INTRODUCTION
“Post-coronavirus disease (COVID)” refers to the signs and symptoms experienced by individuals after recovering from COVID-19; it is a term coined by the Department of Health and Human Services and Centers for Disease Control and Prevention. Alternate nomenclatures include long COVID, post-acute COVID-19 syndrome, long-term effects of COVID, and chronic COVID-19 [1]. Following COVID-19 infection, individuals exhibit heterogeneous symptoms with varying duration and combinations of health issues. “Post-COVID conditions” are characterized by noticeable sequelae emerging at least 4 weeks following the acute phase, with ongoing recovery observed between 4 and 12 weeks. Common clinical presentations include dyspnea, fatigue, exertional malaise and/or poor endurance, cognitive impairment (commonly referred to as “brain fog”), cough, chest pain, headaches, palpitations and tachycardia, arthralgia, and multi-organ damage. The repercussions of treatment or hospitalization for COVID-19 can affect both the physical and mental well-being of affected individuals [2].
Post-infection conditions, encompassing post-COVID, correlate with a diminished quality of life (QoL) attributed to symptoms such as fatigue, dyspnea, anosmia, sleep disturbances, and exacerbated mental health issues [3]. Similar to other neurological or psychiatric manifestations associated with post-COVID complications, the underlying mechanism for impaired sleep remains elusive; however, an excessive autoimmune and inflammatory response appears to play an important role [4]. Social factors, such as isolation and the loss of loved ones [5], likely contribute to the neuropsychiatric manifestations of post-COVID-19 syndrome. Additionally, hospitalization and the prolonged course of critical illness demonstrably impact individuals post-infection [6].
Sleep disorders have consistently been reported in various studies on post-COVID and represent a major concern due to their considerable impact on the QoL of patients. Such disorders can persist from 2 to 48 weeks or more following discharge or receiving a positive COVID-19 test result [7]. Severe COVID-19 survivors frequently report complaints of sleep fragmentation and recurrent awakenings [8]. One study indicated a substantial proportion of patients scoring within the psychopathological range on self-assessment questionnaires: 31% for depression, 20% for obsessive-compulsive symptoms, 42% for anxiety, 28% for post-traumatic stress disorder, and 40% for insomnia. Furthermore, more than half of the patients suffered from mental health issues across one or more clinical dimensions [9]. Sleep is critical for maintaining both physical and mental health, and diminished sleep efficiency may contribute to the development of psychiatric disorders. Additionally, fears stemming from the COVID-19 pandemic may induce emotional distress and disrupt individuals’ circadian rhythms and sleep patterns. Individuals experiencing poor sleep quality often exhibit dysfunctional beliefs and attitudes regarding sleep [10]. Additionally, the deterioration of sleep quality owing to COVID-19 infection and the resulting lockdown or quarantine may correlate with an increase in maladaptive and dysfunctional beliefs about sleep [11].
Dysfunctional beliefs about sleep are influenced by patients’ mental and emotional well-being during the pandemic; concomitantly, these beliefs may influence obsession with COVID-19, mediated by reassurance seeking behavior and anxiety [12]. Dysfunctional beliefs regarding sleep lead to higher levels of anxiety, depression, and insomnia. Individuals suffering from poorer sleep quality are more inclined to harbor dysfunctional beliefs about sleep [10], and thus, sleep disturbances and insomnia resulting from the COVID-19 pandemic may exhibit a strong positive correlation with such beliefs [11].
Conversely, during the COVID-19 pandemic, concerns regarding potential infection have intensified. When individuals feel anxious about becoming infected, they may engage in reassurance-seeking behaviors, such as monitoring their bodily sensations, practicing hand hygiene, or repeatedly searching information about the virus [13]. Thus hypochondriacal phenomenon is well-established within the context of illness anxiety disorder [14]. We have previously investigated whether the cognitive-behavioral model of hypochondriasis is feasible within the context of COVID-19; the findings revealed that the cognitive-behavioral model of COVID-related hypochondriasis has demonstrated feasibility among medical students [15] and firefighters [16]. However, no study to date has investigated the feasibility of this cognitive-behavioral model among infected patients specifically. Furthermore, exploring whether insomnia or sleep disturbances influence COVID-related hypochondriasis among infected individuals is necessary. Previously, we reported that insomnia may mediate the relationship among viral anxiety, virus-related reassurance-seeking behavior, and preoccupation with COVID-19 within the general population [13]. However, no previous report has investigated whether the influence of insomnia on the framework of coronavirus-hypochondriasis is significant among infected individuals.
This study aimed to 1) explore the feasibility of the cognitive-behavioral model of COVID-related hypochondriasis among participants infected with COVID-19; 2) examine whether the severity of their insomnia supports the hypochondriasis model; and 3) explore the demographic or symptom characteristics that may predict post-infection insomnia among participants who did not experience sleep disturbances pre-COVID-19 infection.
METHODS
Participants and procedure
The present study utilized an anonymous survey involving participants from the general population who had experienced COVID-19 infection. The survey was facilitated by a professional survey company (www.embrain.com) from December 19 to 27, 2022. The survey instrument was constructed following the Checklist for Reporting Results of Internet e-Surveys guidelines [17] and incorporated questions regarding participant demographics, including age, sex, marital status, past psychiatric history, and current psychiatric distress. Furthermore, COVID-19-related inquiries, such as history of infection and vaccination, were included. Sample size calculations were based on 30 samples for 10 cells (sex×five age groups) [18]. A target of 300 responses was established from a panel of 1,640,000 individuals registered with the survey platform. Enrollment emails were distributed to 5,949 participants, yielding 706 accesses to the survey, with 151 respondents indicating no COVID-19 infection and 265 completing the survey. The Institutional Review Board of Asan Medical Center (2022-1256) approved this study, waiving the requirement for written informed consent from participants. Rather participants could participate in this survey study by selecting “yes” to the question of agreement of participation. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Boards of Asan Medical Center and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Measures
Post-infection insomnia
We asked participants the following: “Q1. Prior to being infected with COVID-19, did you experience sleep disturbances?” and “Q2. Have you experienced sleep disturbances following COVID-19 infection?” Responses from participants answering “yes” to Q1 (n=49) were excluded, resulting in a final analytic sample of 211 respondents.
Insomnia Severity Index
The Insomnia Severity Index (ISI) is a self-reporting scale designed to measure insomnia severity [19]. Each question is scored on a 0-4 Likert scale, with a higher total score indicating a greater degree of insomnia. The Korean version of the ISI was used in this research [20], revealing a Cronbach’s alpha of 0.659 within this sample.
Obsession with COVID-19 Scale
The Obsession with COVID-19 Scale (OCS) is a self-reporting scale designed to assess persistent disturbed thinking related to COVID-19 [21]. The OCS comprises four items, each rated on a 5-point scale (0, not at all; 4, nearly every day over the last 2 weeks). A total OCS score of 7 is indicative of impaired thinking regarding COVID-19. In this study, the Korean version of the OCS was utilized [22], with a Cronbach’s alpha of 0.645.
Coronavirus Reassurance-Seeking Behaviors Scale
The Coronavirus Reassurance-Seeking Behaviors Scale (CRBS) is a self-rating scale to assess an individuals’ COVID-19-related reassurance seeking behavior [23]. The five items of the CRBS are scored on a 5-point scale (0, not at all; 4, nearly every day). The total score ranges from 0 to 20, where a high total score reflects a more severe extent of reassurance-seeking behavior. This study employed the validated Korean version of the CRBS [24], with a Cronbach’s alpha of 0.634.
Stress and Anxiety to Viral Epidemic-6 items
The Stress and Anxiety to Viral Epidemic-6 items (SAVE-6) is a rating scale that measures anxiety responses to viral epidemics [25]. This instrument is derived from the SAVE-9 scale [26], initially designed to evaluate work-related stress and anxiety among healthcare workers in response to viral outbreaks. The scale comprises six items, each rated from 0 (never) to 4 (always), with a higher total score reflecting an elevated level of anxiety response to viral epidemics. A cutoff value of 15 of 24 indicates a mild degree of anxiety. In this study, we applied the original Korean version of the SAVE-6, and the Cronbach’s alpha was 0.658.
Patient Health Questionnaire-2 items
The Patient Health Questionnaire-2 items (PHQ-2) is a self-reported questionnaire designed to measure an individual’s level of depression. The PHQ-2 is an ultra-brief version of PHQ-9 [27], which is an efficient and reliable screening and diagnostic tool for depression. Is diagnostic sensitivity higher when used in conjunction with PHQ-9 in several studies [28]. The Cronbach’s alpha for this sample was 0.690.
Dysfunctional Beliefs about Sleep-2 items
The Dysfunctional Beliefs about Sleep-2 items (DBS-2) scale is a two-item ultra-brief rating scale designed to measure dysfunctional beliefs about sleep [29]. It is derived from the C-DBS scale that was originally designed for patients with cancer. The DBS-2 comprises two items: “My immune system will go bad if I don’t go to sleep at a certain time.” and “If I don’t sleep well at night, I will easily fall sick.” Both items are rated on a 0 to 10 scale, with a higher total score reflecting more pronounced dysfunctional beliefs about sleep. The DBS-2 developed in the Korean language was used in this study, and its split-half coefficient was 0.706.
Statistical analysis
Continuous variables representing demographic characteristics and rating scale scores were summarized as mean±standard deviation. A significance level of p<0.05 was established as two-tailed. Initially, reliability and validity analyses of the COVID-19-related hypochondriasis model were conducted, followed by an exploration of insomnia severity as a predictive factor among the overall infected cohort (n=260). Pearson’s correlation coefficients were calculated to assess correlations between age and rating scale scores. To validate the COVID-19-related hypochondriasis model, the bootstrap method with 2,000 resamples was implemented to investigate whether COVID-19 reassurance-seeking behavior mediates the influence of anxiety in response to viral epidemics on obsession with COVID-19. Further, a mediation model incorporating the ISI was designed to identify effective mediators elucidating the impact of insomnia on preoccupation with COVID-19.
Subsequently, the sample was filtered to include only participants who did not report sleep disturbances pre-COVID-19 infection. Continuous variables related to demographic characteristics and rating scale scores were then summarized as mean±standard deviation within this selected group (n=211). Logistic regression analysis was conducted to identify prognostic factors for post-infection insomnia among these participants. The JASP (Version 0.17.3, JASP teams) was used for statistical analysis.
RESULTS
Among the 265 individuals infected with COVID-19 who participated in this survey, 260 complete responses were analyzed, excluding five incomplete responses that lacked answers concerning insomnia (Table 1).
Cognitive-behavioral model of COVID-related hypochondriasis among infected cases
The ISI score exhibited a significant correlation with the OCS (r=0.29, p <0.01), CRBS (r=0.32, p<0.01), SAVE-6 (r=0.30, p<0.01), DBS-2 (r=0.40, p<0.01), and PHQ-2 (r=0.37, p<0.01) (Table 2). Moreover, the OCS score was significantly correlated with CRBS (r=0.75, p<0.01), SAVE-6 (r=0.48, p<0.01), DBS-2 (r=0.16, p<0.01), and PHQ-2 (r=0.49, p <0.01).
The feasibility of the cognitive-behavioral model of COVID-related hypochondriasis among infected individuals was assessed (Table 3). Mediation analysis confirmed that viral anxiety directly influenced preoccupation with COVID-19, and this relationship was mediated by reassurance-seeking behavior. Thus, we confirmed that the COVID-related hypochondriasis model is feasible even among infected individuals. Further, an evaluation of whether insomnia and depression contribute to this cognitive-behavioral model was undertaken (Table 4 and Figure 1). Insomnia was found not to directly influence preoccupation with COVID-19; however, this relationship was mediated by COVID-19-related reassurance-seeking behavior, viral anxiety, and depressive symptoms.
Predictor variables for post-infection insomnia
Among the 211 participants without pre-existing insomnia prior to COVID-19, they were categorized into two groups based on the presence or absence of insomnia following COVID-19 infection (Table 5). Compared to the post-COVID non-insomnia group, the post-infection insomnia group exhibited a significantly higher proportion of history of psychiatric disorders (p=0.020) along with elevated levels of ISI (p<0.001), OCS (p=0.006), CRBS (p=0.023), SAVE-6 (p=0.010), DBS-2 (p=0.007), and PHQ-2 scores (p<0.001). Results from logistic regression analysis indicated that elevated DBS-2 (odds ratio [OR]=1.069, p=0.047) and PHQ-2 (OR=1.434, p=0.024) scores, along with a history of psychiatric issues, were significant predictors of post-infection insomnia (Table 6).
DISCUSSION
Our findings indicate a strong correlation between preoccupation with COVID-19 and factors such as anxiety, depression, dysfunctional beliefs about sleep, and reassurance-seeking behavior among the 260 participants infected with COVID-19. Mediation analysis demonstrated that viral anxiety exerted a direct effect on preoccupation with COVID-19, with reassurance-seeking behavior mediating this relationship. Additionally, insomnia impacts preoccupation with COVID-19, with reassurance-seeking behavior, viral anxiety, and depression acting as mediators. Notably, participants’ prior psychiatric histories, depressive symptoms, and dysfunctional beliefs about sleep were predictive of post-infection insomnia.
Consistent with the traditional hypochondriasis framework [14], we observed that the cognitive-behavior model of hypochondriasis remains applicable even among infected individuals. COVID-19-related hypochondriasis, or illness anxiety disorder, manifests as an obsession driven by the fear of the ongoing COVID-19 pandemic despite medical reassurance. Previous studies have suggested a cognitive-behavioral model of hypochondriasis [30], wherein individuals’ anxiety of being sick propels them to seek for safety or medical help. Paradoxically, this behavior aggravates preoccupation with COVID-19, without relieving associated stress and depression. Although reassurance-seeking behaviors may elicit short-term relief for affected individuals, these practices can ultimately amplify fear rather than assuaging it during the prolonged COVID-19 pandemic period, further contributing to preoccupation with the disease.
Insomnia aligns appropriately with the hypochondriasis model and may induce an obsession with COVID-19. This study proposed a mediation framework comprising reassurance-seeking behavior, anxiety, and depression, which serves to illustrate the direct effects of insomnia on virus-related preoccupation. Hence, this viable cognitive-behavioral model of hypochondriasis encompasses insomnia as an independent factor promoting obsession with COVID-19, elucidating why patients may experience poor psychological well-being even after recovery.
Prior studies validated the direct influences of viral anxiety and depression on obsessions surrounding the COVID-19 pandemic. Among medical students, it was noted that viral anxiety and depression contributed to obsession with COVID-19, with reassurance-seeking behavior mediating this relationship [15]. Similarly, other research focusing on healthcare workers established that intolerance of uncertainty directly impacted viral anxiety, with reassurance-seeking behavior and obsession with COVID-19 mediating this interaction [31]. Intolerance of uncertainty emerged as a significant contributor to fears and anxieties related to the pandemic, fostering enduring obsessive thoughts and behaviors. Reassurance-seeking behavior, thus, functions as both a consequence and an exacerbating factor of anxiety. The incapacity to tolerate uncertainty during the COVID-19 era drives individuals to seek reassurance through excessive hygiene practices or recurrently gathering information, ultimately leading to elevated anxiety levels. Psychological distress, encompassing anxiety and depression during the pandemic, compounds reassurance-seeking behaviors, thereby worsening obsession with illness.
Previous studies highlighted that individuals with sleep disorders are more vulnerable to anxiety symptoms, hyperarousal, and other psychiatric and non-psychiatric comorbid health conditions [32]. This suggests that poor sleep quality could predispose COVID-19 survivors to heightened preoccupation with the illness, adversely affecting their well-being through repetitive reassurance-seeking behaviors coupled with unmanaged depression and anxiety levels. Individual perceptions and management of sleep disturbances may manifest as reassurance-seeking behaviors, anxiety, depression, or a combination of these responses. Ultimately, maladaptive responses to insomnia may materialize as obsessive preoccupation with COVID-19, often attributed to dysfunctional beliefs regarding sleep.
Dysfunctional beliefs about sleep represent maladaptive concerns and behaviors relating to sleep that exacerbate sleep disorders, such as difficulty falling or staying asleep, and daytime sleepiness. For survivors of COVID-19, insomnia may precipitate heightened preoccupation with poor sleep quality due to unfounded health-related concerns. Cognitive-behavioral interventions targeting chronic insomnia in this context appear essential for individuals caught in this negative cycle of insomnia, necessitating a thorough understanding of patients’ perceptions regarding their insomnia pathology and an exploration of their underlying dysfunctional beliefs about sleep.
Additionally, a mental health screening conducted on college students with depression revealed that individuals with sleep disorders exhibited more pronounced psychological symptoms than those without such disorders, despite comparable levels of depression. Conversely, individuals without insomnia were more likely to be emotionally and functionally intact. Sleep disorders may manifest as daytime hyperarousal, significantly correlated with anxiety and excessive worries. In the context of COVID-19-related hypochondriasis, sleep disorders may indeed serve as a precipitating factor for illness anxiety and fear. Furthermore, potential mechanisms underpinning sleep disturbances associated with post-COVID-19 conditions have been proposed, including dysregulated cytokine responses, compromised immune systems, autoimmunity, and mitochondrial dysfunction.
To delineate variables that may predict post-infection insomnia, logistic regression analysis was performed on the 211 participants who did not report pre-existing sleep disturbances. The findings indicate that individuals with a history of depression, prior psychiatric disorders, and dysfunctional sleep beliefs are particularly vulnerable to the development of post-infection sleep disorders. This emphasizes the need to address depressive symptoms and any prior neuropsychiatric issues in patients recovering from COVID-19. Additionally, compulsive and maladaptive cognitions regarding sleep have the potential to shape individuals’ behavior, consequently leading to insomnia. Hence, it is crucial to understand and promptly address individuals’ dysfunctional beliefs about sleep.
This study has several limitations. First, this study was conducted via an online survey, and we could not perform PCR tests for viral infection. Therefore, we could not confirm the participants’ infection status. Second, the study lacks a precise time frame for the onset of insomnia following COVID-19 infection. This hinders the establishment of a clear causal relationship between viral infection and development of insomnia symptoms. The inability to determine the existence and nature of specific stressors during insomnia onset further complicates our understanding of potential contributing factors. Third, the number of participants reporting insomnia following confirmed COVID-19 infection is relatively few, making it challenging to generalize the findings to a broader population. Fourth, the survey was conducted during a specific timeframe (December 19-27, 2022), potentially capturing individuals adapted to the challenges posed by COVID-19. This sample is not representative of the experiences of individuals at different COVID-19 stages. Finally, insomnia often coexists with comorbid diseases and is influenced by alcohol or drug use. However, we could not adjust for these confounders in the current study.
In conclusion, we observed the relationship between psychological factors and COVID-related hypochondriasis among infected individuals. Preoccupation with COVID-19 was closely linked to anxiety, depression, and dysfunctional beliefs about sleep, with reassurance-seeking behavior acting as a mediating factor. Moreover, a history of psychiatric disorders, elevated levels of depression, and dysfunctional beliefs about sleep emerged as predictors of post-infection insomnia among individuals recovering from COVID-19. These findings underscore the importance of implementing targeted interventions to address mental health and sleep disturbances in recovering COVID-19 patients, acknowledging the role of cognitive-behavioral factors in shaping their experiences. Such interventions may contribute to improved post-infection outcomes and overall well-being.
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