The reflecting team: an innovative approach for teaching clinical skills to family practice residents.

BACKGROUND AND OBJECTIVES: This paper provides a description and evaluation of the reflecting team approach as a teaching method for family practice residents. We have used the reflecting team approach in our longitudinal behavioral health program for 6 years. Our purpose in using this approach is to 1) teach listening and interviewing skills, 2) teach systems-oriented psychosocial interventions, and 3) provide behavioral health consultations for patients. METHODS: A five-item, self-administered, open-ended questionnaire evaluating the reflecting team approach was administered to a sample of family practice residents. RESULTS: Completed questionnaires were received from 18 of the 22 family practice residents participating in the longitudinal behavioral health program (a response rate of 82%). Responses to the questionnaire items indicated that the residents understood the purpose of the reflecting team approach and felt that they had acquired a variety of clinical skills from the approach, including listening and interviewing skills, positive reframing of patients' problems, how to give positive feedback to promote behavioral change, and increased knowledge of psychosocial assessment procedures and treatment methods. CONCLUSIONS: The residents' responses to the questionnaire items indicated that they perceived the reflecting team approach to be a practical and useful method for learning a variety of clinical skills.

The association of energy intake bias with psychological scores of women.

OBJECTIVE: Assess the association between reporting bias of dietary energy intake and the behavioral and psychological profiles in women. DESIGN: At baseline a series of questionnaires were administered to 37 women, (the Marlowe-Crowne Social Desirability Scale, Weinberger Adjustment Inventory (WAI), the Eating Disorder Inventory (EDI), the Restraint Scale and Sorensen-Stunkard's silhouettes). Subjects received training on how to record dietary records. Subjects recorded three days of dietary records to measure energy intake (EI) during a study to determine total energy expenditure (TEE) using doubly labeled water. Reporting accuracy (RA = EI/TEE x 100) was determined for each subject. Statistical analysis of the data used a mixed effects model accounting for within subject variability to determine if the psychological scores were associated with reporting accuracy. SETTING AND SUBJECT: Women were recruited with local advertisements in Tucson, Arizona. The women had a mean ( +/- 1 s.d.) age of 43.6 +/- 9.3 yrs, body mass index (BMI) of 28.7 +/- 8.5 kg/m2 and total body fat (%TBF) of 31.9 +/- 7.3%. RESULTS: Age and %TBF were significantly and inversely associated with RA. Furthermore, Social Desirability was negatively associated with RA. Body dissatisfaction and associating a smaller body size than one's own as being more healthy were also associated with a lower RA. CONCLUSIONS: These results suggest that Social Desirability and self image of body shape are associated with RA. Modifications in subject training may reduce the effect of these factors on RA.

Development and evaluation of the McKnight Risk Factor Survey for assessing potential risk and protective factors for disordered eating in preadolescent and adolescent girls.

OBJECTIVE: To describe the development, test-retest reliability, internal consistency, and convergent validity of the McKnight Risk Factor Survey-III (MRFS-III). The MRFS-III was designed to assess a number of potential risk and protective factors for the development of disordered eating in preadolescent and adolescent girls. METHOD: Several versions of the MRFS were pilot tested before the MRFS-III was administered to a sample of 651 4th through 12th- grade girls to establish its psychometric properties. RESULTS: Most of the test-retest reliability coefficients of individual items on the MRFS-III were r > .40. Alpha coefficients for each risk and protective factor domain on the MRFS-III were also computed. The majority of these coefficients were r > .60. High convergent validity coefficients were obtained for specific items on the MRFS-III and measures of self-esteem (Rosenberg Self-Esteem Scale) and weight concerns (Weight Concerns Scale). CONCLUSIONS: The test-retest reliability, internal consistency, and convergent validity of the MRFS-III suggest that it is a useful new instrument to assess potential risk and protective factors for the development of disordered eating in preadolescent and adolescent girls.

Factors associated with weight concerns in adolescent girls.

OBJECTIVE: This study examined the association of weight concerns with potential risk factors for the development of eating disorders. METHOD: A self-report survey was given to 103 elementary (Grades 4 and 5) and 420 middle (Grades 6-8) school students in Arizona and California. Of these, 78 elementary and 333 middle school students provided complete data and were used in the analyses. RESULTS: In a multivariate stepwise regression analysis, the importance that peers put on weight and eating was most strongly related to weight concerns in the elementary school girls, accounting for 34% of the variance after adjusting for site differences. Trying to look like girls/women on TV and in magazines as well as body mass index (BMI) entered the final model that accounted for 57% of the variance in weight concerns. In middle school, the importance that peers place on weight and eating was also the strongest predictor accounting for 33% of the variance followed by confidence, BMI, trying to look like girls/women on TV and in magazines, and being teased about weight. Together these variables accounted for 55% of the variance. DISCUSSION: Prevention programs aimed at reducing weight concerns need to address these factors.

Potential risk factors associated with weight control behaviors in elementary and middle school girls.

The purpose of this study was to examine the relationship between weight control behaviors and potential risk factors for disordered eating in a sample of young girls. The McKnight Risk Factor Survey was administered to 523 elementary and middle school girls. In the sample of elementary school girls, results from the multiple regression analyses indicated that frequency/severity of weight control behaviors was associated with body mass index (BMI), self-confidence, peers' weight-related pressures, ethnicity, and the interaction between having divorced/separated parents and BMI. Sensitivity to peers' weight-related pressures and BMI were also associated with weight control behaviors in the middle school girls, along with poor body image, substance use, having divorced/separated parents, and the interaction between having divorced/separated parents and father's pressure for thinness. Longitudinal research is needed to determine how risk factors change over time, beginning in elementary school and continuing through high school.

Attachment style and weight concerns in preadolescent and adolescent girls.

OBJECTIVE: The purpose of this study was to assess the association between attachment style and weight concerns, a major risk factor for eating disorders, in preadolescent and adolescent girls. METHOD: Three hundred and five female elementary and middle school students completed measures of attachment style and weight concerns. RESULTS: Insecurely attached subjects reported higher weight concerns than did securely attached subjects. A greater proportion of insecurely attached subjects obtained "at risk" weight concerns scores than securely attached subjects. DISCUSSION: The findings suggest that attachment style may play an important role in the development of weight concerns, which, in turn, have been shown to be associated with the onset of eating disorders.

Eating disturbances among American minority groups: a review.

OBJECTIVE: The purpose of this paper was to review the research literature related to eating behaviors and disturbances among American minority groups. METHOD: A computer-based literature search was conducted to locate articles pertaining to this topic. RESULTS: This review indicates that, compared to Caucasian females, eating disturbances are equally common among Hispanic females, more frequent among Native Americans, and less frequent among Black and Asian American females. Risk factors for eating disorders (EDs) are greater among minority females who are younger, heavier, better educated, and more identified with White, middle-class values. DISCUSSION: Further studies of EDs among American minority groups are needed, especially studies that are longitudinal and developmental in nature and that focus more specifically on the effects of racism in the development of EDs.

The spectrum of eating disturbances.

OBJECTIVE: The purpose of this paper was to review and summarize the research literature on the spectrum of eating disturbances. METHOD: Literature was searched using a computer data base to identify recent articles related to the prevalence and occurrence of disturbed eating patterns as well as full and partial syndrome eating disorders (EDs). RESULTS: This review indicates that the prevalence of partial syndrome EDs in nonclinical populations is at least twice that of full syndrome EDs, and that there is a progression in some individuals from less to more severe disturbances in eating behavior. DISCUSSION: These findings suggest the need for careful, scientific evaluation of risk factors for EDs in both children and adults. A longitudinal research program in progress is described which aims to identify the risk factors for EDs.

Eating attitudes and weight preoccupation among female high school students in Japan.

Eating disorder tendencies in 197 eleventh grade Japanese girls were examined to ascertain whether or not the reported correlates of eating disorder tendencies in North America would be replicated in Japan. The 26-item Eating Attitudes Test was administered along with a set of supplementary questions. As hypothesized, higher levels of eating disturbances were found in the students who: (1) perceived themselves as being overweight, (2) had been encouraged to diet, (3) reported engaging in frequent conversations with their mother about food and dieting. Implications for future cross-cultural research are discussed.

Is puberty a risk factor for eating disorders?

OBJECTIVE: To examine the association between stage of sexual maturation and eating disorder symptoms in a community-based sample of adolescent girls. PARTICIPANTS: All sixth- and seventh-grade girls (N = 971) enrolled in four northern California middle schools. MAIN VARIABLES EXAMINED: Pubertal development measured using self-reported Tanner stage and body mass index (kg/m2). The section of the Structured Clinical Interview for DSM-III-R Disorders (SCID) discussing bulimia nervosa was used to evaluate symptoms of bulimia nervosa. RESULTS: Girls manifesting eating disorder symptoms, while not significantly older than their peers without such symptoms, were more developmentally advanced as determined with Tanner self-staging. The odds ratio for the association between sexual maturity and symptoms was 1.8 (95% confidence interval, 1.2 to 2.8); ie, at each age, an increase in sexual maturity of a single point was associated with a 1.8-fold increase in the odds of presenting symptoms. The odds ratio for the association between body mass index (adjusted for sexual maturity) and symptoms was 1.02 (95% confidence interval, 1.0 to 1.05). There was no independent effect of age or of the interaction between age and the sexual maturity index. CONCLUSIONS: These results suggest that (1) puberty may be a risk factor for the development of eating disorders, and (2) prevention efforts might best be directed at prepubertal and peripubertal adolescents.

Comparing obligatory to nonobligatory runners.

This study compares "obligatory" runners (runners who continue to run despite clear physical injury or contraindications) to nonobligatory runners. Both groups scored within the normal range on most psychological test indices. The two groups had more similarities than differences. The obligatory runners did present more significant elevations of the Minnesota Multiphasic Personality Inventory scales than did the nonobligatory runners. Based on their responses to the semistructured interview, the obligatory runners were significantly more concerned and rigid about weight control than the nonobligatory runners and the obligatory runners were more likely to prefer being alone. Obligatory runners were more preoccupied with their bodies and reported more positive changes in self-concept and a greater sense of control over their lives since they had begun to run. Female runners reported more satisfaction with and more positive effects from running than did male runners. Strenuous exertion is known to increase prolactin in male and female runners. Clinical research studies suggest that an increase in prolactin is associated with an obsessive preoccupation with diet and/or exercise.

Clinical features of eating disorders and individual psychological functioning.

Relationships between the clinical features of eating disorders and individual psychological functioning were investigated in a population of 114 eating-disordered females, which consisted of 63 bulimics, 9 anorexics, 7 bulimic anorexics, 23 with eating disorders not otherwise specified, and 12 with indications of an eating disorder, but without sufficient data for further differential diagnosis. No significant differences in psychological functioning were found when diagnosis was used to classify the subjects into groups, but significant differences did emerge when subjects were classified by specific clinical features. Among the clinical features associated with greater psychopathology were: low body weight, frequent weight fluctuations, amenorrhea of longer duration, purging via laxatives, frequent exercising, and more frequent binges of longer duration.

Coexistence of bulimia nervosa and mania: a literature review and case report.

A literature review of the relationship between bulimia and affective disorder showed that the evidence from empirical research and case report studies suggests that a sizeable subgroup of bulimics suffer from bipolar disorder as well as bulimia and may benefit from antimanic medications such as lithium. A case report is presented of a bulimic patient with manic symptoms who was successfully treated with lithium. However, the use of lithium should be avoided with any patient who is purging, since it may exacerbate the loss of intracellular potassium, thereby increasing the risk of cardiac toxicity.

Body weight and bulimia as discriminators of psychological characteristics among anorexic, bulimic, and obese women.

Bulimic women from underweight (n = 20), normal-weight (n = 31), and overweight (n = 22) categories were compared with restrictor anorexics (n = 20), normal controls (n = 31), and obese subjects (n = 22). Each subject was administered the Minnesota Multiphasic Personality Inventory, the Internal-External Locus of Control Scale, the Rosenberg Self-Esteem Scale, and the Semantic Differential Potency Scale. Bulimic women in all 3 weight categories exhibited greater psychopathology, more external locus of control, lower self-esteem, and lower sense of personal effectiveness than nonbulimic women at similar weight levels. The highest psychopathology, lowest self-esteem, and most external locus of control were found among the underweight bulimic women. Significant differences between bulimic women of different weight levels suggest the need for some modification of treatment approaches depending on the bulimic women's weight level.

Family dysfunction in normal weight bulimic and bulimic anorexic families.

A group of 24 normal weight bulimics and 13 bulimic anorexics were compared with each other and a normal control group (n = 41) on two self-report measures of family functioning (Family Environment Scale and Family Dynamics Survey). The two bulimic groups perceived their families as more dysfunctional than did the normal control group on the dimensions of cohesion, expressiveness, conflict, recreational orientation, emotional support, communication, and need for counseling. There were few significant differences in the family perceptions of the two bulimic groups.

Prevention of eating disorders among adolescents.

Abstract Since eating disorders frequently begin during adolescence, high school students represent a high risk population for the development of these disorders. For this reason, a pilot project for the prevention of eating disorders was instituted at the high school level. The primary goal of this pilot project was to educate students, faculty, and staff at the school about the incidence, symptoms, and consequences of eating disorders. Consultation and referral services were also provided. An evaluation component of the project assessed the informational impact of the prevention program on the students. On a questionnaire designed for the project, a significantly greater number of questions about eating disorders were answered correctly by students who were recipients of the prevention program than by those who were not. The results of this project demonstrate the feasibility of using the high school setting to promote increased awareness of eating disorders and their consequences among high school students.

Typical patterns in atypical anorexia nervosa.

Only a few published accounts describe atypical anorexia nervosa. To provide more information about this eating-disorder subtype, 15 patients (12 females, 3 males) with atypical anorexia nervosa were studied. In general, the 12 female patients were characterized by 1) older age at onset and presentation, 2) recurring bouts of depression, 3) numerous somatic complaints, 4) unmet dependency needs, and 5) little evidence of distortion in body image. The three male patients were characterized by a younger age at onset compared to the females, and in many ways they resembled young female anorexics or bulimic anorexics.

Eating disorders and substance abuse in women: a comparative study of MMPI patterns.

Psychopathology was compared in women with eating disorders, women with alcohol or drug problems, and women with both an eating disorder and an alcohol or drug problem. Overall psychopathology, as measured by the Minnesota Multiphasic Personality Inventory (MMPI), was greatest in the group with both an eating disorder and substance abuse problems. In general, the women with eating disorders resembled the substance abusers in terms of rebellious and antisocial behavior but differed from the substance abusers in being less hyperactive and experiencing more psychic distress. The differences that were found between eating-disordered women with and without substance abuse problems suggest that treatment interventions may need to be modified if the eating disorder patient has substance abuse problems as well.