The "TOKAI STUDY" is a retrospective study of 258 ischemic heart disease (IHD) patients admitted to the Tokai Univ. Hospital since last 7 years and 373 controls chosen from 495 individuals who visited our Health Counselling Center and were found to have subjectively and objectively normal heart.They were administered a multiple-choice questionnaire with 60 items, of which 15 items are about traditional coronary risk factors and 45 items are about behavior patterns. This questionnaire was developed by Hosaka, T. for the purpose of assessing Type A behavior pattern for Japanese more properly.Hypertension, smoking, diabetes mellitus, obesity and other traditional risk factors were reconfirmed. The 45 items about behavior patterns were factors analyzed for individual scoring, which found to be significantly different between IHD patients and controls (p<0.001), and the questionnaire can therefore be considered as a reliable means for detecting Type A behavior pattern.And there was no correlation with other risk factors except for cigarettes daily smoked, which confirms Western Collaborative Group Study and other western studies.It is therefore possible that Type A behavior pattern is an independent risk factor of IHD.

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The history of Psychosomatic Medicine began with the study of neurosis with somatic symptoms and soon progressed to the study of Psychosomatic Disorders centering around "Seven Holy Diseases". During that period Psychosomatic Medicine remained within the extention of the study of neurosis. For the past 10-20 years there have appeared the following new researches which have imposed fundamental changes on the concept of Psychosomatic Medicine.1. The proposal of the concept of "Alexithymia" which contributes to the differentiation of Psychosomatic Disorders from neurosis.2. The emergence of Biofeedback opened the way for instrumental learning of the autonomic bodily function and has stimulated attention to the inhibition or loss of normal susceptibility to bodily sensations in psychosomatic cases.3. Behavioral Medicine has advocated that the control of socioculturally conditioned self-destructive life habits such as smoking, insufficient bodily exercise, excessive alcohol intake and etc. is essential for the prevention, treatment and rehabilitation for those diseases which constitute the major cause of death at present. The advantage of behavioral therapies which provide us with brief, cost-effective and objective measures has more strongly appealed to general physicians rather than orthodox psychoanalitical approaches which are expensive and time-consuming.4. Noticeable progress in psychosomatic researches for serious organic diseases such as malignant tumors has facilitated the development of psychosomatic concept to Prof. G. Engel's "biopsychosocial medical model" which practically covers the whole medical field.5. The integration of humanistic psychology which signifies the essential difference between human and animal psychology has thrown light upon the treatment of so-called meaningless Psychosomatic Disorders and special care at clinically extreme situations.6. The importance of Bioethics is being stressed in the present medical circle. We envisage that this should help the improvement of quality of life under the collaboration with humanistic psychology rather than staying at the level of the claim of patient's right and physician's duty.7. Oriental thought and approaches have been drawing special attention in Western countries because of mind-body non-dualism, the importance of self-control methods of somatopsychic nature and Oriental existentialism. Oriental somatopsychic self-regulatory approaches are indispensable for dissolving the cortico-subcortical dissociation of the brain and restoring the harmony of cerebral function and should play a core role in holistic medical treatment.We should be open and flexible in our holistic treatment by integrating intuitive, comprehensive and existential approaches based on Oriental wisdom (awareness to the whole person due to mind-body non-dualism) and intellectual, conceptual and technological approaches of Western origin.

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In the treatment of psychosomatic patients on the verbal context, two obstacles are encountered. The first is the so-called "excessive verbalization group (EV)" such as observed in organ neurosis and nosophobia. The second is the so-called "defective verbalization group (DV)", such as seen in eating disorders.In cases of EV, the patient's importunity with persistent physical complaints and the therapist's persuasion to explain the patient's irrational complaints are apt to turn into an endless and fruitless dispute. On the other hand, in cases of DV, repeated interviews end in drawing out minimal and perfunctory replies because of their poor verbalization, which leads the therapist to impose his own remarks and interpretations on the patients. We have often experienced that these two approaches induced unsatisfactory therapeutic results.The author applied psychoanalysis to Case 1,pancreas-carcinoma phobia (EV) and brief psychotherapy to Case 2,anorexia nervosa (DV). Reflecting the therapeutic courses of these two cases, an inquiry was made about the meaning of verbalization in psychosomatic patients under the therapeutic situation.In Case 1 (EV) psychoanalysis was conducted with analytic passivity; neither persuasion nor rebuttal initiated by the therapist. Finally the patient realized that his repeated physical complaints did not function as a means of self-assertion to the therapist and be was eventually recovered.Case 2 (DV) received brief psychotherapy under the behavior restrictions in the ward; no contact with her acquaintances over telephone, no correspondence or meeting etc. neither TV nor reading allowed. The patient's insistence expressed through the disease itself became no more valid under such therapeutic relationships. Consequently, the patient has to express her assertion with her own words in the interviews. Then, the patient obtained her own verbalization.Excessive verbalization as seen in Case 1 was worn out by psychoanalysis, while revival of her verbalization as seen in Case 2 took place by the behavioral restriction.It is considered that the most important turning point in the treatment of the psychosomatics is their experiences of altering verbalization in these therapeutic process.

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A survery was made of the current status of usage of anxiolytics, antidepressants and autonomic stabilizers (drugs commonly used in psychosomatic medicine) by general practitioners, who were also contacted by a questionnaire concerning the incidence of depression and the status of usage of antidepressants.The results indicate that anxiolytics were most frequently used (in 86.3% of cases treated), followed by antidepressants (68.2%) and autonomic stabilizers (63.6%) in that descending order. Anxiolytics were also found to be the drugs of first choice in general practice of psychosomatic medicine, with autonomic stabilizers and antidepressants being positioned as second and third choice drugs, respectively. It was disclosed further that among antidepressants available for the treatment of depression, tricyclic ones were used in a majority of cases and that a considerable number of practitioners were using antidepressants, each in his proper way, according to clinical circumstances.Reference was made to general precautions to be exercised in administering drug therapy with comment on selection of cases in which drug therapy is indicated for use.Lastly, some comment was also made on nonspecific factors that might influence the therapeutic efficacy of drugs, with emphasis on the importance of examining these factors.

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We had an investigation regarding how extensively Autogenic training and Hypnosis were used in the treatment of PSD. The results were summarized as follows : Autogenic training was used by 85.45% of the investigated clinicians and Hypnotherapy by 40.00% of the same sample. Indications for Autogenic training include anxiety and tension, whereas indications for Hypnotherapy include hysteria and highly suggestive cases.With Autogenic training, those using all 5 formulae consisted of 36.17%, and those using the first and second formulae, sometimes up to the sixth formulae, were 63.83%. The group in which more than the standard exercise was used include 40.42%, in which those using organ specific formulae were 19.15% and autogenic neutralization were 8.51%.With regard to the exercise time of one session, 34.78% of therapists spent less than 10 minutes, 32.60% of therapists 10-20 minutes, 21.78% of therapists 20-30 minutes. Thus less than 30 minutes were spent in 89.16% of cases.These methods were proven effective in 81.07% (who had 50-90% effect), but 56.52% of therapists thought that Autogenic training had limited effect. Many therapist confined it with one or more therapy (Behavior therapy 55.32%, Transactional analysis, Counselling, Morita therapy 29.28%, Biofeedback therapy, Fasting therapy 27.66%).Autogenic training is thought as a basic and important therapy for PSD.

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1. In view of clinical application of transactional analysis and Gestalt therapy, it is convenient to classify psychosomatic disorders into 2 major types : a. Actual PSD in which psychological problems are more related to the actual stress situations of life.b. Character PSD in which patients develop symptoms on the basis of their personality disturbances.2. Egograms are used to diagnose psychosomatic disorders. In general, when the egogram shows high scores in the Adapted Child and low scores in the Free Child, psychological influences are indicated in somatization. However, the egogram is not a proper tool to detect deeprooted personality disturbances such as alexithymic traits and basic faults.3. With actual PSD patients, treatment contracts can be made to cause a shift in energy balance in ego states. Behavior analysis and behavior modification techniques are applied to bolster up weak personality parts. Treatment results are evaluated by therapist and patient together weekly to further improve the patient's daily programs. A treatment contract is expected to be fulfilled successfully within 3 months.4. With character PSD patients, resistances to change need to be considered. The idea of impasse, postulated by Gouldings, is useful to discriminate the difficulties of treatment. Gestalt techniques, which is combined with transactional analysis, are used when the patient is able to be aware of his inner conflicts. The techniques include confrontation by use of chair techniques, use of projections, awareness exercise, dream work, body exercise, saying good-bye, etc.5. Patients with severe ego disturbances cannot tolerate the inner dialogues or attacks in Gestalt therapy. When the patient cannot handle the challenging and confronting manner of the therapist, psychological games may be played in the therapeutic situation. The therapist needs to take caution as he is tempted to play the role of an omnipotent figure. A good working relationship is a prerequisite before any integrative work is launched.

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In the clinical practice of psychosomatic diseases, behavior therapy is proven to be useful when the therapist adequately selects the therapeutic techniques. However, the behavioral assessment is not so easily made, because psychosomatic diseases are multifactorial.The behavioral approaches to bronchial asthma include relaxation technique, systematic desensitization, hypnotism and so on, and today biofeedback techniques as visceral learning are getting the attention of researchers. Also Kahn, A.U. and his co-workers suggested a hypothesis that the so-called exercise-induced bronchospasm is classically conditioned, and have performed clinical experiments on asthmatic children.Shapiro, A.P. et al examined the results of behavioral approach to hypertension and concluded that the most of them were effective but they remained at the stage of phase 1. Therefore, we expect further researches to be conducted in the future. With regard to anorexia nervosa, the behavior therapists are trying to treat the patients through an instrumental conditioning approach. The target is to increase the patients' body weight in most cases. Halmi, K.A. points out that the gain of body weight makes the patients' behavior psychologically, socioeconomically, and sexually well adjusted.More than ten years have passed since biofeedback techniques appeared in the behavioral practices. There are so many pilot studies of biofeedback therapies on psychosomatic or psychophysiological disorders. Perhaps EMG biofeedback training on tension headache is one of studies where the most unbroken efforts have been made. But Beaty, E.T. and Haynes, S.N. noticed that placebo effect, motivation, practice at home still effected the results of the therapy and therefore we could not literally accept the therapeutic data of EMG biofeedback.The author has the same idea regarding the treatment of tic syndrome in childhood. He tried EMG Biofeedback training and the results were successful. He also believes, however, the therapeutic intervention with their parents should not be neglected.At present behavior therapy and biofeedback are being integrated into behavioral medicine. The relationship between psychosomatic medicine and behavioral medicine is one of controversial matters. Both approaches are comprehensive in medicine. The former is more concerned with the pathogenesis or etiological factors of diseases, whereas the latter with therapeutic techniques and rahabilitation. The author bilieves that their future development will draw a conclusion on this theme.

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Alexander Lowen (1910-), a practicing psychoanalyst, developed Bioenergetic Therapy which has greatly contributed to the function of the body (SOMA) in relationship to the mind (PSYCHO). A. Lowen commented that the recent psychoanalytic therapy is so adherent to Freudian principles that it has proved ineffective, for the therapist is so much concerned with an exclusive use of verbal communication between patient and therapist.As a former student of Wilhelm Reich and a Reichian Therapist, Lowen believes that character and personality are physically structured, and any psychological problem manifest itself in the body, its structure and movement. Therefore Bioenergetic Therapy puts its main focus on bodily aspects of the patient with the basic view that any psychic phenomenon is expressed in somatic motion in which BIOENERGY manifests itself.Thus, the goal of bioenergetic therapy is to reunite body and mind by getting rid of various obstracles which prohibit the natural flow of bioenergy in man.In this article, the theory and practice of bioenergetic therapy developed by A. Lowen are briefly introduced and discussed.

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"Morita Therapy" is a unique psychosomatic treatment of Japan for the Shinkeishitsu (Morita's neurosis), which was advocated by Dr. Shoma Morita in about 1920.This therapy can be applied for so called Morita Shinkeishitsu-(sho), including (1) the ordinary Shinkeishitsu (hypochondrical neurosis) like a simple complaint, that is, headache, feeling heaviness in the head, dizziness, disturbance of memory, weak attentiveness, insomnia etc. (2) obsession (obsessive neurosis, phobia) complicated conflict like anthrophobia, mysophobia, pathophobia and so on, and (3) paroxysmal neurosis (anxiety neurosis) represented by cardio neurosis.Original treatment of Morita Therapy is a specific hospitalized treatment, divided into the following four periods : the first period (rest in bed) lasts 4-7 days, the second period (light labour period) 1-2 weeks, the third period (hard labour period) 1-2 weeks and the fourth period (preparation for return to society) 1-several weeks.Through the above four periods, the guidance is carried out in order to foster the power to pass fair judgement and criticism on real facets of human society by attaching importance to the patient's own voluntary activity.The treatment for the outpatients of what is called Morita Therapy's Approach ought to be the substitution-treatment based on the principle of Morita's original therapy. In this case, both the acknowledgement of thinking, emotion and feeling of the patient's own, and his own effort toward a real life are the great two targets of this treatment.According to ten guidance items, the guidance proceeds by combining diary guidance and bibliotherapy together.Concerning the effect of this treatment, though the assessment basis is debatable and also proficiency of the therapist is involved, the original therapy is considered to produce the complete recovery in approximately 55% and improvement in about 35%.Moreover, the result of questionnaire was reported, which performed to find how this therapy was actually carried out among the members of the Japanese Society of Psychosomatic Medicine.

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From time immemorial, it has been well known that fasting has an excellent effect on various diseases and has been practiced in world-wide areas as a religious asceticism. However, nowadays, it has being practiced as a proper medical therapy for psychosomatic disorders. Our scientific study of fasting started from 1967,and has been carried out in 576 cases with an efficacy rate of 87%.The following diseases were considered as suitable indications for the therapy; irritable colon, abnormal eating behavior, functional disorders of the digestive organ, neurocirculatory asthenia, borderline hypertension, variable psychosomatic symptoms of puberty, hyperventilation syndrome, bronchial asthma, various kinds of neurosis especially conversion hysteria, reactive depression and many others of psychosomatic diseases.The patient is put on 10-day fasting allowing to have only drinking water and 5% pentose solution by I.V., after that a 5-day recovery dieting period with settled menu is programed. During the fasting period, NAIKAN therapy is performed which is a special self-examination that method based on Buddhism. With regard to the mechanism of effectiveness, our conclusion is the regulating of the peripheral and central autonomic nervous system and of the endocrine system may change psychophysiological functions. At the result, a spontaneous deconditioning of maladaptive bodily and mental behavior might be induced and led to a homeostatic adjustment of the human body.

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