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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

Giorgia Varallo,1 Carlos Suso-Ribera,2 Ada Ghiggia,3 Marco Veneruso,4 Roberto Cattivelli,5 Anna Guerrini Usubini,6,7 Christian Franceschini,1 Alessandro Musetti,8 Giuseppe Plazzi,9,10 Jacopo Maria Fontana,11 Paolo Capodaglio,11,12 Gianluca Castelnuovo6,7 1Department of Medicine and Surgery, University of Parma, Parma, 43121, Italy; 2Department of Basic and Clinical Psychology and Psychobiology, Jaume I University, Castellon de la Plana, 12071, Spain; 3Department of Life Sciences, University of Trieste, Trieste, 34127, Italy; 4Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy; 5Department of Psychology, University of Bologna, Bologna, 40127, Italy; 6Department of Psychology, Catholic University of Milan, Milan, 20123, Italy; 7Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, 28824, Italy; 8Department of Humanities, Social Sciences and Cultural Industries, University of Parma, Parma, 43125, Italy; 9Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy; 10IRCCS Istituto delle Scienze Neurologiche di Bologna (ISNB), Bologna, 40139, Italy; 11Istituto Auxologico Italiano IRCCS, Orthopaedic Rehabilitation Unit and Research Laboratory in Biomechanics and Rehabilitation, San Giuseppe Hospital, Verbania, 28824, Italy; 12Department of Surgical Sciences, Physical and Rehabilitation Medicine, University of Turin, Turin, 10121, ItalyCorrespondence: Jacopo Maria Fontana, San Giuseppe Hospital, Strada Cadorna 90, Verbania, 28824, Italy, Tel +39 0323 514 331, Email j.fontana@auxologico.itPurpose: Individuals with fibromyalgia and obesity experience significant impairment in physical functioning. Pain catastrophizing, kinesiophobia, and pain acceptance have all been identified as important factors associated with the level of disability. The objective of this study was to evaluate the role of pain catastrophizing, kinesiophobia, and pain acceptance as mediators of the association between perceived pain severity and physical functioning in individuals with fibromyalgia and obesity.Patients and Methods: In this cross-sectional study, 165 women with fibromyalgia and obesity completed self-report questionnaires of perceived pain severity (ie, Numeric Pain Rating Scale), pain catastrophizing (ie, Pain Catastrophizing Scale), kinesiophobia (ie Tampa Scale of Kinesiophobia), pain acceptance (ie, Chronic Pain Acceptance Questionnaire), and perceived physical functioning (ie, Physical Functioning subscale of the Fibromyalgia Impact Questionnaire). In addition, a performance-based test (ie, 6-minute walking test) was conducted to assess objective physical functioning. Two multiple mediation analyses were performed.Results: Pain acceptance and kinesiophobia mediated the relationship between pain severity and self-reported physical functioning. Pain catastrophizing and kinesiophobia mediated the relationship between pain severity and performance-based functioning.Conclusion: Pain acceptance, kinesiophobia, and pain catastrophizing should be addressed in rehabilitative intervention to improve physical functioning. Interestingly, the subjective and objective aspects of physical functioning are influenced by different factors. Therefore, interventions for women with fibromyalgia and obesity should focus on factors related to both subjective and performance-based physical functioning.Keywords: chronic pain, fear-avoidance model, fibromyalgia, functioning, obesity, psychological flexibility model

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

Zhongxing Zhang,1 Yves Dauvilliers,2– 4 Giuseppe Plazzi,5,6 Geert Mayer,7 Gert Jan Lammers,8,9 Joan Santamaria,10 Markku Partinen,11 Sebastiaan Overeem,12,13 Rafael del Rio Villegas,14 Karel Sonka,15 Rosa Peraita-Adrados,16 Raphaël Heinzer,17 Aleksandra Wierzbicka,18 Birgit Högl,19 Mauro Manconi,20 Eva Feketeova,21 Antonio Martins da Silva,22 Jitka Bušková,23 Claudio LA Bassetti,24,25 Lucie Barateau,2– 4 Fabio Pizza,5,26 Elena Antelmi,5,6 Jari K Gool,8,9 Rolf Fronczek,8,9 Carles Gaig,10 Ramin Khatami1,24 1Center for Sleep Medicine, Sleep Research and Epileptology, Klinik Barmelweid AG, Barmelweid, Aargau, Switzerland; 2Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France; 3National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; 4Institute for Neurosciences of Montpellier INM, Univ Montpellier, INSERM, Montpellier, France; 5Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; 6IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 7Neurology Department, Hephata Klinik, Schwalmstadt, Germany; 8Sleep Wake Center SEIN Heemstede, Stichting Epilepsie Instellingen Nederland, Heemstede, the Netherlands; 9Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands; 10Neurology Service, Institut de Neurociències Hospital Clínic, University of Barcelona, Barcelona, Spain; 11Helsinki Sleep Clinic, Vitalmed Research Center, Helsinki, Finland; 12Sleep Medicine Center Kempenhaeghe, Heeze, the Netherlands; 13Eindhoven University of Technology, Eindhoven, the Netherlands; 14Neurophysiology and Sleep Disorders Unit, Hospital Vithas Nuestra Señora de América, Madrid, Spain; 15Neurology Department and Centre of Clinical Neurosciences, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic; 16Sleep and Epilepsy Unit – Clinical Neurophysiology Service, University General Hospital Gregorio Marañón, Research Institute Gregorio Marañón, University Complutense of Madrid, Madrid, Spain; 17Center for Investigation and Research in Sleep, Lausanne University Hospital, Lausanne, Vaud, Switzerland; 18Department of Clinical Neurophysiology, Institute of Psychiatry and Neurology, Warsaw, Poland; 19Neurology Department, Sleep Disorders Clinic, Innsbruck Medical University, Innsbruck, Austria; 20Neurology Department, EOC, Ospedale Regionale di Lugano, Lugano, Ticino, Switzerland; 21Neurology Department, Medical Faculty of P. J. Safarik University, University Hospital of L. Pasteur Kosice, Kosice, Slovak Republic; 22Serviço de Neurofisiologia, Hospital Santo António/Centro Hospitalar Universitário do Porto and UMIB-Instituto Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal; 23Department of Sleep Medicine, National Institute of Mental Health, Klecany, Czech Republic; 24Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; 25Department of Neurology, Sechenov First Moscow State University, Moscow, Russia; 26Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, ItalyCorrespondence: Yves Dauvilliers, National Reference Network for Narcolepsy, Sleep-Disorders Center, Department of Neurology, Hopital Gui de Chauliac, INSERM U1061, Montpellier, UM1, France, Email ydauvilliers@yahoo.fr Ramin Khatami, Center for Sleep Medicine, Sleep Research and Epileptology, Klinik Barmelweid AG, Barmelweid, CH-5017, Switzerland, Email ramin.khatami@barmelweid.chPurpose: Narcolepsy type-1 (NT1) is a rare chronic neurological sleep disorder with excessive daytime sleepiness (EDS) as usual first and cataplexy as pathognomonic symptom. Shortening the NT1 diagnostic delay is the key to reduce disease burden and related low quality of life. Here we investigated the changes of diagnostic delay over the diagnostic years (1990– 2018) and the factors associated with the delay in Europe.Patients and Methods: We analyzed 580 NT1 patients (male: 325, female: 255) from 12 European countries using the European Narcolepsy Network database. We combined machine learning and linear mixed-effect regression to identify factors associated with the delay.Results: The mean age at EDS onset and diagnosis of our patients was 20.9± 11.8 (mean ± standard deviation) and 30.5± 14.9 years old, respectively. Their mean and median diagnostic delay was 9.7± 11.5 and 5.3 (interquartile range: 1.7− 13.2 years) years, respectively. We did not find significant differences in the diagnostic delay over years in either the whole dataset or in individual countries, although the delay showed significant differences in various countries. The number of patients with short (≤ 2-year) and long (≥ 13-year) diagnostic delay equally increased over decades, suggesting that subgroups of NT1 patients with variable disease progression may co-exist. Younger age at cataplexy onset, longer interval between EDS and cataplexy onsets, lower cataplexy frequency, shorter duration of irresistible daytime sleep, lower daytime REM sleep propensity, and being female are associated with longer diagnostic delay.Conclusion: Our findings contrast the results of previous studies reporting shorter delay over time which is confounded by calendar year, because they characterized the changes in diagnostic delay over the symptom onset year. Our study indicates that new strategies such as increasing media attention/awareness and developing new biomarkers are needed to better detect EDS, cataplexy, and changes of nocturnal sleep in narcolepsy, in order to shorten the diagnostic interval.Keywords: cataplexy, diagnostic delay, misdiagnosis, symptom onset, machine learning

Anna Guerrini Usubini,1,2 Grazia Terrone,3 Giorgia Varallo,1,2 Roberto Cattivelli,4 Giuseppe Plazzi,5,6 Gianluca Castelnuovo,1,2 Adriano Schimmenti,7 Alessandro Musetti,8 Christian Franceschini9 1Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, Milan, Italy; 2Department of Psychology, Catholic University of Milan, Milan, Italy; 3Department of History, Cultural Heritage, Education and Society, University of Rome Tor Vergata, Rome, Italy; 4Department of Psychology, University of Bologna, Bologna, 40127, Italy; 5Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy; 6IRCCS Institute of Neurological Sciences of Bologna (ISNB), Bologna, 40139, Italy; 7Faculty of Human and Social Sciences, UKE—Kore University of Enna, Cittadella Universitaria, Enna, Italy; 8Department of Humanities, Social Sciences and Cultural Industries, University of Parma, Parma, Italy; 9Department of Medicine and Surgery, University of Parma, Parma, ItalyCorrespondence: Alessandro Musetti, Department of Humanities, Social Sciences and Cultural Industries, University of Parma, Borgo Carissimi 10, Parma, 43121, Italy, Tel +39 0521 034820, Email alessandro.musetti@unipr.itPurpose: The present study aimed to explore the mediating role of emotion dysregulation and problematic Internet use in the relationship between negative affect and excessive daytime sleepiness.Methods: This cross-sectional study included 664 Italian adults aged between 18 and 70 years (M = 32.13; SD = 11.71). Participants were asked to complete the Depression Anxiety Stress Scale, the Difficulties in Emotion Regulation Scale, the Compulsive Internet Use Scale-7, and the Epworth Sleepiness Scale to assess negative affect, emotion dysregulation, problematic internet use, and excessive daytime sleepiness, respectively.Results: According to our results there are significant associations between negative affect, emotion dysregulation, problematic Internet use, and daytime sleepiness. Moreover, the structural equation model showed good fit indices. Emotion dysregulation and problematic Internet use partially mediated the relationship between negative mood and excessive daytime sleepiness.Conclusion: By exploring the role of emotion dysregulation on the association between excessive daytime sleepiness and its possible predictors, our study might represent an important step toward the implementation of psychological intervention for reducing excessive daytime sleepiness. Emotion dysregulation appears to play a significant role in explaining the relationship between negative affect, problematic Internet use, and excessive daytime sleepiness. Thus, it should be considered a treatment target for reducing excessive daytime sleepiness.Keywords: negative affect, psychological distress, excessive daytime sleepiness, emotion dysregulation, problematic Internet use

Vittorio Lenzo,1 Alberto Sardella,2 Alessandro Musetti,3 Maria Francesca Freda,4 Daniela Lemmo,4 Elena Vegni,5 Lidia Borghi,5 Giuseppe Plazzi,6,7 Laura Palagini,8,9 Gianluca Castelnuovo,10,11 Roberto Cattivelli,12 Rachele Mariani,13 Giovanni Michelini,14 Tommaso Manari,3 Emanuela Saita,10 Maria C Quattropani,15 Christian Franceschini16 1Department of Social and Educational Sciences of the Mediterranean Area, University for Foreigners “Dante Alighieri” of Reggio Calabria, Reggio, Calabria, Italy; 2Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy; 3Department of Humanities, Social Sciences and Cultural Industries, University of Parma, Parma, Italy; 4Department of Humanistic Studies, University of Naples Federico II, Naples, Italy; 5Department of Health Sciences, University of Milan, Milan, Italy; 6Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; 7IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 8Department of Clinical and Experimental Medicine, Psychiatric Section, University of Pisa, Azienda Ospedaliera Universitaria Pisana (AUOP), Pisa, Italy; 9Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy; 10Department of Psychology, Catholic University of Milan, Milan, Italy; 11Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, Ospedale San Giuseppe, Verbania, Italy; 12Department of Psychology, University of Bologna, Bologna, Italy; 13Department of Dynamic and Clinical Psychology, University of Rome “La Sapienza”, Roma, Italy; 14Sigmund Freud University, Milano, Italy; 15Department of Educational Sciences, University of Catania, Catania, Italy; 16Department of Medicine and Surgery, University of Parma, Parma, ItalyCorrespondence: Vittorio LenzoDepartment of Social and Educational Sciences of the Mediterranean Area, University for Foreigners “Dante Alighieri” of Reggio Calabria, Via del Torrione 95, Reggio Calabria, 89125, ItalyEmail v.lenzo@unidarc.itPurpose: Previous studies showed poor sleep quality during the first Italian lockdown consequent to the quick spread of the virus. Poor sleep quality remained stable during the so-called “second wave”, which started in Autumn 2020. This study aimed to compare sleep quality between the two waves of contagions and to examine the effect of resilience, together with sociodemographic and COVID-related variables, on sleep quality during the second wave.Patients and Methods: A total of 648 participated in this longitudinal study through an online survey during the first lockdown consequent to the COVID-19 and during the second wave. The Medical Outcomes Study—Sleep Scale (MOS-SS) and the Resilience Scale (RS) were administered. Sociodemographic and COVID-related information were also collected.Results: The results showed sleep quality slightly increased in the second wave, even though with a small effect size. Correlational analysis showed that resilience is inversely correlated with sleep quality measured in the two waves. Sleep quality during the second wave was positively correlated with sleep quality in the first lockdown. Likewise, the results of multiple regression revealed that the sleep quality in the first lockdown and resilience were significant predictors of sleep quality during the second wave.Conclusion: These findings highlighted that the prevalence of poor sleepers remained high during the second wave. Together with the sleep quality in the first lockdown, resilience represents an important factor related to sleep quality during the second wave. Interventions to improve sleep quality among the general population should take into account these findings.Keywords: clinical psychology, health, sleep quality, resilience, longitudinal

Alessandro Musetti,1,&ast; Alessio Gori,2,&ast; Alessia Alessandra,3 Eleonora Topino,4 Grazia Terrone,5 Giuseppe Plazzi,6,7 Marco Cacioppo,4 Christian Franceschini3 1Department of Humanities, Social Sciences and Cultural Industries, University of Parma, Parma, Italy; 2Department of Health Sciences, University of Florence, Florence, Italy; 3Department of Medicine and Surgery, University of Parma, Parma, Italy; 4Department of Human Sciences, Lumsa University of Rome, Rome, Italy; 5Department of History, Cultural Heritage, Education and Society, University of Rome Tor Vergata, Rome, Italy; 6Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; 7IRCCS Institute of Neurological Sciences of Bologna (ISNB), Bologna, Italy&ast;These authors contributed equally to this workCorrespondence: Alessandro MusettiDepartment of Humanities, Social Sciences and Cultural Industries, University of Parma, Borgo Carissimi 10, Parma, 43121, Italy, Tel +39 0521 034820, Email alessandro.musetti@unipr.itPurpose: Although a link between problematic online pornographic use (POPU) and insomnia symptoms has been established, psychological and psychopathological mechanisms underlying this relationship are still not clear. Psychological stress and emotion dysregulation have been pointed out as relevant in the development and maintenance of insomnia. This study aims to explore the associations between POPU, psychological stress, emotion dysregulation and insomnia symptoms and to understand the mediating role of psychological stress and emotion dysregulation in the relationship between POPU and insomnia symptoms.Participants and Methods: A sample of 776 Italian adults aged 19– 48 years (51.4% female; M age = 28.49; SD = 7.33) completed questionnaires regarding demographics, COVID-19-related variables, POPU, psychological stress, emotion dysregulation, and insomnia symptoms.Results: After controlling for demographic covariates and COVID-19-related variables, multiple mediation model showed that higher psychological stress and emotion dysregulation fully mediated the link between POPU and insomnia.Conclusion: The findings underscore the significance of the negative consequences of POPU and underline the importance of working on this and its effects on psychological stress and emotion dysregulation to limit insomnia.Keywords: addictive behaviors, online pornography, problematic online pornographic use, stress, emotion dysregulation, clinical psychology, insomnia

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

Stefania Mondello,1 Firas H Kobeissy,2 Yehia Mechref,2 Jingfu Zhao,3 Samer El Hayek,4 Kazem Zibara,5 Monica Moresco,6,7 Giuseppe Plazzi,6 Filomena II Cosentino,8 Raffaele Ferri8 1Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy; 2Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon; 3Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, 79409, USA; 4Department of Psychiatry, American University of Beirut, Beirut, Lebanon; 5Department of Biology, Faculty of Sciences-I, PRASE, DSST, Lebanese University, Beirut, Lebanon; 6Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy; 7IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 8Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, ItalyCorrespondence: Raffaele FerriSleep Research Centre, Oasi Research Institute - IRCCS, Troina, 94018, ItalyTel +39 0935 936111Fax +39 0935 936231Email rferri@oasi.en.itPurpose: We performed comparative proteomic analyses of blood of patients with RLS and healthy individuals aiming to identify potential biomarker and therapeutic target candidate for RLS.Patients and Methods: Blood serum samples from 12 patients with a clinical diagnosis of RLS (8 females and 4 males, with a mean age of 68.52 years) and 10 healthy controls (5 females and 5 males, with a mean age of 67.61 years) underwent proteomic profiling by liquid chromatography coupled with tandem mass spectrometry. Pathway analysis incorporating protein–protein interaction networks was carried out to identify pathological processes linked to the differentially expressed proteins.Results: We quantified 272 proteins in patients with RLS and healthy controls, of which 243 were shared. Five proteins – apolipoprotein C-II, leucine-rich alpha-2-glycoprotein 1, FLJ92374, extracellular matrix protein 1, and FLJ93143 – were substantially increased in RLS patients, whereas nine proteins – vitamin D-binding protein, FLJ78071, alpha-1-antitrypsin, CD5 antigen-like, haptoglobin, fibrinogen alpha chain, complement factor H-related protein 1, platelet factor 4, and plasma protease C1 inhibitor – were decreased. Bioinformatics analyses revealed that these proteins were linked to 1) inflammatory and immune response, and complement activation, 2) brain-related development, cell aging, and memory disorders, 3) pregnancy and associated complications, 4) myocardial infarction, and 5) reactive oxygen species generation and subsequent diabetes mellitus.Conclusion: Our findings shed light on the multifactorial nature of RLS and identified a set of circulating proteins that may have clinical importance as biomarkers and therapeutic targets.Keywords: idiopathic restless legs syndrome, biomarkers, LC-MS/MS, proteome, interactome

Maria Pia Giannoccaro,1,2 Rocco Liguori,1,2 Giuseppe Plazzi,1,3 Fabio Pizza1,2 1IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy; 2Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; 3Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, ItalyCorrespondence: Giuseppe PlazziIRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, via Altura 3, Bologna, 40139, ItalyTel +39 051 4966926Fax +39 051 4966176Email giuseppe.plazzi@unibo.itAbstract: Narcolepsy type 1 (NT1) is a lifelong sleep disorder, primarily characterized clinically by excessive daytime sleepiness and cataplexy and pathologically by the loss of hypocretinergic neurons in the lateral hypothalamus. Despite being a rare disorder, the NT1-related burden for patients and society is relevant due to the early onset and chronic nature of this condition. Although the etiology of narcolepsy is still unknown, mounting evidence supports a central role of autoimmunity. To date, no cure is available for this disorder and current treatment is symptomatic. Based on the hypothesis of the autoimmune etiology of this disease, immunotherapy could possibly represent a valid therapeutic option. However, contrasting and limited results have been provided so far. This review discusses the evidence supporting the use of immunotherapy in narcolepsy, the outcomes obtained so far, current issues and future directions.Keywords: narcolepsy type 1, immunotherapy, immunomodulation, intravenous immunoglobulin, steroid, monoclonal antibodies

Anita D’Anselmo,1,2 Sergio Agnoli,2,3 Marco Filardi,1 Fabio Pizza,1,4 Serena Mastria,2,3 Giovanni Emanuele Corazza,2,3,5 Giuseppe Plazzi4,6 1Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy; 2Marconi Institute for Creativity (MIC), Bologna, Italy; 3Department of Electrical, Electronic, and Information Engineering “Guglielmo Marconi”, University of Bologna, Bologna, Italy; 4IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; 5Université de Paris and Univ Gustave Eiffel, LaPEA, Paris, France; 6Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, ItalyCorrespondence: Giuseppe PlazziIRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura N° 3, Bologna 40139, ItalyTel +39 051 4966929Fax +39 051 4966176Email giuseppe.plazzi@unibo.itPurpose: A higher creative potential has been reported in narcoleptic patients and linked to lucid dreaming. The aim of the present study was to explore the role of narcolepsy symptoms (presence and severity) in predicting creativity.Patients and Methods: Sixty-six consecutive type 1 narcolepsy patients (mean age 38.62 ± 17.05, 31 females) took part in this study. Creative achievement in different life domains and creative beliefs were assessed by a self-reported questionnaire and a scale measuring the creative self, respectively; creative performance was measured through a divergent thinking test (generation of alternative original solutions to an open problem).Results: We found a key effect of hypnagogic hallucinations in modulating creative behaviour. We therefore tested at first whether hypnagogic hallucinations could interact with specific mental states associated with creativity and in particular mind wandering, a factor associated with both creative performance and achievement. Secondly, we verified if hypnagogic hallucinations could influence the definition of creative identity in type 1 narcolepsy patients, which in turn could predict their creative achievement and creative performance. Results showed that spontaneous mind wandering influenced creative achievement through a moderation effect of sleep paralysis and hypnagogic hallucinations. Moreover, sleep paralysis and hypnagogic hallucinations indirectly influenced, through creative identity, both creative achievement and performance (fluency score).Conclusion: Our results highlight the role of hypnagogic hallucinations in triggering the process of mind wandering which leads to greater creative success. In addition, this symptom affects creative identity in narcolepsy, leading in turn to higher creative success and creative potential of narcoleptic patients.Keywords: narcolepsy type 1, creativity, hypnagogic hallucinations, daydreaming, mind wandering

Marco Filardi,1 Silvia Morini,1 Giuseppe Plazzi1,2 1Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy; 2IRCCS, Istituto delle Scienze Neurologiche di Bologna, AUSL di Bologna, Bologna, ItalyCorrespondence: Giuseppe PlazziDepartment of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Via Altura n° 3, Bologna 40139, ItalyTel +39 051 4966929Fax +39 051 4966176Email giuseppe.plazzi@unibo.itPurpose: To evaluate chronotype and the sleep management strategy adopted by sailors before the offshore solo sailing race “Mini Transat La Boulangère”. As secondary aim, we assessed whether adopting pre-race sleep management strategy influences performance at race.Materials and Methods: Forty-two solo sailors completed questionnaires on sleep quality, sleepiness, chronotype and an ad hoc questionnaire on the pre-race sleep management strategy adopted. Arrival times, separately for each race’s leg, were provided by the race organization team.Results: Solo sailors present mainly with a morning-type (40%) and intermediate-type (60%) chronotype, while none have an evening-type chronotype. Fifty-five percent of sailors adopted pre-race sleep management strategy. Sailors that adopted strategy have travelled more miles in offshore compared to sailors that did not adopt strategy (p< 0.05). Significant differences emerged in rMEQ scores, with sailors that adopted strategy presenting lower score compared to sailors that did not adopt sleep strategy (p< 0.05), as well as in chronotype distribution with morning-type sailors that are less likely to adopt pre-race sleep management strategy compared to intermediate type sailors (p< 0.05). No differences emerged in final arrival times and in arrival time at leg1 and leg2. The most commonly adopted strategy (52% of sailors) consists of sleep extension, followed by the polyphasic sleep (26%), and sleep deprivation (22%) strategy. Sailors trained in polyphasic sleep have higher ESS than sailors trained in sleep deprivation (p< 0.05).Conclusion: Morning-type chronotype is overrepresented in this large cohort of solo sailors compared to the general population; moreover, chronotype seems to influence the adoption of sleep management strategy. A little over half of solo sailors participating in the Mini Transat trained in sleep management strategy before the race; however, neither the general adoption of pre-race sleep management strategy nor the adoption of a specific sleep strategy seems to significantly influence final arrival times.Keywords: sleep, solo sailing, chronotype, sport medicine, training

ObjectivesWe aimed to provide a consensus statement by the International Rapid Eye Movement Sleep Behavior Disorder Study Group (IRBD-SG) on devising controlled active treatment studies in rapid eye movement sleep behavior disorder (RBD) and devising studies of neuroprotection against Parkinson disease (PD) and related neurodegeneration in RBD.MethodsThe consensus statement was generated during the fourth IRBD-SG symposium in Marburg, Germany in 2011. The IRBD-SG identified essential methodologic components for a randomized trial in RBD, including potential screening and diagnostic criteria, inclusion and exclusion criteria, primary and secondary outcomes for symptomatic therapy trials (particularly for melatonin and clonazepam), and potential primary and secondary outcomes for eventual trials with disease-modifying and neuroprotective agents. The latter trials are considered urgent, given the high conversion rate from idiopathic RBD (iRBD) to Parkinsonian disorders (i.e., PD, dementia with Lewy bodies [DLB], multiple system atrophy [MSA]).ResultsSix inclusion criteria were identified for symptomatic therapy and neuroprotective trials: (1) diagnosis of RBD needs to satisfy the International Classification of Sleep Disorders, second edition, (ICSD-2) criteria; (2) minimum frequency of RBD episodes should preferably be ⩾2 times weekly to allow for assessment of change; (3) if the PD-RBD target population is included, it should be in the early stages of PD defined as Hoehn and Yahr stages 1-3 in Off (untreated); (4) iRBD patients with soft neurologic dysfunction and with operational criteria established by the consensus of study investigators; (5) patients with mild cognitive impairment (MCI); and (6) optimally treated comorbid OSA. Twenty-four exclusion criteria were identified. The primary outcome measure for RBD treatment trials was determined to be the Clinical Global Impression (CGI) efficacy index, consisting of a four-point scale with a four-point side-effect scale. Assessment of video-polysomnographic (vPSG) changes holds promise but is costly and needs further elaboration. Secondary outcome measures include sleep diaries; sleepiness scales; PD sleep scale 2 (PDSS-2); serial motor examinations; cognitive indices; mood and anxiety indices; assessment of frequency of falls, gait impairment, and apathy; fatigue severity scale; and actigraphy and customized bed alarm systems. Consensus also was established for evaluating the clinical and vPSG aspects of RBD. End points for neuroprotective trials in RBD, taking lessons from research in PD, should be focused on the ultimate goal of determining the performance of disease-modifying agents. To date no compound with convincing evidence of disease-modifying or neuroprotective efficacy has been identified in PD. Nevertheless, iRBD patients are considered ideal candidates for neuroprotective studies.ConclusionsThe IRBD-SG provides an important platform for developing multinational collaborative studies on RBD such as on environmental risk factors for iRBD, as recently reported in a peer-reviewed journal article, and on controlled active treatment studies for symptomatic and neuroprotective therapy that emerged during the 2011 consensus conference in Marburg, Germany, as described in our report.