Pre-sleep arousal and sleep quality during the COVID-19 lockdown in Italy

Association Between Sleep-related Cognitions, Sleep-related Behaviors, and Insomnia in Patients with Anxiety and Depression: A Cross-sectional Study

Background

The cognitive model of insomnia states that worry about sleep contributes to poor sleep quality. Besides worry, beliefs about sleep and maladaptive safety behaviors also affect sleep quality. We aimed to find the association among the presence of insomnia, sleep-related cognitions, and behaviors among patients diagnosed with anxiety or depression.

Methodology

The present cross-sectional comparison study included patients with anxiety spectrum or depressive disorders as per the Diagnostic and Statistical Manual for Mental Disorders-fifth edition and healthy controls. Mood status, insomnia severity, sleep quality, dysfunctional beliefs about sleep, maladaptive safety behaviors, and pre-sleep arousal were evaluated using Hamilton Anxiety Scale (HAM-A), Montgomery Åsberg Depression Rating Scale (MADRS), Insomnia Severity Index, Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes Sleep Scale (DBAS), Sleep-related Behavior Questionnaire (SRBQ), and Pre-sleep Arousal Scale (PSAS), respectively. A p value ≤.05 was considered statistically significant.

Results

Both patients (n = 80) and controls (n = 80) were similar in sociodemographic profile, though the sample was predominantly female. Comparison between patients with insomnia (n = 60), patients without insomnia (n = 20), and healthy controls (n = 80) showed that HAM-A and MADRS, DBAS, SRBQ, and PSAS scores were higher in patients with insomnia compared to their counterparts. DBAS and SRBQ scores positively correlated with increasing severity of insomnia. Dysfunctional beliefs regarding sleep (OR: 1.05; 95% CI = 1.00-1.09) and maladaptive behaviors related to sleep (OR: 1.02; 95% CI = 1.00-1.05) predicted insomnia in patients with depression or anxiety.

Conclusion

Insomnia in anxiety or depression is associated with illness severity, dysfunctional beliefs regarding sleep, and sleep-related maladaptive behaviors. Maladaptive cognitions and behaviors can independently influence sleep quality.

Dreaming while awake: The beneficial effects of yoga Nidra on mental and physical recovery in two elite karate athletes

Yoga Nidra (YN) naturally stimulates a hypnagogic state wherein an individual is physiologically asleep yet maintains a certain awareness to follow a guide's instructions. The aim of this study was to investigate the effects of this aware sleep state on recovery-stress balance in two elite karate athletes adopting an idiosyncratic and multimodal approach. One male and one female athlete underwent a YN intervention. Before intervention, after intervention and three weeks later, recovery-stress balance specific scales, perceived stress, cognitive and somatic anxiety, subjective and objective sleep quality, and individual alpha peak frequency (iAPF) values were assessed. Perceived quality of recovery was continuously monitored for three months including the period of the investigation. Feelings and arousal levels before and after each YN session were also examined. Our results showed a YN general positive effect; however, the intervention had higher sport specific effects in the male compared to the female athlete. On the other hand, in the female athlete, YN seems to have effects both from an emotional and physical point of view. We also noted the intertwined relationship among interoception, perceived stress and YN effects. Also, findings suggest that iAPF modulation reflected improved recovery skills or a better control of stressful situations, while the acute effects on arousal levels were expression of anxiety or energy reduction. Overall, YN improved both the perceived quality of recovery and sleep quality, shedding light on the importance of YN for recovery-stress balance enhancement in the sport context.

Predicting the Persistence of Insomnia Symptoms during the COVID-19 Pandemic

OBJECTIVE

The goal of this study is to evaluate the factors associated with vulnerability and course of insomnia longitudinally in the COVID-19 pandemic and examine differences between: (a) those who never demonstrated clinical insomnia symptoms, (b) those who demonstrated clinically elevated insomnia symptoms at 1 or 2 time points, and (c) those who demonstrated clinically elevated insomnia symptoms at all 3 time points.

METHODS

Participants (≥18 years old) completed measures of insomnia (ISI), depression (PHQ-8), anxiety (GAD-7), and pre-sleep arousal (PSAS) at 3 time points (baseline, 1 month, and 3 months). Data were analyzed using univariable odds ratios and multivariable multicategory logistic regression to determine demographic, psychological, and behavioral predictors of insomnia persistence.

RESULTS

A total of 129 participants completed all 3 assessments (70 female, age M = 44 years, SD = 16). We found that 40% (N = 51) never had insomnia symptoms, 33% (N = 42) reported transient insomnia symptoms (1 or 2 time points), and 28% (N = 36) reported persistent insomnia symptoms (all 3 time points). From the multivariable multicategory logistic analyses, pre-sleep arousal, gender, and income were significant predictors of insomnia persistence.

CONCLUSIONS

Findings indicate elevated insomnia symptoms were persistent in a substantial number of individuals throughout the pandemic. Results suggest additional insomnia and psychological interventions are needed to improve sleep and mental health.

Mediation analysis of chronotype, sleep-related factors, and depressive symptoms among workers: a cross-sectional study

Background

This study aimed to examine the impact of chronotype on depressive symptoms and explore the mediating effects of sleep quality, pre-sleep cognitive arousal, and social jetlag in a sample of wage earners.

Methods

A total of 3,917 waged workers were surveyed online in July 2022. Logistic regression and mediation analysis were used to assess the relationship between chronotype (morningness, intermediate, and eveningness) and depressive symptoms (Patient Health Questionnaire ≥ 5), and the mediating effects of Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and Pre-Sleep Arousal Scale (PSAS). All analyses were adjusted for age, education level, income level, marital status, coffee consumption, alcohol consumption, physical activity, occupation, employment status, and working hours to calculate odds ratios (ORs).

Results

The chronotypes of all the participants were divided into morningness (4.7%), intermediate (93.5%), and eveningness (1.8%). Multiple logistic regression analysis showed an increased risk of depression in the eveningness chronotype (OR: 2.96; 95% confidence interval [CI]: 1.51, 5.86). Regarding the mediation analysis, ISI mediated 28.44% (95% CI: 16.39-40.5), PSQI for 31.25% (95% CI: 19.36, 43.15), and PSAS-Cognitive Score (PSAS-C) for 23.58% (95% CI: 10.66, 36.50) of the association between chronotype and depressive symptoms. However, social jetlag did not significantly mediate this relationship. (percentage mediated = 0.75%, 95% CI: -3.88, 5.39).

Conclusions

Evening chronotypes exhibit an increased risk of depressive symptoms, which ISI, PSQI, and PSAS-C partially mediated. This suggests that interventions to improve sleep quality and maintain adequate sleep habits may effectively prevent and treat depression in employees with an eveningness chronotype.

Beneficial Effects of an Online Mindfulness-Based Intervention on Sleep Quality in Italian Poor Sleepers during the COVID-19 Pandemic: A Randomized Trial

Sleep of inadequate quantity and quality is increasing in the present 24 h society, with a negative impact on physical and mental health. Mindfulness-based interventions (MBIs) generate a state of calm behavior that can reduce hyperactivity and improve sleep. We hypothesized that our specific MBI, administered online, may improve sleep quality and foster emotion regulation and mindfulness. The Pittsburgh Sleep Quality Index (PSQI), Sleep Condition Indicator (SCI), Arousal Predisposition Scale (APS), Ford Insomnia Response to Stress Test (FIRST), Sleep Hygiene Index (SHI) and Insomnia Severity Index (ISI) were used to measure sleep quality and stability. Emotion regulation and mindfulness were measured via the Emotion Regulation Questionnaire (ERQ) and Five Facet Mindfulness Questionnaire (FFMQ). Our MBI included 12 biweekly integral meditation (IM) classes, recorded IM training for individual practice, and dietary advice to promote sleep regulation. Fifty-six voluntary poor sleepers with a PSQI score of >5 were randomly allocated to treated (n = 28) and control (n = 28) groups. Linear mixed models were used to estimate the effectiveness of the intervention. Statistically significant results were observed in the FFMQ sub-domain non-reactivity to inner experience (β = 0.29 [0.06; -0.52], p = 0.01), PSQI (β = -1.93 [-3.43; -0.43], p = 0.01), SCI (β = 3.39 [0.66; 6.13], p = 0.02) and ISI (β = -3.50 [-5.86; -1.14], p = 0.004). These results confirm our hypothesis regarding the beneficial effects of our intervention on sleep quality.

Age-Based Differences in Sleep Quality, Pre-Sleep Arousal, and Psychosocial Factors during the Second Wave Lockdown of the COVID-19 Pandemic in Georgia-A Higher Vulnerability of Younger People

The COVID-19 pandemic has deeply disrupted sleep and mental health of people around the world. We aimed to investigate age-based differences in the prevalence of and relationship between sleep quality, pre-sleep arousal, and psychosocial factors during the second wave lockdown of the COVID-19 pandemic in Georgia. Data were collected through an online survey (n = 1117). Participants were categorized into four age groups: 18-29, 30-41, 42-53, and 54-70 years. The youngest participants reported the most prevalent disruption of sleep behavior. Overall, 58.3% of respondents were poor sleepers. The Pittsburgh Sleep Quality Index (PSQI) global score was highest in the youngest age group but the difference was not significant. There was a significant difference in the PSQI component scores for subjective sleep quality, sleep latency, and daytime dysfunction, all being worse in young respondents. We also observed a significantly higher prevalence rate of worse sleep quality in the youngest age group, relative to the pre-pandemic period. On the other hand, the oldest respondents showed significantly greater use of sleeping medications. Significantly higher levels of somatic and cognitive pre-sleep arousal, perceived stress, feeling depressed, anxious, and socially isolated were reported by the youngest age group. Study findings indicate a higher vulnerability of younger people to the impact of the COVID-19 pandemic. Assessment of pre-sleep arousal and implementation of specific, age-based interventions may prove beneficial to improve possible consequences of the pandemic on sleep and mental health.

Insomnia Severity Mediates the Association between COVID-19 Related Anxiety and Increase in Tobacco Smoking During the COVID-19 Pandemic among Adults

OBJECTIVES

Examining the associations of COVID-19 related anxiety and insomnia with increased smoking following the outbreak of the COVID-19 pandemic, and investigating whether increased insomnia severity mediates the association between COVID-19 related anxiety and increased smoking.

METHODS

598 participants, aged 18-40, out of whom 140 self-identified as smokers, completed online questionnaires during the third wave of the COVID-19 pandemic. Measures included two items assessing COVID-19 related anxiety, the Pittsburgh Sleep Quality Index, and the Insomnia Severity Index, which included a pre-pandemic retrospective report.

RESULTS

Compared with nonsmokers, smokers reported lower sleep quality and more severe symptoms of insomnia. Among smokers, more severe symptoms of insomnia were associated with greater odds of increased smoking during the COVID-19 outbreak. COVID-19 related anxiety was indirectly associated with greater odds of increased smoking through greater insomnia severity during the COVID-19 outbreak, after controlling for pre-pandemic levels of insomnia.

CONCLUSIONS

Smokers experienced more sleep difficulties during the COVID-19 pandemic than nonsmokers. The results also lend support to the suggestion that anxiety, such that was experienced during the COVID-19 pandemic, may lead to further exacerbation of sleep difficulties, leading in turn to increase in smoking. These findings have important clinical implications that may be particularly relevant to attempts to minimize smoking during stressful circumstances.

The role of sleep and dreams in long‐ COVID

Recent investigations show that many people affected by SARS-CoV2 (COVID-19) report persistent symptoms 2-3 months from the onset of the infection. Here, we report the Italian findings from the second International COVID-19 Sleep Study survey, aiming to investigate sleep and dream alterations in participants with post-acute symptoms, and identify the best determinants of these alterations among patients with long-COVID. Data from 383 participants who have had COVID-19 were collected through a web-survey (May-November 2021). Descriptive analyses were performed to outline the sociodemographic characteristics of long-COVID (N = 270, with at least two long-lasting symptoms) and short-COVID (N = 113, with none or one long-lasting symptom) participants. They were then compared concerning sleep and dream measures. We performed multiple linear regressions considering as dependent variables sleep and dream parameters discriminating the long-COVID group. Age, gender, work status, financial burden, COVID-19 severity and the level of care were significantly different between long-COVID and short-COVID subjects. The long-COVID group showed greater sleep alterations (sleep quality, daytime sleepiness, sleep inertia, naps, insomnia, sleep apnea, nightmares) compared with the short-COVID group. We also found that the number of long-COVID symptoms, psychological factors and age were the best explanatory variables of sleep and oneiric alterations. Our findings highlight that sleep alterations are part of the clinical presentation of the long-COVID syndrome. Moreover, psychological status and the number of post-acute symptoms should be considered as state-like variables modulating the sleep problems in long-COVID individuals. Finally, according to previous investigations, oneiric alterations are confirmed as a reliable mental health index.

Dreaming during the COVID-19 pandemic: A narrative review

According to several influential models, dreams can be affected by state- and trait-like factors, sleep features, and diurnal experiences. The COVID-19 pandemic globally affected daily habits, emotional experiences, and sleep. Previous studies suggested an influence of collective traumatic events on dreaming. Starting from these premises, several studies assessed the effect of the pandemic on dreams. This paper aims to review findings concerning the oneiric activity during the COVID-19 pandemic. We report pandemic-related changes in dreams and nightmares, and we consider the possible factors associated with dreaming. Moreover, we provide results about changes in the oneiric activity in different phases of the pandemic. The reviewed findings suggest a pandemic-related enhancement of dream and nightmare frequency, emotional intensity, and distressing contents, modulated by modifications in restrictive measures and associated with diurnal experiences, emotional status, and sleep pattern. We highlight several methodological issues and a large heterogeneity in the present literature, limiting results’ generalizability. However, we provide possible interpretations of the most consistent findings in light of the main theoretical frameworks about dreaming.

The Oneiric Activity during and after the COVID-19 Total Lockdown in Italy: A Longitudinal Study

A growing body of evidence highlights that the COVID-19 pandemic affected oneiric activity. However, only a few studies have assessed the longitudinal changes in dream phenomenology during different phases of the pandemic, often focused on a limited number of dream variables. The aim of the present study was to provide an exhaustive assessment of dream features during total lockdown (TL) and a post-lockdown (PL) period characterized by eased restrictive measures in Italy. We performed a longitudinal study using a web-based survey to collect demographic, COVID-19 related, clinical, sleep, and dream data at TL and PL. Our final sample included 108 participants. The high frequency of poor sleep quality, anxiety, and depressive symptoms observed during TL remained stable at PL, while sleep latency (t = −4.09; p < 0.001) and PTSD-related disruptive nocturnal behaviors (t = −5.68; p < 0.001) exhibited a reduction at PL. A PL decrease in time spent with digital media was observed (t = −2.77; p = 0.007). We found a strong PL reduction in dream frequency (t = −5.49; p < 0.001), emotional load (t = −2.71; p = 0.008), vividness (t = −4.90; p < 0.001), bizarreness (t = −4.05; p < 0.001), length (t = −4.67; p < 0.001), and lucid dream frequency (t = −2.40; p = 0.018). Fear was the most frequently reported emotion in dreams at TL (26.9%) and PL (22.2%). Only the frequency of specific lockdown-related dream contents exhibited a reduction at PL. These findings highlight that the end of the home confinement had a strong impact on the oneiric activity, in the direction of reduced dream frequency, intensity, and lockdown-related contents. The co-occurrence of such changes with a decline in nocturnal PTSD-related symptoms, sleep latency, and time with digital media suggests an influence of post-traumatic stress levels, lifestyle modifications, and sleep pattern on dream changes during different phases of the pandemic. The stable prevalence of fear in dreams and the large frequency of poor sleep quality, depressive symptoms, and anxiety are probably related to the persistence of many negative consequences of the pandemic. Overall, these results are consistent with the continuity hypothesis of dreams.

Decreased Transition Rate From Situational Insomnia to Chronic Insomnia by One-Week Internet Cognitive Behavioral Treatments for Insomnia During the COVID-19 Pandemic

PURPOSE

The purpose of the study was to determine the long-term effects of one-week self-guided internet cognitive behavioral treatments for insomnia (CBTI) on situational insomnia during the COVID-19 pandemic.

PATIENTS AND METHODS

The participants with situational insomnia (n = 194) were recruited from March 2020 to April 2020 in Guangzhou, China. The insomnia severity index (ISI), pre-sleep arousal scale (PSAS), and hospital anxiety and depression scale (HADS) were evaluated at baseline and a one-week internet CBTI program was delivered to all individuals. The participants were divided into the complete treatment group (the participants completed all seven modules of the CBTI course, n = 75), and the incomplete treatment group (the participants completed 0-6 modules of the CBTI course, n = 119). A total of 135 participants completed the post-intervention assessments. At 3 months follow-up, a total of 117 participants (complete treatment group: n = 51; incomplete treatment group: n = 66) completed the assessments of the ISI, PSAS and HADS. The transition rate from situational insomnia to chronic insomnia (duration of insomnia ≥ 3 months and ISI ≥ 8) was calculated in the two groups. Linear mixed effect model was used to investigate the effect of group (between the two groups), time (baseline vs. follow-up), and interaction (group x time) on various questionnaire score.

RESULTS

The transition rate from situational insomnia to chronic insomnia was significantly lower in the complete treatment group compared to the incomplete treatment group (27.5%, 14/51 vs. 48.5%, 32/66, p = 0.023). There were significant differences in group effect (p = 0.032), time effect (p = 0.000) and group × time effect (p = 0.048) between the two groups in the ISI total score. The ISI total scores decreased in both groups during follow-up compared to their baseline values, with a greater magnitude of decrease in the complete treatment group. There were no significant group x time effects between the two groups in the PSAS-total score, PSAS-somatic, PSAS-cognitive score, HADS total score, HADS anxiety score or HADS depression score.

CONCLUSION

Our results suggested that one-week self-guided internet CBTI prevented the development of chronic insomnia from situational insomnia during the COVID-19 pandemic.

Insomnia, Pre-Sleep Arousal, Psychosocial Factors and Changes in Sleep Pattern during the Second Wave Lockdown of the COVID-19 Pandemic in Georgia

Studies performed across the COVID-19 pandemic waves point to the persistent impact of the pandemic on sleep and mental health. We expand these data by examining insomnia, pre-sleep arousal, psychosocial factors, and retrospective changes in sleep pattern during the COVID-19 second wave lockdown period in Georgia. Data were collected through an online survey (n = 1117). The prevalence rate of probable insomnia disorder was 24.2%. Clinically relevant somatic and cognitive pre-sleep arousal was present in 49.8% and 58.0% of participants, and high levels of anxiety, depression and social isolation were found in 47.0%, 37.3%, 47.2% of respondents, respectively. We observed high prevalence rates of worse sleep quality, delayed bedtimes and risetimes, longer sleep latencies, higher awakenings and shorter sleep durations, relative to the pre-pandemic period. COVID-19-infected participants showed more severe sleep and mental problems. Specific predictors differentially affected insomnia, somatic and cognitive pre-sleep arousal. Depression and COVID-19 infection emerged as vulnerability factors for pre-sleep arousal, which, in turn, was associated with a higher predisposition to insomnia disorder. We confirm the strong deteriorating impact of the COVID-19 pandemic on sleep and psychosocial well-being during the second wave lockdown period. The specific association between pre-sleep arousal, insomnia, and psychosocial factors is of clinical relevance for the prevention of severity and persistence of sleep and mental problems across the repeated lockdown/reopening waves. Modulation of pre-sleep arousal may prove beneficial to implement targeted interventions.

Persistence of the Effects of the COVID-19 Lockdown on Sleep: A Longitudinal Study

The effects of the COVID-19 pandemic on sleep have been widely documented, but longitudinal evaluations during different phases of the “COVID-19 era” are needed to disentangle the specific consequences of the r145estrictive measures on sleep variables. The aim of this study was to assess the immediate effect of the lockdown’s end on sleep and sleep-related dimensions in an Italian sample, also considering the stress and depressive symptoms. We used an online survey to longitudinally collect data on sociodemographic, environmental, clinical, sleep, and sleep-related variables in two time points: during and immediately after the lockdown. The final sample included 102 participants. The large prevalence of poor sleep quality, clinically relevant pre-sleep arousal, and depressive symptoms, as well as poor sleep quality and pre-sleep arousal score observed during the lockdown, remained stable after its end. On the other hand, the prevalence of moderate-to-severe event-related stress and intrusive symptom scores exhibited a drastic reduction after the end of home confinement. Both bedtime and rise time were anticipated after the lockdown, while sleep quality exhibited only a trend of post-lockdown sleep disturbance reduction. Our findings point to a reduced stress level (specific for the intrusive symptomatology) after the end of the lockdown and persistence of sleep problems, suggesting two non-mutually exclusive hypotheses: (a) the strict restrictive measures are not the main cause of sleep problems during the pandemic and (b) home confinement induces long-lasting effects on sleep observable after its end, and a longer period of time might be needed to observe an improvement.