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Sleep appraisal Delphi study 1
The development of a theoretically derived measure exploring extreme appraisals of sleep in
Bipolar Disorder:
A Delphi study with professionals
*Blind Review*
RUNNING HEAD: Sleep appraisal Delphi study
Correspondence concerning this article should be addressed to:
*Blind Review*
The authors declare no conflicts of interest with respect to this publication.
This research received no specific grant from any funding agency, commercial or not-for-profit
sectors.
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out
by the APA.
When consulted, the university research ethics committee did not require ethical approval since this
study only asked professionals non-sensitive questions deemed strictly within their professional
competence. Additionally, personal identifiable data was not collected from the participants.
2
Abstract
Background: Sleep and mood are known to be linked and this is particularly evident in people with
a diagnosis of bipolar disorder (BD). It has been proposed that psychological interventions
improving sleep can be a pathway for improving mood. In order to develop an appropriate
psychological sleep intervention, the common cognitive processes maintaining the range of sleep
disturbances need to be investigated.
Aim: This study aimed to explore and identify expert consensus on positive and negative sleep
appraisals in the context of low and high mood states, using the Integrative Cognitive Model as a
theoretical guide.
Method: A Delphi approach was utilised to allow clinical and research professionals, with
experience in the field of BD, to be anonymously consulted about their views on sleep appraisals.
These experts were invited to participate in up to 3 rounds of producing and rating statements that
represented positive and negative sleep appraisals.
Results: A total of 38 statements were developed and rated, resulting in a final list of 19 statements
that were rated as “Essential” or “Important” by >80% of the participants. These statements
represent the full range of extreme sleep appraisals this study had set out to explore, confirming the
importance of better understanding and identifying positive and negative sleep cognitions in the
context of high and low mood.
Conclusion: The statements reviewed in this study will be used to inform the development of a
sleep cognition measure that may be useful in cognitive therapy addressing sleep disturbances
experienced along the bipolar spectrum.
Keywords: bipolar disorder; mood swings; insomnia; hypersomnia; circadian; cognitive appraisals;
reduced need for sleep; cognitive therapy
Sleep appraisal Delphi study 3
Exploring extreme appraisals of sleep in Bipolar Disorder:
A Delphi study with professionals
Mood and sleep are recognised to have a bidirectional relationship (Alvaro, Roberts, &
Harris, 2013; Kahn, Sheppes, & Sadeh, 2013), and this is particularly evident in the mental health
difficulty bipolar disorder (BD) (Abreu & Braganca, 2015; Plante & Winkelman, 2008). BD is a
mood disorder characterised by at least one episode of elevated or irritable mood and/or episodes of
depressed mood. Changes to sleeping patterns are reported as a possible symptom during both
depressed mood states and elevated mood states (Ritter et al., 2015; Rosa et al., 2013). During
depression a person might experience difficulties with falling and staying asleep (insomnia), or the
person might sleep more than usual (hypersomnia). During elevated or irritable mood a person
might experience feeling rested after only 3 hours of sleep, referred to as reduced need for sleep
(American Psychiatric Association, 2013).
These clinically significant changes in sleeping patterns are not only a symptom during low
or elevated mood, but are also known to occur before a mood episode happens (Correll et al., 2007;
Gruber et al., 2011) and between mood episodes (Rosa et al., 2013). It has also been shown to be a
risk factor for BD (Ritter et al., 2015), as evidenced in research that has looked at familial risk
groups (Duffy, Alda, Hajek, Sherry, & Grof, 2010; Ng et al., 2015; Ritter et al., 2015), groups who
score high on measures that indicate a tendency toward high mood (Ankers & Jones, 2009; Ng et
al., 2015) and those who meet bipolar at-risk criteria (Castro et al., 2015).
Both sleep and mood related difficulties are known to have significant negative impacts on a
person’s quality of life (Roth & Ancoli-Israel, 1999). The impact is also felt on society due to
occupational and health related costs for the person (Altshuler et al., 2006; Boland et al., 2015;
Murray & Lopez, 1997), such as taking extended time off from work (Das Gupta & Guest, 2002).
For these reasons, it is important that research is done in order to better understand and inform
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intervention options. Due to the increasing recognition that sleep and mood are bidirectional, as
discussed above, it is important that interventions incorporate support for both difficulties.
Pharmacological approaches are a common intervention for supporting those with BD and sleep
disturbances. However, it is important to consider psychological interventions as this would enable
more treatment choice and is in line with current NICE guidelines (National Institute for Health and
Care Excellence [NICE], 2014). Additionally, psychological interventions have a range of positive
advantages over pharmacological approaches. Harvey, Kaplan, and Soehner (2015) explain the
disadvantages of medication include adverse drug interactions with mood stabilising medication,
the risk of daytime residual effects, and possible dependence on or abuse of the medication (Levin
& Hennessy, 2004). It should be noted that psychological interventions can have unintended side
effects due to factors such as clients’ expectations to being met and limits in therapist competence
(Curran et al., 2019). In order to improve potential adverse effects of psychological intervention,
robust research needs to be conducted and disseminated.
A psychological intervention that incorporates sleep support in the field of BD is the
behavioural psychotherapy intervention Interpersonal and Social Rhythm Therapy. This therapy
focuses on the importance of maintaining a regular social rhythm (Frank, Swartz, & Kupfer, 2000).
Although this intervention has shown reduced recurrence of mood episodes when delivered
following a mood episode (Frank et al., 2005), it emphasises a biological approach that mood
difficulties are due to circadian rhythm irregularities. However, sleep disturbances are not explained
by biological processes alone. For this reason, it is important a psychological intervention is
informed by an approach that considers the common biological and cognitive behavioural processes
(Harvey, Watkins, Mansell, & Shafran, 2004). Cognitive sleep research has primarily focused on
the sleep disturbance insomnia, and has identified cognitive processes that maintain this
disturbance. This is detailed in the Cognitive Model of Insomnia and includes negative cognitive
beliefs a person endorses about difficulties with sleeping (Harvey, 2002). Identifying these
cognitive beliefs informs Cognitive Therapy (CT) intervention, which then targets these beliefs
Sleep appraisal Delphi study 5
(Edinger & Wohlgemuth, 2001). CT has been shown to be a useful intervention for people with
insomnia (Morin, Vallieres, & Ivers, 2007). Additionally, CT for insomnia has been shown to have
positive outcomes on both mood and sleep for people with a diagnosis of depression (Manber et al.,
2008) and BD (Harvey et al., 2015).
In order to identify these cognitive processes, a sleep cognition measure is required. A
recently conducted scoping review aiming to identify the range of sleep cognition measures for
sleep duration disturbances highlighted that there is currently no available measure developed
specifically for use with hypersomnia or reduced need for sleep (Pearson, Mansell, Turner, &
Parker, 2018). The review instead highlighted that sleep cognitions in insomnia have been widely
researched. However, the cognitive processes proposed to maintain insomnia might not account for
these other sleep disturbances. There is a need for a cognitive model that accounts for the range of
sleep disturbances and can guide CT intervention for people with fluctuating sleep duration
disturbances. Without an available cognitive model in the sleep literature, the area of BD research is
a useful guide since BD is a psychiatric disorder that accounts for mood and sleep fluctuations.
Healy and Williams (1989) first proposed that circadian rhythm disruption, such as sleep
disturbances caused by stressors, in conjunction with cognitive distortions play a significant role in
BD vulnerability. Jones (2001) further explained this relationship by proposing a model guided by
Power and Dalgleish (1997) & Jones (1979) that explains it is one’s internal attribution of circadian
change that facilitates and maintains BD symptoms. Building on these theoretical models in BD, the
Integrative Cognitive Model (ICM) (Mansell, Morrison, Reid, Lowens, & Tai, 2007) and explains
that multiple, extreme positive and negative appraisals about mood play an important role in driving
mood up into an elevated state and down into a negative state. For example, heightened mood could
be appraised positively as a sign of great success or negatively such as an impending breakdown
(Dodd, Mansell, Bentall, & Tai, 2011). These appraisals contribute to the person engaging in
either ascent (Mansell & Lam, 2003) or descent behaviours in order to control their internal state,
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causing mood to fluctuate as different appraisals enter the person’s awareness (Mansell, 2006). In a
recent systematic review of 31 studies, multiple lines of evidence have suggested that these extreme
appraisals are associated with mood difficulties across the BD spectrum in both clinical and non-
clinical groups (Kelly, Dodd, & Mansell, 2017). It is this conflict of multiple, extreme appraisals
that could also play a role in the changes in sleep disruption across the shifting mood states. For
example, a person might be driven to reduce sleep to a few hours per night when in an activated
mood state, so they can ‘do as much as possible’ following a period in which they were low in
mood and perhaps sleeping much more. However, they may also appraise sleeping much less per
night as a risk for relapsing into mania and being admitted into hospital. Therefore, periods of only
a few hours’ sleep to make up for lost time may be followed by several days of sleeping much
longer than usual in an attempt to stave off a mood episode.
Building on the previous research in the insomnia literature, the aim of this Delphi study
was to explore and identify expert consensus on the range of positive and negative appraisals a
person might endorse about their sleep in the context of the different sleep disturbances experienced
in BD, in line with the theoretical ICM. These appraisals can then inform the development of a
measure that will offer a unique and novel identification of cognitions that may be maintaining a
more complex range of sleep changes and disturbances found across the BD spectrum. This
potential measure has the opportunity for providing a more comprehensive identification of sleep
related cognitions that can better inform and suit the needs of a person engaging in CT for sleep and
mood difficulties. This study complements parallel work streams in a research program for
psychometrically testing this sleep cognition measure, reviewing it with service users, and
incorporating it in studies to test the role of sleep within the ICM framework.
1. Method
1.1. Delphi Method
Sleep appraisal Delphi study 7
The Delphi method is an anonymous consensus method that sets out to determine how much
experts (those who are highly knowledgeable about the domain of interest (Boateng, Neilands,
Frongillo, Melgar-Quinonez, & Young, 2018)) agree on a particular topic or issue. As explained by
Hasson, Keeney, and McKenna (2000) and Jones and Hunter (1995), this method follows a series of
rounds in which the identified experts contribute independent suggestions and recommendations on
the topic or issue. These suggestions and recommendations are then developed into relevant
headings or statements, which the experts are then invited to rank their level of agreement with.
Additional rounds are completed to ensure that consensus is reached by the entire participant group.
For these additional rounds, information from the previous round is supplied, such as the rate of
agreement among the group. This allows the individual participant an opportunity to change their
ranking based on the information of how the group ranked the statement. For the purposes of this
study, the authors followed the approach used by Law and Morrison (2014) and Morrison and
Barratt (2010) in which Round 1 is a preliminary phase for a smaller group of experts who are
invited to help refine the statements for consensus with a larger participant group in later rounds.
Conducting this study with experts who have a range of both clinical and research experience
working with those who have BD enables a wide range of experiences to be taken into account with
this clinical group. In addition, both the use of experts and the Delphi methodology are
recommended in the development and evaluation of scales (Boateng et al., 2018).
1.2. Participants.
For the development and refinement of statements in Round 1, published academics and/or
research and training professionals were recruited who had been identified in the literature as
having made a significant contribution to the understanding of BD and in some instances also in the
field of sleep research and/or in the ICM. Each potential participant was sent an invitation e-mail
introducing the team conducting this study and a brief introduction about the study and what it
involved. A secure online link for SelectSurvey was included in the e-mail for the participant to
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take part anonymously in the study. The online link included the participant information sheet and
statements for the participant to provide feedback on along with the opportunity for suggesting new
statements.
For the remaining rounds in consensus rating, the panel of experts was widened to include
more participants who had worked clinically with people who experienced mood and sleep
difficulties. The inclusion criteria for these additional rounds were:
Minimum training level of either qualified occupational therapist, qualified social worker,
research assistant, grade 6 nurse, CBT therapist, trainee clinical psychologist, or junior
doctor.
At least 1 years’ experience working with people who experience significant low and
elevated mood difficulties (e.g. bipolar disorder or bipolar at-risk) AND who have reported
sleep difficulties (e.g. initiating, maintaining, or not needing sleep).
For these rounds, the same experts invited for Round 1 were also invited to take part.
Additionally, the invitation asked the participant to inform colleagues who might be suitable to take
part based on the inclusion criteria. Participants were also invited who worked in mental health
services across the northwest of England, where the authors of this study have close links with
relevant services. Only the participants who took part in Round 2 were invited to take part in the
final Round 3. All participants completed the study through the SelectSurvey platform
anonymously. A separate SelectSurvey link was available for the participant to leave their e-mail
address for being invited to the additional rounds. This meant the data provided by the participants
was anonymous to the researcher. Participants were given 4 weeks to complete each round, and
were sent reminder e-mails when 2 and 1 week(s) remained. It was made clear that at any time an
invitee or participant wanted to withdraw from taking part they could request to be removed from
the e-mail invitation list.
1.3. Procedure.
Sleep appraisal Delphi study 9
When consulted, the university research ethics committee did not require ethical approval
since this study only asked professionals non-sensitive questions deemed strictly within their
professional competence. Additionally, personal identifiable data was not collected from the
participants.
Before Round 1, an initial group of statements representing extreme positive and negative
appraisals were developed by the research team based on the theory of the ICM. This was
completed by reviewing the literature and commonly used self-report measures for sleep disruptive
cognitions, including the Dysfunctional Beliefs and Attitudes about Sleep Scale (Morin, Stone,
Trinkle, Mercer, & Remsberg, 1993). Additionally, one of the authors (L.P.) reviewed an online
BD Forum (www.psychforums.com) in September 2016 for themes about sleep from a service user
perspective that were reported in the messages on the forum. This is a widely used psychology and
mental health forum with over 100,000 members, and enables discussion about personal
experiences on a wide range of mental health topics. In the BD forum, the keywords “sleep”,
“insomnia”, and hypersomnia” were used in the search bar to locate relevant postings for review
that dated back to 2005. The themes obtained included difficulties around falling asleep and impact
on mood, sleep as an avoidance of emotions, lack of sleep allowing motivation and creativity, and
the positive impact of sleep on mood and stability.
In line with the theory of the ICM, the authors wrote the statements as accounting for the
following 4 domains: positive appraisals of sleeping less than usual, positive appraisals of sleeping
more than usual, negative appraisals of sleeping less than usual, and negative appraisals of sleeping
more than usual. The research team agreed the statements should reflect extreme positive and
negative appraisals of sleep, whilst also accounting for the change in sleep duration that is
represented by the sleep disturbances that are characteristic of BD, e.g. reduced need for sleep or
insomnia is sleeping less than usual, whilst hypersomnia is sleeping more than usual. The result was
31 statements that were developed by the research team as a starting point for Round 1.
10
1.3.1. Round 1.
The participants for Round 1 were instructed to review the developed statements and rate
how essential the statement was for inclusion on the new self-report measure. This was completed
using a 5 point scale (1 = essential, 2 = important, 3 = do not know/depends, 4 = unimportant, 5 =
should not be included). The participants were also invited to provide feedback on each of the
statements with reasons for their choice of rating and any additional comments such as word
changes. Finally, there was an option at the end for the participant to provide additional comments,
statements or other suggestions for the measure based on their clinical and research expertise.
The authors reviewed the consensus rating and feedback and suggestions from Round 1, and
amended the statements accordingly. Statements that received a high consensus rating of being
either essential or important with minimal feedback or comments were kept the same. Statements
that had received a low consensus rating and had significant comments or suggestions were
replaced with amended versions. Comments and suggestions for new statements that were not on
the original list were discussed in the research team and written by the authors as new statements.
This resulted in 13 statements remaining the same, 15 statements amended, 3 statements removed,
and 10 new statements added.
1.3.2. Round 2.
The revised list of 38 statements was then put out for Round 2 with the wider group of
participants for consensus rating only. Following the method employed by (Langlands, Jorm,
Kelly, & Kitchener, 2008; Law & Morrison, 2014; Morrison & Barratt, 2010), the following cut-off
points were used by the research team to determine items for inclusion, exclusion, and re-rating:
Statements rated by 80% or more of the participants as essential or important will be
included in the self-report measure.
Sleep appraisal Delphi study 11
Statements rated by 70-79% of the participants as essential or important will be re-rated in a
further round for a further consensus check.
Any statements that did not meet at least 70% rating of essential or important will be
excluded.
The participants were asked to read each statement and rate how relevant the statement was
for being included in a sleep measure for use with those who have mood swings. The participants
rated each statement using the same 5-point scale used in Round 1. This resulted in the inclusion of
16 items, 17 items discarded, and 5 items for re-rating.
1.3.3. Round 3.
In Round 3, the participants from Round 2 who had left their contact details for taking part
in additional rounds were invited to take part anonymously via an online link with SelectSurvey.
Participants were asked to re-rate only those items that 70-79% of respondents had rated as essential
or important during Round 2 (n=5). To help inform the participants’ decision for re-rating, the
percentage from Round 2 was included with each of the statements. It was explained that any
statements from this round that met 79% or less consensus for essential or important would be
discarded. Of these 5 statements, 3 were retained and 2 discarded. Table 1 outlines the phases of
this Delphi study.
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Table 1: Delphi Study Outline
Phase 1: Initial development of items Define the construct
Literature review
Review online BD forum for sleep themes
Initial list of 31 items developed by the research team
Phase 2: Delphi method; Preliminary phase Round 1: Development and refinement of items
Experts in the field of BD invited
Experts rated items for importance of including in the measure, offered wording changes and gave suggestions for new items.
Research team reviewed experts feedback and revised statements, resulting in 38 items.
Phase 3: Delphi method consensus rounds Round 2: Wider group of experts invited to take part in consensus rounds.
Participants rated items for importance (1 = “essential” to 5 = “should not be included”).
Research team used cut-off points to determine what items reached high consensus (rated as “essential” or “important” by > 80% of the participants) and what items were discarded (items that did not meet rating of “essential” or “important” by more than 70% of the participants).
Round 3: Participants who took part in Round 2 were invited to take part in Round 3 to re-rate the 5 items that were rated by 70-79% of the participants as “essential” or “important.”
2. Results
2.1 Demographics
For Round 1, the research team invited 24 experts identified in the literature, 12 of whom
responded to take part (50% response rate). However, there were 10 participants who completed
the round in full and so only their responses were used for analysis. For Round 2, 25 participants
took part and for Round 3, 18 of the 25 participants took part (72% response rate). Table 2 provides
an overview of the demographic information for all 3 rounds. Participants reported their current
professional role (noted in Table 2) but also shared what previous relevant career history they had
Sleep appraisal Delphi study 13
with BD and this included having been a researcher, an assistant psychologist, or having worked in
different clinical settings.
Table 2: Participant Characteristics
Round 1
(n = 10)
Round 2
(n = 25)
Round 3
(n = 18)Gender
Male
Female
6 (60%)
4 (40%)
9 (35%)
16 (64%)
9 (50%)
9 (50%)Age
Mean Age 41 35 34
Current ProfessionConsultant Clinical Psychologist
Clinical Psychologist
Trainee Clinical Psychologist
Psychological Therapist
Assistant Psychologist
Research Assistant
Lecturer / Research
Professor
Assistant Practitioner
Mental Health Nurse
2 (20%)
5 (50%)
0
1 (10%)
0
0
1 (10%)
1 (10%)
0
0
1 (4%)
11 (44%)
1 (4%)
2 (8%)
2 (8%)
3 (12%)
1 (4%)
2 (8%)
1 (4%)
1 (4%)
1 (6%)
10 (56%)
1 (6%)
1 (6%)
1 (6%)
3 (17%)
1 (6%)
0
0
0
2.2 Ratings of Importance Results
A total of 19 statements were retained in the final statement list after being rated as
important or essential by > 80% of participants. Figure 1 summarises the number of items included,
re-rated, and excluded at each round of the study.
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Figure 1: Number of items included, rerated, and excluded at each round of the study
Table 3: High Consensus Items
Item Stage Included
Percentage Agreement
Appraisal Domain
The only way I can stop myself thinking is to sleep more 2 80% + / ↑
Round 1Reviewed by n=10
31 statements
Items remaining the same
13 statements
Items amended
15 statements
Items removed
3 statements
Items added
10 statements
Round 2Reviewed by n=26
38 statements
Items kept
16 statements
Items for re-rating
5 statements
Items discarded
17 statements
Round 3Reviewed by n=18
5 statements
Items kept
3 statements
Items discarded
2 statements
Sleep appraisal Delphi study 15
than normal.I sleep more to escape from the real world. 2 100% + / ↑
I have to sleep more to keep my mood stable. 2 80% + / ↑
Sleep prevents me from completing my many projects. 3 83% - / ↑
When I sleep more than normal I feel so useless 2 84% - / ↑
Sleeping too much is a sign that I am becoming depressed. 2 96% - / ↑
If I only need a few hours of sleep, it is a sign that I'm on top of things.
3 83% + / ↓
I stay up very late or all night to bring on my elevated mood.
2 80% + / ↓
It is necessary for me to stay up very late or all night to get all of my work done.
2 92% + / ↓
I stay up very late or all night because of all my good ideas. 2 80% + / ↓
I stay up very late or all night because this is when I feel most creative.
2 88% + / ↓
I stay up very late or all night when I have elevated mood, because this is when I feel my best.
3 89% + / ↓
The less I sleep, the more likely it is I get everything done. 2 88% + / ↓
If I do not get enough sleep each night, I become extremely anxious.
2 88% - / ↓
If I do not get enough sleep each night, I won't be able to function at all the next day.
2 96% - / ↓
If I do not get enough sleep each night I will not be able to get done what needs to be done the next day.
2 84% - / ↓
If I do not get enough sleep each night, my moods become uncontrollable.
2 92% - / ↓
If I do not get enough sleep, I will feel it in my body. 2 88% - / ↓
If I do not get enough sleep at night, this will have a terrible impact on me the next day.
2 96% - / ↓
The final 19 statements are shown below in Table 3. The two statements that did not meet at
least 70% for a further re-rating both reached only 67% consensus for essential or important by the
participant group. The three statements that were included each reached above 80% consensus. For
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this reason, a further round of re-rating was not required. Also depicted in Table 2 are the
statements included by each round, the percentage of agreement, and the domain the statement
assesses for: positive appraisals of sleeping more than usual (n = 3), negative appraisals of sleeping
more than usual (n = 3), positive appraisals of sleeping less than usual (n = 7), and negative
appraisals of sleeping less than usual (n = 6).
There were 6 items that reached extremely high consensus in Round 2 (> 90%). These
statements have been highlighted in grey in Table 2 and are from the following domains: positive
appraisals of sleeping more than usual (n = 1), negative appraisals of sleeping more than usual (n =
1), positive appraisals of sleeping less than usual (n = 1), and negative appraisals of sleeping less
than usual (n = 3).
3. Discussion
The aim of this Delphi study was to explore and identify expert consensus on positive and
negative sleep appraisals using the ICM as the theoretical framework for development of items. The
results suggest that professionals working in the field of BD recognise that those who have sleep
and mood difficulties endorse a range of extreme sleep appraisals. A total of 38 statements were
developed and rated, resulting in high consensus for half of the statements. These final 19
statements all represent the range of extreme positive and negative appraisals of sleep that are in
line with the theory of the ICM the authors had set out to investigate. This range covers four
domains: positive appraisals of sleeping less than usual, positive appraisals of sleeping more than
usual, negative appraisals of sleeping less than usual, and negative appraisals of sleeping more than
usual.
With the focus in the literature and past research on cognitions about sleep having been
focused on negative beliefs regarding insomnia (e.g. CT for insomnia), it is of particular interest
that the domain that reached the most number (n = 7) of high consensus for statements was the
domain assessing for positive appraisals of sleeping less than usual. This domain represents sleep
Sleep appraisal Delphi study 17
appraisals in the context of reduced need for sleep. As highlighted by the recent scoping review
conducted (Pearson et al., 2018), there have not been measures developed that assess for this
domain. However, this Delphi study has shown that experts and clinicians in the field of BD
recognise this to be at least as important compared to the more widely recognised and researched
negative appraisals of sleeping less than usual (e.g. insomnia).
3.1 Clinical Implications
The extreme sleep appraisals identified in this Delphi study can inform the development of a
new sleep cognition measure that will offer a unique and novel identification of sleep cognitions
that may be maintaining a more complex range of sleep changes and disturbances found across the
BD spectrum. This potential measure has the opportunity for providing a more comprehensive
assessment that can better inform and suit the needs of a person with BD engaging in CT for sleep
disturbances.
3.2 Strengths and Limitations
This study had several strengths. First, the strength of a Delphi consensus method enables
decision making to be shared amongst a group of equally level participants anonymously (Jones &
Hunter, 1995). This prevents the risk of anyone dominating the consensus process, since everyone
independently provides their response in the rounds (Keeney, Hasson, & McKenna, 2006; Rowe &
Wright, 2001). Specific to this study, the recommendations and the consensus of the experts went
beyond what has been reported in the literature regarding the additional domains of positive and
negative sleep appraisals in the context of sleeping more or less than usual. Second, the response
rate for Round 3 was 72%, which meets the recommended rate of at least 70% (Hasson et al., 2000).
Third, service user input was included to help identify the range of positive and negative sleep
appraisals people with BD might endorse. This was completed through reviewing postings on an
online forum. Forums have been reported to provide a comfortable space for people to
anonymously discuss personal issues (Campbell et al., 2001) whilst also enabling participants to
18
join in the discussions at their convenience (Hsiung, 2000) . It could be argued that this allows a
person to give an honest explanation of their difficulties at times when they are experiencing
symptoms. Fourth, the appraisals identified and explored in this study were derived using the ICM
as the theoretical framework. These appraisals will inform the development of a sleep cognition
measure which will be assessed on content validity. Content validity is the degree to which the
measure adequately reflects the construct in question. Assessment of construct validity for a
measure includes rating if the measure’s origin of construct was defined by a theoretical model
(Terwee et al., 2018), which this study has clearly stated.
There are several limitations to this study. First, it is increasingly recognised that service
users should be involved in questionnaire development in order to truly capture their perspectives
and to ensure the questionnaire is understandable (Terwee et al., 2018). Although the research team
utilised an online BD forum for sleep themes, it is unknown what number of service users had a
clinical history of elevated or depressed mood across the BD spectrum. To ensure the measure is
understandable and relevant for those who experience sleep fluctuations common across the BD
spectrum, a service user review will be conducted. This will be an opportunity for service users to
rate the measure for content validity and compare it to a commonly used, validated measure of
insomnia specific cognitions. Additionally, future research could include qualitative interviews with
those who have BD in order to further develop and refine the statements. A second limitation was
the response rate was less than 70% for Round 1 (when 24 people had been invited) and thus did
not meet the recommended 70% rate (Hasson et al., 2000). Second, there were relatively low
numbers of participants taking part in each round. One reason for this may be because invitations to
take part in the study were mainly conducted by e-mail, whereas previous research has found that
conducting the first round in person has led to a higher response rate in subsequent rounds
(McKenna, 1994). Additionally, because there are low numbers of experts taking part in the study it
may be that the range of appraisals has not been fully identified. However, there was consensus for
Sleep appraisal Delphi study 19
all four domains this study set out to explore which does give validity to the range having been
represented.
4. Conclusion
To the authors’ knowledge, this is the first study to have sought the expert opinion and
consensus on extreme positive and negative sleep appraisals in the context of low and high mood
states. A high level of consensus was reached for a range of sleep appraisals that cover each of the
four domains this study set out to explore and identify. These findings confirm shared agreement
amongst professionals in the field of BD that extreme positive and negative sleep appraisals are
important to understand and identify across the range of mood states. The statements reviewed in
this study will be used to inform the development of a sleep cognition measure that will be tested
for use with CT addressing fluctuating sleep disturbances experienced across the BD spectrum.
5. Acknowledgments
The authors would like to thank all the participants for their time and contributions to this
research.
6. Reference List
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