{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T06:07:41Z","timestamp":1788847661564,"version":"build-2803163510"},"reference-count":40,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T00:00:00Z","timestamp":1788825600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Psychiatry"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Anxiety symptoms are common but often under-recognized in patients with obstructive sleep apnea (OSA). Conventional polysomnographic severity indices may not fully capture the psychological burden of OSA. This study aimed to develop and internally validate a nomogram for clinically significant anxiety symptoms in patients with OSA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A total of 787 patients with OSA were randomly divided into a training cohort (n=551) and a validation cohort (n=236) at a 7:3 ratio. Demographic characteristics, comorbidities, laboratory parameters, patient-reported scales, and polysomnographic variables were collected. Ten-fold cross-validated LASSO logistic regression was used to select predictors from 36 candidate variables. A post-LASSO multivariable logistic model was constructed to develop the nomogram. Discrimination, calibration, and clinical utility were assessed using ROC analysis, bootstrap calibration, Hosmer-Lemeshow testing, and decision curve analysis. Restricted cubic spline analysis examined the association between longest obstructive apnea duration and anxiety symptoms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among the 787 included patients, 71 patients (9.0%) had clinically significant anxiety symptoms. Six predictors were retained: gender, cardiovascular disease, hemoglobin, neutrophil-to-lymphocyte ratio, body mass index, and longest obstructive apnea duration. Patients with anxiety symptoms had poorer subjective sleep quality but relatively milder OSA-related parameters, including lower AHI and ODI, shorter longest obstructive apnea duration, and higher minimum SpO\n                      <jats:sub>2<\/jats:sub>\n                      . Restricted cubic spline analysis showed a significant overall association between longest obstructive apnea duration and anxiety symptoms (Wald \u03c7\u00b2=12.21, df=3, P\u00a0=\u00a00.0067), with borderline non-linearity (P\u00a0=\u00a00.0583). Compared with the 60-100-second group, patients with a duration &amp;lt;60 seconds had a higher anxiety risk (OR\u00a0=\u00a02.84, 95% CI 1.43-5.62, P\u00a0=\u00a00.0028). The nomogram showed acceptable discrimination, with AUCs of 0.735 and 0.751 in the training and validation cohorts, respectively. Calibration was acceptable, with non-significant Hosmer-Lemeshow tests (P\u00a0=\u00a00.1056 and 0.4948). Decision curve analysis indicated positive net benefit across broad threshold ranges.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This LASSO-based nomogram showed acceptable performance for predicting SAS-defined clinically significant anxiety symptoms in patients with OSA. Anxiety risk may not be fully captured by conventional respiratory severity indices alone and may reflect a multifactorial risk profile. External validation is warranted.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpsyt.2026.1899687","type":"journal-article","created":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T05:34:54Z","timestamp":1788845694000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Development and internal validation of a LASSO-based nomogram for predicting SAS-defined anxiety symptoms in obstructive sleep apnea"],"prefix":"10.3389","volume":"17","author":[{"given":"Qing","family":"Feng","sequence":"first","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lingyu","family":"Song","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jinqiao","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jie","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaopei","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rongrong","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xueyan","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jihua","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, The First Hospital of Hebei Medical University","place":["Shijiazhuang, Hebei, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,8]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1016\/S2213-2600(25)00243-7","article-title":"Projecting the 30-year burden of obstructive sleep apnoea in the USA: a prospective modelling study","volume":"13","author":"Boers","year":"2025","journal-title":"Lancet Respir Med"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1016\/j.rmed.2025.108348","article-title":"Unmasking obstructive sleep apnea: estimated prevalence and impact in the United States","volume":"248","author":"S\u00f6nmez","year":"2025","journal-title":"Respir Med"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.5664\/jcsm.11864","article-title":"Evaluation and management of obstructive sleep apnea in adults hospitalized for medical care: an American Academy of Sleep Medicine clinical practice guideline","volume":"21","author":"Mehra","year":"2025","journal-title":"J Clin Sleep Med"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.5664\/jcsm.11866","article-title":"Evaluation and management of obstructive sleep apnea in adults hospitalized for medical care: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment","volume":"21","author":"Auckley","year":"2025","journal-title":"J Clin Sleep Med"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000988","article-title":"Obstructive sleep apnea and cardiovascular disease: a scientific statement from the American Heart Association","volume":"144","author":"Yeghiazarians","year":"2021","journal-title":"Circulation"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2024.02.059","article-title":"Interactions of obstructive sleep apnea with the pathophysiology of cardiovascular disease, part 1: JACC State-of-the-Art Review","volume":"84","author":"Javaheri","year":"2024","journal-title":"J Am Coll Cardiol"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCRESAHA.125.325676","article-title":"Obstructive sleep apnea and cardiometabolic disease: obesity, hypertension, and diabetes","volume":"137","author":"Tasali","year":"2025","journal-title":"Circ Res"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1016\/j.smrv.2024.101996","article-title":"Obstructive sleep apnea and obesity: a review of epidemiology, pathophysiology and the effect of weight-loss treatments","volume":"78","author":"Messineo","year":"2024","journal-title":"Sleep Med Rev"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.3389\/fphar.2022.898072","article-title":"Obstructive sleep apnea and cardiovascular risk: the role of dyslipidemia, inflammation, and obesity","volume":"13","author":"Zdravkovic","year":"2022","journal-title":"Front Pharmacol"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.3390\/life12040537","article-title":"Endothelial dysfunction and cardiovascular risk in obstructive sleep apnea: a review article","volume":"12","author":"Peracaula","year":"2022","journal-title":"Life (Basel)"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1016\/j.sleep.2022.09.023","article-title":"Association between sleep apnea severity and symptoms of depression and anxiety among individuals with obstructive sleep apnea","volume":"101","author":"Lee","year":"2023","journal-title":"Sleep Med"},{"key":"B12","article-title":"Prevalence of depression and anxiety in obstructive sleep apnea","volume":"100","author":"Gharsalli","year":"2022","journal-title":"Tunis Med"},{"key":"B13","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1186\/s12888-025-06532-w","article-title":"Depressive, anxiety, and sleep disturbance symptoms in patients with obstructive sleep apnea: a network analysis perspective","volume":"25","author":"Luo","year":"2025","journal-title":"BMC Psychiatry"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2025.49137","article-title":"Obstructive sleep apnea risk and mental health conditions among older Canadian adults in the Canadian Longitudinal Study on Aging","volume":"8","author":"Kendzerska","year":"2025","journal-title":"JAMA Netw Open"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.3389\/fmed.2022.799792","article-title":"Associations of depression, anxiety, and life events with the risk of obstructive sleep apnea evaluated by Berlin Questionnaire","volume":"9","author":"Duan","year":"2022","journal-title":"Front Med (Lausanne)"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.4088\/JCP.22r14521","article-title":"Recognition and management of obstructive sleep apnea in psychiatric practice","volume":"84","author":"Benca","year":"2023","journal-title":"J Clin Psychiatry"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1186\/s43045-024-00416-7","article-title":"Comorbidity of depression and anxiety with obstructive sleep apnea in a sample of Egyptian patients","volume":"31","author":"Abdel Latif","year":"2024","journal-title":"Middle East Curr Psychiatry"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1007\/s11325-020-02234-7","article-title":"Effect of continuous positive airway pressure on symptoms of anxiety and depression in patients with obstructive sleep apnea","volume":"25","author":"Lundetr\u00e6","year":"2021","journal-title":"Sleep Breath"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1080\/19932820.2025.2569152","article-title":"Impact of obstructive sleep apnea\u2013hypopnea syndrome severity on quality of life, anxiety disorders, and productivity in an active population","volume":"20","author":"Fki","year":"2025","journal-title":"Libyan J Med"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.3390\/medicina59111938","article-title":"Implementation of the Baveno Classification in obstructive sleep apnea and its correlation with symptoms of anxiety and depression","volume":"59","author":"Su\u0161a","year":"2023","journal-title":"Med (Kaunas)"},{"key":"B21","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1016\/j.sleep.2023.08.024","article-title":"Improved depressive symptoms, and emotional regulation and reactivity, in individuals with obstructive sleep apnea after short- and long-term CPAP therapy use","volume":"111","author":"Pattison","year":"2023","journal-title":"Sleep Med"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.3390\/life13020296","article-title":"Adherence to CPAP treatment: can mindfulness play a role","volume":"13","author":"Pataka","year":"2023","journal-title":"Life (Basel)"},{"key":"B23","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1016\/j.arbres.2022.08.005","article-title":"Hypoxic burden in obstructive sleep apnea: present and future","volume":"59","author":"Martinez-Garcia","year":"2023","journal-title":"Arch Bronconeumol"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1093\/sleep\/zsae269","article-title":"The association between hypoxic burden and the risk of cognitive impairment in patients with obstructive sleep apnea","volume":"48","author":"Huang","year":"2025","journal-title":"Sleep"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1111\/jsr.70136","article-title":"Hypoxic load and average oxygen-saturation during sleep and wake are associated with cognitive function in obstructive sleep apnea","volume":"35","author":"Thorisdottir","year":"2026","journal-title":"J Sleep Res"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.11203","article-title":"The prevalence of anxiety and depression symptoms in obstructive sleep apnea","volume":"12","author":"Akberzie","year":"2020","journal-title":"Cureus"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1111\/pcn.13352","article-title":"Age and sex differences on the association between anxiety disorders and obstructive sleep apnea: a nationwide case-control study in Taiwan","volume":"76","author":"Chen","year":"2022","journal-title":"Psychiatry Clin Neurosci"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.3389\/fphys.2021.792633","article-title":"Gender differences in the context of obstructive sleep apnea and metabolic diseases","volume":"12","author":"Martins","year":"2021","journal-title":"Front Physiol"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.3390\/life14050592","article-title":"Impact of intermittent hypoxia related to obstructive sleep apnoea syndrome on low-grade inflammation","volume":"14","author":"Hein","year":"2024","journal-title":"Life (Basel)"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.3390\/jcm12123935","article-title":"Evaluation of inflammation and oxidative stress markers in patients with obstructive sleep apnea","volume":"12","author":"Pau","year":"2023","journal-title":"J Clin Med"},{"key":"B31","doi-asserted-by":"publisher","first-page":"48","DOI":"10.1016\/j.sleep.2024.06.018","article-title":"The relationship between haemoglobin concentrations and obstructive sleep apnea syndrome: a systematic review and meta-analysis","volume":"121","author":"Zoroddu","year":"2024","journal-title":"Sleep Med"},{"key":"B32","doi-asserted-by":"publisher","first-page":"33","DOI":"10.14744\/cpr.2026.30899","article-title":"Clinical and anthropometric correlates of polysomnography-defined severity in obstructive sleep apnea syndrome","volume":"48","author":"Topaloglu","year":"2026","journal-title":"J Clin Pract Res"},{"key":"B33","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2023.1348803","article-title":"A machine learning model to predict the risk of depression in US adults with obstructive sleep apnea hypopnea syndrome: a cross-sectional study","volume":"11","author":"Li","year":"2024","journal-title":"Front Public Health"},{"key":"B34","doi-asserted-by":"publisher","first-page":"6127","DOI":"10.1038\/s41598-024-56629-7","article-title":"A risk prediction nomogram for resistant hypertension in patients with obstructive sleep apnea","volume":"14","author":"Lin","year":"2024","journal-title":"Sci Rep"},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.29333\/ejgm\/12131","article-title":"Prediction models and morbidities associated to obstructive sleep apnea: an updated systematic review","volume":"19","author":"Kasmaoui","year":"2022","journal-title":"Electron J Gen Med"},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.1136\/bmj-2023-078378","article-title":"TRIPOD+AI statement: updated guidance for reporting clinical prediction models that use regression or machine learning methods","volume":"385","author":"Collins","year":"2024","journal-title":"BMJ"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.1002\/sim.9025","article-title":"Minimum sample size for external validation of a clinical prediction model with a binary outcome","volume":"40","author":"Riley","year":"2021","journal-title":"Stat Med"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.1016\/j.spinee.2021.02.024","article-title":"Decision curve analysis to evaluate the clinical benefit of prediction models","volume":"21","author":"Vickers","year":"2021","journal-title":"Spine J"},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.1136\/bmj-2023-074820","article-title":"Evaluation of clinical prediction models, part 2: how to undertake an external validation study","volume":"384","author":"Riley","year":"2024","journal-title":"BMJ"},{"key":"B40","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1186\/s12916-019-1466-7","article-title":"Calibration: the Achilles heel of predictive analytics","volume":"17","author":"Van Calster","year":"2019","journal-title":"BMC Med"}],"container-title":["Frontiers in Psychiatry"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1899687\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T05:34:55Z","timestamp":1788845695000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1899687\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,8]]},"references-count":40,"alternative-id":["10.3389\/fpsyt.2026.1899687"],"URL":"https:\/\/doi.org\/10.3389\/fpsyt.2026.1899687","relation":{},"ISSN":["1664-0640"],"issn-type":[{"value":"1664-0640","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,8]]},"article-number":"1899687"}}