key: cord-0948377-35ewwjfv authors: Zhang, Fan; Shang, Zhilei; Ma, Haiying; Jia, Yanpu; Sun, Luna; Guo, Xin; Wu, Lili; Sun, Zhuoer; Zhou, Yaoguang; Wang, Yan; Liu, Nianqi; Liu, Weizhi title: High risk of infection caused posttraumatic stress symptoms in individuals with poor sleep quality: A study on influence of coronavirus disease (COVID-19) in China date: 2020-03-24 journal: nan DOI: 10.1101/2020.03.22.20034504 sha: dd490f517576690e975816f640dfdd3f26397a05 doc_id: 948377 cord_uid: 35ewwjfv The influence of the outbreak of coronavirus disease (COVID-19) on mental health was poorly understood. The present study aimed to exam sleep problems and posttraumatic stress symptoms (PTSS) in Chinese immediately after the massive outbreak of COVID-19. A total of 2027 Chinese participated in the present study. Wuhan-expose history, sleep quality and PTSS were measured with self-rating scales. Results showed that there were significant differences of PCL-5 and of sleep quality scores in different data-collection dates (ps<0.05). There were significant differences of PCL-5 scores (p<0.05) and latency onset of sleep (p<0.05) between participants with and without Wuhan-expose history. The interaction effect of Wuhan exposure history × sleep quality significantly influenced PCL-5 (ps<0.05). These results indicate that keeping good sleep quality in individuals with high infectious risk is a way to prevent PTSS. According to the Diagnostic and Statistical Manual of Mental Disorders-5th edition (APA, 2013), Posttraumatic Stress Disorder (PTSD) is characterized by four symptom groups: (a) involuntary memories of the trauma such as intrusions or nightmares; (b) persistent avoidance of stimuli associated with the traumatic event; (c) negative alterations in cognitions and mood that are associated with the trauma; and (d) alterations in arousal and reactivity that are associated with the trauma. Also in DSM-5, exposure to traumatic events is the immediate causes of PTSD and an essential condition of diagnosis. Being infected with a life-threatening physical illness is a traumatic event and can lead to posttraumatic stress symptoms. For example, 12%-15% survivors of SARS showed one type of PTSD symptom (PTSS) at one month after discharge (Wu et al, 2005) ; the morbidity of PTSD in patients with traumatic injury reached 9.6% at months (Bryant et al., 2017) . In addition, not only being attacked by traumatic illness could cause PTSD symptoms, being contacts and carers of a deadly virus could also lead to symptoms like alternations in mood and arousal (Tine et al., 2016) . Living in the endemic area, every Chinese is a carer and a ( Previous studies have proved that massive outbreaks of epidemics like SARS and Ebola virus disease (EVD) could cause sleep problems in relevant individuals. For example, Yu et al. (2005) reported that midlife women felt "sleep was restless" during SARS and this problem was closely associated with their overall negative emotions. Another study showed that chronic post-SARS symptoms were characterized by sleep-related problems (Moldofsky and Patcai, 2011) . Survivors of EVD also reported various sleep quality problems (Keita et al., 2017) . More importantly, Sleep and PTSS are closely related, and sleep disturbances are core features of PTSD. According to the model raised by Richard et al. (2020) , sleep disturbances (short sleep duration, frequent arousals, and et al.) could lead to maladaptive sleep-related compensatory behaviors and cause hyperarousal and anxiety-related disorders like PTSD. Sleep disruption also promoted anxious emotions by disrupt emotion regulation and adaptive memory functions. Thus, it was reasonable to hypothesize that wide-spread transmission of COVID-19 could causes sleep problems in Chinese and result in PTSS. In early December 2019, the first pneumonia case was identified in Wuhan, the capital city of Hubei province (Huang et al., 2020) . With the spreading of the epidemic, Wuhan became the worst influenced area, where the mortality and incidence rate of COVID-19 were above the national level according to the National Health Commission of China (2020). Moreover, not only Wuhan residents were more likely to be infected, 72.3% nonresidents of Wuhan had contact with individuals lived in Wuhan (Guan et al., 2020) . Wuhan expose history had become an important . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 24, 2020 . . https://doi.org/10.1101 diagnosis standard and a source of fear. As a result, we collected data of Wuhan exposure to measure the risk of infection. We hypothesized that Wuhan residents and individuals who had been to Wuhan or contacted with Wuhan residents, would show more sleep problems and PTSS for they were faced with high possibility of infection of COVID-19. We also explored the relationship among the infection risk, sleep and PTSS to identify the role of sleep problems in the development of PTSD. We hope the current study could reflect the influence of COVID-19 on psychological well-being in Chinses and shed light on post-epidemic psychological intervention. The methods and reporting procedures were in accordance with the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist. A total of 2032 subjects form 31 provinces in the mainland of China, Hong Kong, Macao and Taiwan participated in the present study. Criteria for inclusion was that subjects should be Chinese race and age ≥ 18 years at the time of the COVID-19 infection. Table 1 demonstrated demographic statistics of subjects. The average age of all subjects was 35.47±11.32. All the study participants were provided with written informed consent. This project was approved by the Ethics Committee of the Naval Military Medical University. Subjects who were Wuhan residents, or had been to Wuhan, or had contacted with anyone from Wuhan during the outbreak of COVID-19 scored 1 point and those not scored 0. A total of 230 subjects showed a history of exposure to Wuhan. According to previous findings, certain types of sleep quality disturbances were more common across anxiety-related disorders than others (Leskin et al., 2002; Neylan, 1998) . As a result, we only selected the most related items from the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989) to investigate sleep quality. 4 items form PSQI were used to measure subject's sleep quality. The first was the subjective sleep quality measuring participants' satisfaction with sleep. Subject scored 0 if they had very good subjective sleep quality and scored 3 for very bad subjective sleep quality. The second item collected data on latency onset of sleep. Scores varied from 0~3 with 0 standing for having no problems falling asleep and 3 standing for hard to fall asleep for 3 times or more within a week. The third item was the sleep fragment. Subjects score 1 for no occurrence of the problem and scored 3 if they had the problem for 3 times or more within a week. The last item collected data on everyday sleep duration and the scores varied form 0 (more than 7 hours) to 3 (less than 5 hours). In summary, 0 and 1 point of the 1 st item indicated very good and good subjective sleep quality and 2 and 3 indicated sleep quality problems. For the remaining items, 0 point indicated good sleep quality and 1 to 3 points indicated increasingly sever sleep quality problems. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . https://doi.org/10. 1101 PTSD Checklist for DSM-5 (PCL-5) (Weathers et al., 2013) was used to measure PTSS. PCL-5 is a self-report 5-point Likert-Type scale (1=not at all, and 5=extremely) with 20 items measuring PTSS of instruction, avoidance, numbing and hyperarousal. The Chinese version of PCL-5 showed excellent consistency and convergent validity in previous studies (Li et al., 2018; Liu et al., 2014) . Internal consistency (Cronbach's α ) of PCL-5 in the present study was 0.87. The data was collected during Jan 30, 2020 to Feb 3, 2020 through an online survey platform https://www.wjx.cn/. To complete the survey, participants had to answer all the listed questions in a time limitation of 2 to 30 minutes. Answers with response time below 2 mins or above 30mins were invalid and would be deleted in the following analysis. 5 participants were deleted because of illegal response time. Data from 2027 participants were analyzed. One-way variance analysis (ANOVA) and Least-Significant Difference (LSD) test were used to analyze the differences of PTSS during each day of survey. Chi-square test was applied to analyzed differences of sleep quality by time and Wuhan-exposed history. Scores of PTSS were compared between subjects with and without Wuhan exposure history using t-test. Interaction effects of sleep and Wuhan exposure history on PTSS was analyzed using two-way ANOVAs and simple effect analyses. Figure 1 showed trends of PCL-5 scores and sleep quality during the 5-day survey. Both PCL-5 scores and sleep quality scores showed raising tendency from Jan 30, 2020 to Feb 2, 2020 and decreased in Feb 3, 2020. One-way ANOVA showed that there was a significant difference of PCL-5 scores on different dates, F=4.38, p<0.05. LSD test showed significant increases was illustrated from Jan 31 to Feb 2 (ps<0.05); however, the PCL-5 score in Feb 3, 2020 were significantly lower than that in Feb 2, 2020 (p<0.05). Chi-square test showed significant differences of sleep quality in the 5-days period, Results demonstrated that participants with Wuhan exposure history generally showed more latency onset of sleep (χ 2 =9.77, p<0.05) than those not. Wuhan exposure history also significantly influence PCL-5 scores (t=-2.93, p<0.05). However, there no significant differences of other sleep problems between participants with and without Wuhan-exposure history. See table 2 for detailed information. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . https://doi.org/10. 1101 According to National Health Commission of China (NHC), until Feb 4, 2020, prevalence rate and fatality rate of COVID-19 in Wuhan were much high above the national level (NHC, 2020), making exposure to Wuhan a risk factor of infection and a cause of mental health problem. The current study aimed to investigate the influence of potential danger of infection on sleep and PTSS. We also explored regulating effects of sleep quality on the relationship between Wuhan exposure history during outbreak of COVID-19 and PTSS. To this end, we conducted ANOVAs and Chi-square tests with the above variables. Results indicated that data of PTSS growth rapidly in the first 4 days in our study, and decreased in the last day. Interestingly, scores of sleep quality showed the same tendency. This might indicate the close relationship between sleep and PTSD. Moreover, up to the end of our survey, the firmed cases and susceptive cases were still frantically increased, showing no sign of decline (WHO, 2020e). We assumed that results of the present study suggested that emergence of psychological "inflection point" which meant a turning from deterioration of mental health to growth of resilience showed on Feb 3, 2020. It was a date before the number of confirmed cases of COVID-19 showed any sign of downward trends in China. We supposed that the change in psychological response might be a result of Chinese government's efforts in disease management, psychoeducation and prevention education. Results illustrated that Wuhan exposure history affected PTSS. For those having Wuhan-expose experiences, PTSS were more obvious. This result was in line with previous findings that subjective perception of dangerousness during SARS related with severity of PTSD . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020 . . https://doi.org/10.1101 .03.22.20034504 doi: medRxiv preprint symptoms (Mak et al., 2010 . Results also highlighted the influence of trauma expose on latency onset of sleep, which was different in subjects with and without Wuhan exposure history. Difficulty in falling asleep might be a result of increased presleep cognitions. According to Fast (2003) , traumatic experiences caused reactions of fear, increased arousal and re-experience, and these reactions affected presleep cognitions and leaded to chances of sleep onset latency. Increased sleep onset latency then influenced mood, cognition and physiological responses. Limitations of the current study included the use of a health example and the fact that we used online survey in data collection. Only a few subjects were confirmed or suspected COVID-19 patients in our study. And the mean levels of sleep quality and PTSS were in the moderate range. For those being infected with COVID-19, sleep and metal health problems might be far more severe. Considering the risk of infection, we used online survey to investigate relationship among Wuhan exposure history, sleep and PTSS. However, it was hard to guarantee authenticity with this method and the validity was limited. We suggested that future studies could exam PTSD and related factors among COVID-19 survivors with face-to-face investigation or interview. The present study suggested that sleep quality level decreased and posttraumatic stress symptoms increased with time and change of this tendency was shown on 3 rd Feb, 2020. Individuals with and without Wuhan-expose history showed different levels of PTSS and sleep onset latency under the influence of COVID-19. Wuhan-expose history influenced PTSS severity in individuals with poor sleep quality, but not those with high-quality sleep. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020 . . https://doi.org/10.1101 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200204-sitrep-14-ncov. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020 . . https://doi.org/10.1101 Figure 1 Changes of PCL-5 scores and participants with sleep quality problems in the 5-day survey . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020. . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted March 24, 2020 . . https://doi.org/10.1101 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted March 24, 2020 . . https://doi.org/10.1101 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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