed increased activation after such lapses in approximately the same regions (bilateral AIC, ACC, DLPFC, occipital and parietal visual regions), possibly correspond ing to renewed attention37. They suggested that the AIC/IFG is involved in the stimulus triggered reorienting of attention and that the ACC is involved in the detection and/or resolution of processing conflicts; however, if the AIC/IFG and the ACC are regarded as complementary limbic sensory and motor regions, respectively (BOX 1), then this response profile would also be consistent with the interpretation that target awareness is engendered in the AIC/IFG and control of directed effort is engendered in the ACC. In another study, a wellpractised behavioural task was used to encourage mindwandering (stimulusindependent thought), and the authors found activation associated with selfreported mindwandering periods in several regions, particularly the insula (middle and posterior) and the ACC38. They interpreted the insular activity with reference to interoception and emotional awareness. Perceptual decision making. I highlight three seminal reports in this category. First, Ploran et al.39 tracked brain activation in subjects watching a screen on which an image was slowly being revealed. They found a gradual increase in activation in brain regions that are involved in object identification, but a sudden burst of activ ity in the AIC and the ACC at the moment of recognition (that is, coinciding with the awareness of the percept itself). Second, Thielscher and Pessoa40 examined a two choice perceptual task using a graded series of morphed emotional faces (an experimen tally generated bistate percept). They found an invertedushaped correlation between perceptual choice and both reaction time (which represented the decisionmaking process) and bilateral AIC/IFG (R>L) and ACC activation. They concluded that the AIC may have been important in the actual generation of the perceptual choice. Finally, Kikyo et al.41 examined the
PersPectives
Box 3 | Forebrain asymmetry of emotion
There are two sides of the brain, and so if there are separate time-based representations of the sentient self that subserve awareness in the anterior insular cortex (AIC) (one in each side), how are they coordinated to generate one unified self? The homeostatic model of awareness presented in this and prior articles1,78 suggests that there is an energy efficiency-optimal process that is based on the coordinated opponency of the autonomic system that activity in the right side of the forebrain is associated with energy expenditure, sympathetic activity, arousal, withdrawal (aversive) behaviour and individual-oriented (survival) emotions, and activity in the left side is associated with energy nourishment, parasympathetic activity, relaxation, approach (appetitive) behaviour and group-oriented (affiliative) emotions. This proposal is described in detail in prior articles78,95. Briefly, the origin of this asymmetry can be related to the asymmetric autonomic innervation of the heart, and its evolutionary development would have been compelled by the need for energy optimization in the brain (which consumes 25% of the bodys energy). This model fits with an accumulating body of psychophysical literature which indicates that the left and right forebrain halves are differentially associated with positive and negative affect96 and, importantly, with the anatomical and functional asymmetry in the homeostatic afferent input to the insular cortex5,97,98 and in forebrain cardiac control99. It can explain why under particular conditions the AIC is more active on one side (FIG. 2) but also why in most conditions the two sides display joint activity, which mirrors the coordinated sympathetic and parasympathetic control of the heart. The model offers explanations for why positive emotions can reduce or block negative emotions (and vice versa), why the left (affiliative, vagal) side controls deictic pointing and verbal communication, and how increased parasympathetic activity (for example, activation of vagal afferents by gastric distension, slow breathing or elecrical stimulation) can reduce negative emotions (for example, pain). Given the many asymmetries in the activations of the AIC noted in this article, investigations addressing this model in split-brain patients could be enlightening, particularly if performed with those rare patients in whom both the corpus callosum and the anterior commissure are sectioned100,101.
feeling of knowing, which is the subjective sense of knowing a word before recalling it. (The feeling of knowing has been inter preted as a subjective feeling that represents the retrievability, accessibility or familiarity of the particular target word, which corre lates with the subsequent ease of recall41,42.) using a welltested set of generalknowledge questions without prior exposure or prim ing, they found pronounced activation in the bilateral AIC/IFG and the ACC that cor related parametrically with the strength of the feeling of knowing. The bilateral AIC/ IFG was not recruited during the successful recall process itself, which implied to the authors a particular role in metamemory processing for this area. Cognitive control and performance monitoring. Several reports in this major field of study described strong activation in the AIC. One described functionalconnectivity analyses that were performed on brain acti vation during a combined workingmemory and targetswitching task; a cognitive control network was identified that includes the bilateral AIC and the ACC43. In another report, brain activation was ana lysed during various cognitivecontrol tasks and the authors concluded that the bilateral AIC and the ACC form a highly intercon nected core system for taskdependent control of goaldirected behaviour and
sensory processing 44. A study that used a stopsignal paradigm in which the subjects voluntarily initiated a hand movement but on signalled trials inhibited the movement at the last possible subjective instant found that the bilateral AIC (L>R) and a small region in the MPFC near the ACC region were specifically involved in the active, willed inhibition of a motor act (which the authors called free wont, as opposed to free will)45. The authors associated the AIC activation with the affective consequence of cancelling a motor intention (frustration), and other investigators in similar studies associated such activation with autonomic arousal46. However, an alternative inter pretation is that the occurrence of the stop signal naturally elicited an immediately heightened awareness such heightened awareness would certainly have increased with the rarity of the stop signal, as the investigators found for the AIC46 and the MPFC region45. In another study, per formance errors were examined in subjects engaged in a demanding repetitive task, similar to that used in the lapseofattention study described above37, and then independent component analyses and back ward deconvolutions were performed to identify brainactivation patterns that pre ceded errors47. The authors found four sets of brain regions in which activity patterns predicted the commission of an error; the
first set consisted of the bilateral AIC and the ACC, which they suggested act as a perform ance monitor. Another set of brain regions they identified consisted of the right AIC/IFG and an MPFC region near the ACC, which they associated with the evaluation of task costs and the maintenance of task effort. In the latter regions, activation declined just before an error occurred and increased after an error had occurred, similar to the pattern of attentionrelated activity in the study of lapses of attention described above37. These results are therefore also consistent with the alternative interpretation that the AIC activ ity represents awareness and that the ACC activity represents the control of directed effort. A recent study performed several sophisticated connectivity and correlation analyses of attentional transitions and con firmed that the AIC and the ACC act as a cognitivecontrol network and, further, that the right AIC in particular plays a critical and causal role in switching between the central executive network and the defaultmode or selfreflective network48. Finally, a study by Klein et al.23 may pro vide direct evidence that the AIC engenders awareness. The authors used an antisaccade task with a distractor (in which subjects were instructed to shift their gaze in the opposite direction to a briefly displayed indicator but were occasionally misdirected by an inter vening cue that indicated the other direc tion), which produced occasional erroneous saccades that the subjects were either aware of (and signalled with a button press) or unaware of. The subjects errorawareness reports were corroborated by slowed reac tion times and improved performance (for most subjects) on trials following aware errors but not following unaware errors. The fMRI data on error trials revealed acti vation of the bilateral AIC and three small MPFC regions near the ACC. By contrasting brain activity during aware errors with that during unaware errors, the authors found activation only in the left inferior AIC (simi lar activation in the right AIC was just sub threshold). Significantly, activation near the ACC was not associated with error aware ness. The authors suggested that the activity of the AIC during aware errors might be explained by interoceptive awareness of greater autonomic responses to aware errors (which have been documented previously), but they also recognized that the AIC activ ity and error awareness might precede the autonomic response23. They recommended the use of electroencephalographic record ings to resolve this uncertainty, because the temporal resolution of fMRI is too low.
PersPectives
Box 4 | Alternative perspectives
There are many alternative views of the neural substrates that are involved in human awareness or consciousness. Two particular viewpoints suggest that the anterior cingulate cortex (ACC) has a singular role in the representation of the self and emotional awareness of internal processes102,103, but neither has incorporated the anatomical perspective that the anterior insular cortex (AIC) and the ACC are complementary limbic regions or the evidence reviewed here. Some investigators suggest that the posteromedial cortex (including the cingulate and the precuneus) provides the basis for self-awareness (for example, see ReF. 104). However, this area is part of the so-called default network, which seems to be involved in self-reflective episodic memory retrieval, and activity in this area is inversely correlated in functional-imaging studies with the activation in the AIC that is associated with awareness and task-related attention44,90. The default network also seems to be present in the macaque monkey105. There are numerous proposals for the neural basis of the various forms of the clinical syndrome anosognosia (a lack of awareness of a functional impairment), but these are complicated by the multiple levels of integration that are required for each perceptual capacity and by confounding issues in the clinical documentation67,106. Recent clinical and anatomical correlations in patients with anosognosia for hemiplegia and hemianaesthesia have focused on the insula66,67. Prior studies implicated the right inferior parietal cortex and the angular gyrus, but recent authors agree with the idea that this region processes a representation of extrapersonal space that incorporates self-generated movements, and that this module precedes the integration of information about the self in the AIC66,67,106, although this idea remains to be tested. Several authors suggest the existence of different levels of awareness or consciousness51,70,107. Although this view is not incompatible with the present hypothesis, because more than one conceptual level of awareness might be instantiated in the AIC (including a comparator that could feel like an observer), other investigators might regard it as unlikely, because they prefer the notion that consciousness depends on recurrent activity in a distributed network across the entire brain (for example, see ReF. 77). For example, one author suggested that the orbitofrontal cortex is part of a global workspace that underlies consciousness108, although its role in hedonic valuation (especially for feeding behaviour) is well-developed in all mammals and it is not disproportionately enlarged in humans109. Nevertheless, the AIC certainly does not operate autonomously and the evidence reviewed here indicates that it is involved in more than one functional network; further, there are probably numerous modules in the AIC, the complexity of which might increase from the posterior to the anterior, that could accommodate higher levels of abstraction21,22,83,110. For example, although the hurt that is associated with social exclusion was reported to overlap with the AIC region that is activated during physical pain, a close examination of the imaging data reveals that in fact the activation lies considerably more anterior111.
damage to right parietal cortex), an impair ment in the movement of ones limbs (ano sognosia for hemiplegia following damage to the midinsula) or ones entire autobiographi cal history and yet maintain phenomenal awareness of feelings and existence (for example, the patient with only visceral feelings remaining and an intact anterior insula51, or patient R.B., who lives in a mov ing 40second window of present time51,52). A further proposal is that a reflective awareness of oneself across time that can compare the effects of ones actions now, in the past and in the future was required for the evolution of deliberate social signalling (intentional emo tional interaction between individuals)49,53. Some investigators view this capacity as a higherorder level of awareness that might provide the introspective feeling of subjec tivity 51,53 (see BOX 4 and further discussion below). The mirror test for selfrecognition has been used as an operational test for self awareness, and although objections to this test have been raised, I concur with the view that it has validity as a sufficient but not nec essary criterion5457; that is, a feeling of owner ship of and identification with movements and emotional gestures reflected in a mirror is possible only with a mental representation of a sentient self. Recently, it has also been proposed that awareness in humans could be measured with postdecision wagering 58. The implications of the imaging data. The results highlighted in the categories Interoception, Awareness of body move ment and Emotional awareness indicate that the AIC provides a unique neural sub strate that instantiates all subjective feelings from the body and feelings of emotion in the immediate present (now). The anatomical posteriortomidtoanterior progression of integration from the primary interoceptive representations to the middle integration zone to the ultimate representation of all of ones feelings (that is, the sentient self) is now well documented and supports the proposition that subjective awareness is built on homeostasis1,4,51,61. The noted studies on the perception of bistable percepts2729, time synchronization30, inspection time31, the attentional blink32 and perceptual deci sion making 39,40 all imply directly that the AIC supports awareness of the immediate moment with a coherent representation of my feelings about that thing. The dem onstration that the AIC activates during selfrecognition satisfies the criterion of instantiation of selfawareness, equivalent to the mirror test 15, because it reveals a subjec tive feeling of enhanced emotional salience
The role of the AIC This brief review reveals that an astonish ing number of recent studies from a broad range of fields reported activation of the AIC. These studies associate the AIC not just with all subjective feelings but also with attention, cognitive choices and intentions, music, time perception and, unmistakably, awareness of sensations and movements2,3,1114, of visual and auditory percepts2729,31,32, of the visual image of the self 15, of the reliability of sensory images30 and subjective expectations24,25, and of the trustworthiness of other individuals (see ReF. 1 for further detail). In several key experiments, the AIC was activated without apparent activation in the ACC1114,16,2325,34. No other region of the brain is activated in all of these tasks, and the only feature that is common to all of these tasks is that they engage the awareness of the subjects. Thus, in my opinion, the accumulated evidence compels the hypothesis that the AIC engenders human awareness.
NATuRE REVIEwS | NeuroscieNce
What is awareness? until we know more about how brains work, only a working definition is possible. I regard awareness as knowing that one exists (the feeling that I am); an organism must be able to experience its own existence as a sentient being before it can experience the existence and salience of anything else in the environment. One proposal holds that awareness of any object requires, first, a mental representation of oneself as a feeling (sentient) entity; second, a mental representation of that object; and third, a mental representation of the salient interrelationship between oneself and that object in the immediate moment (now)49,50. As in Damasios neural self (ReF. 51), this formulation inherently creates a subjective (personal) perspective that differentiates inner and outer realms, because the inner feelings that underlie ones representation of oneself as a sentient being are accessible only from ones own brain51,52. In this view, one can lose the ability to perceive a portion of extrapersonal space (for example, following
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in the representation of the sentient self during selfidentification. Further, the dem onstration that AIC activation is correlated with the feeling of knowing (ReF. 41) sug gests that the AIC also engenders awareness of feelings that are associated with mental constructs and operations59,60. The highlighted findings in the catego ries Risk, uncertainty and anticipation, Time perception and Cognitive control and performance monitoring are consist ent with the notion that the AIC contains a representation of the sentient self not only in the immediate moment but at each moment across a finite period of time. The AIC is a central component of a neural substrate that represents the passage of time34, it is sensitive to time synchronization30 and it is uniquely involved in automatic comparisons of feel ings in the present moment with those in the past and the future25. These findings also indicate that the AIC incorporates a buffer, or comparator, that is used for such com parisons. These observations suggest that the AIC fulfils a requirement of the proposed49,53 evaluative and predictive role of awareness in the evolution of emotional communica tion, and that it affords an integral mecha nism for decision making. (Interestingly, a stable comparator might be perceived introspectively as an ephemeral observer, or a Cartesian theater, that nonetheless cannot see itself, as described61 for consciousness.) Significantly, the evidence that the AIC is also associated with predictions of future feelings can explain its involvement in the distorted interoceptive predictions that are associated with anxiety and functional somatic disorders62,63. The findings I highlighted on perceptual decision making (choice)40 and cognitive control (free wont (ReF. 45), preparation for error commission47 and attentional transi tions48) imply that the AIC has a role in the subjective guidance of mental and physical behaviour. This inference is consistent with the introspective feeling that I am not sim ply a passive observer (whether this is an illusion or not; see ReF. 64). Such involvement does not contradict the idea that the ACC subserves volitional agency (BOX 1), an idea that is supported by the ACCs joint (with the AIC) activation in almost all of these studies and by its association with action and the descending limbic motor system1,65. Finally, the highlighted findings on the activation of the AIC during musical enjoy ment and heightened awareness point to specific characteristics of the AIC that need to be explained by any model of its role in awareness.
66 | JANuARy 2009 | VOLuME 10 2009 Macmillan Publishers Limited. All rights reserved
Clinical observations. Clinical observa tions offer corroborative evidence for the hypothesis that the AIC engenders human awareness. Supplementary information S1 (table) lists clinical reports that indicate involvement of the AIC and the midinsula with conditions that include anosognosia, anergia, anxiety, alexithymia, depression, aphasia, amusia, ageusia, drug craving, eat ing disorders, conduct disorder, panic dis order, mood disorders, posttraumatic stress disorder, schizophrenia, SmithMagenis syndrome, cardiac arrhythmia, vertigo and frontotemporal dementia (FTD). Many of these reports are quite narrowly focused and do not describe comprehensive behavioural testing, whereas the evidence reviewed above suggests that most patients with insu lar damage could have several significant neurological deficits. Several clinical studies indicate that damage to or abnormal activation or development of the AIC is associated with altered awareness. Two studies reported that anosognosia for hemiplegia is specifi cally associated with damage in the right midinsula66,67; adolescents with conduct disorder were found to have a significant decrease in grey matter volume in the bilateral AIC that correlated with a lack of empathy and with aggressive behaviour 68; patients with borderline personality dis order who are incapable of cooperating do not display the graded activation of the AIC that is associated with awareness of social gestures in normal subjects69; high functioning people with autism displayed increased alexithymia and decreased empa thy, both of which were correlated with reduced activation in the AIC (in a task in which the subjects assessed their feel ings about unpleasant images)70 (however, see ReFs 71,72); hyperactivity in the right AIC was selectively associated with anxi ety 62; infarcts of the AIC were reported to produce anergia, or complete listlessness73; and congenital malformation of the bilat eral insula (SmithMagenis syndrome) produces childhood mental retardation and the disruption of selfguided behaviour 74. Most significantly, patients with FTD asso ciated with degenerate frontoinsular and cingulate cortices display a selective loss of selfconscious behaviours and a loss of emotional awareness of self and others75; in fact, Seeley et al. reported the landmark finding that the loss of subjective emotional awareness in patients with FTD is specifi cally associated with the degeneration of VENs76. These reports are especially nota ble in light of the obvious difficulties in
demonstrating deficits in emotional awareness in adult humans who have wellestablished behavioural patterns. Summary. Thus, the available data provide compelling support for the concept that the AIC contains the anatomical substrate for the evolved capacity of humans to be aware of themselves, others and the environment. In my opinion, these data suggest that the AIC uniquely fulfils the requirements to be the neural correlate of awareness. The brain is well organized into networks that distrib ute functionality across multiple sites, and the localization of awareness of feelings and existence in a single substrate might seem unlikely 67,77. Nevertheless, the evidence sug gests that the AIC and the adjoining frontal operculum (on both the left and right sides) contains an ultimate representation of the sentient self in humans (and perhaps homi noid primates, elephants and whales; BOX 2). These data recommend a discussion of the possibility that the AIC is a neural correlate of consciousness (ReF. 77) and of the question of how the AIC might engender awareness.
A model for awareness in the AIC In a recently published book chapter 78, I expanded on the ideas presented in the 2002 Perspective article1 by outlining a theoreti cal model for the structural instantiation of awareness in the AIC. The evidence described above of a role for the AIC in awareness is consistent with this model, and thus I elaborate the model here and incorporate these recent findings. Briefly, in this model the cortical basis for awareness is an ordered set of repre sentations of all feelings at each immediate moment extending across a finite period of time. The key to the cortical (that is, men tal) representation of the sentient self is the integration of salience across all relevant conditions at each moment. The salience of any factor is determined by its significance for the maintenance and advancement of the individual and the species. At the most fundamental level, this means the energy efficient maintenance of the health of the physical body (and the brain) in other words, homeostasis. In this view, the neural basis for awareness is the neural representa tion of the physiological condition of the body, and the homeostatic neural construct for a feeling from the body is the foundation for the encoding of all feelings1,78. The phylogenetically new homeostatic afferent pathway from lamina I and the solitary nucleus in primates provides the basis for the sense of the physiological
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condition of the entire body in the posterior insular cortex 1; this includes numerous individually mapped and distinct feelings from the body. These neural constructs are then rerepresented in the midinsula and again in the AIC (on the left or right side or both, depending on the source of the activ ity; BOX 3). The midinsula integrates these homeostatic rerepresentations with activity that is associated with emotionally salient environmental stimuli of many sensory modalities, probably by way of input from higherorder sensory regions, the temporal pole and the amygdala. Recent functional connectivity analyses indicate that the mid insula is also modulated directly by the ventral striatum (the nucleus accumbens)79, which provides an important incentive, or hedonic, signal for the integration of salience. Thus, this posteriortoanterior progression which is consistent with the general processing gradient for increasing complexity in the frontal cortex 22,65 and with the enormous expansion of the anterior insula across hominoid primates provides a substrate for the sequential integration of homeostatic conditions with the sensory environment and with motivational, hedonic and social conditions represented in other parts of the brain, and this substrate is con structed on the foundation provided by the feelings from the body (FIG. 3a). I propose that the integration of sali ence across all of these factors culminates in a unified final metarepresentation of the global emotional moment near the junction of the anterior insula and the frontal oper culum. This processing stage is key, because it generates an image of the material me (or the sentient self) at one moment in time now. An anatomical repetition of this fun damental unit, indexed by an endogenous timebase, is all that is required to generate a set of repeated metarepresentations of glo bal emotional moments that extends across a finite period of time, and this anatomical structure (a metamemory) provides the basis for the continuity of subjective emo tional awareness in a finite present 78 (FIG. 3b). The recent data emphasize that storage buff ers for individual global emotional moments must be present to enable comparisons of past, present and future feelings; this would instantiate a reflexive observer, as noted above. The anticipatory global emotional moments must be influenced by stored rep resentations of expectations that are based on acquired internal models of ones own and others behaviour. A straightforward, although speculative, anatomical inference of this model is that metarepresentations of
global emotional moments might be engen dered by clusters of VENs in the AIC, and that these are interconnected with similar clusters of VENs in the ACC and probably in the AIC and ACC on the opposite side (BOX 1), but the connections and functions
a
Posterior insula
of VENs still need to be identified. I believe that each successive stage of integration in this model could have provided an evolu tionary advantage, in that it would improve emotional communication between con specifics crucial for hominoid primates80
Anterior insula
Primary interoceptive representation
Homeostatic motor function (hypothalamus and amygdala)
Environmental conditions (entorhinal and temporal poles)
Hedonic conditions (nucleus accumbens, and orbitofrontal cortex)
Motivational, social and cognitive conditions (ACC, VMPFC and DLPFC) Future
b Normal time passage
Present
Past
Subjective time passage
When salient moments occur rapidly, the number of global emotional moments increases during that time and, as a consequence, subjective time dilates
Figure 3 | A proposed model of awareness. Cartoons illustrating features of the proposed structural model of awareness. a | The posited integration of salient activity, progressing from the posterior insula (left) to the anterior insula (right). The primary interoceptive representations of feelings from the body Nature Reviews | Neuroscience provide a somatotopic foundation that is anchored by the associated homeostatic effects on cardiorespiratory function, as indicated by the focus of the colours in the chest. The integration successively includes homeostatic, environmental, hedonic, motivational, social and cognitive activity to produce a global emotional moment, which represents the sentient self at one moment of time. b | The top cartoon shows how a series of global emotional moments can produce a cinemascopic image of the sentient self across time. The lower cartoon shows how the proposed model can produce a subjective dilation of time during a period of high emotional salience, when global emotional moments are rapidly filled up. ACC, anterior cingulate cortex; DLPFC, dorsolateral prefrontal cortex; vMPFC, ventromedial prefrontal cortex.
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Box 5 | Future research questions following from the model
What are the anatomical connections of the anterior insular cortex (AIC)? Modern imaging studies using diffusion spectrum imaging and functional and effective connectivity analyses are needed that incorporate the AICs dynamic connectivity83. Comprehensive analysis of the hodology of the macaque insular cortex using classic tract-tracing methods is also needed. How do the two sides of the AIC differ, and how do they interact? Does one side lead48 and the other side monitor23,48 at different times? Direct statistical comparisons of laterality in activation are needed. Advanced analyses based on demonstrated asymmetries (FIG. 2) can be designed; for example, one could examine changes in activation patterns and effective connectivity during the modulation of pain by pleasant music112. Is there one somatotopic map that provides a common-resource pool of global emotional moments, represents all feelings and is dynamically accessed at each moment? Or are there numerous modules in the AIC that are coordinated to represent different feelings at each global emotional moment? For example, evidence suggests that the eyes and the face are represented in the anterior ventral AIC and that the hand and the foot are represented more posteriorly, which is consistent with the presence of one map; however, the somatotopy in the one study that included stimulation of multiple body parts is reversed10. Similarly, is there only one module in each AIC that represents time, as suggested by the tiny areas of activation in the AIC found in one study34? And does the activity in these areas correlate with subjective time dilation? Are these areas asymmetric on the two sides with respect to the contrasting effects of arousal and pleasant mood on time perception113? How are comparisons made between feelings at different points in time? Where are the intermediate meta-memory buffers and how are they interconnected? The neuropsychological construct called a feeling is crucial. Why is it important that this construct has a homeostatic basis? What do feelings from the body and feelings about objects or people or cognitions have in common? Do all feelings have autonomic sequelae that is, do they move the heart? Can every thought be regarded as a feeling? Are feelings indeed the common currency of awareness? Does emotional congruence between individuals reflect homeostatic resonance? Do elephants really make infrasonic music together? What about whales? Infants do not pass the mirror test or show self-conscious behaviours until they are ~18 months old50,53. Does the connectivity of their AIC and anterior cingulate cortex (ACC) show a similar developmental threshold? The activation of the AIC or the ACC has been used for biofeedback training. Could this application be refined in light of the considerations set out in this article?
and that each stage would have been easily realizable by evolutionary neuroanatomical modifications.
Implications and future directions It is fascinating that the proposed model for awareness in the AIC produces an emer gent basis for the uniquely human faculty of music: viewed as the rhythmic temporal progression of emotionally laden moments, music arises as a natural concomitant of this structural model. The engagement of the AIC by emotional feelings, by the feeling of movement and by the sense of time encour ages the view that this model can explain the observed activation of the AIC by rhythm16 and by musical enjoyment17, as well as the primal emotional effects of communal musicmaking, because music would inherently involve the core of awareness. This model also suggests a mechanism for the subjective time dilation, or slowing of time, that occurs during an intensely emo tional period81. A high rate of salience accu mulation would fill up global emotional moments quickly, because the information
capacity of the neural instantiation of a glo bal emotional moment must be finite. Thus, the endogenous timebase would effectively speed up during such a period (FIG. 3b) and, consequently, time would appear to stand still to the observer. Psychophysical data from rapidvisualsearch studies suggest that the maximal rate of passage of indi vidual moments is ~8 Hz31. A similar pro cess for the recruitment of global emotional moments could provide the basis for height ened awareness of the immediate moment and for the enhanced activation of the AIC that is associated with such moments. In this model, the close integration between the AIC and the ACC implies that activity in the AIC can incorporate the urges of the volitional agent that is represented in the ACC, and also that feelings in the AIC can be modulated by that agent 82, so that each global emotional moment com prises both feelings and motivations (BOX 1). Indeed, the representation in the sentient self of the active behavioural agent (the I) fills a gap in the somatic marker hypoth esis51 and challenges a main criticism of
the JamesLange theory 51, namely that the theory did not allow for feelings of internally generated emotion. In the model presented in this article, all stimuli, incentives, inten tions and cognitions that have salience are represented by feelings, a crucial neuropsy chological construct composed of nested sets of integrative associations that are elaborated on an interoceptive template and endowed with characteristic homeostatic sequelae (and thus, all feelings move the heart). In this model, feelings are the computational common currency of awareness59,60. Finally, this model includes the possibility that emotional behaviours can occur without awareness (that is, by activation of the ACC without integration in the AIC), it implies that animals without these structures are not aware in the same way that we are (BOX 2) and it provides a ready basis for the inclusion of a module that would assign responsibil ity for the behavioural agents actions to the sentient self 64. It is important to note this models cur rent limitations. It does not explain how a feeling is constructed, the nature of the timebase and its relation to homeostatic activity (such as ones heartbeat), the mecha nism for shifting moments across time, the neural metric of salience, the differentiation of emotions, the necessary dynamic con nectivity of global emotional moments83 or the integration between the two sides of the AIC (BOX 3). It does not specify the location of memories of past feelings or the loca tion of the internal behavioural models that produce anticipatory feelings. The evidence reviewed above suggests that the final repre sentation of the sentient self in the AIC may consist of one coherent somatotopic map that has sufficiently global characteristics and dynamic connectivity to encompass all possible feelings, but few studies have compared different emotions and different bodypart associations. It is even difficult to systematically predict how lesions of the AIC and the ACC should differ in terms of their effects considering their intimate con nectivity (for example, see the contrasting results in the literature on alexithymia7072). I look forward particularly to the future iden tification of the various functional modules in the AIC and the characteristics and the language of VENs. There are many other questions that need to be addressed, some of which are listed in BOX 5.
A. D. (Bud) Craig is at the Atkinson Research Laboratory, Barrow Neurological Institute, Phoenix, Arizona 85013, USA. e-mail: [email protected] doi:10.1038/nrn2555
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Acknowledgements
I thank J. Allman, L. Feldman Barrett, P. Churchland, M. Paulus and I. Strigo for their comments on the manuscript, and Professor T. P. Naidich for supplying the photograph in figure 1. I am grateful for funds from the James S. McDonnell Foundation and for continuous support from the Barrow Neurological Foundation.
FURTHER InFORMATIOn
A. D. (Bud) craigs homepage: http://www.thebarrow.org/ research_and_Clinical_Trials/Basic_research_ Laboratories/Atkinson_Pain_research_Lab/index.htm National Geographic film on elephant song: http://ngm. nationalgeographic.com/ngm/0510/feature5/audio.html
SUppLEMEnTARY InFORMATIOn
see online article: s1 (table)
All liNks Are Active iN the oNliNe pdf
OpInIOn
Brain banking: opportunities, challenges and meaning for the future

Hans Kretzschmar
Abstract | Brain banks collect post-mortem human brains to foster research into human CNs function and disease. They have been indispensable for uncovering the secrets of many diseases, including Alzheimers and Parkinsons. At a time when there are so many open questions in neuroscience and the incidence of brain diseases continues to increase in parallel with the aging of the population, brain banking remains at the heart of brain research. However, the major source of brain banks, the clinical autopsy, is rapidly falling into limbo. New strategies, including donor programmes, medico-legal autopsies and banking in networks, as well as fresh considerations of the ethics and public relations, are required.
when, in 1906, Alois Alzheimer first observed the characteristics of the disease that was to bear his name, he did so using silverimpregnated tissue sections of a formalinfixed brain1. He described argyro philic senile plaques and neurofibrillary tan gles (NFTs). The biochemical nature of these structures remained enigmatic for decades, until amyloid (A), the major component of senile plaques, was isolated from human brain tissue that had been neuropathologi cally well characterized and frozen unfixed after autopsy 2,3. A spate of biochemical and molecularbiological work led to the dis covery of amyloid precursor protein (APP), APP mutations associated with familial Alzheimers disease (AD), and the metabo lism of APP, as well as to the creation of transgenic animal models for AD and the development of therapeutic strategies. Over

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PErsPECTIvEs

Attention to heat pain

Heartbeat awareness Moment of recognition Inspection time Maternal affiliation

Learned pain now

Happy voices Decision making

ACC Anterior insula

Seeing or making a smile

VOLuME 10 | JANuARy 2009 | 61

Hippocampus Rhinal sulcus Collateral sulcus Laterobasal cortical amygdala

2009 Macmillan Publishers Limited. All rights reserved

2009 Macmillan Publishers Limited. All rights reserved

2009 Macmillan Publishers Limited. All rights reserved

2009 Macmillan Publishers Limited. All rights reserved

Primary interoceptive representation

Homeostatic motor function (hypothalamus and amygdala)

Environmental conditions (entorhinal and temporal poles)

Hedonic conditions (nucleus accumbens, and orbitofrontal cortex)

b Normal time passage

Subjective time passage

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VOLuME 10 | JANuARy 2009 | 69

Brain banking: opportunities, challenges and meaning for the future

70 | JANuARy 2009 | VOLuME 10

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