Decreased mononuclear cell NR3C1 SKA2 and FKPB5 expression levels among adult survivors of suicide bombing terror attacks in childhood are associated with the development of PTSD.

Life threatening trauma and the development of PTSD during childhood, may each associate with transcriptional perturbation of immune cell glucocorticoid reactivity, yet their separable longer term contributions are less clear. The current study compared resting mononuclear cell gene expression levels of the nuclear receptor, subfamily 3, member 1 (NR3C1) coding the glucocorticoid receptor, its trans-activator spindle and kinetochore-associated protein 2 (SKA2), and its co-chaperon FKBP prolyl isomerase 5 (FKBP5), between a cohort of young adults first seen at the Hadassah Emergency Department (ED) after surviving a suicide bombing terror attack during childhood, and followed longitudinally over the years, and matched healthy controls not exposed to life threatening trauma. While significant reductions in mononuclear cell gene expression levels were observed among young adults for all three transcripts following early trauma exposure, the development of subsequent PTSD beyond trauma exposure, accounted for a small but significant portion of the variance in each of the three transcripts. Long-term perturbation in the expression of immune cell glucocorticoid response transcripts persists among young adults who develop PTSD following life threatening trauma exposure in childhood, denoting chronic dysregulation of immune stress reactivity.

Resting mononuclear cell NR3C1 and SKA2 expression levels predict blunted cortisol reactivity to combat training stress among elite army cadets exposed to childhood adversity.

Childhood adversity (CA) may alter reactivity to stress throughout life, increasing risk for psychiatric and medical morbidity, yet long-term correlates of milder CA levels among high functioning healthy adolescents are less studied. The current study examined the prevalence and impact of CA exposure among a cohort of healthy motivated elite parachute unit volunteers, prospectively assessed at rest and at the height of an intensive combat-simulation exposure. We found significantly reduced gene expression levels in resting mononuclear cell nuclear receptor, subfamily 3, member 1 (NR3C1), and its transactivator spindle and kinetochore-associated protein 2 (SKA2), that predict blunted cortisol reactivity to combat-simulation stress among CA exposed adolescents. Long-term alterations in endocrine immune indices, subjective distress, and executive functions persist among healthy high functioning adolescents following milder CA exposure, and may promote resilience or vulnerability to later real-life combat exposure.

The imprint of childhood adversity on emotional processing in high functioning young adults.

Adverse childhood experiences (ACEs) have been acknowledged as risk factors for increased mental health complications in adulthood, specifically increasing susceptibility to developing psychopathology upon exposure to trauma. Yet, little is known regarding the impact of mild ACEs on highly functioning population. In this study forty participants were selected from a group of 366 highly selected military parachute trainees using the self-report "childhood trauma questionnaire," and classified into two groups of 20 each, with and without ACEs. Behavioral measurements were obtained before and at the peak of an intensive combat training period, including anxiety, depression and executive function assessment. Functional MRI including a negative emotional face perception task was conducted at the first time point. Psychometric and cognitive measurements revealed higher levels of anxiety and depressive symptoms, and more difficulties in executive functioning in the ACE group at baseline. Slower reaction time to emotional faces presentation was found in the ACE group. Lower activation in response to negative emotional faces stimuli was found in this group in bilateral secondary visual areas, left anterior insula, left parietal cortex and left primary motor and sensory regions. In contrast, higher activation in the ACE group was found in the right ventral lateral prefrontal cortex (Vlpfc). No significant differences between groups were detected in the amygdala. To conclude, mild adverse childhood experiences produce long-term sequela on psychological wellbeing and neurocircuitry even in high functioning population. Brain regions modulated by childhood trauma may instigate avoidance mechanisms dampening the emotional and cognitive effects of intensive stress.

Trait-related changes in brain network topology in premenstrual dysphoric disorder.

The female predominance in the prevalence of depression is partially accounted by reactivity to hormonal fluctuations. Premenstrual dysphoric disorder (PMDD) is a reproductive subtype of depression characterized by cyclic emotional and somatic symptoms that recur before menstruation. Despite the growing understanding that most psychiatric disorders arise from dysfunctions in distributed brain circuits, the brain's functional connectome and its network properties of segregation and integration were not investigated in PMDD. To this end, we examined the brain's functional network organization in PMDD using graph theoretical analysis. 24 drug naïve women with PMDD and 27 controls without premenstrual symptoms underwent 2 resting-state fMRI scans, during the mid-follicular and late-luteal menstrual cycle phases. Functional connectivity MRI, graph theory metrics, and levels of sex hormones were computed during each menstrual phase. Altered network topology was found in PMDD across symptomatic and remitted stages in major graph metrics (characteristic path length, clustering coefficient, transitivity, local and global efficiency, centrality), indicating decreased functional network segregation and increased functional network integration. In addition, PMDD patients exhibited hypoconnectivity of the anterior temporal lobe and hyperconnectivity of the basal ganglia and thalamus, across menstrual phases. Furthermore, the relationship between difficulties in emotion regulation and PMDD was mediated by specific patterns of functional connectivity, including connections of the striatum, thalamus, and prefrontal cortex. The shifts in the functional connectome and its topology in PMDD may suggest trait vulnerability markers of the disorder.

Gender differences in the effect of medical humanities program on medical students' empathy: a prospective longitudinal study.

BACKGROUND: Previous studies have suggested that Medical students' empathy declines during medical school, especially during the clinical studies. The aim of this study was to examine. Changes in medical students' empathy during their first clinical experience, and to determine the impact of gender and humanities curriculum on empathy changes. METHODS: In this prospective longitudinal study, 262 4th year students from three consecutive classes were assessed. Empathy was assessed before and at 4th-year-end, using the Jefferson Scale of Physician Empathy-Student Version (JSPE-S). The three classes differed in humanities curriculum [limited Medical Humanities (MH(lim)) vs. extended Medical Humanities (MH(ext))], and in admission system [Personal Interview (PI) vs. multiple mini interviews (MMI)]. RESULTS: Overall, there was a small but significant decrease in JSPE-S during the fourth year (114.40 ± 11.32 vs. 112.75 ± 14.19, p = 0.034). Among men there was a statistically significant decline in JSPE-S during the fourth year, and the MH(ext) (but not the MH(lim)) was associated with the decline (t(35) = 2.38, p = 0.023). Women students showed no decline in empathy during the fourth-year of studies, regardless of type of humanities program. In addition, women who participated in MH(ext) had a higher JSPE-S scores during the 4th -year as compared to women who participated in MH(lim). CONCLUSION: Pre-clinical humanities program was associated with a decline in empathy among men medical students during the fourth-year of medical studies. Gender differences in response to medical humanities programs require further study.

Elevated salivary uric acid levels among adolescents with eating disorders.

OBJECTIVE: Uric acid (UA) is increasingly recognized as having important physiological roles and associated with several peripheral and central pathophysiological outcomes, and might play a role in eating disorders (ED) pathogenesis. We investigated whether UA levels are altered among adolescents with ED. METHODS: Morning salivary UA concentrations were compared between adolescents referred to treatment at the Herman Dana Center receiving a DSM-V diagnosis of an ED and matched healthy controls. RESULTS: Salivary UA was significantly elevated among ED compared with control values (ED mean 3.9 ± 1.2 mg/dl, control mean 2.9 ± 1.9 mg/dl, t = - 3.13 df = 81, p = 0.003). DISCUSSION: Salivary UA is elevated among adolescents with ED. Further studies are required to replicate and extend this finding and evaluate its generalizability as a state or trait marker as regards ED subtypes, other body fluids (plasma and cerebrospinal fluid), and recovery or premorbid stages, as well as its putative mechanistic relevance to ED. LEVEL OF EVIDENCE: Level III, case-control analytic study.

Selflessness as a predictor of remission from an eating disorder: 1-4 year outcomes from an adolescent day-care unit.

OBJECTIVE: To assess the potential role of selflessness in predicting remission from an eating disorder (ED) following discharge from an adolescent day-care unit. METHOD: Participants were 95 female patients (aged 13-19 years) with an ED diagnosis across the spectrum admitted to an adolescent day-care unit for EDs between 2008 and 2012. Forty-one of these participants completed the follow-up assessment, between 12 and 46 months following discharge. No significant differences were found in Time 1 variables between patients who participated in Time 2 and those who did not. At both time points, ED and psychiatric comorbidity diagnoses were made using standard structured interviews. Patients were also administered the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), The Eating Attitude Test (EAT-26), The Eating Disorder Inventory (EDI-2) and the Selflessness Scale (SS)*. RESULTS: Only baseline Selflessness Scale was significant in predicting the continuous variable of ED symptomatology level in follow-up. When dividing EDI total score into its subscales at baseline, one of those, maturity fears, was found, together with the SS, significant in the prediction. In predicting remission (this time as a dichotomized variable) in follow-up, only the SS, maturity fears, EDI total, and EAT-26, at baseline, predicted remission at follow-up, but the strength of selflessness was the greatest. CONCLUSIONS: Psychological features are not the main target of the important search for predictors of remission from ED. The findings of the present study add the psychological feature of selflessness to this search. Psychotherapy can be enriched by identifying psychological features such as selflessness as one of its foci. The present findings might also renew interest in maturity fears as an additional focus in psychotherapy. LEVEL OF EVIDENCE: Level III, cohort study.

The effect of food-related stimuli on inhibition in high vs. low restrained eaters.

Restrained eaters constantly limit their eating behavior to avoid gaining weight. Previous research suggests that fundamental deficits in response inhibition might play a role in the development of disinhibited eating among restrained eaters. The current study focuses on the impact of food vs. non-food stimuli on response inhibition in high vs. low restrained eaters. Seventy-five females (38 high and 37 low restrained eaters) completed a novel food stop-signal task in which they were required to discriminate between food and non-food images while inhibiting their response when a stop-signal appeared. The ability to inhibit a response was assessed separately for food and non-food trials, which were used to assess specific inhibition to food and general inhibitory abilities, respectively. Overall, high restrained eaters exhibited poorer response inhibition to non-food stimuli compared to low restrained eaters. Most importantly, high restrained eaters were better able to inhibit a response following presentation of food compared to non-food stimuli. In contrast, low restrained eaters were better at inhibiting a response following non-food compared to food stimuli. We suggest that this pattern is due to fast and strong activation of the response inhibition system in high restrained eaters when facing food stimuli - an activation which might later lead to a paradoxical breakdown of control over eating behavior.

Long-Term Immune Alterations Accompanying Chronic Posttraumatic Stress Disorder following Exposure to Suicide Bomb Terror Incidents during Childhood.

BACKGROUND AND AIM: Long-term immune alterations have been proposed to play a mechanistic role in posttraumatic stress disorder (PTSD) as well as in its associated increase in medical morbidity and mortality. Better characterization of altered immune function may help identify diagnostic and prognostic biomarkers and potentially targets for preventive intervention. METHODS: As part of an ongoing study, we conducted a preliminary case-control comparison of resting immune inflammatory profiles between terror victims treated in childhood at the emergency department over the previous decade, who developed chronic PTSD upon long-term follow-up, and healthy controls. RESULTS: Our preliminary results in a subsample of this ongoing study support and extend elevated resting levels of granulocyte colony-stimulating factor, interleukin-4, and regulated on activation, normal T cell expressed and secreted in childhood onset chronic PTSD. CONCLUSION: Chronic immune alterations may participate in inflammatory activation and signal to the CNS through the neurovascular unit, as well as modulate the neuroendocrine axis. Better characterization and understanding of these preliminary findings may point to diagnostic and prognostic biomarkers and potentially elucidate mechanistic involvement of immune activation in PTSD.

Emotional regulation difficulties and premenstrual symptoms among Israeli students.

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS) reported to affect 3-8 % of women of reproductive age and resulting in marked emotional and occupational impairment. Despite its prevalence, the etiology of PMDD is largely unknown, and patients remain mostly undiagnosed and poorly treated. It has been suggested that PMDD is a manifestation of underlying depressive disorder which is associated with the inability to regulate emotions in an adaptive manner. Therefore, we hypothesized that women with PMDD would exhibit increased difficulty with emotional regulation. A total of 648 female Israeli college students were assessed by the Premenstrual Symptoms Screening Tool (PSST) and the Difficulties in Emotion Regulation Scale (DERS). Of these women, 166 (25.6 %) met the criteria for PMS. Sixty-four (9.9 %) suffered from PMDD. More emotion regulation deficits were observed in the PMDD and PMS groups compared to the control group. Furthermore, there were more emotional regulation deficits among the predominantly psychological and mixed symptom subtype compared to the predominantly physical symptom subtype group. This is the first study to report an association between emotional dysregulation and PMDD. These findings may lead to development of more individually tailored treatment protocols focused on improving emotional regulation techniques.

The Role of Narcissistic Vulnerability in Predicting Adult Posttraumatic Symptoms from Childhood Sexual Abuse.

The aim of the present study is to determine whether narcissistic vulnerability can aid in clarifying the debate regarding the relationship between childhood sexual abuse (CSA) and adulthood adjustment to traumatic events. 157 survivors (mean age = 31.1, SD = 10.9) of a traumatic event (war activities and road and work accidents) were assessed 1 week, 1, and 4 months following the event. Of the 157 participants, 15 reported experiencing CSA, and 26 reported experiencing childhood physical abuse (CPA). In the first-week assessment, patients were administered the Narcissistic Vulnerability Scale (NVS) and the Beck Depression Inventory (BDI). In the follow-up assessments, subjects were interviewed on the Clinician-Administered PTSD Scale. Narcissistic vulnerability was found, both in 1- and 4-month follow-ups, to increase the likelihood of participants who experienced CSA to develop PTSD symptoms later in their adult life, when exposed to other additional trauma. Narcissistic vulnerability, in both follow-ups, did not increase the likelihood of participants who experienced CPA to develop PTSD symptoms later in their life when exposed to other additional trauma. The NVS predicted the development of PTSD symptoms in the whole sample, both in the 1- and 4-month follow-ups, above and beyond the prediction of the BDI. In other words, narcissistic vulnerability can add additional information above and beyond general negative emotionality. In conclusion, it is recommended to take into consideration the interplay between CSA and the individual's narcissistic vulnerability when assessing the long term effects of CSA such as acute or chronic PTSD.

The effect of medical students' gender, ethnicity and attitude towards poetry-reading on the evaluation of a required, clinically-integrated poetry-based educational intervention.

BACKGROUND: Art-based interventions are widely used in medical education. However, data on the potential effects of art-based interventions on medical students have been limited to small qualitative studies on students' evaluation of elective programs, and thus their findings may be difficult to generalize. The goal of this study is to examine, in an unselected students' population, the effect of students' gender, ethnicity and attitude towards poetry on their evaluation of a clinically-integrated poetry-based educational intervention. METHODS: A required Clinically- Oriented Poetry-reading Experience (COPE) is integrated into the 4th year internal medicine clerkship. We constructed a questionnaire regarding the program's effects on students. Students completed the questionnaire at the end of the clerkship. We performed a Confirmatory Factor Analysis, and examined the relationship between students' evaluation of the program and students' ethnicity, gender, attitude towards poetry-reading, and the timing of the program (early/late) during the fourth year. RESULTS: 144 students participated in the program, of which 112 completed the questionnaires. We identified two effect factors: "student-patient" and "self and colleagues". The average score for "student-patient" factor was significantly higher as compared to the "self and colleagues" factor.Evaluation the "student- patient" effect factor was higher among Arab and Druze as compared to Jewish students. Students' attitude towards poetry-reading did not correlate with the "student-patient" effect, but correlated with the "self and colleagues" effect. The evaluation of the "self and colleagues" effect was higher among students who participated in the program during their second as compared with the first clerkship. Students' gender was not associated with any of the effects identified. Students favored obligatory participation in COPE as compared with elective course format. CONCLUSIONS: According to students' evaluation, a format of integrated, obligatory poetry-based intervention may be suitable for enhancing "student-patient" aims in heterogeneous student populations. The higher evaluation of the "patient-student" effect among Arab and Druze as compared to Jewish students may be related to cultural differences in the perception of this component of medical professionalism. Further research can provide insight into the effect of cultural and ethnic differences on actual empathy of medical students in patient encounters.

Psychiatric referrals to the general hospital emergency department: are we being effective?

Introduction: General hospital emergency departments (GHEDs) are notoriously overcrowded. This is caused, in part, by ineffective referrals, that is to say referrals that do not require medical examination or other interventions in the context of a general hospital. This study aims to investigate the contribution of psychiatric referrals to this issue, to identify potential determinants of these referrals and offer means to reduce them. Materials and methods: Retrospective data were collected from psychiatric admission files within a GHED of a tertiary-care city hospital over a 1 year period. Two experienced clinicians separately reviewed each file to determine rationale of referrals according to predetermined criteria. Results: A total of 2,136 visits included a psychiatric examination, 900 (42.1%) were determined "effective," and 1,227 (57.4%) were deemed "potentially ineffective." The leading causes for potentially ineffective referrals to a GHED were psychiatric illness exacerbation (43.4%), and suicidal ideations (22%). Most referrals (66.9%) were initiated by the patient or their family, and not by a primary care physician or psychiatrist. Conclusion: More than half of the psychiatric referrals did not necessarily require the services of a general hospital, and may be more suitable for referral to a dedicated psychiatric facility. Ineffective referrals to the GHED pose a burden on general hospital resources, and may be less effective for the psychiatric patients. This calls for clear guidelines for the provision of optimal emergency treatment for mental-health patients.

Aberrant Intrinsic Brain Network Functional Connectivity During a Face-Matching Task in Women Diagnosed With Premenstrual Dysphoric Disorder.

BACKGROUND: Premenstrual dysphoric disorder (PMDD) is characterized by affective, cognitive, and physical symptoms, suggesting alterations at the brain network level. Women with PMDD demonstrate aberrant discrimination of facial emotions during the luteal phase of the menstrual cycle and altered reactivity to emotional stimuli. However, previous studies assessing emotional task-related brain reactivity using region-of-interest or whole-brain analysis have reported conflicting findings. Therefore, we utilized both region-of-interest task-reactivity and seed-voxel functional connectivity (FC) approaches to test for differences in the default mode network, salience network, and central executive network between women with PMDD and control participants during an emotional-processing task that yields an optimal setup for investigating brain network changes in PMDD. METHODS: Twenty-four women with PMDD and 27 control participants were classified according to the Daily Record of Severity of Problems. Participants underwent functional magnetic resonance imaging scans while completing the emotional face-matching task during the midfollicular and late-luteal phases of their menstrual cycle. RESULTS: No significant between-group differences in brain reactivity were found using region-of-interest analysis. In the FC analysis, a main effect of diagnosis was found showing decreased default mode network connectivity, increased salience network connectivity, and decreased central executive network connectivity in women with PMDD compared with control participants. A significant interaction between menstrual cycle phase and diagnosis was found in the central executive network for right posterior parietal cortex and left inferior lateral occipital cortex connectivity. A post hoc analysis revealed stronger FC during the midfollicular than the late-luteal phase of PMDD. CONCLUSIONS: Aberrant FC in the 3 brain networks involved in PMDD may indicate vulnerability to experience affective and cognitive symptoms of the disorder.

Adult patients' adjustability to orthodontic appliances. Part I: a comparison between Labial, Lingual, and Invisalign™.

This prospective study examined the adult patient's perception of recovery after insertion of three types of orthodontic appliances: Buccal, Lingual and Invisalign. The sample consisted of sixty-eight adult patients (45 females and 23 males) who comprised three groups: 28 Buccal, 19 Lingual, and 21 Invisalign patients. After appliance insertion, patients completed a Health-Related Quality of Life questionnaire daily for the first week and again on day 14, in order to assess patients' perception of pain and analgesic consumption. In addition, four areas of dysfunction were assessed: oral dysfunction, eating disturbances, general activity parameters, and oral symptoms. Lingual appliance was associated with more severe pain and analgesic consumption, the greatest oral and general dysfunction, and the most difficult and longest recovery. The Invisalign patients complained of relatively high levels of pain in the first days after insertion; however this group was characterized by the lowest level of oral symptoms and by a similar level of general activity disturbances and oral dysfunction compared to the Buccal appliance. Many Lingual and some Buccal patients did not reach a full recovery from their eating difficulties by the end of the study period. The present study provides information to adult patients and clinicians assisting them in choosing the most appropriate treatment modality in relation to Health-Related Quality of Life parameters.

Seizure phobia: A distinct psychiatric disorder among people with epilepsy.

OBJECTIVE: Epilepsy is characterized by unpredictable attacks. Hence, people with epilepsy (PWE) may develop anxious anticipation of upcoming seizures. Seizure phobia is an anxiety disorder wherein seizure anticipatory situations trigger fear, accompanied by avoidance behaviors. Research on seizure phobia among PWE is scarce. Therefore, we aimed to describe the diagnosis of seizure phobia and its association with demographic, psychiatric and neurological variables. METHODS: This is a cross-sectional study of adult PWE in a tertiary epilepsy outpatient clinic. Data were collected from semi-structured interviews, demographic questionnaires and medical records. Patients with and without seizure phobia were compared in terms of sociodemographic, psychiatric, and neurological variables. A logistic regression analysis was performed to identify variables that predicted seizure phobia. RESULTS: Among 69 PWE included in the study, 19 (27.5%) were diagnosed with seizure phobia. In comparison with PWE without seizure phobia, PWE with seizure phobia were predominantly female (84.2% vs 44.2%, p = 0.005), and had more comorbid anxiety disorders (84.2% vs 34.9%, p = 0.01), past major depressive episode (MDE) (63.2% vs 20.9%, p = 0.003), and post-traumatic stress disorder (26.3% vs 7%, p = 0.05). There was a significant association between seizure phobia and comorbid psychogenic non-epileptic seizures (36.8% vs 11.6%, p = 0.034). However, no significant association was found with epilepsy-related variables. A multivariate logistic regression model indicated anxiety and a past MDE as predictive factors for seizure phobia (R2 = 0.43). CONCLUSION: Seizure phobia is a distinct psychiatric entity among PWE. Further research is required to understand its etiology, risk factors, and potential interventions for these patients.

Selflessness and perfectionism as predictors of pathological eating attitudes and disorders: A longitudinal study.

This paper examines the role that selflessness and perfectionism may play as possible predictors of pathological eating attitudes and eating disorders (ED). 1057 schoolgirls (seventh to ninth grade) participated in the initial screening phase. They were administered the Eating Attitudes Test (EAT-26), Selflessness Scale (SS) and Multidimensional Perfectionism Scale (MPS). Based on their EAT-26 scores, 150 girls were invited to a clinical interview 2 years later (second phase). In the third phase 4 years later, 243 girls who completed the questionnaires in the seventh grade were the target of re-administration of these scales. Seventh-grade selflessness scores at initial screening phase predicted ED status determined in clinical interview at the 2-year interval and abnormal eating attitudes at the 4-year interval, above and beyond baseline seventh-grade eating-attitude scores. Perfectionism was not found to predict the development of neither ED nor abnormal eating attitudes. Preventional and therapeutic implications of the role of selflessness as a predisposing factor for ED are discussed.

Psychosocial predictors of weight loss and psychological adjustment following bariatric surgery and a weight-loss program: the mediating role of emotional eating.

OBJECTIVE: To examine a structural equation model of the effects of personal and interpersonal factors on treatment outcome of bariatric surgery and weight-loss program. METHOD: Forty-four participants of the surgery group and 47 participants of the diet group completed questionnaires before treatment and 1 year afterward. Predictor measures are as follows: social support, motivation for control, sense of control, self-esteem, neuroticism, fear of intimacy, and emotional eating (EE). OUTCOME MEASURES: Weight loss, quality of life, and mental health. RESULTS: Neurotic predisposition (NP), a latent variable indicated by neuroticism, low self-esteem, and fear of intimacy, had an effect on weight loss that was fully mediated by EE. NP also had an effect on quality of life improvement that was fully mediated by EE and weight loss in both treatment groups. DISCUSSION: Both NP and EE predict outcome of obesity treatments, but EE is the more proximal variable that mediates the effect of NP.

The influence of a primary prevention program on eating-related attitudes of Israeli female middle-school students.

The present study aimed to assess the impact of a primary prevention program on eating-related attitudes in 231 female 7th graders at baseline and following a six-session prevention program. Fifty-nine 7th grade control females received six unstructured lectures about adolescence. One hundred and three experimental students and 37 controls were re-evaluated after one year. Among the participants in the prevention program, there was a significant post-intervention and one-year improvement in the total score of the eating-related attitudinal Treatment Efficacy Scale (TES) and in several of its domains. Whereas no change occurred in the attitudes of the controls at post-intervention, some improvement was shown in several TES domains after one year, compared to baseline. Attitudinal changes were significantly more favorable in the prevention program participants than in the controls both at post-intervention and at one-year follow-up. These findings suggest that eating-related attitudes of female middle-school students may improve following a primary prevention program, with some of these improvements persisting after one year.