Stress management and sleep improvement. Scientific evidence.
Mechanism of insomnia
Sleep is a condition that supports emotional, physiological, and reparative regeneration. It is known to affect a person’s quality of life and well-being. There are several factors able to affect regular sleep: age, gender, environment, psychological state, illnesses, and the use of medication.
Insomnia may be present in cases of a long sleep latency, frequent nocturnal awakenings, prolonged periods of wakefulness during the sleep period and even frequent transient arousals [Sateia]. Population-based studies indicate that about 30% of adults from different countries report common symptoms of insomnia: difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and poor quality of sleep which does not provide rest [Ancoli].
Currently insomnia is considered to be a disorder due to hyperarousal experienced within the day which may lead to difficulty initiating and maintaining sleep at night [Roth]. This process is explained by the cognitive model which states that worry and concerns due to usual daily stress affect sleep, leading to onsets of insomnia. Usually it manifests mostly with problems in initiating sleep and returning back to sleep after an awakening [Harvey]. Since a person begins to experience sleep difficulties, worry and concerns change their focus from usual stress to worries about insomnia. This negative cognitive activity becomes only worse when exacerbated by the sleep deficit.
Approaches to the stress management
Proper stress management is crucial in the insomnia treatment approaches, as evidence shows that relaxation exercises may improve sleep quality by relaxing the body, lowering blood pressure, stimulating circulation, and relaxing the muscles. Relaxation exercises are based on reducing fear, excitement, anxiety, palpitations, and spasms, as well as slowing thought [Örsal]. They are useful to create a calm, comfortable and relaxed response [Sri].
At the same time personal health technologies look promising in the domain of health and welfare self-management. Number of studies have showed a positive influence of the Web-based therapies for the treatment of stress and anxiety. Furthermore, interventions via mobile apps are gaining more and more popularity. Their advantages are that these resources are accessible at any time and allow the user to avoid the embarrassment of visiting a professional [Blázquez].
Researches show that provision of mobile apps for calming, relaxation, and mindfulness interventions has the potential to become a part of ongoing patient care under the supervision of healthcare providers [Weekly].
A review of the studies assessing mental health mobile applications in a psychotherapy context [Lui] found that the preliminary results were promising with the suggestion that further detailed research in this area may lead to consideration by the clinicians to cautiously incorporate apps as an adjunct to treatment or recommending apps to clients.
How does Loóna work
The effectiveness of mobile phone apps as a sleep intervention tool was assessed in the systematic review [Shin]. Analysis found that mobile phone interventions have the capability to attenuate sleep disorders and to enhance sleep quality. Assessed phone apps were able to perform diverse functions: tracking, sleep advice which offered real-time recommendations to promote awareness related to healthy sleep behaviors, and optimized alarms. Some of the mobile phone apps performed elements of Cognitive Behavioral Therapy for Insomnia (CBT-I), which is one of the traditional standard treatments for improving sleep behavior.
Loóna has a different unique approach to relaxation and preparation for sleep. Time-bounded sessions in the app each has its specific aim to help control the pre-sleep screen time, reinforce relaxation and instill better sleep hygiene.
First, Loóna provides the users with a coloring activity based on simple motions. It encourages the brain to utilize its motor skills in as well as contributes on concentrating for the creative process of changing an art object. This calm activity is regaining focus and eliciting a relaxation response. In addition to cognitive ways of coping, creative arts activity target creation, interoception (body experience), and expression in order to change emotional pattern (embodied appraisal), providing opportunities geared toward health maintenance and health-promoting aspects [Prinz]. Attention and concentration are influenced by the perception, exploration, and creation of artistic content as well as by the explicit use of body perception and expression. Thereby art is considered to be a method to activate resources and abilities to increase flexibility, self-efficacy, and empowerment [Koch].
Creative arts interventions were found to have a positive impact on perceived stress and stress management. Art techniques were effective in reduction of anxiety levels and improved the subjects’ mood. This may be due to certain therapeutic mechanisms that researchers assume to be relevant: hedonism and play, aesthetic experience and authenticity, nonverbal communication and symbolizing, test-acting in an enactive transitional space, creation and generativity [Martin].
In a randomized controlled trial, art activity by individuals with breast cancer led to improvement of general well-being through the reduction of negative and the enhancement of positive emotions [Puig]. In patients with chronic illness, art activity contributed to the improvement of overall health and well-being by distracting individuals from thoughts of illness, and improving self-identity [Reynolds]. A biological substrate of creative self-expression also was found in the study where participants' cortisol (stress hormone) levels after 45 minutes of art-making were significantly lower than before this activity [Kaimal]. Another study found that one hour of art making, which consisted of using brushes and paint to decorate a tile decreased cortisol levels and helped to reduce feelings of sluggishness and improve concentration in people receiving blood and marrow transplants [Lawson]. Same results were obtained in the study which determined that level of cortisol and the state of anxiety in healthcare workers decreased significantly after the art therapy [Visnola].
At the same time along with the art component of Loóna, accompanying soothing ambient music in the app provides the influence on the mental activity relaxing and allowing the brain to concentrate on sedative, and organic sounds, strengthening the calm environment.
The restorative effect of music has been recognized for many years. In the 16th and 17th centuries, music was used to treat mood disorders and during the World War II music was found to ease distress among patients recovering from shell shock. To date, the use of music for therapeutic purposes has become prevalent worldwide, and its effect on various mental disorders has been studied [Bloch].
Significant effects of music listening on sleep quality have been found in children, students, various patient populations, elderly persons and persons with sleep problems due to psychological distress. Sleep improvements were assessed by polysomnography which is considered as a gold standard of sleep measurement [De Niet]. Several studies found significant improvement in sleep quality by music influence with additional interventions like imagery, guided relaxation procedure or progressive muscle relaxation, other studies examined music listening alone with results suggesting that music in itself can be effective in improving sleep.
The final Loóna component is the element of storytelling which dips the user into the process to re-create the comfortable and secure atmosphere.
This type of a mind-body intervention can be considered as sort of guided imagery which is called a pleasant imagery. Pleasant imagery guides the individual to imagine a calm, comfortable place. This may include images of mountains, oceans, or past memories that generate feelings of calm and nurturance [Van Kuiken].
Imagery is the thought process that takes into account and translates the senses for the nervous system to, in turn, produce healing change throughout the body. Guided imagery may be done through prompting by a live practitioner or an audio record. Several theories for this process have been proposed. Imagery induces a deep sense of calm and an avenue of reframing emotions and thus changing the balance of the nervous system. A neuroanatomic model suggests that nonverbal images and the processing of emotions occur in the right cerebral hemisphere. This association is translated into an autonomic response. The left hemisphere’s conscious control of the voluntary nervous system then modulates the emotional-autonomic response pathway [Zeller].
As a treatment intervention, there is a strong evidence base for guided imagery in stress and anxiety management in different populations, including nursing students, patients coping with medical-related anxiety, first time mothers, and individuals with speech anxiety [Nguyen].
All of the above components in the Loóna app are combined to create a unique interactive experience: a sleepscape. The sleepscape is a space where users interact dynamically with the app, and where the elements of guided imagery, art activities and music come together organically.
Initially, the sleepscape is a monochrome three-dimensional diorama with an unusual object depicted on it in the form of a house, a vehicle or a shrine, for example. The original style of the object, its surroundings and its details make the sleepscape unique. The image on the diorama is interactive, with the ability to manually unfold the image from any angle and zoom in and out.
The sleepscape starts with storytelling: a pleasant voice-over begins to tell a story about the object depicted in the diorama. The user is immersed in a rhythmical, calm narration. Soon, the narrator initiates the guided imagery element by describing a particular detail of the object in the diorama, and inviting the user to identify it and then colour it by tapping on the detail. When the user taps on the detail, it is painted with a wave of soft, spreading colour, accompanied by a pleasant sound. This is part of the art activity in Loóna. As the story continues leisurely, the user turns the diorama, carefully examining it, searching for the details mentioned by the narrator and colouring them with taps.
This entire process is accompanied by calm, ambient music, which enhances the relaxation effect of the guided imagery and art activity.
The user's interaction with the sleepscape is considered to be complete when the user has coloured all the details of the diorama and it 'comes to life' with the inclusion of additional sounds and animation. At this point, the narrator ends the story. The duration of each sleepscape is individual as it depends on the pace of the user.
Thus, Loóna app organically combines three science-based components that can effectively influence sleep quality and assist in the stress management. It is known that sleep hygiene is very important for a good quality of sleep, and the use of various devices before bedtime [Brick], including mobile phones [Akçay, Owusu-Marfo], can negatively affect it. Using the right mobile apps, like Loóna, as an alternative to ordinary sticking in a mobile phone at bedtime which is irresistible for certain persons, can help to maintain good sleep hygiene and improve sleep quality.
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