Catherine M Shisslak

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• Shisslak, C. M. (2013). Cultural Competence Education for Practicing Physicians: Lessons in Cultural Humility, Nonjudgmental Behaviors, and Health Beliefs Elicitation. JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 33(3): 164-173, 2013, 33(3), 164-173.
• Shisslak, C. M., & Shisslak, C. M. (2013). Assessing Culturally Competent Diabetes Care With Unannounced Standardized Patients. Family Medicine, 45(6), 400-408.
• Kutob, R. M., Bormanis, J., Crago, M., Harris, J. M., Senf, J., & Shisslak, C. M. (2013). Cultural competence education for practicing physicians: Lessons in cultural humility, nonjudgmental behaviors, and health beliefs elicitation. Journal of Continuing Education in the Health Professions, 33(3), 164-173.
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  PMID: 24078364;Abstract: Introduction: Although numerous studies have examined cultural competence training, debate still exists about efficacious approaches to this training. Furthermore, little focus has been placed on training and evaluating practicing physicians. Methods: A skills-based course on culturally competent diabetes care was developed and subsequently tested in a controlled trial of primary physicians caring for patients enrolled in one state's Medicaid program. We hypothesized that physicians completing the course would show higher levels of self-reported cultural competence as measured by a Cultural Competence Assessment Tool (CCAT) than those in the control group. Differences in CCAT subscale scores were also compared. Results: Ninety physicians completed the study, with 41 in the control and 49 in the intervention group. Most were female (66%), with an average age of 44, and 12 years in practice. There were no significant differences on total CCAT score (212.7 ± 26.7 for control versus 217.2 ± 28.6 for intervention, p =444) or subscales measuring cultural knowledge. There were significant positive differences on the subscales measuring physicians' nonjudgmental attitudes/behaviors (subscale score 2.38 ± 0.46 for control versus 2.69 ± 0.52 for intervention, p =004) and future likelihood of eliciting patients' beliefs about diabetes and treatment preferences (3.11 ± 0.53 for control versus 3.37 ± 0.45 for intervention, p =014). There was, however, a significant negative difference on the subscale measuring cultural self-awareness (3.48 ± 0.36 for control versus 3.26 ± 0.48 for intervention, p =018). Discussion: A predominantly skills-based approach to training physicians did not change aggregate measures of cultural competence, but did affect key attitudes and behaviors, which may better reflect the goals of cultural competence training. © 2013 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.
• Kutob, R. M., Bormanis, J., Crago, M., Senf, J., Gordon, P., & Shisslak, C. M. (2013). Assessing culturally competent diabetes care with unannounced standardized patients. Family Medicine, 45(6), 400-408.
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  PMID: 23743940;Abstract: BACKGROUND AND OBJECTIVES: More effective diabetes care is desperately needed, especially for ethnic minority populations. Provider cultural competence promises to be an important means for reducing disparities in outcomes for patients with diabetes. The objectives of this study were to understand the role of cultural competence in the diabetes office visit. METHODS: Unannounced standardized patients (SPs) were sent to the offices of 29 family and internal medicine residents and practicing physicians. The SPs portrayed a Mexican American woman newly diagnosed with type 2 diabetes. Using a checklist developed with the input of experts in Hispanic/Latino health care and cultural competence, the SPs evaluated physicians' cultural competence, diabetes care, and general communications skills. RESULTS: The average total SP Checklist score was 70.7±11.0%, with a range of 43.9% to 90.2%. Physicians scored highly on items that measured general communication skills (95.9%) but were less likely to ask about social history (ie, family and community support issues, 51.9% and 48.1%, respectively). Sixty-seven percent of physicians ordered a hemoglobin A1c, 44% referred to ophthalmology, and 15% performed a monoflament exam. Physicians' inquiry into SPs explanatory model of disease (ie, asking about the SPs' views regarding their disease and its treatment) correlated with the performance of several diabetes treatment-related behaviors, Spearman's rho=.466. CONCLUSIONS: The findings provide support for a relationship between inquiry into patients' explanatory models of disease and effective diabetes care. Social history and explanatory model elicitation skills are vital parts of cultural competence training programs and potentially valuable tools for mitigating health disparities.
• Siwik, V., Kutob, R. M., Ritenbaugh, C., Crus, L., Meyer, H., Senf, J., Aickin, M., Larez, M., Carruth, L., Shisslak, C., Going, S., & Shatte, A. (2013). Intervention in overweight children improves BMI and physical Activity. The Journal of the American Board of Family Medicine, 26, 12637.
• Hicks, P., Hicks, X. E., Meyer, H., & Shisslak, C. M. (2012). Treating Drug Resistant Depression: Augmenting Anti- Depressants in Primary Care. Journal of Family Practice, 3, 232-240.
• Kutob, R. M., Bormanis, J., Crago, M., Gordon, P., & Shisslak, C. M. (2012). Using Standardized Patients to Teach Cross-Cultural Communication Skills to Pre-Clinical Medical Students. Medical Teacher, 34(7), 594.
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  PMID: 22489982;
• Hicks, P., Hicks, X. P., Meyer, H., & Shisslak, C. (2010). How best to manage treatment-resistant depression?. Journal of Family Practice, 59(9), 490-492+495-497.
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  PMID: 20824225;
• Kutob, R. M., Senf, J. H., Crago, M., & Shisslak, C. M. (2010). Concurrent and longitudinal predictors of self-esteem in elementary and middle school girls. Journal of School Health, 80(5), 240-248.
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  PMID: 20529197;Abstract: Background: The purpose of this study was to analyze the effects of factors related to self-esteem, both cross-sectionally and longitudinally, among 2 cohorts of girls over a period of 4 years, from elementary through middle school.METHODS: A multiethnic sample of 656 elementary school girls recruited from 13 schools in Hayward, CA, and Tucson, AZ, was evaluated annually over a 4-year period. The McKnight Risk Factor Survey IV was administered, which consists of 103 questions that assess self-esteem, appearance appraisal, effect of body changes, depressed mood, teasing, school performance, and other factors. In addition, participants' heights and weights were measured.RESULTS: The most important predictor of self-esteem in each grade was appearance appraisal, and, in all grades but the eighth, weight-related teasing by either boys or girls was also a predictor of self-esteem. Teasing about weight was more important than body weight itself in predicting self-esteem. Self-esteem was lower in girls who were teased about their weight, even if they believed that it had no effect on how they felt about themselves. School performance predicted self-esteem in grades 6 and 8. In longitudinal analyses, the participant's current perception of her appearance was more important than her previous level of self-esteem in predicting current self-esteem.CONCLUSIONS: The results of this study support the need to allocate funding to address the issue of teasing as 1 of the stressors in the school environment, and to explore further the important relationship between school performance and self-esteem. © 2010, American School Health Association.
• Smolak, L., Krieg, D. B., Hayward, C., Shisslak, C. M., & Taylor, C. B. (2007). The reliability of self-reported menarcheal timing. Journal of Early Adolescence, 27(3), 386-397.
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  Abstract: Self-reports of grade at first menstrual period for 1,967 fourth-grade through ninth-grade girls were used to categorize girls as early maturers. The categories of early maturer and other (on-time or late maturers) were then examined for stability over a 3-year period using McNemar tests and k coefficients. Although the results showed significant stability, 15% through 20% of the early maturing girls were eventually reclassified into the other category. This was true for Hispanic, Black, and White girls as well as for 1-, 2-, and 3-year time spans. Implications for measuring menarcheal timing and its effects are discussed. © 2007 Sage Publications.
• Senf, J. H., Shisslak, C. M., & Crago, M. A. (2006). Does dieting lead to weight gain? A four-year longitudinal study of middle school girls. Obesity, 14(12), 2236-2241.
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  PMID: 17189551;Abstract: Objective: A majority of the published longitudinal research on children has reported that dieting is related to weight gain at a later point in time. The purpose of this study was to look at weight control behaviors and patterns of weight gain and loss, specifically whether dieting is related to weight gain. Research Methods and Procedures: Baseline data were collected from 1358 female students in grades 6 to 9 from schools in Hayward, CA, and Tucson, AZ. Data were obtained annually over a 4-year period. Paper-and-pencil questionnaires and height and weight were obtained during the students' regular classroom periods. Dieting was measured both with the single item, "In the past year, how often have you been on a diet to lose weight?" scored from "never" to "always," and with a Dieting Behavior Scale including five items on weight control behaviors. Changes in BMI z-scores were analyzed. Results: On average, girls who reported "never" dieting were most likely to have an increased BMI z-score at the next measurement, and those who reported "always" dieting were most likely to have a decreased BMI z-score. The same pattern was true for the Dieting Behavior Scale. Discussion: Our finding that dieting and weight gain were not related, independently of initial BMI, does not mean that dieting to lose weight is appropriate, especially among young girls. Additional research is needed both to examine this relationship and to determine exactly what behaviors children are engaging in when they report that they are dieting. Copyright © 2006 NAASO.
• Shisslak, C. M., Mays, M. Z., Crago, M., Jirsak, J. K., Taitano, K., & Cagno, C. (2006). Eating and weight control behaviors among middle school girls in relationship to body weight and ethnicity. Journal of Adolescent Health, 38(5), 631-633.
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  PMID: 16635783;Abstract: This study examined the links among body mass index (BMI), weight control practices, binge eating, and eating disorders in 1164 middle school girls. Both the prevalence and frequency of weight control behaviors increased as BMI increased, but binge eating was reported approximately equally by girls across the BMI spectrum. © 2006 Society for Adolescent Medicine.
• Crago, M., & Shisslak, C. M. (2003). Ethnic differences in dieting, binge eating, and purging behaviors among American females: A review. Eating Disorders, 11(4), 289-304.
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  PMID: 16864294;Abstract: The research literature related to ethnic differences in dieting, binge eating, and purging behaviors among American females was reviewed. Relevant publications were located by means of computer searches utilizing MedLine and PsycInfo databases. The majority of the dieting studies that have been published thus far indicate that this behavior is more prevalent among White females while most studies of binge eating and purging behaviors indicate that these behaviors are as common among minority females as among White females. Factors that may influence the results of studies focusing on ethnic differences in eating-related behaviors are discussed. Recommendations for improving future research in this area are proposed.
• Wright, A. L., Schwindt, L. A., Bassford, T. L., Reyna, V. F., Shisslak, C. M., A., P., & Reed, K. L. (2003). Gender differences in academic advancement: Patterns, causes, and potential solutions in one U.S. College of Medicine. Academic Medicine, 78(5), 500-508.
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  PMID: 12742788;Abstract: Purpose. The influx of women into academic medicine has not been accompanied by equality for male and female faculty. Women earn less than men in comparable positions, progress more slowly through academic ranks, and have not attained important leadership roles. This study tested hypotheses about why gender disparities exist in salary, rank, track, leadership, and perceptions of campus climate at one academic center, the University of Arizona College of Medicine, Tucson. Method. Salary, rank, and track data were obtained from institutional databases for the 1999-2000 fiscal year. A structured, online questionnaire was made available to 418 faculty members to collect information about their goals, attitudes, and experiences. Results. A total of 198 faculty members completed the questionnaire. The data showed significant gender differences in faculty salaries, ranks, tracks, leadership positions, resources, and perceptions of academic climate. On average, women earned $12,777 or 11% less than men, after adjusting for rank, track, degree, specialty, years in rank, and administrative positions (p < .0003). Of female faculty, 62% were assistant professors (49% of women were non-tenure-eligible assistant professors), while 55% of male faculty were promoted and tenured. Almost a third of women reported being discriminated against, compared with only 5% of men (p < .00001). Conclusion. Substantial gender differences in the rewards and opportunities of academic medicine remain, that can not be attributed to differences in productivity or committment between women and men.
• Smolak, L., Harris, B., Levine, M. P., & Shisslak, C. M. (2001). Teachers: The forgotten influence on the success of prevention programs. Eating Disorders, 9(3), 261-265.
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  PMID: 16864545;
• Lebensohn-Chialvo, P., Crago, M., & Shisslak, C. M. (2000). The reflecting team: An innovative approach for teaching clinical skills to family practice residents. Family Medicine, 32(8), 556-560.
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  PMID: 11002866;Abstract: 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.
• Shisslak, C. M., Renger, R., Sharpe, T., Crago, M., McKnight, K. M., Gray, N., Bryson, S., Estes, L. S., Parnaby, O. G., Killen, J., & Taylor, C. B. (1999). Development and evaluation of the McKnight risk factor survey for assessing potential risk and protective factors for disordered eating in preadolescent and adolescent girls. International Journal of Eating Disorders, 25(2), 195-214.
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  PMID: 10065397;Abstract: 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.
• Taren, D. L., Tobar, M., Hill, A., Howell, W., Shisslak, C., Bell, I., & Ritenbaugh, C. (1999). The association of energy intake bias with psychological scores of women. European Journal of Clinical Nutrition, 53(7), 570-578.
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  PMID: 10452412;Abstract: 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. Sponsorship: This project was supported by a grant from the National Institute of Diabetes, Digestive and Kidney Diseases.
• Renger, R., Gotkin, V., Crago, M., & Shisslak, C. (1998). Research and legal perspectives on the implications of the family privacy protection act for research and evaluation involving minors. American Journal of Evaluation, 19(2), 191-202.
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  Abstract: This paper reviews the Family Privacy Protection Act of 1995 (FPPA) and its potential impact on research and evaluation involving minors. First it discusses the issues surrounding the FPPA as debated in the United States House of Representatives. The FPPA requires written, or "active," consent from the parent/guardian for survey research involving minors, rather than "passive" consent, which researchers have presumed when parents fail to return forms "opting" their children out of studies. The paper then presents perspectives from researchers and an attorney. It concludes with a case presentation in which researchers relied upon passive consent, and discusses how that case might have been different had the FPPA been in effect.
• Shisslak, C. M., Crago, M., McKnight, K. M., Estes, L. S., Gray, N., & Parnaby, O. G. (1998). Potential risk factors associated with weight control behaviors in elementary and middle school girls. Journal of Psychosomatic Research, 44(3-4), 301-313.
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  PMID: 9587875;Abstract: 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.
• Taylor, C. B., Sharpe, T., Shisslak, C., Bryson, S., Estes, L. S., Gray, N., McKnight, K. M., Crago, M., Kraemer, H. C., & Killen, J. D. (1998). Factors associated with weight concerns in adolescent girls. International Journal of Eating Disorders, 24(1), 31-42.
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  PMID: 9589309;Abstract: 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.
• Sharpe, T. M., Killen, J. D., Bryson, S. W., Shisslak, C. M., Estes, L. S., Cray, N., Crago, M., & Taylor, C. B. (1997). Attachment style and weight concerns in preadolescent and adolescent girls. International Journal of Eating Disorders, 23(1), 39-44.
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  PMID: 9429917;Abstract: 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.
• Crago, M., Shisslak, C. M., & Estes, L. S. (1996). Eating disturbances among American minority groups: A review. International Journal of Eating Disorders, 19(3), 239-248.
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  PMID: 8704722;Abstract: 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.
• Shisslak, C. M., Crago, M., & Estes, L. S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18(3), 209-219.
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  PMID: 8556017;Abstract: 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.
• Mukai, T., Crago, M., & Shisslak, C. M. (1994). Eating attitudes and weight preoccupation among female high school students in Japan. Journal of Child Psychology and Psychiatry and Allied Disciplines, 35(4), 677-688.
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  PMID: 8040220;Abstract: 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.
• Yates, A., Shisslak, C., Crago, M., & Allender, J. (1994). Overcommitment to sport: Is there a relationship to the eating disorders?. Clinical Journal of Sport Medicine, 4(1), 39-46.
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  Abstract: This article explores recent research in psychology, physiology, endocrinology, and animal behavior that bears on the relationship between compulsive athleticism and the eating disorders. There are several differences and a number of likenesses between these groups. Both groups are composed of persistent, perfectionistic, high-achieving persons. Compulsive ('addicted') athletes appear healthier than eating-disordered patients on psychological tests, even though the athletes may do or say things that appear irrational. The relationship between compulsive athleticism and the eating disorders can best be described in terms of a risk-factor model. Perfectionistic persons can be easily caught up in a diet or exercise program and can become even more committed through social reinforcement and the formation of a reciprocal feedback loop. When perfectionistic persons engage in extreme exertion while following a restricted, 'healthy' diet, this can increase obsessional behavior by affecting mood and cognition. Eating-disordered patients experience similar changes in personality and behavior secondary to stress and dietary restriction.
• Killen, J. D., Hayward, C., Litt, I., Hammer, L. D., Wilson, D. M., Miner, B., Taylor, C. B., Varady, A., & Shisslak, C. (1992). Is puberty a risk factor for eating disorders?. American Journal of Diseases of Children, 146(3), 323-325.
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  PMID: 1543180;Abstract: 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.
• Yates, A., Shisslak, C. M., Allender, J., Crago, M., & Leehey, K. (1992). Comparing obligatory to nonobligatory runners. Psychosomatics, 33(2), 180-189.
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  PMID: 1557483;Abstract: 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.
• Shisslak, C. M., Perse, T., & Crago, M. (1991). Coexistence of bulimia nervosa and mania: A literature review and case report. Comprehensive Psychiatry, 32(2), 181-184.
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  PMID: 2022118;Abstract: 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. © 1991.
• Swain, B., Shisslak, C. M., & Crago, M. (1991). Clinical features of eating disorders and individual psychological functioning. Journal of Clinical Psychology, 47(5), 702-708.
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  PMID: 1939718;Abstract: 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.
• Shisslak, C. M., Crago, M., & Neal, M. E. (1990). Prevention of eating disorders among adolescents. American Journal of Health Promotion, 5(2), 100-106.
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  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.
• Shisslak, C. M., McKeon, R. T., & Crago, M. (1990). Family dysfunction in normal weight bulimic and bulimic anorexic families. Journal of Clinical Psychology, 46(2), 185-189.
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  PMID: 2324302;Abstract: 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 selfreport 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.
• Shisslak, C. M., Pazda, S. L., & Crago, M. (1990). Body Weight and Bulimia as Discriminators of Psychological Characteristics Among Anorexic, Bulimic, and Obese Women. Journal of Abnormal Psychology, 99(4), 380-384.
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  PMID: 2266212;Abstract: 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 woman's weight level.
• Shisslak, C. M., Crago, M., & Yates, A. (1989). Typical patterns in atypical anorexia nervosa. Psychosomatics, 30(3), 307-311.
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  PMID: 2762490;Abstract: Only a few published accounts describe atypical anorexia nervosa. To provide more information about this eating-disorder sybtype, 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.
• Shisslak, C. M., Gray, N., & Crago, M. (1989). Health care professionals' reactions to working with eating disorder patients. International Journal of Eating Disorders, 8(6), 689-694.
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  Abstract: A survey of 71 health care professionals involved in work with eating disorder patients revealed that 20 (28%) of the participants in the survey perceived themselves as moderately to greatly affected by their work with these patients. Among the changes they attributed to their work were an increased awareness of food, their physical condition, their appearance, and feelings about their body. In addition, they reported a positive change in body image and an increased ingestion of healthier foods. The group of health care professionals who perceived themselves as moderately to greatly afffected by their work with eating disorder patients was composed approximately equally of normal eaters, binge eaters, and those who reported having experienced eating disorder symptoms at some time in their lives. Length of experience in the field of eating disorders was not a significant factor in being affected or unaffected by work in this area.
• Shisslak, C. M., Schnaps, L. S., & Crago, M. (1988). Eating disorders and substance abuse in women: A comparative study of MMPI patterns. Journal of Substance Abuse, 1(2), 209-219.
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  PMID: 2980871;Abstract: 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. © 1989 Ablex Publishing Corporation.
• Yates, A., Shisslak, C. M., Allender, J. R., & Wolman, W. (1988). Plastic surgery and the bulimic patient. International Journal of Eating Disorders, 7(4), 557-560.
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  Abstract: Some bulimic women resort to plastic surgery in an attempt to make their bodies more acceptable. The surgery serves the function of changing the appearance of the body, thus temporarily diminishing the underlying depression. This may precipitate a transient remission of bulimic symptoms.
• Shisslak, C. M., Crago, M., Neal, M. E., & Swain, B. (1987). Primary Prevention of Eating Disorders. Journal of Consulting and Clinical Psychology, 55(5), 660-667.
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  PMID: 3331629;Abstract: Eating disorders have increased dramatically over the past two decades, but the primary prevention of these disorders has received little attention. This article summarizes our current understanding of anorexia nervosa and bulimia and offers some suggestions for the primary prevention of these disorders at the individual, family, and community levels. © 1987 American Psychological Association.
• Breslow, M., Yates, A., & Shisslak, C. (1986). Spontaneous rupture of the stomach: A complication of bulimia. International Journal of Eating Disorders, 5(1), 137-142.
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  Abstract: Spontaneous rupture of the stomach is an uncommon and often lethal condition. Although it has never before been attributed to bulimia, a number of previously reported cases have occurred in women who have eaten heavily. A case is presented in which rupture of the stomach clearly followed bingeing in a bulimic patient. The mechanism by which this could occur and the ramifications for treatment are discussed.
• Shisslak, C. M., Crago, M., Schnaps, L., & Swain, B. (1986). Interactional group therapy for anorexic and bulimic women. Psychotherapy, 23(4), 598-606.
• Williams, R. L., Schaefer, C. A., & Shisslak, C. M. (1986). Eating attitudes and behaviors in adolescent women: Discrimination of normals, dieters, and suspected bulimics using the Eating Attitudes Test and Eating Disorder Inventory. International Journal of Eating Disorders, 5(5), 879-894.
• Shisslak, C. M., Beutler, L. E., & Scheiber, S. (1985). Patterns of caffeine use and prescribed medications in psychiatric inpatients. Psychological Reports, 57(1), 39-42.
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  PMID: 2864713;Abstract: Two matched groups of inpatients (N = 40) who had access only to caffeinated versus decaffeinated coffee on an acute psychiatric ward were compared using pre- and postchange measures. The two groups did not differ significantly on any of the psychological assessments or in medication use over the course of treatment, with the exception that patients given caffeinated coffee who received prescribed phenothiazines had significantly higher dosages than those in the groups given decaffeinated coffee.
• Leehey, K., Yates, A., & Shisslak, C. M. (1984). Alteration of case reports in "running--an analogue of anorexia?".. New England Journal of Medicine, 310(9), 600-.
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  PMID: 6582351;
• Allender, J., Shisslak, C., Kaszniak, A., & Copeland, J. (1983). Stages of psychological adjustment associated with heart transplantation. Heart Transplantation, 2(3), 228-231.
• Yates, A., Leehey, K., & Shisslak, C. M. (1983). Running - an analogue of anorexia?. New England Journal of Medicine, 308(5), 251-255.
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  PMID: 6848935;Abstract: We have explored the apparent similarity between patients with anorexia nervosa and a subgroup of male athletes designated as 'obligatory runners.' Case examples are provided from interviews with more than 60 marathon and trail runners. Obligatory runners resemble anorexic women in terms of family background; socioeconomic class; and such personality characteristics as inhibition of anger, extraordinarily high self-expectations, tolerance of physical discomfort, denial of potentially serious debility, and a tendency toward depression. Anorexic women and members of their families are often compulsively athletic, and obligatory runners may demonstrate a bizarre preoccupation with food and an unusual emphasis on lean body mass. We speculate that both phenomena could represent a partially successful - albeit dangerous - attempt to establish an identity. These preliminary observations will require study for validation.
• Kendall, P. C., Williams, L., Pechacek, T. F., Graham, L. E., Shisslak, C., & Herzoff, N. (1979). Cognitive-behavioral and patient education interventions in cardiac catheterization procedures: The Palo Alto medical psychology project. Journal of Consulting and Clinical Psychology, 47(1), 49-58.
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  PMID: 429666;Abstract: The invasive medical procedures of cardiac catheterization were conceptualized as a crisis. Two interventions; a cognitive-behavioral treatment and a patient education treatment; were compared with an attention placebo intervention control group and a current hospital conditions control group. Patient self-reported state anxiety was assessed at preintervention, postintervention, and retrospectively with regard to the actual catheterization procedure. Professional (physician and technician) blind ratings of the patient's adjustment during catheterization were also taken. In addition, a self-statement inventory pertaining to the process of catheterization was administered retrospectively. Results of both sets of adjustment ratings indicated that the intervention groups were significantly more adjusted than each of the controls and that the cognitive-behavioral treatment was the superior intervention. State-anxiety analyses suggested that although both the interventions and the attention placebo control reduced postintervention subjective anxiety, only the two interventions produced levels of recalled (during the catheterization) state anxiety that were significantly lower than controls. Negative self-statements were related to poorer adjustment ratings. The findings support the utility of cognitive-behavioral crisis interventions.
• Danaher, B. G., Shisslak, C. M., Thompson, C. B., & Ford, J. D. (1978). A smoking cessation program for pregnant women: An exploratory study. American Journal of Public Health, 68(9), 896-898.
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  PMID: 686216;PMCID: PMC1654039;Abstract: The present results provide tentative support for the hypothesis that an intensive program of risk education and behavioral skills-training can assist pregnant women to stop smoking. The absolute level of abstinence achieved - both during the remaining period of pregnancy and postpartum - ranks well above other results reported in the literature. The data further suggest that risk had been substantially reduced for some participants.

Presentations

• Kutob, R., Bormanis, J., Crago, M., Senf, J., & Shisslak, C. M. (2013, May). Lessons in Cultural Humility and NonJudgemental Behavior: Teaching Cultural Skills in the Context of Diabetes Education. Presented at the Society of Teachers in Family Medicine. Baltimore MD.
• Shisslak, C. M., & Gordon, P. (2013, May). Improving Attending Physician Communication Skills with Residents by Utilizing Video Precepting. Presented at the Society of Teachers in Family Medicine. Baltimore, MD.
• Shisslak, C. M. (2012, March). The Use of Projective Tests in Applied Clinical Settings. Clinical Psychology Colloquium. University of Arizona.
• Shisslak, C. M., & Grace Project Collaborative, . (2012, May). The Grace Project. College of Medicine Women in Academic Medicine Meeting.