Cognitive Attentional Syndrome Research Articles

Qualitative analysis of emotional distress in burns, plastic and reconstructive surgery patients from the perspectives of cognitive and metacognitive models.

Burns and other injuries requiring plastic and/or reconstructive surgery (BPRS) are lifechanging, often unexpected, and increase the risk of psychiatric morbidity. There are no published studies we are aware of that explores the applicability of psychological models to BPRS patients. Cognitive behavioural therapy (CBT) is the benchmark treatment in mental health but may be less effective in physical health settings. Metacognitive therapy (MCT)can be more effective than CBT in mental health settings and shows promise in reducing anxiety and depression symptoms in people with cancer and cardiac disease. The present study explored the psychological experiences (feelings, thoughts, and coping strategies) of BPRS patients, and whether the concepts underpinning cognitive and metacognitive models can be elicited from these accounts. Semi structured interviews were conducted with 11 patients recruited from a BPRS psychology service. Data was analysed using Thematic Analysis. Patients described a range of emotions including low mood, anxiety, anger, guilt, loss, and negative thinking. From the perspective of the cognitive model, there were examples of each of 10 pre-specified distorted thinking types (cognitive distortions), and patient talk seemed to fit problem-specific cognitive models. From the perspective of the metacognitive model, all patients described the "cognitive attentional syndrome," i.e., how they engaged in repetitive negative thinking (worry, rumination) and thought-focused regulation strategies. Patient talk also demonstrated both positive and negative metacognitive beliefs. The implications of applying the findings from each model to clinical practice are discussed. The metacognitive model may offer benefits in clinical practice that should be investigated further.

Group metacognitive therapy for children and adolescents with anxiety and depression: A preliminary trial and test of proposed mechanisms

Preliminary research supports the feasibility of metacognitive therapy (MCT) in children with generalized anxiety, but the effectiveness of MCT in treating children with other anxiety and depressive disorders largely remains unknown. The purpose of this study was to investigate the effects associated with MCT in targeting symptoms of anxiety and depression in children and adolescents and to investigate mechanisms proposed by the metacognitive model. Ninety-seven participants aged 10–17 years (M = 12.9 ± 1.9, 82.5 % females) with anxiety and depressive disorders received eight sessions of group MCT. Participants were diagnostically assessed at pre- and post-treatment and completed symptom and process measures before, during, and after treatment, and again at three- and six-month follow-up. Multilevel models were conducted to investigate treatment-related and mediation effects. Results showed large reductions in total symptoms following treatment (d = 1.28). These reductions were associated with, and temporally preceded by changes in cognitive attentional syndrome (CAS), metacognitive beliefs, and self-reported attention control, but not objective attention control. Treatment gains were maintained at six-month follow-up (d = 1.18). Our results indicate that MCT may be a promising treatment for children and adolescents with anxiety and depression and provide preliminary evidence of changes in CAS, metacognition, and perceived attention control as potential drivers of treatment effects.

Gaming Disorder in Individuals Experiencing Stress: Cognitive Attentional Syndrome and Metacognitions as Mediators

Gaming Disorder in Individuals Experiencing Stress: Cognitive Attentional Syndrome and Metacognitions as Mediators

Cognitions and Metacognitive Beliefs in Posttraumatic Stress Disorder.

There has been an increasing interest in understanding what contributes to the development and what maintains posttraumatic stress disorder (PTSD). The cognitive model emphasizes that it is a disturbance of the autobiographical memory for the trauma, cognitive beliefs and maladaptive behaviour that maintain trauma symptoms. Interventions are based on cognitive restructuring and behaviour experiments to modify these beliefs. In contrast, the metacognitive model emphasizes that it is the metacognitive beliefs that give rise to the cognitive attentional syndrome (CAS) that maintain trauma symptoms. The focus of treatment is reducing CAS and working on metacognitive beliefs. The aim of this study was to explore the contribution of cognitions and metacognitive beliefs to trauma symptoms and investigate what predicts symptom burden in traumatized patients. Participants (N = 290) diagnosed with PTSD were included, and hierarchical multiple regression analyses were performed to explore if cognitions and metacognitive beliefs explained additional and independent variance in trauma symptoms while controlling for age and gender. Both cognitions and metacognitive beliefs contributed independently and significantly to predicting trauma symptoms. The results provide further support for investigating what maintains trauma symptoms and what to target in treatment. This may have clinical implications for our theoretical and practical understanding of PTSD.

Metacognitive strategies mediate the association between metacognitive beliefs and perceived quality of life.

Quality of life may be understood as a multidimensional evaluation of life circumstances in relation to values, expectations, and perceived well-being. Quality of life is thus dependent on the subjective perception of the current life situation, not only objective circumstances. According to metacognitive theory, metacognition guides the appraisal of inner experiences (i.e., thoughts and feelings) and influences how one relates to external stressors. Hence, dysfunctional metacognitive beliefs and the cognitive attentional syndrome (CAS), which includes perseverative thinking, threat monitoring and ineffective coping strategies, may negatively influence subjective quality of life. Therefore, we aimed to investigate if metacognitive beliefs and CAS strategies were associated with quality of life. A sample of 503 participants (77.1% women, mean age 41.0, SD = 11.5) completed the metacognitions questionnaire 30 (MCQ-30), the CAS-1 and the quality of life scale (QOLS). We used structural equation modelling (SEM) to estimate associations between the variables founded in metacognitive theory. The results of the SEM showed a significant direct relationship between metacognitive beliefs and quality of life. CAS strategies mediated the effect of metacognitive beliefs on quality of life. Higher level of metacognitive beliefs was associated with greater use of CAS strategies, which in turn was associated with lower quality of life. Further, more CAS strategies were associated with lower quality of life. The results support the generic metacognitive model and suggest that stronger endorsement of dysfunctional metacognitive beliefs and corresponding CAS strategies are associated with lower quality of life. This observation held even when controlling for relevant covariates and suggests that modifying metacognitive beliefs may impact on subjective quality of life.

'I felt like I'd lost control of everything': An exploration of metacognition and masculinity in men experiencing suicidality.

Seventy-five per cent of UK suicides are completed by men, and associated masculinity beliefs are well researched. The self-regulatory executive functioning (S-REF) model of distress is governed by metacognitive beliefs about mental processes, such as worry and rumination. Little is known about metacognition in male suicidality and how these processes interact with masculinity beliefs, suicidal ideation and behaviour. To identify which aspects of the S-REF model were present in a sample of men experiencing suicidality, and to consider how these processes interact with masculinity beliefs, suicidal ideation and behaviour. Fifteen men experiencing suicidal ideation or behaviour were recruited from a home-based treatment team. Semi-structured interviews and self-report measures were administered to identify metacognitive processes and masculinity beliefs. Interviews were analysed using the framework approach. The S-REF model was identified across three super-ordinate themes; 'the cognitive attentional syndrome (CAS) and maladaptive coping', 'metacognitive beliefs about worry, uncontrollability and danger' and 'consequences'. Thirteen sub-ordinate themes included processes such as 'worry' and 'rumination', metacognitive beliefs such as 'worrying helps me avoid problems' and 'worry is dangerous for me' and emotional consequences such as 'overwhelm', 'emasculation' and 'escape'. Perseverative thinking and erroneous metacognitive beliefs were associated with reduced functioning, which was incompatible with masculinity beliefs about leadership and strength, and suicide was considered as re-establishing control. Further research into metacognitive processes in male suicidality would enhance theoretical understanding.

Did Cognitive Attentional Syndrome Symptoms Predict Stress- and Trauma-Related Symptoms in the Initial Phase of the COVID-19 Pandemic? Results from a Two-Wave Study on a Sample of Polish Internet Users.

According to metacognitive theory, Cognitive Attentional Syndrome (CAS) is a transdiagnostic factor and a main mechanism of psychopathology maintenance. The main goal of this study is to examine whether CAS predicted stress- and trauma-related symptomatology in the first months of the COVID-19 pandemic and three months later. Initially, 1792 participants were recruited online via social media; the data were collected at two time points. The measures included the Cognitive Attentional Syndrome Questionnaire, the Adjustment Disorder-New Module 20, the International Trauma Questionnaire, and additional measures. Structural equation modeling was conducted in order to determine the relations between the reported stressors, CAS, and symptomatology. At both time points, CAS was a significant mediator between the stressors and symptoms of adjustment disorder. Despite the decrease in the intensity of adjustment disorder symptoms between waves, it was a significant predictor of other psychopathologies at both time points, except for traumatic stress. The findings confirm the assumption that CAS is a transdiagnostic factor of psychopathology and has a mediating role in the relationship between stressors and adjustment disorder and co-occurring symptomatology. The effect was particularly significant in the initial phase of the pandemic, which was highly stressful for many people.

Development and Validation of the Cognitive Attentional Syndrome Scale 1 Revised–Japanese Version1

AbstractThe Cognitive Attentional Syndrome Scale 1 Revised (CAS‐1R) is a 10‐item self‐report measure designed to assess dysfunctional metacognition, a transdiagnostic predictor of psychological disorders (e.g., generalized anxiety disorder, major depression disorder). Dysfunctional metacognition is classified into “cognitive attentional syndrome” and “metacognitive beliefs,” and the latter in turn into negative and positive beliefs. We translated the CAS‐1R into Japanese (CAS‐1R‐J) and examined its reliability and validity in a Japanese community sample. We recruited 552 participants via the Internet and received responses from 552 individuals (Time 1) and 112 individuals (Time 2). Of these, the data of 87 individuals were used to examine test–retest reliability. Confirmatory factor analysis indicated that the factor structure (three‐factor model) of the CAS‐1R‐J was appropriate. Each subscale showed good internal consistency. Hierarchical logistic regression analysis showed discriminant and incremental validity for anxiety and depressive symptoms, meaning the CAS‐1R‐J is valid to assess state cognitive attentional syndrome and metacognitive beliefs among Japanese individuals.

Investigating the specific domains of the cognitive attentional syndrome that predict posttraumatic stress symptoms: The moderating effect of attentional control

The metacognitive model of posttraumatic stress disorder (PTSD) suggests that persistent use of the maladaptive self-regulation strategies that comprise the cognitive attentional syndrome (CAS) increases the likelihood of developing PTSD symptoms following trauma exposure. The metacognitive model also suggests that flexible regulation of attention might be protective against developing maladaptive outcomes that are associated with the CAS. The aims of this study were to (1) examine associations between all seven domains of the CAS and PTSD symptoms using a recently developed, multidimensional measure of the CAS, and (2) examine the moderating effect of self-reported attentional control on associations between the CAS and PTSD symptoms. Participants were trauma-exposed community adults (N = 237) who completed a battery of self-report measures. Results from linear regression analyses showed that worry, substance use, and internal threat monitoring accounted for unique variance in PTSD symptoms when all seven CAS domains were entered into the same model. Moderation analyses showed that attentional control dampened the effect of the CAS, specifically external threat monitoring, on PTSD symptoms. Study results support attentional control as a protective factor against the maladaptive effects of the CAS on PTSD symptoms.

Effect of CBT on Metacognitive Beliefs in Depressive Disorders.

Metacognitive beliefs operate through cognitive attentional syndrome, where attention concentrated on negative automatic thoughts results in rumination. This perseverative thinking style manifesting in the form of rumination and worry intensifies depression. This study aims to assess the effect of cognitive behaviour therapy (CBT) on metacognitive beliefs, symptom severity, quality of life, and functionality. A pre-post study design comparing CBT-alone and CBT-with-medication was employed using purposive sampling to recruit 40 participants diagnosed with depressive disorders. All the participants received 10 sessions of CBT. Pre and post assessment measures were Beck Depression Inventory-II, Metacognitive Questionnaire-30, World Health Organization Quality of Life- Brief, and Global Assessment of Functioning. Paired t-test analysis revealed significant difference on outcome measures in both groups. Between-subject analysis revealed that the CBT-alone group was not significantly different in terms of improvement than CBT-withmedication group even when confounding variables were statistically controlled by way of testing analysis of covariance and propensity score match (nearest neighbour match). Keywords: Cognitive behaviour therapy, metacognition, depressive disorders, metacognitive beliefs, depression, quality of life.

Study protocol of ConquerFear-HK: a randomised controlled trial of a metacognition-based, manualised intervention for fear of cancer recurrence among Chinese cancer survivors

IntroductionFear of cancer recurrence (FCR) is a prevalent and frequently debilitating response to a cancer diagnosis, affecting a substantial proportion of cancer survivors. Approximately 30% of local Hong Kong Chinese...

Cognitive-Attentional Syndrome Moderates the Relationship Between Fear of Coronavirus and Symptoms of Coronavirus-Specific Health Anxiety

This study was aimed at exploring the possible roles of the cognitive attentional syndrome (CAS) and metacognitive beliefs in moderating the relationships between fear of coronavirus during the pandemic and health anxiety. Because some symptoms of health anxiety may overlap with symptoms of other anxiety disorders, we also tried to ascertain whether our hypothesized relations would be maintained when taking other anxiety disorder symptoms into account. We hypothesized that CAS strategies and meta-beliefs would play a role in the progression from fears of the coronavirus to coronavirus health anxiety. The method done was a cross-sectional study with n = 783 participants who completed questionnaires on fear of coronavirus, coronavirus-specific health anxiety, CAS, and symptoms of anxiety disorders. Fear of coronavirus and coronavirus health anxiety are correlated with medium effect size. CAS and metacognitive beliefs moderate the relationship between fear of coronavirus and symptoms of coronavirus-specific health anxiety. CAS predicts a unique part of health anxiety symptoms variance above symptoms of other anxiety disorders. The results of this cross-sectional study preclude causal inferences but tentatively suggest that CAS strategies may play a role in moderating the relationship between fear of coronavirus and coronavirus-related health anxiety. These relationships were obtained after controlling for variance shared with agoraphobia, social phobia, and general physical symptoms of anxiety.

Cultural adaptation and validation of the Arabic version of the multidimensional cognitive attentional syndrome scale (MCASS)

ABSTRACT The cognitive attentional syndrome (CAS) is a core concept within metacognitive theory. The premise of the CAS is related to metacognition, however its role in psychopathology is distinct. Due to the complex nature of the CAS, a theoretically driven and psychometrically sound self-report measure of the CAS for the Arabic population is yet to be developed. We translated the Multidimensional Cognitive Attentional Syndrome Scale (MCASS) into the Arabic language and tested its structural validity. The MCASS was translated according to the standard guidelines of forward-translation followed by backward-translation. In Study 1, the MCASS was administered to a larger sample (N = 1027), selected from 22 Arabic-speaking countries in the Arab League countries, and exploratory factor analysis (EFA) was used to examine the factor structure of the measure. Those who participated in Study 1 were excluded from participating in Study 2. Confirmatory factor analysis (CFA) was used in Study 2 (N = 567) to assess the latent factor structure of MCASS, which supported a six-factor model. Results support multidimensional assessment of the CAS using the MCASS, and demonstrate suitability for use in Arab speaking samples. Implications of this study and recommendations for use of the Arabic version of MCASS are discussed.

Metacognitions About Health in Relation to Coronavirus Anxiety: The Mediating Role of Cognitive Attentional Syndrome and Distress Tolerance.

The current study aimed to investigate the mediating role of cognitive attentional syndrome (CAS) and distress tolerance in the relationship between health-related metacognitions and coronavirus anxiety. The sample of this study consisted of 462 participants (381 female). Participants voluntarily completed self-report questionnaires on each of the variables mentioned above. The results of the structural modeling analysis showed that health-related metacognitions have a significant effect on the mediator variable of distress tolerance and CAS. Also, health-related metacognitions had a direct effect on coronavirus anxiety. Also, based on the results of the bootstrap test, it can be argued that health-related metacognitive beliefs, apart from their direct effect, play an important role in coronavirus anxiety, with CAS acting as a mediator. This study provides insights into the relationships among metacognitive beliefs, coronavirus anxiety, CAS, and distress tolerance. In particular, dysfunctional metacognitive beliefs, including an individual's beliefs about the uncontrollability of disease-related thoughts, are risk factors that could negatively affect mental health, leading to coronavirus anxiety. In addition, the association of dysfunctional beliefs with maladaptive behaviors resulting from the cognitive attentional syndrome is also involved in predicting and causing coronavirus anxiety. Given the insignificant role of emotional distress tolerance in the psychopathology of COVID-19 anxiety, the findings emphasize the importance of cognitive factors in this context.

‘Thinking about Them is only making me feel worse’. The mediating role of metacognitive factors in the relationship between paranoia-like beliefs and psychopathology symptoms in a community sample

IntroductionParanoia in community samples is associated with higher levels of depression, anxiety symptoms and suicidality. The metacognitive model assumes the role of metacognitive factors in these associations. Positive and negative metacognitive beliefs (PMB and NMB, respectively) and cognitive-attentional syndrome (CAS) are to mediate between paranoia-like beliefs and psychopathology symptoms. The current study is an attempt to test this prediction. MethodsA cross-sectional community study with n = 840 participants. We used R-GPTS's persecutory subscale to measure paranoia-like beliefs, CAS-1 for CAS and metacognitive beliefs and SCL-27-plus for psychopathology symptoms. ResultsIndirect effects of PMB, CAS and NMB accounted for 22% to 56% (CI 95%) of total effects of relationships between paranoia-like beliefs and vegetative symptoms, symptoms of social phobia, agoraphobia, depression and suicidality screening. ConclusionsWe demonstrated that PMB, CAS and NMB mediate between paranoia-like beliefs and various psychopathological symptoms, as predicted by the metacognitive model of psychopathology. We also uncovered other indirect effects, including negative mediation effect of PMB on the relationship between paranoia-like beliefs and depressive symptoms and suicidality.

The Relationship Between Metacognition, Meta-worry, Rumination, and Cognitive-Attentional Syndrome in Iranian Combat Veterans with Post-traumatic Stress Disorder

Background: Post-traumatic stress disorder (PTSD) metacognitive model is considered a model with good power. There are not enough data that this model is appropriate to combat veterans with chronic PTSD. Objectives: This study aimed to investigate the association between metacognition components, including metacognitive beliefs and attitudes, meta-worry, rumination, and cognitive-attentional syndrome (CAS), in Iranian combat veterans with PTSD. Methods: The population of this study included all combat veterans referred to the rehabilitating center of Sari, Mazandaran province in 2016. After a clinical interview by a clinical psychologist, the veterans were divided into three groups (PTSD, non-PTSD, and non-traumatized). These three groups matched in age, gender, and socio-economic status. Exclusion criteria for three groups were as follows: Those who had a significant psychiatric disorder that has been active during the research plan. Moreover, data gathering instrument used in the current research was Metacognition Questionnaire [including Metacognitive Questionnaire (MCQ), Ruminative Responses Scale (RRS), Cognitive-Attentional Syndrome Scale (CAS-1), Impact of Event Scale-Revised (IES-R), and Meta-worry Questionnaire (MWQ)]. One-way variance analysis was used to compare groups in terms of metacognition, meta-worry, rumination, and CAS. Conclusions: Consistent with the metacognitive model of PTSD, metacognition components, ruminative responses, cognitive-attentional syndrome, and meta-worry have significant differences with non-PTSD and non-traumatized. It appears that meta-cognitive components are more disruptive in PTSD patients than other control groups. This finding could be integrated into the metacognition theory.

Effectiveness of Acceptance and Commitment Therapy on Stress, Cognitive-Attentional Syndrome, and Blood Sugar Indices in Patients with Type II Diabetes

Background: Psychological problems are mainly overlooked in patients with chronic diseases. Objectives: The present study aimed to investigate the effectiveness of acceptance and commitment therapy on stress, cognitive-attentional syndrome, and blood sugar indices in patients with type II diabetes. Methods: In this quasi-experimental study, 40 patients with type II diabetes, referred to Birjand Diabetes Clinic in 2019 were selected via convenience sampling method. Later, subjects meeting inclusion criteria were randomly assigned into experimental and control groups. The former received treatment based on acceptance and commitment therapy (ACT) in eight 90-minute weekly sessions. Controls received no intervention. Fasting Blood Sugar (FBS) and glycosylated hemoglobin indices were measured for all participants before and after the intervention. The data were collected, followed by administering DASS scale developed by Lovibond and Lovibond (1995) and Wells cognitive attentional syndrome or CAS (2009) questionnaires and analyzed using SPSS 22. Univariate and multivariate analyses of covariance were also performed at a significance level of 0.05. Results: The participants’ mean educational level and age were (1.53 ± 2.70) and (6.03 ± 45.58), respectively. Also, the mean values of the variables CAS, stress, HBA1C, and FBS were (22.51 ± 94.09), (09.09 ± 36.30), (0.90 ± 7.34) and (29.09 ± 151.82), respectively. Also, the mean scores of stress (P = 0.002), CAS (P = 0.001), FBS (P = 0.001), and glycosylated hemoglobin (P = 0.001) indices were significantly lower in experimental compared to controls after the intervention. Conclusions: In general, ACT effectively reduced stress, cognitive attention syndrome, and blood sugar indices among patients with type II diabetes. Experts should consider formality of this training in diabetes care treatment programs.

Brain structural correlates of cognitive-attentional syndrome - a Voxel-Based Morphometry Study.

Cognitive-attentional syndrome (CAS) is in the self-regulatory executive function model a set of cognitive and behavioural strategies aimed at regulating cognition and emotion originating from maladaptive metacognitive beliefs. Investigating the brain structure of people with high levels of CAS enables a better understanding of the syndrome and bridging between the metacognitive model of psychopathology and previous results on structural abnormalities in various psychological disorders. Participants with high (n=40) and low levels of CAS (n=44) underwent structural Magnetic Resonance Imaging session. Voxel-Based Morphometry analytical approach was used to compute grey matter volume (GMV) differences between the groups. The group with a high level of CAS had lower GMV in the dorsal part of the anterior cingulate cortex. Our results are in line with the self-regulatory executive function model of psychopathology, showing a link between CAS and lowered GMV in the brain region associated with the regulation of cognition and emotion. They are also in agreement with meta-analytical results on structural correlates of various psychological disorders.

Cognitive attentional syndrome in Hong Kong people with depression

Objective: The aim of this study was to examine the occurrence of Cognitive Attentional Syndrome (CAS) in the Hong Kong Chinese population with depression and to assess the psychometric properties of the translated Traditional Chinese version of the CAS-1 questionnaire. Method: The English version of the CAS-1 questionnaire was translated into Traditional Chinese for this study. Study participants with (N=64) and without (N=64) depression completed the Chinese version of the CAS-1 and the psychometric properties assessed. Results: The internal consistency of the total CAS-1 scores (α=0.704), metacognitive strategies (α=0.789) and metacognitive belief subscales (α=0.716) of the translated Chinese CAS-1 were found to be statistically acceptable. ANCOVA indicated a statistically significant difference between participants with depression and those without depression in CAS-1 total scores (F=4.574, p<0.035) and CAS-1 metacognitive strategies subscale (F=46.615, p<0.0001), treating education level and sex as covariates. Conclusion: The results support the use of the Traditional Chinese version of the CAS-1 questionnaire in clinical settings. In addition, the findings provide the first empirical evidence of the existence of CAS in Hong Kong people with depression.

Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up.

Insomnia is highly prevalent and associated with anxiety and depression in patients with coronary heart disease patients. The development of effective psychological interventions is needed. Worry and rumination are potential risk factors for the maintenance of insomnia, anxiety, and depression that may be modified by psychological treatment grounded in the Self-Regulatory Executive Function model. However, the relationships between worry, rumination, anxiety and depression, and insomnia are not known. Therefore, we investigated these relationships both cross-sectionally and longitudinally among patients with coronary heart disease. A cross-sectional study consecutively included 1,082 patients in 2014-2015, and 686 were followed up after mean of 4.7 years. Data were gathered from hospital records and self-report questionnaires comprising assessment of worry (Penn State Worry Questionnaire), rumination (Ruminative Responses Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and insomnia (Bergen Insomnia Scale). Insomnia correlated moderately with all other psychological variables (R 0.18-0.50, all P values < .001). After adjustments for anxiety and depression, odds ratios for insomnia at baseline were 1.27 (95% confidence interval 1.08-1.50) and 1.60 (95% confidence interval 1.31-1.94) per 10 points increase of worry and rumination, respectively. Corresponding odds ratios for insomnia at follow-up were 1.28 (95% confidence interval 1.05-1.55) and 1.38 (95% confidence interval 1.09-1.75). Depression was no longer significantly associated with insomnia after adjustments for worry and rumination, but anxiety remained significant. Worry and rumination predicted insomnia both cross-sectionally and prospectively, even after controlling for anxiety and depression, although anxiety remained significant. Future studies may test psychological interventions targeting these factors in patients with coronary heart disease and insomnia. Frøjd LA, Papageorgiou C, Munkhaugen J, etal. Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up. J Clin Sleep Med. 2022;18(3):779-787.