A FEAR OF DYING: HOW AN OBSESSION WITH DEATH DURING THE PANDEMIC CONTRIBUTES TO MORE SEVERE INSOMNIA

Introduction: The prevalence of insomnia and other sleep disorders increased during the COVID-19 pandemic. While general anxiety, which increased during the pandemic, may account for some of the rise in sleep complaints, other factors may also contribute to insomnia. Here, we examined the potential contribution of fear of dying from the novel coronavirus on the severity of insomnia. We hypothesized that those endorsing a high fear of dying specifically from COVID-19 within 12 months of their assessment would demonstrate more severe insomnia. Methods: From April 2020 through October 2021, 13,298 U.S. participants (18-92 years old;57.5% female) completed a online survey (~1,000 participants per month) that included an assessment of their perceived likelihood of dying from COVID in the next year, the Generalized Anxiety Disorder scale-7 (GAD-7), and the Insomnia Severity Index (ISI). We examined insomnia over the course of the first year of the pandemic and divided the sample into those who endorsed at least a 50% or greater perceived likelihood that they would die from COVID-19 in the next year versus those who endorsed a less than 50% perceived likelihood of dying from the illness. Results: Fear of dying (50% chance or higher) was associated with higher ISI scores (p<.00001) and tended to decline over the course of the year (p<.00001). A significant month x fear interaction (p=.021) suggested that individuals who believed they would die within the year showed significantly fluctuations in insomnia over the course of 13 months with peaks around June and October 2020. Even accounting for situational anxiety (GAD-7), those with a fear of dying still demonstrated higher insomnia levels than their counterparts (p<.00001). Conclusion: Self-perceived likelihood of dying from COVID-19 in the near future was associated with significantly elevated severity of insomnia, and this remained true even when controlling for a clinical assessment of generalized anxiety levels. These findings suggest that fear of succumbing to the novel coronavirus contributed significantly to the severity of sleep problems during the first year of the pandemic.

Insomnia in those diagnosed with COVID-19

Introduction: Recent meta-analyses suggest that as many as 75% of COVID-19 patients report sleep problems. Here, we sought to characterize this in terms of self-reported insomnia. We hypothesized that those endorsing a positive COVID-19 diagnosis would also report greater levels of insomnia than those with a negative diagnosis. Methods: Between April and September 2020 we administered the Insomnia Severity Index (ISI), each month to a total of 6162 English speaking adults in the United States ranging in age from 18-84 (M=36.2 years, SD=12.1;53.9% female), recruited from all 50 states and the District of Columbia using Amazon Mechanical Turk (MTurk) crowdsourcing platform. Data collections occurred cross-sectionally, approximately one month apart. Data were analyzed using Kruskal- Wallis H tests. Results: In total, 247 (4.01%) participants responded “Yes” to the question “Have you been formally diagnosed with COVID-19?” (male=128, female=119). Those reporting “yes” had a higher mean score on the ISI (M=14.52, SD=5.56) compared to reporting “no” (M=9.98, SD=6.55). Total ISI scores were higher for those who reported that they were diagnosed with COVID-19 than those that did not, χ2(1)=121.818, p=0.0001. Among those that reported that they were diagnosed with COVID-19, 57.11% had ISI scores indicating moderate to severe clinical insomnia compared to 25.42% of those who were not diagnosed with COVID-19. Conclusion: Those who reported that they had been diagnosed with COVID 19 had greater insomnia compared to those without such a diagnosis. This could be due to greater stress and anxiety in those who had a positive COVID-19 diagnosis due to the many uncertainties surrounding the short and long-term prognosis as well as potential impacts on the individual's family and workplace. However, it is important to consider the broader health picture of those diagnosed with COVID-19. This study is limited by the nature of the self-reported data, where we cannot verify a positive COVID-19 test. Causality cannot be inferred due to the cross-sectional nature of this study. Future work will need to determine the extent to which sleep-related factors are due to biological versus psychological factors associated with the diagnosis of COVID-19.

Sleeping well during a pandemic: The role of various forms of social support in protecting against insomnia

Introduction: Social support from friends, family, and significant loved ones is critical to sustaining mental health during crises. During the course of the COVID-19 pandemic, the populace has had to restrict many aspects of normal social contact. Consequently, social isolation and accompanying feelings of loneliness have spiked. There has also been a contemporaneous increase in the rates of insomnia. Considering this correlation, we investigated the potential role of various types of social/emotional support on the severity of insomnia. We hypothesized that greater social support from family, friends, and significant loved ones would all contribute to lower insomnia during the pandemic. Methods: During October 2020, 1020 participants (58.2% female) completed an online survey that included the Multidimensional Scale of Perceived Social Support (MSPSS), a measure of social support, and the Insomnia Severity Index (ISI), a measure of insomnia. The severity of insomnia was predicted using multiple linear regression, with the three sources of support from the MSPSS (family, friend, and significant other) entered stepwise. Results: All three sources of support were significantly correlated with lower ISI scores (family, r=-.163, p= p = 1.6x10-7;friend, r=-.125, p=6.5x10-5;significant other, r=-.095, p=.002). However, when all three variables were entered into stepwise regression, only increased familial support was significantly associated with lower insomnia levels (R2 = 0.027, β =-.163, p = 1.6x10-7). In contrast, neither the support of friends nor support from significant others added any additional predictive power once family support was in the model. Conclusion: While perceived social support from friends and significant others was correlated with lower insomnia, we found that ISI scores were most significantly associated with perceived family support. In fact, once family support was accounted for, other sources of support did not account for additional variance. Ongoing family support plays a critical role in mental health and wellbeing, which is clearly demonstrated in the quality of sleep. During the social distancing imposed by the pandemic, it is vital that we find creative ways to maintain familial social support. Future work may benefit by examining the association between the use of electronic technologies to sustain social support and sleep outcomes.

Loneliness and lockdowns: The effects of the COVID-19 pandemic on insomnia symptoms

Introduction: Insomnia is a critical health issue that has serious consequences for both psychological and physical health. These consequences have become even more exacerbated during the course of the ongoing COVID-19 pandemic, as fears of the virus continue to grow and community lockdowns persist. Loneliness has also become a growing mental health concern as a result of the pandemic, and previous research has identified COVID-19 loneliness as a contributing factor to higher rates of insomnia. The current study aimed to investigate the relationship between insomnia, loneliness, and lockdown orders across the first 6-months of the pandemic. We hypothesized that being lonely and under lockdown would lead to greater insomnia, even after controlling for anxiety, and this would become more pronounced over the course of the pandemic. Methods: 6,101 English-speaking adults from across the U.S. (18-84 years old;53.6% female) completed an online, monthly, cross-sectional (∼1000 participants per month), battery of assessments that included the Insomnia Severity Index (ISI), UCLA Loneliness Scale - Version 3, Generalized Anxiety Disorder-7 scale (GAD 7), demographic questions, and a COVID-19 questionnaire between April 2020 and September 2020. A 2 (lonely vs. not lonely) x 2 (lockdown vs. no lockdown) x 2 (Time 1 April-June vs. Time 2 July-September) ANCOVA was conducted to determine the effects of these variables on insomnia, while also controlling for anxiety symptoms. Results: Significant main effects of lockdown status, F(1,8) = 22.72, p < .001, time, F(1,8) = 4.94, p = .026, and loneliness, F(1,8) = 65.18, p < .001, were observed, as a well as a significant interaction effect between lockdown status and time, F(1,8) = 8.47, p = .004, after controlling for anxiety. Conclusion: Overall, lonely people under lockdown had the highest levels of insomnia at both Time 1 and Time 2. Non-lonely people consistently had lower levels of insomnia than lonely people across the 6-month period;however, being under lockdown also contributed to higher levels of insomnia regardless of loneliness, which increased with each passing month of the pandemic. Loneliness and lockdowns each appear to be independently associated with elevated insomnia during the COVID-19 pandemic.

Insomnia as a risk for PTSD during the COVID-19 pandemic

Introduction: The COVID-19 pandemic and associated attempts to curb its spread have led to a significant increase in mental health issues. Evidence suggests that sleep provides a protective resilience against the adverse effects of stress. Moreover, sleep disruption is often considered the “hallmark symptom” of posttraumatic stress disorder (PTSD). Here we hypothesized that insomnia would increase during the first six months of the pandemic, and that higher insomnia would be associated with elevated rates of PTSD. Methods: A total of 6,190 adults ranging in age from 18 to 84 years (53.6% female), completed an online cross-sectional survey at one of six time points between April and September 2020 (∼1,000 per administration). Instruments included the Insomnia Severity Index (ISI), Primary Care PTSD Checklist (PC-PTSD), and the PTSD Checklist-5 (PCL-5). Standard clinical cutoffs were used for ISI (≥10) and PCL-5 (≥38). Data were analyzed with analysis of variance, chi-square contingency tables, and bivariate correlations. Results: Over the first six-months of the pandemic, PTSD increased with each passing month on both the PC-PTSD (p=.001) and PCL-5 (p<.0001). Similarly, ISI scores increased month-by-month (p<.0002). Insomnia scores were highly correlated with PCL-5 PTSD scores (r=.62, p<.0001), even when sleep items on the scale were excluded (r=.60, p<.0001). Finally, the rate of PTSD remained below 5% across all months for those without insomnia, but among those with insomnia, the prevalence of PTSD increased between May (26% positive) and September (40% positive), representing an increase of 56% over the data collection period (interaction p=.0004). Conclusion: Both insomnia and PTSD have increased dramatically over the first six months of the COVID-19 pandemic. Moreover, insomnia appears to be highly linked with the emergence of PTSD during this time. While it is not possible to make causal attributions from these cross-sectional findings, the steadily increasing rates of PTSD over time only among those with insomnia, raise the possibility that sleep disruption could act as a diathesis for the development of PTSD symptoms in response to the pandemic. Addressing insomnia during the pandemic may be an important aspect of maintaining psychological resilience in the populace.

An election during a pandemic: Relationship between political affiliation and pandemicrelated sleep and dreams

Introduction: In 2020, a global pandemic impacted sleep for many people in the US, which was also experiencing an extremely contentious election season. These overlapped somewhat, as the liberal/left side of the political spectrum was more vocal about the dangers of COVID-19 and the pandemic, while the conservative/right frequently expressed less concern about COVID-related risks. Perhaps this confluence was borne out in sleep quality and dreams. Methods: A sample of N=419 US adults completed online surveys about sleep and COVID-19 experiences. Participants rated their political affiliation on a scale of 0 (Very Conservative/Right) to 6 (Very Liberal/Left). Participants were also asked whether, since the pandemic, their sleep improved or worsened, whether their dream content has become more positive (more or less positive content, versus same) or negative (more or less negative content, versus same), the number of nightmares they recall, and whether their dreams included themes of politics and/or COVID. Regression analyses examined political affiliation as independent variable with ordinal logistic analyses for sleep improvement/worsening, multinomial logistic analyses for positive/ negative content, linear regression analyses for nightmare frequency, and binary logistic analyses for presence of political/COVID themes in dreams. All analyses were adjusted for age, sex, and race/ethnicity. Results: Greater liberal/left affiliation was associated with a greater likelihood of worsened sleep (oOR=1.20, p=0.002), but no difference in likelihood of sleep improvement. Greater liberal/left affiliation was associated with a greater likelihood of decreased positive dream content (RRR=1.29, p=0.001) but no different in likelihood of increased positive content. In addition, greater liberal/left affiliation was associated with an increased likelihood of more negative dream content (RRR=1.33, p<0.0005) but no difference in the experience of less negative content. Liberal/left affiliation was also associated with more frequent nightmares during the pandemic (B=1.55, p=0.019), and more political dreams (OR=1.29, p=0.010) but no difference in COVID-related dreams. Conclusion: During the COVID-19 pandemic, more liberal/left individuals reported a greater degree of worsening sleep and dream content that was less positive and more negative in nature. Though there was no difference in COVID-related dream content, there was a difference in political content in dreams.

Pandemic-related sleep changes associated with COVID-related general, financial, food, housing, family and relationship stress

Introduction: The COVID-19 pandemic has caused widespread disruption and stress for people of all ages and circumstances around the world. This study investigates the relationship between general and specific stressors and various dimensions of sleep health. Methods: A sample of N=419 US adults completed online surveys about sleep and COVID-19 experiences. Participants were asked whether they experienced increased general, financial, food, housing, family and relationship stress due to the COVID-19 pandemic. They were also asked whether they experienced a more regular schedule, improved sleep, worsened sleep, more early insomnia, more middle-of-the-night insomnia, more daytime sleepiness, and more naps due to the COVID-19 pandemic. Ordinal logistic regressions with sleep change as outcome and stress variable as predictor were adjusted for age, sex, and race/ethnicity. Results: COVID-19-related general, financial, food, housing, family, and relationship stress were all associated with a decreased likelihood of maintaining a more regular schedule (oOR=0.52-0.67, all p<0.001) and improved sleep (oOR=0.56-0.67, all p<0.001). They were also all associated with a greater likelihood of worsened sleep (oOR=1.48- 2.41, all p<0.001), early insomnia (oOR=1.63-1.85, all p<0.001), middle-of-the-night insomnia (oOR=1.40-2.00, all p<0.001), and daytime sleepiness (oOR=1.58-2.07, all p<0.001). Increased napping was also associated with more COVID-related financial, food, and housing stress (oOR=1.33-1.55, all p<0.005). Conclusion: Regular sleep schedules can be disrupted by stressors directly, or by the anxiety that so often accompanies stress. Stressed individuals may experience increased difficulty falling asleep, or more nighttime arousals, or find themselves waking up earlier than usual, all as a result of ruminating thoughts, stress-induced nightmares, or outside disturbances. Disruption to sleep at night often results in increased daytime sleepiness and fatigue, with a higher chance of napping. This study reports the significant association of some of these with COVID- 19 pandemic-related stress. More individuals now find themselves working from home with greater flexibility in their schedules, but this has not necessarily led to better sleep. The impact of the pandemic on various health outcomes as a result of stress is still to be revealed.

Changes in dream recall during the COVID-19 pandemic: Associations with sleep, stress and dream content

Introduction: During the COVID-19 pandemic, individuals have faced unprecedented events, which are often stressful. Stress has an important impact on dreams, and stress-induced sleep difficulties may also impact dream recall. The present study evaluated associations between sleep, stress and dream content on dream recall during the pandemic. Methods: A sample of N=419 US adults completed online surveys about sleep and COVID-19 experiences. Participants were asked if they remember more, fewer or about the same amount of dreams as before the pandemic. They were also asked whether the pandemic was associated with more stress, a more regular schedule, improved sleep, worse sleep, more early insomnia, more middle-of-the-night insomnia, more sleepiness, and more naps. They also completed the Insomnia Severity Index, Fatigue Severity Scale, Epworth Sleepiness Scale, Brief Index of Sleep Control, Assessment of Sleep Environment, GAD-7 anxiety scale, and PHQ9 depression scale. Multinomial logistic regressions examined correlates of increased or decreased recall (versus same), adjusted for age, sex, and race/ethnicity. Results: Those who experienced greater schedule regularity were less likely to report decreased recall (RRR=0.50,p<0.0005), as were those who reported sleep improvement (RRR=0.48,p=0.006). Those whose sleep worsened were more likely to report both increased (RRR=1.64,p=0.003) and decreased (RRR=2.16,p<0.0005) recall. Those suffering maintenance insomnia were more likely to report both increased (RRR=1.70,p=0.001) and decreased (RRR=2.68,p<0.0005) recall, as did those who reported more daytime sleepiness (Increased RRR=1.57,p=0.006;Decreased RRR=1.94,p=0.001). Those whose dream content was more negative were more likely to report both increased (RRR=4.05,p<0.005) and decreased (RRR=3.35,p<0.0005) recall, as did those who reported less negative content (Increased RRR=4.20,p<0.0005;Decreased RRR=5.05,p<0.0005). Similarly, those who reported more positive dream content reported both increased (RRR=17.37,p<0.0005) and decreased (RRR=7.14,p=0.02) recall, as did those who reported less positive content (Increased RRR=4.49,p<0.0005;Decreased RRR=5.59,p<0.0005). Less recall was associated with greater insomnia severity (RRR=1.08,p=0.001), fatigue (RRR=1.04,p=0.001), sleepiness (RRR=1.09,p=0.01), COVID stress (RRR=1.67,p=0.03), anxiety (RRR=1.08,p=0.01), and depression (RRR=1.06,p=0.007), worse sleep environment (RRR=1.06,p=0.005), and less sleep control (RRR=0.56,p=0.001). Conclusion:: The results of this survey suggest that a sudden decrease in dream recall in reaction to a new stress could be considered as a pejorative indicator regarding sleep quality and mental health.

Nightmare content during the COVID-19 pandemic: Influence of COVID-related stress and sleep disruption

Introduction: Nightmares are often associated with psychiatric disorders, though acute stress can also induce them. This study explores how the COVID-19 pandemic may have influenced the frequency and content of nightmares. Methods: A sample of N=419 US adults completed online surveys about sleep and COVID-19 experiences. Participants were asked the degree to which they agree with statements including that due to the COVID-19 pandemic, they have greater general stress, worse overall sleep, and more middle-of-the-night insomnia. They were also asked if they experienced nightmares during the pandemic on a range of topics, including confinement, claustrophobia, suffocation, oppression, drowning, failure, helplessness, natural disasters, anxiety, evil forces, war, domestic abuse, separation from loved ones, totalitarian regimes, being chased, dangerous animals, sickness, death, COVID- 19, and apocalypse. Logistic regression analyses examined each nightmare content as outcome and increased stress, worse sleep, and more middle-of-the-night insomnia as predictors, adjusted for age, sex, and race/ethnicity. Results: Those who reported greater general COVID-related stress were more likely to have nightmares about confinement (OR=1.66,p<0.03), failure (OR=1.64,p<0.005), helplessness (OR=2.89, 0<0.0005), anxiety (OR=2.37,p<0.0005), war (OR=3.42,p<0.0005), separation (OR=2.23,p<0.0005), totalitarianism (OR=3.78,p<0.003), sickness (OR=1.92,p<0.003), death (OR=1.66,p<0.01), COVID (OR=1.96,p<0.01), and apocalypse (OR=2.92,p<0.0005). Those who reported worsened sleep were more likely to have nightmares about confinement (OR=1.80,p<0.003), oppression (OR=2.99,p<0.0005), failure (OR=2.12,p<0.0005), helplessness (OR=1.67, 0<0.0005), disaster (OR=1.86,p<0.005), anxiety (OR=1.97,p<0.0005), evil forces (OR=1.56,p<0.02), war (OR=2.08,p<0.002), domestic abuse (OR=2.22,p<0.009), separation (OR=2.01,p<0.0005), totalitarianism (OR=3.39,p<0.0005), sickness (OR=1.74,p=0.003), death (OR=2.03,p<0.0005), COVID (OR=2.15,p<0.001), and apocalypse (OR=1.86,p<0.006). Those who reported worsened middleof- the-night insomnia were more likely to have nightmares about confinement (OR=1.60,p<0.01), oppression (OR=1.97,p<0.002), failure (OR=2.00,p<0.0005), helplessness (OR=1.60,p<0.001), disaster (OR=1.52,p<0.04), anxiety (OR=2.27,p<0.0005), war (OR=2.10,p<0.001), domestic abuse (OR=1.74,p<0.04), separation (OR=1.86,p<0.0005), totalitarianism (OR=1.87,p<0.03), sickness (OR=1.80,p<0.001), death (OR=2.00,p<0.0005), COVID (OR=1.68,p<0.009), and apocalypse (OR=1.65,p<0.01). Conclusion: The results suggest that increased stress may induce negatively-toned dreams related to that stress. Future studies will have to determine whether (and when) this symptom indicates an emotional regulation mechanism at play or the failure of such a mechanism.

Sleep disturbances during the COVID-19 pandemic associated with worries and fears about possible infection

Introduction: The sudden COVID-19 pandemic and the uncertainty surrounding the virus has led to increased worry and fear. How this fear is associated with sleep remains unknown. Methods: 419 US adults completed online surveys about sleep and COVID-19 experiences. Participants were asked about agreement with statements endorsing beliefs that they were currently infected, that they would someday be infected, that they fear testing, and that they are worried about a family member becoming infected. They were asked to rate agreement with statements regarding changes to sleep during the pandemic. Ordinal logistic regressions with degree of agreement with statements about sleep changes were outcomes, agreement with statements about COVID infection beliefs as predictor, and age, sex, and race/ethnicity as covariates were examined. Results: Those who believed they were infected were 65% less likely to be keeping a regular schedule (p=0.001), 61% less likely to report improved sleep (p=0.009), 2.9 times as likely to report worse sleep (p=0.001), 2.7 times as likely to report difficulty falling asleep (p=0.002), 2.1 times as likely to report sleep maintenance problems (p=0.03), 2.9 times as likely to report sleepiness (p=0.001). Those who believed they would be infected in the future were 83% less likely to report improved sleep (p=0.005), 7.49 times as likely to report worse sleep (p=0.001), 5.3 times as likely to report difficulty falling asleep (p=0.003), 4.1 times as likely to report sleep maintenance problems (p=0.01), and 5.7 times as likely to report sleepiness (0.003). Those that feared testing were 5.7 times as likely to report more sleepiness (p=0.03). Those that worried about family were 80% less likely to be keeping a regular schedule (p=0.01), 75% less likely to report improved sleep (p=0.02), 4.5 times as likely to report worse sleep (p=0.02), 4.5 times as likely to report sleep maintenance problems (p=0.01), and 8.3 times as likely to report sleepiness (p=0.001). Conclusion: Those who believed they were infected reported worsening sleep, though the degree was even greater among those who anticipated infection for themselves or a family member. Worries about COVID-19 may result in more adverse impact on sleep than potential infection itself.

Changes in sleep due to the COVID pandemic associated with sleep environment

Introduction: The COVID-19 pandemic has resulted in adverse impacts on sleep for many people. The physical environment has been a focus for health-related behaviors during the pandemic since movement restrictions have led to a heightened awareness of the living environment. This study examined whether those whose physical environment was more disruptive to sleep systematically experienced more pandemic-related sleep problems. Methods: A sample of N=419 US adults completed online surveys (mostly during the summer months) about sleep and COVID-19 experiences. Participants were asked the degree to which they endorsed statements that due to the pandemic, (1) they were able to keep a regular schedule, (2) they had more problems falling asleep, (3) they had more problems with nighttime awakenings, (4) they experienced more daytime sleepiness, and (5) they napped more. Sleep environment was assessed using the Assessment of Sleep Environment (ASE), a 13-item questionnaire that quantifies the degree to which sleep is disrupted environmental influences (scores range from 0-39). Ordinal logistic regression analyses, with degree of agreement with statements about changing sleep due to the pandemic as outcome, ASE score as independent variable, and age and sex as covariates. Results: Worse sleep environment was associated with a decreased likelihood of being able to keep a regular schedule (oOR=0.96, p<0.04) and an increased likelihood of more problems falling asleep (oOR=1.04, p<0.02), problems with nighttime awakenings (oOR=1.03, p<0.02), daytime sleepiness (oOR=1.03, p<0.03), and napping (oOR=1.03, p<0.04). Post-hoc analyses examine contributions of individual items, and the one that was independently most associated with changes in sleep was sleeping environment being too warm. Conclusion: Those with a more disruptive sleep environment experienced a greater degree of problematic sleep problems as a result of the COVID-19 pandemic. The fact that these assessments largely took place in warmer months may explain why sleeping environments being “too warm” was especially salient.

Changes in sleep due to COVID pandemic associated with changes to dietary patterns

Introduction: The COVID-19 pandemic has affected sleep and diet for many people. The present study sought to examine potential associations between changes to sleep and eating habits during the COVID- 19 pandemic. Methods: A sample of N=419 US adults completed online surveys about sleep and COVID-19 experiences. Questions for diet asked, “since quarantine: I'm eating healthier, eating more processed foods, home-cooked meals and more regularly,” “I'm enjoying food in quarantine and I'm struggling with overeating in quarantine.” Sleep questions asked “since quarantine: I have managed to keep a regular sleep-wake schedule, my sleep has improved, I'm struggling to fall asleep, I'm waking up more during the night, I'm more sleepy during the day and I'm taking more naps during the day.” Answers were reported on a 4-point scale ranging from “strongly disagree to strongly agree.” Ordinal logistic regressions were used, adjusted for age and sex and examined each dietary variable as ordinal outcome and each sleep variable as predictor. Results: Those who report that they kept a more regular schedule were more likely to report eating healthier (oOR=3.13, p=0.007), eating more home-cooked meals (oOR=3.19, p=0.005), and less likely to be eating more processed foods (oOR=0.39, p=0.02), struggle with overeating (oOR=0.39, p=0.02) or undereating (oOR=0.30, p=0.004) or snacking (oOR=0.25, p=0.001). Those reporting more difficulty falling asleep were less likely to be eating healthier (oOR=0.25, p=0.002) and more likely to be eating more processed foods (oOR=3.07, p=0.009) and snacking (oOr=2.36, P=0.04). Those reporting more difficulty with awakenings were less likely to report eating healthier (oOR=0.34, p=0.03) and more likely to report eating more processed foods (oOR=4.52, p=0.001). Those with more sleepiness were less likely to report eating healthier (oOR=0.29, p=0.01) and more homecooked meals (oOR=0.40, p=0.046) and more likely to report eating more processed foods (oOR=6.42, p<0.0005), overeating (oOR=3.63, p=0.01) and snacking (oOR=5.81, p=0.001). Conclusion: Research studying psychological, behavioral and environmental factors that are contributing to changes in sleep and dietary patterns is especially important during a pandemic that has forced people into changes that they may not have been prepared for and which may result in long-term health outcomes.

Changes in physical activity during the COVID-19 pandemic associated with changes in sleep

Introduction: The COVID-19 global pandemic has likely led to changes in physical activity as behavioral patterns were disrupted. This is important because sleep and physical activity are interrelated and promote health, and well-being. This study examined whether changes to physical activity were related to changes to sleep health as a result of the COVID-19 pandemic. Methods: A sample of N=419 US adults completed online surveys about sleep and COVID-19 experiences. Participants were asked to estimate the number of minutes per day they engaged in physical activity during the pandemic, as well as before. These were subtracted from each other, and a difference score was computed. Then, responses were categorized as no change (<=15 mins difference), 16-45 minutes more or less activity, or 46+ minutes more or less activity (5 categories total). Outcome variables included the degree to which participants believed that due to the pandemic, they experienced (1) more schedule regularity, (2) better sleep, (3) worse sleep, (4) more difficulty falling asleep, (5) more difficulty maintaining sleep, (6) more sleepiness, and (7) more napping. Ordinal regressions were adjusted for age, and sex. Results: Those who increased their activity by over 45 minutes per day reported that they were less likely to experience more daytime sleepiness (oOR=0.28, p<0.02). Those who decreased their activity by over 45 minutes per day reported that they were more likely to experience worse sleep (oOR=2.38, p<0.01) and less likely to experience a more regular schedule (oOR=0.37, p<0.003) than prior to the pandemic. Conclusion: Overall, those who increased their physical activity since the beginning of the pandemic reported less daytime sleepiness;and those who decreased their physical activity reported worse sleep experiences and a more irregular schedule. The relationship between physical activity and sleep during the pandemic may be bidirectional.

Changing sleep during the COVID pandemic associated with daytime cognitive function

Introduction: The novel Coronavirus has caused major disruptions to sleep and cognitive function of many individuals. The present study evaluated the degree to which daytime cognitive dysfunction may be related to worsening sleep. Methods: Data from adults aged 18 and older in the 2020 Coronavirus and Impact on Dreams (CovID) study were used. Individuals were asked “how would you rate your sleep quality overall” and answered with “very good, fairly good, fairly bad, or very bad.” Subjects were asked if it takes “30 minutes or more to fall asleep” and answered with how frequently that happened. In addition, participants were asked how often they wake up during the night. Participants were then asked how much they think their sleep problems have contributed to daytime functioning and answered on a scale of 0 to 5, from “not at all” to “very much,” respectively. Results: 46% of the sample did not report problems with daytime cognitive function, while 33%, 12%, and 9% reported mild, moderate, and severe problems, respectively. Those who reported that they have kept a regular schedule during the pandemic were 83% less likely to report greater daytime cognitive dysfunction (95%CI:0.08,0.37, p<0.0005). Those who indicated that overall their sleep worsened or improved did not demonstrate a difference in likelihood of daytime cognitive problems. Regarding specific sleep experiences, those who reported more problems falling asleep due to the pandemic were 8.2 times more likely to report daytime cognitive dysfunction (95%CI:3.53,19.07, p<0.0005) and those who reported more problems with morning awakenings were 5.7 times more likely (95%CI:2.10,15.56, p<0.001). Those who reported that they were sleepier as a result of the pandemic were 9.3 times as likely to report daytime cognitive dysfunction (95%CI:3.53,24.46, p<0.0005) and those who reported taking more naps were 4.4 times more likely (95%CI:1.90,10.40, p<0.001). Conclusion: In general, people who reported increased sleepiness, a less regular schedule, more insomnia, and more napping were more likely to experience daytime cognitive dysfunction during the COVID- 19 pandemic.

COVID-19 pandemic sleep disturbances related to dietary behavior at the Us-Mexico border

Introduction: The COVID-19 pandemic has disrupted life at the US-Mexico border in many ways, including sleep and dietary behavior. Given the potential long-term impact of worsening sleep and metabolic health due to the pandemic, the present study examines whether changes to dietary behavior were associated with changes to sleep. Methods: Participants were 155 individuals who completed the Nogales Cardiometabolic Health and Sleep (NOCHES) Study and were contacted about completing a COVID-19 sub-study (95% Hispanic/Latino). Participants reported the degree to which they experienced pandemic-related changes to sleep, including a more regular schedule, overall improvement, overall worsening, more initial insomnia, more middle-of-the-night insomnia, more daytime sleepiness, and more napping. They were also asked whether as a result of the pandemic they consumed an overall healthier diet, more homecooked meals, more processed meals, more regular meals, whether they enjoyed food more, and degree of overeating. Ordinal regressions with diet change as outcome and sleep change as predictor were adjusted for age, sex, education, and socioeconomics. Results: Those who reported more regular sleep were more likely to report a healthier overall diet (oOR=3.12,p<0.0005), more homecooked meals (oOR=2.18,p=0.001), more enjoyment of food (oOR=1.71,p=0.028), and less likelihood of overeating (oOR=0.59,p=0.033). Similarly, those who reported more “improved” sleep reported healthier overall diet (oOR=7.42,p<0.0005), more homecooked meals (oOR=2.59,p=0.001), more regular diet (oOR=2.15,p=0.006), more enjoyment of food (oOR=2.92,p<0.0005), less consumption of processed foods (oOR=0.54,p=0.039), and less overeating (0.33,p<0.0005). Those whose sleep worsened reported eating more processed foods (oOR=1.78,p=0.030) and overeating (oOR=3.90,p<0.0005). Those who reported more initial insomnia reported eating more processed foods (oOR=1.93,p=0.016), more regular diet (oOR=1.65,p=0.042), and overeating more often (oOR=4.11,p<0.0005). More middleof- the-night insomnia was associated with eating more processed foods (oOR=2.45,p=0.001), more regular diet (oOR=1.66,p=0.031), and overeating more often (oOR=3.68, <0.0005). Those with more daytime sleepiness also reported eating more processed foods (oOR=2.36,p=0.003), more regular diet (oOR=1.79, =0.019), and overeating more often (oOR=3.28,p<0.0005). More napping was associated with a more regular diet (oOR=1.90,p=0.011) and more overeating (oOR=3.53,p<0.0005). Conclusion: Overall, worse sleep led to worse dietary behavior, especially eating more processed food and overeating.

COVID-19 pandemic sleep disturbances related to stress experiences at the US-Mexico border

Introduction: The COVID-19 pandemic has impacted many individuals at the vulnerable US-Mexico border region in a variety of ways. Fear, worry, and stress have increased for many, as has poor sleep. The present study evaluated the degree to which worsened sleep due to the pandemic impacted stress experiences. Methods: Participants were N=155 individuals who completed the Nogales Cardiometabolic Health and Sleep (NOCHES) and were contacted about completing a COVID sub-study (95% Hispanic/Latino). They were asked the degree to which their sleep worsened due to the pandemic. They also reported the degree to which they agreed with statements regarding various pandemic-related stress experiences. These included infection-related stresses, stresses about community impact, personal psychosocial stresses, stresses about consequences of potential infection, media and society-related stresses, feelings of safety, and how the pandemic has impacted home life. Ordinal logistic regressions were used to determine whether changes in sleep were associated with agreement with statements about pandemic-related stress experiences, adjusted for age, sex, financial status, education, and mental health (PHQ4). Results: Those who perceived that their sleep worsened were more likely to report greater endorsement of beliefs that they were infected (ordinal Odds Ratio [oOR]=2.82,p<0.0005), they could possibly be infected (oOR=1.98,p=0.003), they feared testing (oOR=1.94,p=0.006), COVID- 19 would impact their community (oOR=1.75,p=0.017) and would do so for a long time (oOR=1.90,p=0.006), they experience more general (oOR=4.10,p<0.0005), financial (oOR=3.15,p<0.0005), food-related (oOR=2.97,p<0.0005), housing-related (oOR=2.14,p=0.002), familyrelated (oOR=2.53,p<0.0005) and relationship (oOR=3.37,p<0.0005) stress, their shopping was impacted by scarcity (oOR=1.76,p=0.014), and they are at high risk for COVID (oOR=1.87,p=0.008). Furthermore, media coverage of COVID-19 had increased their stress (oOR=2.46,p<0.0005), there is too much panic about COVID-19 (oOR=1.67,p=0.032), and they themselves are scared of getting COVID-19 (oOR=1.95,p=0.005), worried about the future (oOR=1.71,p=0.022), feel less secure (oOR=0.59,p=0.028), are thriving less (oOR=0.40,p<0.0005), and their mental health is not improving (oOR=0.46,p=0.002). Conclusion: Worse sleep due to the COVID-19 pandemic was associated with increased reports of stresses across a wide range of domains. Perhaps sleep health interventions could improve social and emotional health in these domains and reduce stress experiences and better cope with the pandemic. Alternatively, mental health interventions should perhaps be targeted to this population.

COVID-19 pandemic sleep changes related to social and financial impacts at the us-mexico border

Introduction: The COVID-19 pandemic has caused major impacts to social and financial status for many people, including those living in the vulnerable US-Mexico border region. This study examined relationships between changes in sleep and perceived impacts to social and financial stability due to the pandemic. Methods: Participants were 155 individuals who completed the Nogales Cardiometabolic Health and Sleep (NOCHES) and were contacted about completing a COVID sub-study (95% Hispanic/Latino). Participants were asked if the COVID-19 pandemic was causing them to feel more socially isolated, negatively impacting their finances, causing increased worry about finances, affecting their primary job, causing a job loss, and impacting their belief life will one day return to normal. In addition, they were asked to report the degree to which they experienced pandemic-related changes to sleep, including a regularity, overall improvement/worsening, initial and middle-of-the-night insomnia, daytime sleepiness, and napping. Logistic regression analyses were adjusted for age, sex, socioeconomics, and mental health (PHQ4). Results: Those who kept a more regular schedule had lower odds of endorsing isolation (OR=0.32,p<0.0005) and higher odds of believing things will return to normal (OR=1.67,p=0.041). Those whose sleep improved also had lower odds of feeling isolated (OR=0.40,p=0.005). Those with worsened sleep had increased odds of feeling isolated (OR=2.14,p=0.023), experiencing a financial impact (OR=1.85,p=0.016) and increased financial worry (OR=1.71,p=0.033), and lower odds of believing things will return to normal (OR=0.53,p=0.012). More initial insomnia was associated with isolation (OR=3.62,p=0.001), financial impact, (OR=1.89,p=0.015), financial worry (OR=1.87,p=0.016) and job impact (OR=1.95,p=0.010). More middle-of-the-night insomnia was associated with financial worry (OR=1.82,p=0.016) and job impact (OR=1.93,p=0.009). More sleepiness was associated with job loss (OR=1.84,p=0.043). More napping was associated with financial impact (OR=1.89,p=0.017) and worry (OR=1.88,p=0.017), impact to job (OR=1.89,p=0.016) or lost job (OR=1.81,p=0.041), and decreased likelihood of believing things will return to normal (OR=0.45,p=0.003). Conclusion: Pandemic-related stress was linked with sleep disturbances. Worse sleep was indicative of increased social isolation, greater financial fears, more job-related impacts and less of a general sense that things would return to normal.

COVID-19 pandemic sleep and dreams at the us-mexico border

Introduction: The impact of the COVID-19 pandemic in the border region is not well-described, including the impact of pandemic-related sleep disturbances on dream experiences, despite frequent reports of meaningful changes to dreams in the population. Methods: Participants were 155 individuals who completed the Nogales Cardiometabolic Health and Sleep (NOCHES) Study and a COVID sub-study (95% Hispanic/Latino). Participants were asked whether, as a result of the pandemic, they have experienced more schedule regularity, improved/worsened sleep, more initial or middleof- the-night insomnia, more sleepiness, and more napping. They were also asked whether they experienced more, fewer, or the same amount of dreams in general, positive dreams, and negative dreams. Multinomial logistic regressions were used to examine overall, positive, and negative dream recall (more or less vs same) as outcome and perceived change in sleep as independent variable, adjusted for age, sex, socioeconomics, and mental health symptoms (assessed with PHQ4). Results: Those who reported more schedule regularity were less likely to report more negative dreams (Relative Risk Ratio [RRR]=0.40, p=0.010). Those who reported improved sleep were also more likely to report more positive dreams (RRR=3.97, p=0.004). Those with worsened sleep were more likely to report fewer dreams overall (RRR=2.23, p=0.037), fewer positive dreams (RRR=2.24, p=0.003) and more negative dreams (RRR=3.69, p<0.0005). Those with more initial insomnia were more likely to report fewer positive dreams (RRR=2.43, p=0.002) and more negative dreams (RRR=4.12, p<0.0005). Those with more middle-of-the-night insomnia reported fewer dreams overall (RRR=2.35, p=0.018), fewer positive dreams (RRR=2.55, p=0.001), and more negative dreams (RRR=5.01, p<0.0005). Those with more daytime sleepiness were more likely to report fewer dreams overall (RRR=4.75, p<0.0005), fewer positive dreams (RRR=1.92, p=0.019), and more negative dreams (RRR=3.91, p<0.0005), and were less likely to report more positive dreams (RRR=0.26, p=0.018). Those who reported napping more were more likely to report fewer dreams overall (RRR=2.78, p=0.008), fewer positive dreams (RRR=2.10, P=0.008), and more negative dreams (RRR=2.83, p=0.003), and were less likely to report more positive dreams (RRR=0.16, p=0.004). Conclusion: Those whose sleep worsened due to the pandemic reported less dream recall, and dream content that was more negative and less positive overall.

COVID-19 pandemic nightmares at the us-mexico border

Introduction: The COVID-19 pandemic has impacted individuals in many ways, including anecdotal reports of nightmares. However, little data exists regarding the experience of COVID-related nightmares, especially among the distressed population at the US-Mexico Border. This is especially relevant given the clinical importance of nightmares as risk factors for poor mental health and sleep disturbances. Methods: Participants were N=155 individuals who completed the Nogales Cardiometabolic Health and Sleep (NOCHES) and were contacted about completing a COVID sub-study (95% Hispanic/Latino). Participants were asked for the number of nightmares that they have experienced since the pandemic started. They were also asked whether they had nightmares about confinement, claustrophobia, suffocation, oppression, drowning, failure, helplessness, natural disasters, anxiety, evil forces, war, separation from loved ones, being chased, sickness, death, COVID, and apocalypse. They were also asked whether they experienced, due to the pandemic, increased general, financial, food, housing, familial, relationship, and media-related stress. Each of these items was coded from 0 ('Strongly Disagree') to 3 ('Strongly Agree'), with total scores ranging from 0-21. Regression analyses (linear for frequency and binary logistic for content) examined stress score as independent variable, adjusted for age, sex, financial status, education, and mental health (PHQ4). Results: Those who experienced greater pandemic-related stress reported more nightmares (age/sex-adjusted B=0.23, p<0.0005, fully-adjusted B=0.23, p<0.0005). They were also more likely to have nightmares about confinement (adjusted odds ratio [OR]=1.69, p=0.008), suffocation (OR=1.41, p=0.020), failure (OR=1.23, p=0.049), being chased (OR=1.24, p=0.013), sickness (OR=1.26, p=0.022), and COVID (OR=1.37, p=0.003). Conclusion: Those who experienced more pandemic-related stress reported more nightmares, even after adjusting for depression/anxiety symptoms. In addition, those with more pandemic-related stress were more likely to have nightmares about COVID itself, as well as confinement and suffocation, being chased, failure, and sickness in general. Perhaps efforts to reduce pandemic-related stress will reduce these nightmare experiences, which may have beneficial effects on other areas of mental health.

Self-reported sleep and resilience

Introduction: Psychological resilience is the ability to withstand setbacks, adapt positively to challenges, and bounce back from the adversities of life. While the construct of resilience is broadly understood, the specific individual factors that contribute to the ability to be resilient and persevere in the face of difficulties remain poorly understood. We recently showed that psychological resilience during the COVID-19 pandemic was associated with a number of factors, including fewer complaints of insomnia, and others have suggested that sleep is an important contributor. We therefore tested the hypothesis that sleep quality and acute sleep quantity would combine to predict measures of psychological resilience and perseverance (i.e. 'grit'). Methods: We asked 447 adults (18-40 yrs;72% female) to report the number of hours of sleep obtained the night before their assessment session (SLEEP), and complete several questionnaires, including the Pittsburgh Sleep Quality Index (PSQI), the Connor- Davidson Resilience Scale (CD-RISC), Bartone Dispositional Resilience Scale (Hardiness), and the Grit Scale. Sleep metrics were used to predict resilience, hardiness, and grit using multiple linear regression. Results: For resilience, PSQI (β=-.201, p<.00003) and SLEEP (β=.155, p<.001) each contributed uniquely to prediction of CD-RISC (R2=.08, p<.00001). Hardiness was also predicted (R2=.08, p<.00001) by a combination of PSQI (β=-.218, p<.00001) and SLEEP (β=.128, p=.007). Interestingly, worse sleep quality over the past month on the PSQI (β=.13, p=.008) in combination with more SLEEP the night before the assessment (β=.137, p=.005) each contributed uniquely to higher Grit (i.e., perseverance;R2=.03, p=.003). Conclusion: Self-reported sleep quality and quantity were both independently associated with greater self-reported resilience, hardiness, and grit. While better sleep quality and more sleep the night before testing each uniquely predicted greater resilience and hardiness, a different pattern emerged for Grit. The combination of lower quality sleep over the past month followed by greater recent sleep duration was associated with increased perseverance. Whereas sleep quality appears to be more important for general resilience/hardiness, recent sleep time appears more important for the subjective perception of perseverance. Because these data are purely self-report and cross sectional, future work will need to determine the longitudinal effects on behavior.