We explored in this study whether insomnia, viral anxiety, reassurance-seeking behavior, and preoccupation with coronavirus disease (COVID-19) are related among the general population. As well, we explored the possibility that insomnia may mediate the association between COVID-19 viral anxiety and preoccupation.
During November 9–15, 2021, 400 participants voluntarily completed this survey, and participants’ age, sex, living location, and marital status were collected. Responses to questions about COVID-19 were also gathered, and their symptoms were rated using the Obsession with COVID-19 Scale (OCS), Coronavirus Reassurance-Seeking Behaviors Scale (CRBS), Fear of COVID-19 scale (FCV-19S), and Insomnia Severity Index (ISI).
Preoccupation with COVID-19 was predicted by young age (β = -0.08, p = 0.012), CRBS (β = 0.52, p < 0.001), FCV-19S (β = 0.30, p < 0.001), and ISI (β = 0.07, p = 0.029) (adjusted R2 = 0.62, F = 163.6, p < 0.001). Mediation analysis showed that insomnia partially mediates the influence of reassurance seeking behavior and viral anxiety on preoccupation with COVID-19.
Sleep disturbances can contribute to a vicious cycle of hypochondriacal preoccupation with COVID-19. In order to reduce an individual’s viral anxiety, insomnia symptoms must be addressed.
The coronavirus disease (COVID-19) pandemic has brought about many changes, and psychological distress is one of them. There has been a survey study in China to investigate the association between mental health symptoms, including depression and anxiety, and their prevalence and risk factors during the COVID-19 pandemic. In this study, depressive symptoms were reported in 27.9% and anxiety symptoms in 31.6%, and those with confirmed or suspected COVID-19, those at risk of occupational exposure, and residents of Hubei Province had more severe symptoms [
High prevalence of psychiatric disorders in pandemics has been reported in several studies. A study of severe acute respiratory syndrome (SARS) is about significant rates of psychiatric morbidity related to SARS [
Fear of contamination and excessive checking are the symptoms most frequently associated with COVID-19 [
In this COVID-19 pandemic, if one is afraid of being infected in this COVID-19 pandemic, then one may engage in reassurance-seeking behavior, such as checking bodily sensation, maintaining hand hygiene, or reading repeated media articles [
A number of studies were conducted which explored the relationship between viral anxiety, feelings provoked by worries about exposure to virus and infection and insomnia during the COVID-19 pandemic. It is well known that insomnia symptoms were associated with depression or anxiety [
In this study we aimed to explore whether insomnia, viral anxiety, reassurance-seeking behavior, and preoccupation with COVID-19 are related among the general population in this study. In addition, we tried to explore whether insomnia may mediate the viral anxiety and preoccupation with COVID-19. We hypothesized that 1) reassurance-seeking behavior will be positively related to preoccupation with COVID-19, 2) viral anxiety will be positively associated with preoccupation with COVID-19, 3) insomnia will be positively associated with preoccupation with COVID-19, and 4) insomnia will at least partially mediate the relationships between reassurance-seeking behavior and preoccupation with COVID-19 among the general population.
Surveys were conducted anonymously during November 9–15, 2021, and 400 participants voluntarily participated in this study after checking “yes” to the statement of agreeing to participate. They completed it through the survey system of professional survey company EMBRAIN (www.embrain.com). Participants’ age, sex, living location, and marital status were collected, but no personally identifiable information was collected. We also gathered responses to questions about COVID-19, such as “Did you experience being quarantined due to infection with COVID-19?”, “Did you experience being infected with COVID-19?”, or “Did you get vaccinated?” Additionally, participants’ past psychiatric history was checked with a question such as “Have you ever suffered depression, anxiety, or insomnia?” and current psychiatric distress with a question of “Now, do you think you are depressed or anxious, or do you need help for your mood state?” Before the investigators received the data, all identifying personal information was removed. Asan Medical Center’s Institutional Review Board (IRB) approved the study protocol (2021-1490), and the IRB waived obtaining written informed consent.
The Obsession with COVID-19 Scale (OCS) is a self-report mental health screening tool that measures persistently disturbing thoughts related to COVID-19 [
Coronavirus Reassurance-Seeking Behaviors Scale (CRBS) is a self-report measure of reassurance-seeking behaviors associated with concerns about Coronavirus infection [
A self-rating questionnaire, Fear of COVID-19 scale (FCV-19S), can be used to measure viral anxiety during a COVID-19 pandemic [
An Insomnia Severity Index (ISI) is designed to measure insomnia severity [
The mean and standard deviation of participants’ demographic characteristics and rating scale scores are summarized. Two-tailed significance was determined by a p value of 0.05. Correlation analysis was performed using Pearson’s correlation coefficient. We used linear regression to examine which variables can predict obsession with COVID-19. The bootstrap method with 2000 resamples was implemented to determine whether insomnia mediates the influence of viral anxiety or reassurance seeking behavior on preoccupation with COVID-19. The SPSS version 21.0 (IBM Co., Armonk, NY, USA) was used to conduct the general statistical analysis, and AMOS version 27 (IBM Co.) and Jamovi ver 1.6.23 (The jamovi project, Sydney, NSW, Australia) were used to conduct the mediation analysis.
Among the 400 participants were residents of Seoul (n = 117, 29.3%), Pusan (n = 30, 7.5%), Daegu (n = 18, 4.5%), Daejeon (n = 9, 2.3%), Gwangju (n = 10, 2.5%), Incheon (n = 31, 7.8%), Ulsan (n = 8, 2.0%), Gyeonggi Province (n = 108, 27.0%), Chungcheong Province (n = 20, 5.0%), Jeolla Province (n = 11, 2.8%), Gyeongsang Province (n = 29, 7.3%), Gangwon Province (n = 7, 1.8%), and Jeju Province (n = 2, 0.5%). Demographic characteristics of participants were presented in
Pearson’s correlation analysis showed that age was significantly correlated with OCS (r = -0.23, p < 0.01), CRBS (r = -0.26, p < 0.01), and ISI (r = -0.17, p < 0.01). The OCS score was significantly correlated with CRBS (r = 0.74, p < 0.01), FCV-19S (r = 0.63, p < 0.01), and ISI (r = 0.37, p < 0.01). The CRBS was significantly correlated with FCV-19S (r = 0.59, p < 0.01) and ISI (r = 0.34, p < 0.01). FCV-19S was correlated with ISI (r = 0.36, p < 0.01) (
Linear regression analysis was done to explore which variables can predict the preoccupation with COVID-19, and we observed that preoccupation with COVID-19 was expected by age (β = -0.08, p = 0.012), CRBS (β = 0.52, p < 0.001), FCV-19S (β = 0.30, p < 0.001), and ISI (β = 0.07, p = 0.029) (adjusted R2 = 0.62, F = 163.6, p < 0.001) (
Mediation analysis showed that the complete pathway from reassurance-seeking behavior or viral anxiety (independent variable) to insomnia (mediator) to preoccupation with COVID-19 (dependent variable) was significant (
In this study, we investigated whether insomnia, viral anxiety, reassurance seeking behavior, and preoccupation with COVID-19 are related among the general population. Moreover, we investigated whether insomnia may mediate COVID-19 anxiety and preoccupation. We observed that preoccupation with COVID-19 was predicted by younger age, coronavirus reassurance seeking, and viral anxiety or insomnia severity. Additionally, we observed that insomnia partially mediated the influence of reassurance seeking behavior and viral anxiety on preoccupation with COVID-19.
Preoccupation with COVID-19 virus was associated with younger age, insomnia, viral anxiety, and reassurance-seeking behavior in this study. Vicious cycle among viral anxiety, reassurance-seeking, and preoccupation with COVID-19 was already reported. We reported previously that the reassurance seeking behavior of healthcare workers and their preoccupation with COVID-19 were associated with work-related stress and viral anxiety of healthcare workers [
Age and preoccupation with COVID-19 are inversely correlated, and this relationship is complicated. Having an underlying medical condition and old age were risk factors for COVID-19 infection [
In this study, we observed that reassurance-seeking behavior and viral anxiety were predicting variables for preoccupation with COVID-19. And also, we observed that insomnia can be a mediator on this vicious cycle model of hypochondriacal preoccupation. In this COVID-19, high prevalence of insomnia was reported. Approximately 38% of participants in Greek population-based study reported that sleep problems [
This study has some limitations. First, the online survey design has the potential to cause bias. In order to prevent the spread of the virus during this pandemic era, we decided to conduct an online survey rather than a face-to-face interview. However, the responses may not be as reliable as they seem. Second, the result of a small sample size cannot be applied to the entire population. The sample we collected included similar allocation by sex, age group, and entire area of Korea, and we could improve the representativeness of the sample. Third, Since COVID-19, viral anxiety, reassurance seeking, and insomnia are related to anxiety, there needs to be caution when explaining their connection. Moreover, there could be confounders not considered in this study, such as occupation, education level, or social economic status, that might affect the results. Lastly, the study took place from November 9–15, 2021. The Korean government started implementing the “living with Coronavirus” policy starting November 1st, 2021, and soon the number of confirmed cases exceeded 7000 per day. Although the rapid spread of the virus may affect these results, we should also take into account the fact at the same time that people have already become used to 2 years of pandemic.
In conclusion, we observed that insomnia partially mediated the vicious cycle of the hypochondriacal preoccupation with COVID-19 linked to reassurance seeking-behavior and viral anxiety. Sleep specialists should address the insomnia symptoms of people in order to reduce viral anxiety and repetitive reassurance-seeking behavior that can contribute to the preoccupation with COVID-19.
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conceptualization: Young Rong Bang, Junseok Ahn. Data curation: Eulah Cho, Inn-Kyu Cho, Dongin Lee, Joohee Lee. Formal analysis: Eulah Cho, Inn-Kyu Cho, Dongin Lee, Joohee Lee. Methodology: Young Rong Bang, Eulah Cho. Visualization: Dongin Lee, Joohee Lee. Writing—original draft: all authors. Writing—review & editing: all authors.
The authors have no potential conflicts of interest to disclose.
None
We would like to thank Dr. Seockhoon Chung (Department of Psychiatry, University of Ulsan College of Medicine) for the ideas of and wonderful discussion about this study.
Mediation model showing that the effect of coronavirus reassurance-seeking behavior or viral anxiety (independent variables) on preoccupation with coronavirus (outcome) is mediated by insomnia (mediator). e1, e2: error term. *Standardized estimator, p < 0.01.
Clinical characteristics of the study subjects (n = 400)
Variable | Value | |
---|---|---|
Male | 204 (51.0) | |
Age (yr) | 44.7 ± 13.0 | |
18–29 | 70 (17.5) | |
30–39 | 73 (18.3) | |
40–49 | 87 (21.8) | |
50–59 | 93 (23.3) | |
≥ 60 | 77 (19.3) | |
Marital status | ||
Single | 132 (33.0) | |
Married, with kids | 220 (55.0) | |
Married, without kids | 25 (6.3) | |
Others | 23 (5.8) | |
Questions on COVID-19 | ||
Did you experience being quarantined due to infection with COVID-19? (Yes) | 46 (11.5) | |
Did you experience being infected with COVID-19? (Yes) | 7 (1.8) | |
Did you get vaccinated? (Yes) | 366 (91.5) | |
Psychiatric history | ||
Have you ever experienced or treated depression, anxiety, or insomnia? (Yes) | 76 (19.0) | |
Now, do you think you are depressed or anxious, or do you need help for your mood state? (Yes) | 52 (13.0) | |
Symptoms rating | ||
Obsession with COVID-19 Scale (OCS) | 2.5 ± 3.0 (0–16) | |
Coronavirus Reassurance-Seeking Behaviors Scale (CRBS) | 3.4 ± 4.0 (0–20) | |
Fear of COVID-19 scale (FCV-19S) | 16.2 ± 6.7 (7–35) | |
Insomnia Severity Index (ISI) | 10.6 ± 5.7 (0–28) |
Values are presented as number (%), mean ± standard deviation, or mean ± standard deviation (range).
Correlation coefficients of each variable in all participants
Variables | Age | OCS | CRBS | FCV-19S | ISI |
---|---|---|---|---|---|
Age | 1.00 | ||||
OCS | -0.23 |
1.00 | |||
CRBS | -0.26 |
0.74 |
1.00 | ||
FCV-19S | 0.02 | 0.63 |
0.59 |
1.00 | |
ISI | -0.17 |
0.37 |
0.34 |
0.36 |
1.00 |
p < 0.01.
OCS, Obsession with COVID-19 Scale; CRBS, Coronavirus Reassurance-Seeking Behaviors Scale; FCV-19S, Fear of COVID-19 scale; ISI, Insomnia Severity Index.
Linear regression analysis expecting preoccupation with COVID-19
Dependent variable | Included parameter | Beta | p-value | Adjusted R2 | F, p-value |
---|---|---|---|---|---|
OCS | Age | -0.08 | 0.012 | 0.62 | F = 163.6, p < 0.001 |
CRBS | 0.52 | < 0.001 | |||
FCV-19S | 0.30 | < 0.001 | |||
ISI | 0.07 | 0.029 |
OCS, Obsession with COVID-19 Scale; CRBS, Coronavirus Reassurance-Seeking Behaviors Scale; FCV-19S, Fear of COVID-19 scale; ISI, Insomnia Severity Index.
The results of direct, indirect, and total effects on mediation analysis
Effect | Standardized estimator | S.E. | Z-value | p | 95% CI |
---|---|---|---|---|---|
Direct effect: | |||||
CRBS → OCS | 0.552 | 0.029 | 14.25 | < 0.001 | 0.36 to 0.47 |
FCV-19S → OCS | 0.276 | 0.017 | 7.07 | < 0.011 | 0.09 to 0.16 |
Indirect effect: | |||||
CRBS → ISI → OCS | 0.017 | 0.006 | 2.07 | 0.038 | 0.0001 to 0.03 |
FCV-19S → ISI → OCS | 0.021 | 0.004 | 2.20 | 0.028 | 0.001 to 0.02 |
Component | |||||
CRBS → ISI | 0.198 | 0.081 | 3.49 | < 0.001 | 0.12 to 0.44 |
ISI → OCS | 0.087 | 0.018 | 2.58 | 0.010 | 0.01 to 0.08 |
FCV-19S → ISI | 0.298 | 0.048 | 4.24 | < 0.001 | 0.11 to 0.30 |
Total effect: | |||||
CRBS → OCS | 0.570 | 0.029 | 14.77 | < 0.001 | 0.37 to 0.49 |
FCV-19S → OCS | 0.297 | 0.017 | 7.70 | < 0.001 | 0.10 to 0.17 |
CRBS, Coronavirus Reassurance-Seeking Behaviors Scale; OCS, Obsession with COVID-19 Scale; FCV-19S, Fear of COVID-19 scale; ISI, Insomnia Severity Index; S.E., standard error; CI, confidence interval.