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Valentina Alfonsi,1 Agostino Carbone,2 Serena Scarpelli,1 Maurizio Gorgoni,1,3 Antonella Luchini,4 Patrizia D’Andrea,5 Stefania Cherubini,5 Cristina Costarelli,4 Alessandro Couyoumdjian,1 Fiorenzo Laghi,2 Luigi De Gennaro1,3 1Department of Psychology, Sapienza University of Rome, Rome, Italy; 2Department of Developmental and Social Psychology, Sapienza University of Rome, Rome, Italy; 3IRCCS Fondazione Santa Lucia, Rome, Italy; 4Liceo Scientifico Statale “Isacco Newton”, Roma, Italy; 5Istituto di Istruzione Superiore via Copernico, Pomezia, ItalyCorrespondence: Valentina Alfonsi, Department of Psychology, University of Rome “Sapienza”, Rome, 00185, Italy, Tel +39 649917508, Email valentina.alfonsi@uniroma1.itBackground: Delaying school start times has been proposed as a potential solution to address chronic sleep curtailment among adolescents and its negative consequences on their physical and mental well-being. This study investigates the impact of delayed school start times due to the COVID-19 pandemic on academic achievement.Subjects and Methods: Two separate observational studies were conducted involving high school students from the first/second year (n=232) (Study 1) and from the final year (n=39) (Study 2). Multivariate Analyses of Covariance were performed to assess for statistical differences in academic performance (ie, global, humanistic, and scientific performance) and absenteeism (ie, number of school absences). Two main factors were considered: “school start time” (ie, standard-8:00 AM vs late-9:40 AM) and “time interval” (ie, first academic semester vs second academic semester), controlling for the school year (Study 1) and circadian preference (Study 2).Results: Delaying school start times was positively associated with better academic performance in scientific subjects among first/second-year students (F1,229=6.083, p=0.026) and global academic performance among last-year students (F1,35=4.522, p=0.041). Furthermore, first/second-year students significantly increased their school achievement (F1,229> 29.423, p< 0.001) and school absences (F1,229=66.160, p< 0.001) during the second semester of the academic year. No significant effect of “school start time” on school attendance was observed. Additionally, circadian preference was found to be a significant covariate among last-year students, with early chronotypes exhibiting better academic performance (r> 0.369, p< 0.025).Conclusion: These findings confirm past evidence about the beneficial effects of delayed school start times on academic outcomes, with the additional advantage of observing them within a natural context that emerged during the pandemic. Further research is needed to explore the phenomenon more systematically and take into account the broader implications of implementing this change.Keywords: later school start time, academic achievement, adolescents, COVID-19 pandemic, circadian preference

Serena Scarpelli,1 Valentina Alfonsi,1 Milena Camaioni,1 Maurizio Gorgoni,1,2 Antonio Albano,3 Alessandro Musetti,4 Maria Catena Quattropani,5,6 Giuseppe Plazzi,7,8 Luigi De Gennaro,1,2 Christian Franceschini3 1Department of Psychology, University of Rome Sapienza, Rome, Italy; 2Body and Action Lab, IRCCS Fondazione Santa Lucia, Rome, Italy; 3Department of Medicine and Surgery, Faculty of Medicine and Surgery, University of Parma, Parma, Italy; 4Department of Humanities, Social Sciences and Cultural Industries, University of Parma, Parma, Italy; 5Department of Educational Sciences, University of Catania, Catania, Italy; 6Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy; 7Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; 8IRCCS Institute of Neurological Sciences, Bologna, ItalyCorrespondence: Serena Scarpelli, Department of Psychology, University of Rome Sapienza, Via dei Marsi 78, Rome, 00185, Italy, Tel +39 06 49917508, Email serena.scarpelli@uniroma1.itPurpose: COVID-19 pandemic waves have strongly influenced individuals’ behaviors and mental health. Here, we analyzed longitudinal data collected in the Spring 2020 and 2021 from a large Italian sample with the aim of assessing changes in dream features between the first and third wave. Specifically, we evaluated the modifications of pandemic dream activity as a function of the general distress variations over time. Also, we detected the best explanatory variables of nightmare frequency and distress.Materials and Methods: Participants previously involved in the web survey during the first wave of the pandemic were asked to complete a new online survey on sleep and dream features available in Spring 2021 (N=728). Subjects decreasing their level of psychological general distress in the third (T3) vs the first (T1) pandemic wave were defined as “Improved” (N=330). In contrast, participants with an unchanged or increased level of general distress were defined as “Not Improved” (N=398).Results: Statistical comparisons revealed that dream recall frequency, nightmare frequency, lucid dream frequency, and emotional intensity show a reduction in T3 than T1. Moreover, the Improved group is characterized by lower nightmare rate and nightmare distress than Not Improved people. Our findings confirmed that beyond the trait-like variables (ie, age, sex), specific sleep-related measures are related to nightmare features. In particular, poor sleep hygiene was one of the best determinants of nightmare distress among Not Improved subjects.Conclusion: Our findings revealed that people experienced an adaptation to the pandemic during the third wave. We also strengthen the notion that nightmares and their variations over time are strongly related to human well-being, suggesting that specific trait-like and sleep-related factors could modulate the relationship between mental health and nightmare features.Keywords: nightmare, distress, sleep, pandemic, third wave, clinical psychology

Brigitte Holzinger,1,2 Franziska Nierwetberg,1 Frances Chung,3 Courtney J Bolstad,4 Bjørn Bjorvatn,5 Ngan Yin Chan,6 Yves Dauvilliers,7 Colin A Espie,8 Fang Han,9 Yuichi Inoue,10 Damien Leger,11 Tainá Macêdo,12 Kentaro Matsui,13,14 Ilona Merikanto,15,16 Charles M Morin,17 Sérgio A Mota-Rolim,18 Markku Partinen,19 Giuseppe Plazzi,20,21 Thomas Penzel,22 Mariusz Sieminski,23 Yun Kwok Wing,6 Serena Scarpelli,24 Michael R Nadorff,4,25 Luigi De Gennaro24,26 1Institute for Consciousness and Dream Research, Vienna, Austria; 2Medical University Vienna, Postgraduate Master ULG Sleep Coaching, Vienna, Austria; 3Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada; 4Mississippi State University, Mississippi State, MS, USA; 5Department of Global Public Health and Primary Care, University of Bergen and Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway; 6Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, Special Administrative Region, People’s Republic of China; 7Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, INM, Univ Montpellier, INSERM, Montpellier, France; 8Sir Jules Thorn Sleep & Circadian Neuroscience Institute (SCNi), University of Oxford, Oxford, UK; 9Department of Pulmonary and Critical Care Medicine, Peking University People’s Hospital, Beijing, People’s Republic of China; 10Tokyo Medical University, Tokyo, Japan; 11Université de Paris, APHP, Hôtel-Dieu, Centre du Sommeil et de la Vigilance, Paris, France; 12Department of Psychology, Federal University of Rio Grande do Norte, Natal, Brazil; 13Department of Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan; 14Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan; 15SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; 16Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland; 17École de Psychologie, Centre d’étude des troubles du sommeil, Centre de recherche CERVO/Brain Research Center, Université Laval, Québec, QC, Canada; 18Brain Institute, Physiology and Behavior Department, and Onofre Lopes University Hospital - Federal University of Rio Grande do Norte, Natal, Brazil; 19Helsinki Sleep Clinic, Terveystalo Healthcare, and Department of Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland; 20IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 21Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; 22Sleep Medicine Center, Charité Universitätsmedizin Berlin, Berlin, Germany; 23Department of Emergency Medicine, Medical University of Gdansk, Gdansk, Poland; 24Department of Psychology, Sapienza University of Rome, Rome, Italy; 25Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; 26IRCCS Fondazione Santa Lucia, Rome, ItalyCorrespondence: Brigitte Holzinger, Tel +43 699 101 99 042, Email brigitte.holzinger@meduniwien.ac.atPurpose: The COVID-19 pandemic affects mental health and sleep, resulting in frequent nightmares. Therefore, identifying factors associated with nightmare frequency is important, as it can indicate mental health issues. The study aimed to investigate increases in nightmare frequency comparing the pre-pandemic and pandemic period, and identify its risk factors. Further, the mediating role of post-traumatic stress disorder symptoms between the pandemic and nightmares is explored.Patients and Methods: For this cross-sectional survey data were obtained via self-rating online survey (ICOSS: details in Partinen et al, 2021), which was open to anyone older than 18 years. The final volunteer sample consisted of 15,292 participants, divided according to their nightmare frequency (high: ≥ 1– 2 nights/week; low: < 1– 2 nights/week). A total of 9100 participants were excluded if answers on variables of interest were missing or receiving rewards for participation. Chi-square tests identified changes of nightmare frequency. Predictors of high nightmare frequency were assessed using logistic regression and presented as Odds Ratios. Post-hoc mediation models were used to investigate the role of post-traumatic stress symptoms (PTSS).Results: The mean age was 41.63 (SD=16.55) with 64.05% females. High nightmare frequency increased significantly from 13.24% to 22.35% during the pandemic. Factors associated with it included self-reported PTSS (OR=2.11), other mental disorders and various sleep disorders or problems. Financial burden due to the pandemic, confinement, having had COVID-19, and work situation during the pandemic were associated with nightmare frequency, those relations were partly mediated through PTSS.Conclusion: Our results display the pandemic influence on nightmare frequency, which in turn connects to multiple mental health and sleep factors. These relations were partly mediated through PTSS. The COVID-19 pandemic appears to have caused traumatization of a substantial proportion of society. Health care workers should consider nightmares in their screening routines, as it might indicate PTSS and/or other mental and sleep disorders.Keywords: COVID-19, nightmares, mental health, sleep, post-traumatic stress disorder, collective trauma

Serena Scarpelli,1 Michael R Nadorff,2,3 Bjørn Bjorvatn,4 Frances Chung,5 Yves Dauvilliers,6 Colin A Espie,7 Yuichi Inoue,8 Kentaro Matsui,9,10 Ilona Merikanto,11,12 Charles M Morin,13 Thomas Penzel,14 Mariusz Sieminski,15 Han Fang,16 Tainá Macêdo,17 Sérgio A Mota-Rolim,18 Damien Leger,19 Giuseppe Plazzi,20,21 Ngan Yin Chan,22 Markku Partinen,23 Courtney J Bolstad,2 Brigitte Holzinger,24,25 Luigi De Gennaro1,26 1Department of Psychology, Sapienza University of Rome, Rome, Italy; 2Mississippi State University, Mississippi State, MS, USA; 3Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; 4Department of Public Health and Primary Care, University of Bergen and Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway; 5Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Canada; 6Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, INM, Univ Montpellier, INSERM, Montpellier, France; 7Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; 8Tokyo Medical University, Tokyo, Japan; 9Department of Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan; 10Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan; 11SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; 12Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland; 13École de Psychologie, Centre d’étude des troubles du sommeil, Centre de recherche CERVO/Brain Research Center, Université Laval, Québec, Canada; 14Sleep Medicine Center, Charité Universitätsmedizin Berlin, Berlin, Germany; 15Department of Emergency Medicine, Medical University of Gdansk, Gdansk, Poland; 16Department of Pulmonary and Critical Care Medicine, Peking University People’s Hospital, Beijing, People’s Republic of China; 17Department of Psychology, Federal University of Rio Grande do Norte, Natal, Brazil; 18Brain Institute, Physiology and Behavior Department, and Onofre Lopes University Hospital - Federal University of Rio Grande do Norte, Natal, Brazil; 19Université de Paris, APHP, Hôtel-Dieu, Centre du Sommeil et de la Vigilance, Paris, France; 20IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 21Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; 22Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, Special Administrative Regions, People’s Republic of China; 23Helsinki Sleep Clinic, Terveystalo Healthcare, and Department of Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland; 24Institute for Consciousness and Dream Research, Vienna, Austria; 25Medical University Vienna, Postgraduate Master Program Medical Sleep Coaching, ZK-Schlafcoaching, Vienna, Austria; 26IRCCS Fondazione Santa Lucia, Rome, ItalyCorrespondence: Luigi De Gennaro, Tel +39-06-49917647, Fax +39-06-49917711, Email luigi.degennaro@uniroma1.itIntroduction: A growing number of studies have demonstrated that the coronavirus disease-19 (COVID-19) pandemic has severely affected sleep and dream activity in healthy people. To date, no investigation has examined dream activity specifically in COVID-19 patients.Methods: As part of the International COVID-19 Sleep Study (ICOSS), we compared 544 COVID-19 participants with 544 matched-controls. A within-subjects comparison between pre-pandemic and pandemic periods computed separately for controls and COVID-19 participants were performed on dream recall and nightmare frequency (DRF; NF). Also, non-parametric comparisons between controls and COVID-19 participants were carried out. Further, we compared psychological measures between the groups collected during pandemic. Ordinal logistic regression to detect the best predictors of NF was performed.Results: We found that people reported greater dream activity during the pandemic. Comparisons between controls and COVID-19 participants revealed a) no difference between groups concerning DRF in the pre-pandemic period and during the pandemic; b) no difference between groups concerning nightmare frequency in the pre-pandemic period; and c) COVID-19 participants reported significantly higher NF than controls during pandemic (p = 0.003). Additionally, we showed that a) anxiety, depression, post-traumatic stress-disorder (PTSD) symptom scores were higher in COVID-19 participants than controls; and b) quality of life and health as well as wellbeing (WHO-5) scores were significantly higher in controls than COVID-19 participants. Finally, ordinal logistic regression indicates that DRF (p < 0.001), PTSD (p < 0.001), anxiety (p = 0.018), insomnia (p = 0.039), COVID-19 severity (p = 0.014), sleep duration (p = 0.003) and age (p = 0.001) predicted NF.Discussion: Our work shows strong associations between increased nightmares in those reporting having had COVID-19. This suggests that the more that people were affected by COVID-19, the greater the impact upon dream activity and quality of life.Keywords: dreaming, pandemic, sleep, PTSD, anxiety, COVID-19 severity

Luiz Eduardo Mateus Brandão,1 Teemu Martikainen,1 Ilona Merikanto,2– 4 Brigitte Holzinger,5,6 Charles M Morin,7– 9 Colin A Espie,10,11 Courtney J Bolstad,12 Damien Leger,13 Frances Chung,14 Giuseppe Plazzi,15 Yves Dauvilliers,16 Kentaro Matsui,17,18 Luigi De Gennaro,19– 21 Mariusz Sieminski,22 Michael R Nadorff,12,23 Ngan Yin Chan,24 Yun Kwok Wing,24 Sérgio Arthuro Mota-Rolim,25– 27 Yuichi Inoue,28 Markku Partinen,29,30 Christian Benedict,31 Bjorn Bjorvatn,32,33 Jonathan Cedernaes1,34 1Department of Medical Sciences, Uppsala University, Uppsala, Sweden; 2Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland; 3Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland; 4Orton Orthopaedic Hospital, Helsinki, Finland; 5ZK-Schlafcoaching, Medical University Vienna, Vienna, Austria; 6Institute for Consciousness and Dream Research, Vienna, Austria; 7École de Psychologie, Université Laval, Québec, Canada; 8Centre d’étude des troubles du sommeil, Université Laval, Québec, Canada; 9Centre de recherche CERVO/Brain Research Center, Université Laval, Québec, Canada; 10Sleep & Circadian Institute, University of Oxford, Oxford, UK; 11Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; 12Department of Psychology, Mississippi State University, Starkville, MS, USA; 13APHP, VIFASOM, Hôtel-Dieu, Centre du Sommeil et de la Vigilance, Université de Paris, Paris, France; 14Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; 15Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy; 16Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, Montpellier, France; 17National Center of Neurology and Psychiatry National Institute of Mental Health, Department of Clinical Laboratory and Department of Sleep-Wake Disorders, Tokyo, Japan; 18Tokyo Women’s Medical University, Department of Psychiatry, Tokyo, Japan; 19Department of Psychology, Sapienza University of Rome, Rome, Italy; 20IRCCS Fondazione Santa Lucia, Rome, Italy; 21IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 22Department of Emergency Medicine, Medical University of Gdansk, Gdansk, Poland; 23Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; 24Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People’s Republic of China; 25Brain Institute, Federal University of Rio Grande do Norte, Natal, RN, Brazil; 26Physiology and Behaviour Department, Federal University of Rio Grande do Norte, Natal, RN, Brazil; 27Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, RN, Brazil; 28Department of Somnology, Tokyo Medical University, Tokyo, Japan; 29Helsinki Sleep Clinic, Vitalmed Research Center, Terveystalo Biobank and Research, Helsinki, Finland; 30Department of Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland; 31Sleep Science Laboratory, Department of Neuroscience, Uppsala University, Uppsala, Sweden; 32Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; 33Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway; 34Department of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USACorrespondence: Jonathan Cedernaes Email jonathan.cedernaes@medsci.uu.sePurpose: Lifestyle and work habits have been drastically altered by restrictions due to the COVID-19 pandemic. Whether the associated changes in sleep timing modulate the risk of suffering from symptoms of insomnia, the most prevalent sleep disorder, is however incompletely understood. Here, we evaluate the association between the early pandemic-associated change in 1) the magnitude of social jetlag (SJL) – ie, the difference between sleep timing on working vs free days – and 2) symptoms of insomnia.Patients and Methods: A total of 14,968 anonymous participants (mean age: 40 years; 64% females) responded to a standardized internet-based survey distributed across 14 countries. Using logistic multivariate regression, we examined the association between the degree of social jetlag and symptoms of insomnia, controlling for important confounders like social restriction extension, country specific COVID-19 severity and psychological distress, for example.Results: In response to the pandemic, participants reported later sleep timing, especially during workdays. Most participants (46%) exhibited a reduction in their SJL, whereas 20% increased it; and 34% reported no change in SJL. Notably, we found that both increased and decreased SJL, as a result of the COVID-19 pandemic, were associated with later sleep midpoint (indicating a later chronotype) as well as more recurrent and moderate-to-severe symptoms of insomnia (about 23– 54% higher odds ratio than subjects with unchanged SJL). Primarily those with reduced SJL shifted their bedtimes to a later timepoint, compared with those without changes in SJL.Conclusion: Our findings offer important insights into how self-reported changes to the stability of sleep/wake timing, as reflected by changes in SJL, can be a critical marker of the risk of experiencing insomnia-related symptoms – even when individuals manage to reduce their social jetlag. These findings emphasize the clinical importance of analyzing sleep-wake regularity.Keywords: BNSQ, ISI, midsleep, MSFsc, PHQ-4, psychological distress

Eirin Fränkl,1 Serena Scarpelli,2 Michael R Nadorff,3,4 Bjørn Bjorvatn,5 Courtney J Bolstad,3 Ngan Yin Chan,6 Frances Chung,7 Yves Dauvilliers,8 Colin A Espie,9 Yuichi Inoue,10,11 Damien Leger,12,13 Tainá Macêdo,14 Kentaro Matsui,15,16 Ilona Merikanto,17– 19 Charles M Morin,20 Sérgio Mota-Rolim,21 Markku Partinen,22,23 Thomas Penzel,24 Giuseppe Plazzi,25,26 Mariusz Sieminski,27 Yun Kwok Wing,6 Luigi De Gennaro,2,28 Brigitte Holzinger1,29 1Institute for Consciousness and Dream Research, Vienna, Austria; 2Department of Psychology, Sapienza University of Rome, Rome, Italy; 3Mississippi State University, Mississippi State, MS, USA; 4Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; 5Department of Global Public Health and Primary Care, University of Bergen, and Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway; 6Li Chiu Kong Family Sleep Assessment Unit, Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, People’s Republic of China; 7Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Canada; 8Sleep-Wake Disorders Center, Department of Neurology, Gui-de-Chauliac Hospital, Institute for Neurosciences of Montpellier INM, INSERM, University of Montpellier, Montpellier, France; 9Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; 10Department of Somnology, Tokyo Medical University, Tokyo, Japan; 11Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan; 12Université de Paris, VIFASOM (EA 7331 Vigilance Fatigue, Sommeil et Santé Publique), Paris, France; 13APHP, Hotel-Dieu de Paris, Centre du Sommeil et de la Vigilance, Paris, France; 14Department of Psychology, Federal University of Rio Grande do Norte, Natal, Brazil; 15Department of Clinical Laboratory and Department of Sleep-Wake Disorders, National Center of Neurology and Psychiatry National Institute of Mental Health, Kodaira, Japan; 16Department of Psychiatry, Tokyo Women’s Medical University, Tokyo, Japan; 17Sleep Well Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; 18Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland; 19Orton Orthopaedics Hospital, Helsinki, Finland; 20École de Psychologie, Centre d’étude des troubles du sommeil, Centre de recherche CERVO/Brain Research Center, Université Laval, Québec, Canada; 21Brain Institute, Physiology and Behavior Department, and Onofre Lopes University Hospital, Federal University of Rio Grande do Norte, Natal, Brazil; 22Helsinki Sleep Clinic, Terveystalo Healthcare, Helsinki, Finland; 23Department of Neurosciences, Clinicum, University of Helsinki, Helsinki, Finland; 24Sleep Medicine Center, Charité Universitätsmedizin Berlin, Berlin, Germany; 25IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 26Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; 27Department of Emergency Medicine, Medical University of Gdansk, Gdansk, Poland; 28IRCCS Fondazione Santa Lucia, Rome, Italy; 29Medical University Vienna, ZK-Schlafcoaching, Vienna, AustriaCorrespondence: Brigitte HolzingerInstitute for Consciousness and Dream Research, Canongasse 13/1, Vienna, 1180, AustriaTel +43699-101 99 042Fax +4301-25330334600Email brigitte.holzinger@meduniwien.ac.atObjective: Many have reported odd dreams during the pandemic. Given that dreams are associated with mental health, understanding these changes could provide crucial information about wellbeing during the pandemic. This study explored associations between COVID-19 and dream recall frequency (DRF), and related social, health, and mental health factors.Methods: We conducted a cross-sectional web survey of 19,355 individuals in 14 countries from May to July 2020. We collected data on COVID-19, mental health, sleep and DRF during the pandemic. We performed McNemar Tests to compare low (< 3 nights per week) and high DRF (≥ 3 nights per week) before and during COVID-19 and to evaluate changes in sleep variables segmented by DRF. Chi-square tests were conducted to compare characteristics between low and high DRF. Logistic regression analyses were conducted to examine associations between various independent variables and DRF.Results: Reports of high DRF during the pandemic were higher than before the pandemic (P< 0.001). Female gender (aOR=1.25, 95% CI 1.10– 1.41), nightmares (aOR=4.22, 95% CI 3.45– 5.17), sleep talking (aOR= 2.36, 1.73– 3.23), sleep maintenance problems (aOR=1.34, 95% CI 1.15– 1.56), symptoms of REM sleep behavior disorder (RBD; aOR=1.24, 95% CI 1.09– 1.41) and repeated disturbing thoughts (posttraumatic stress disorder (PTSD) symptoms) were associated with high DRF. Age group 55– 64 years (aOR=0.69, 95% CI 0.58– 0.83) reported less high DRF than younger participants. Unadjusted OR showed associations between depression, anxiety, and DRF; however, in adjusted regression depression (aOR= 0.71, 0.59– 0.86) and anxiety (aOR=0.79, 95% CI 0.66– 0.94) were negatively associated with high DRF.Conclusion and Relevance: DRF was higher than pre-pandemic levels across four continents. DRF was associated with gender and parasomnias like nightmares and RBD symptoms, sleep maintenance problems, PTSD symptoms and negatively associated with depression and anxiety. The results implicate that COVID-19 is reflected in our dreams as an expression of the emotional intensity of the pandemic.Keywords: sleep, sleep disorder, mental health, parasomnia, collective threat

Milena Camaioni,1 Serena Scarpelli,1 Maurizio Gorgoni,1 Valentina Alfonsi,2 Luigi De Gennaro1,2 1Department of Psychology, Sapienza University of Rome, Rome, Italy; 2IRCCS Fondazione Santa Lucia, Rome, ItalyCorrespondence: Luigi De GennaroDepartment of Psychology, Sapienza University of Rome, Via dei Marsi, 78, Rome, 00185, ItalyTel +39-06-49917647Fax +39-06-49917711Email luigi.degennaro@uniroma1.itIntroduction: Non-rapid eye movement (NREM) parasomnias are defined as abnormal nocturnal behaviors that typically arise from the NREM sleep stage 3 during the first sleep cycle. The polysomnographic studies showed an increase in sleep fragmentation and an atypical slow wave activity (SWA) in participants with NREM parasomnias compared to healthy controls. To date, the pathophysiology of NREM parasomnias is still poorly understood. The recent investigation of the EEG patterns immediately before parasomnia events could shed light on the motor activations’ processes. This systematic review aims to summarize empirical evidence about these studies and provide an overview of the methodological issues.Methods: A systematic literature search was carried out in PubMed, Web of Science, and Scopus, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The documents obtained were evaluated using the Newcastle–Ottawa Scale (NOS).Results: Nine studies were included in the qualitative synthesis. The major evidence revealed an increased slow frequency EEG activity immediately before the motor activations in frontal and central areas and increased beta activity in the anterior cingulate cortices.Discussion: The investigation of EEG patterns before parasomniac episodes could provide new insight into the study of NREM parasomnia pathophysiology. The high- and low-frequency EEG increase before the episodes could represent a predictive electrophysiological pattern of the motor activations’ onset. Overall, identifying specific sleep markers before parasomnias might also help differentiate between NREM parasomnias and other motor sleep disorders. Different methodological protocols should be integrated for overcoming the lack of consistent empirical findings. Thus, future studies should focus on the topographical examination of canonical EEG frequency bands to better understand spatial and time dynamics before the episodes and identify the networks underlying the onset of activations.Keywords: NREM parasomnias, episodes, motor activations, sleep EEG, polysomnography, electroencephalography

Valentina Alfonsi,1,2 Rossella Palmizio,3 Annalisa Rubino,3 Serena Scarpelli,2 Maurizio Gorgoni,1 Aurora D’Atri,4 Mariella Pazzaglia,1,2 Michele Ferrara,4 Salvatore Giuliano,3 Luigi De Gennaro1,2 1Department of Psychology, “Sapienza” University of Rome, Rome, Italy; 2I.R.C.C.S. Fondazione Santa Lucia, Rome, Italy; 3I.I.S.S. “Ettore Majorana”, Brindisi, Italy; 4Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, ItalyCorrespondence: Luigi De Gennaro“Sapienza” University of Rome, Via Dei Marsi, 78, Rome 00185, ItalyTel (+39) 06-49917647Fax (+39) 06-49917711Email luigi.degennaro@uniroma1.itPurpose: In adolescence, physiological (circadian and homeostatic regulation of sleep) and social habits contribute to delayed sleep onset, while social obligations impose early sleep offset. The effects of delayed school start time on the subjective/objective measures of sleep–wake patterns and academic achievement have not been established.Methods: This pre-, post-, and longitudinal non-randomized study included an early (8:00 am; ESC=30 students) and the late (9:00 am; LSC=21 students) start class. Multiple sleep data included a weekly sleep diary, Karolinska Sleepiness Scale, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. Sustained attention was measured using the Psychomotor Vigilance Task. Academic performance was evaluated by two different mathematical and scientific standard tests (entrance and final) and by school attendance indicators. Data were collected at monthly intervals from October 2018 to May 2019 and the beginning and end of the academic year (pre/post).Results: All students turned their lights off at similar times (LSC=11:21pm, ESC=11:11pm), but LSC students woke up later (7:23am) than ESC students (6:55am; F1,48=11.81, p=0.001) on school days. The groups did not differ in total sleep duration on non-school days. Longitudinal measures revealed a significant increase (8.9%, 34 min) in total sleep duration of LSC students across the academic year. ESC students maintained approximately the same sleep duration. Furthermore, changes in sleep duration had parallelled significant differences in sustained attention, with LSC students outperforming ESC students. Longitudinal changes of sleep and sustained attention were associated with a coherent pattern of changes in academic performance.Conclusion: Findings indicate that a one-hour delay in school start time is associated with longer sleep, better diurnal sustained attention, attendance, and improved academic performance. Notably, sleep changes were limited to school days. A delay in school start time should be seriously considered to improve sleep and academic achievements of students.Keywords: sleep, school start time, attention, school health, sleep loss, adolescence

Serena Scarpelli,1,2 Chiara Bartolacci,1 Aurora D’Atri,1,3 Milena Camaioni,1 Ludovica Annarumma,1 Maurizio Gorgoni,1 Chiara Cloos,1 Michele Ferrara,3 Luigi De Gennaro1,2 1Department of Psychology, Sapienza University of Rome, Rome 00185, Italy; 2IRCCS Fondazione Santa Lucia, Rome, Italy; 3Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Coppito, L’Aquila 67100, ItalyCorrespondence: Luigi De GennaroDepartment of Psychology, Sapienza University of Rome, Via Dei Marsi, 78, Rome 00185, ItalyTel +39-06-49917647Fax +39-06-49917711Email luigi.degennaro@uniroma1.itPurpose: In the current study, we aimed to investigate the EEG correlates of dream recall (DR) monitoring both the homeostatic and state-trait like factors. We assessed the influence of the time of night on the EEG correlates of DR from REM sleep. Specifically, we tested the continuity-hypothesis (on the theta EEG band) and the activation-hypothesis (on the delta and beta bands).Methods: Twenty-seven subjects underwent polysomnography with multiple provoked awakenings during REM sleep. Only the subjects showing combinations of dream recall (REC) and non-REC (NREC) conditions in both first (1st– 2nd sleep cycle) and second (3rd– 4th sleep cycle) part of the night were included in the analyses. The final sample was composed of 10 subjects (mean age 24± 0.70). EEG power spectra of the 5-min of REM sleep preceding each awakening were computed by a fast Fourier transform. The following frequency bands were considered: delta (0.50– 4.75 Hz), theta (5.00– 7.75 Hz), and beta (16.00– 24.75 Hz). We also calculated the delta/beta power ratio as an integrated EEG index of activation.Results: The 2× 2 within-subjects ANOVA recall × time revealed: a) no significant effect for time and no interaction; b) significant differences over the occipital area in the beta band; c) significant differences over the parietal area for the activation index values. Overall, the results indicated that DR is associated with higher activation regardless of homeostatic pressure across the night of sleep.Conclusion: In line with recent findings, we have shown that DR is predicted by desynchronized EEG activity during REM sleep, providing clear evidence in favor of the activation-hypothesis. We have also confirmed that the EEG pattern of DR can be ascribed to state-like factors. Further studies should assess whether homeostatic modulation may interact with some dream features and the related EEG predictors.Keywords: dream recall, REM sleep, EEG, activation hypothesis, multiple awakenings, sleep homeostasis

Federico Salfi,1 Marco Lauriola,2 Daniela Tempesta,1 Pierpaolo Calanna,3 Valentina Socci,1 Luigi De Gennaro,4 Michele Ferrara1 1Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy; 2Department of Social and Developmental Psychology, Sapienza University of Rome, Rome, Italy; 3Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy; 4Department of Psychology, Sapienza University of Rome, Rome, ItalyCorrespondence: Michele FerraraDepartment of Biotechnological and Applied Clinical Sciences, University of L’Aquila, Via Vetoio (Coppito 2), Coppito 67100, AQ, ItalyEmail michele.ferrara@univaq.itStudy Objectives: To evaluate the effects of total and partial sleep deprivation on reflection impulsivity and risk-taking in tasks requiring deliberative decision-making processes.Participants and Methods: Seventy-four healthy young adults were selected to participate in two independent experiments, each consisting of a crossover design. In Experiment 1, 32 participants were tested after one night of regular sleep (RS), and after one night of total sleep deprivation (TSD). In Experiment 2, 42 participants were tested following five nights of RS and after five nights of partial sleep deprivation (PSD), implying five hours of sleep per night. In both the experiments, two deliberative decision-making tasks were administered, involving different decision-making constructs. The Mosaic Task (MT) assessed reflection impulsivity, the tendency to gather information before making a decision. The Columbia Card Task cold version (CCTc) evaluated risk-taking propensity in a dynamic environment.Results: Unlike TSD, PSD led to an increment of reflection impulsivity and risk-taking. Nevertheless, analyses taking into account the individuals’ baseline (RS) performance showed consistent results between the two experimental sleep manipulations. Participants who gathered more information to make decisions in the MT when well-rested, then relied on less evidence under sleep loss, and more cautious participants in the CCTc tended to make riskier decisions.Conclusion: Results pointed to differential consequences of sleep deprivation depending on the habitual way to respond during decision-making involving deliberative reasoning processes. Results were interpreted according to a putative interaction between sleep loss effect and individual difference factors.Keywords: sleep deprivation, sleep restriction, reflection impulsivity, risk-taking, deliberative decision-making, individual differences

Aurora D’Atri,1,2 Serena Scarpelli,1 Maurizio Gorgoni,1 Valentina Alfonsi,1 Ludovica Annarumma,1 Anna Maria Giannini,1 Michele Ferrara,3 Fabio Ferlazzo,1 Paolo Maria Rossini,4,5 Luigi De Gennaro1,2 1Department of Psychology, University of Rome “Sapienza”, Rome, Italy; 2Area of Neuroscience, IRCCS San Raffaele Pisana, Rome, Italy; 3Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy; 4Institute of Neurology, Catholic University of the Sacred Heart, Rome, Italy; 5Department Geriatrics, Neuroscience & Orthopaedics, Policlinic A. Gemelli Foundation-IRCCS, Rome, ItalyCorrespondence: Luigi De GennaroDepartment of Psychology, University of Rome “Sapienza”, Via Dei Marsi, 78, Rome 00185, Italy, Tel +39 06-49917647Fax +39 06-49917711Email luigi.degennaro@uniroma1.itPurpose: Recent studies demonstrate that 5-Hz bilateral transcranial alternating current stimulation (θ-tACS) on fronto-temporal areas affects resting EEG enhancing cortical synchronization, but it does not affect subjective sleepiness. This dissociation raises questions on the resemblance of this effect to the physiological falling asleep process. The current study aimed to evaluate the ability of fronto-temporal θ-tACS to promote sleep.Subjects and methods: Twenty subjects (10 F/10 M; mean age: 24.60 ± 2.9 y) participated in a single-blind study consisting of two within-subject sessions (active/sham), one week apart in counterbalanced order. Stimulation effects on EEG were assessed during wake and post-stimulation nap. The final sample included participants who fell asleep in both sessions (n=17).Results: Group analyses on the whole sample reported no θ-tACS effects on subjective sleepiness and sleep measures, while a different scenario came to light by analysing data of responders to the stimulation (ie, subjects actually showing the expected increase of theta activity in the wake EEG after the θ-tACS, n=7). Responders reported a significant increase in subjective sleepiness during wakefulness after the active stimulation as compared to the sham. Moreover, the sleep after the θ-tACS compared to sham in this sub-group showed: (1) greater slow-wave activity (SWA); (2) SWA time-course revealing increases much larger as closer to the sleep onset; (3) stimulation-induced changes in SWA during sleep topographically associated to those in theta activity during wake.Conclusion: Subjects who show the expected changes during wake after the stimulation also had a consistent pattern of changes during sleep. The enhancement of cortical synchronization by θ-tACS during wakefulness actually corresponds to increased sleep pressure, but it occurs only in some individuals. Thus, θ-tACS can enhance sleep, although individual factors to be further investigated affect the actual responsiveness to this treatment.Keywords: transcranial alternating current stimulation, sleep, EEG, slow-wave activity, sleep onset

Anastasia Mangiaruga, Serena Scarpelli, Chiara Bartolacci, Luigi De Gennaro Department of Psychology, University of Rome “Sapienza”, Rome, Italy Abstract: Brain and sleep maturation covary across different stages of life. At the same time, dream generation and dream recall are intrinsically dependent on the development of neural systems. The aim of this paper is to review the existing studies about dreaming in infancy, adulthood, and the elderly stage of life, assessing whether dream mentation may reflect changes of the underlying cerebral activity and cognitive processes. It should be mentioned that some evidence from childhood investigations, albeit still weak and contrasting, revealed a certain correlation between cognitive skills and specific features of dream reports. In this respect, infantile amnesia, confabulatory reports, dream-reality discerning, and limitation in language production and emotional comprehension should be considered as important confounding factors. Differently, growing evidence in adults suggests that the neurophysiological mechanisms underlying the encoding and retrieval of episodic memories may remain the same across different states of consciousness. More directly, some studies on adults point to shared neural mechanisms between waking cognition and corresponding dream features. A general decline in the dream recall frequency is commonly reported in the elderly, and it is explained in terms of a diminished interest in dreaming and in its emotional salience. Although empirical evidence is not yet available, an alternative hypothesis associates this reduction to an age-related cognitive decline. The state of the art of the existing knowledge is partially due to the variety of methods used to investigate dream experience. Very few studies in elderly and no investigations in childhood have been performed to understand whether dream recall is related to specific electrophysiological pattern at different ages. Most of all, the lack of longitudinal psychophysiological studies seems to be the main issue. As a main message, we suggest that future longitudinal studies should collect dream reports upon awakening from different sleep states and include neurobiological measures with cognitive performances. Keywords: dreaming, sleep mentation, development, sleep, continuity hypothesis, aging

Nicola Tarantino,1 Francesco Santoro,1,2 Luisa De Gennaro,3 Michele Correale,1 Francesca Guastafierro,1 Antonio Gaglione,1 Matteo Di Biase,1 Natale Daniele Brunetti1 1University of Foggia, Foggia, Italy; 2Asklepios Klinik – St Georg, Hamburg, Germany; 3Ospedale San Paolo, Bari, Italy Abstract: Lipids disorder is the principal cause of atherosclerosis and may present with several forms, according to blood lipoprotein prevalence. One of the most common forms is combined dyslipidemia, characterized by high levels of triglycerides and low level of high-density lipoprotein. Single lipid-lowering drugs may have very selective effect on lipoproteins; hence, the need to use multiple therapy against dyslipidemia. However, the risk of toxicity is a concerning issue. In this review, the effect and safety of an approved combination therapy with simvastatin plus fenofibrate are described, with an analysis of pros and cons resulting from randomized multicenter trials, meta-analyses, animal models, and case reports as well. Keywords: fibrates, simvastatin, fixed-dose combination, combined dyslipidemia, review