The aim of this speech is to indicate as a medical doctor how to think about, learn, practice and also teach psychosomatic medicine at a university hospital using concrete cases with digestive diseases.I believe it is necessary to drop abstract discussions and to demonstrate actual evidence and its proof when we teach the younger generation.It is also essential to show how to actually cure the patients. To this end, I have indicated what kinds of clinical and experimental approach to digestive diseases-particularly peptic ulcer-should be made.I would finally like to emphasize that it is extremely important to maintain a holistic approach to medical care in psychosomatic medicine. I believe that the learning and prectice of medicine should place the happiness of the patient above anything else and I would like to further this belief in my future work.

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The human being has become a creature of advanced intelligence with the new cortex under the progress of mankind. As the result, however, human health which is supposed to be integrated by the old brain, has been dusrupted, resulting in killing each other, comitting suicide and causing psychosomatic disorders.Hence, the human being has become accustomed to conduct negative parental care, and the health of primary creature is heing destroyed.The advancement of intelligence improves science and constructs a society of a developed country type, which facilitates the destruction of the ecosystem of the global nature. Morerover, in the developed countries, communities with atmospheric conditions which are necessary for keeping family holds and protecting parents and children, are also destroyed.As a result, psychosomatic disorders increase, healthy development of the human character is impaired, and many other disturbances and abnormalities which are characteristic of the developed country type, are produced (secondary distruption of health).

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Behavioural disorder, psychosomatic disease and neurotic reaction in childhood are caused by their defective disposition and/or improper upbringing history. So these various, different expressions have reciprocal relationships among themselves.Figure 2 shows the mechanisms involved in the outbreak of behavioural disorders and the relationships among their various expressions. Emotioinal disturbances may be caused by aging and social life. Usually, children with normal disposition and/or favourale familial environment can settle their emotional disturbance within socially accepted behaviours. Those who have defective disposition and/or have been up in an improper familial and educational environment can not settle their emotional reactions within the social norm, so they display behavioural disorders. The differences in the way they express their behavioural disorders are due to their inner energy. Vigorous children express their emotional disturbances extroverted as in the case of delinquency and/or school violence which include truancy. Powerless children express their emotional disturbances introvertedly as neurotic reaction and/or psychosomatic disease. Family violence and school refusal often occur concurrently. Mutism is often seen in children with the least power. Psychosomatic diseases are observed in children who tend to be hypersensitive both in mind and body.Pediatricians often have influences on the upbringing of clildren through physical check-ups as a home doctor and/or school physician. I think they also have the responsibilty of guiding parents as an educational consultant. Most children first display their emotional disturbances as somatic complaints, so pediatricians should work as the first consultant in all kinds of problems.

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Egogram developed by John M. Dusay on the basis of Transactional Analysis Theory has been used mainly among the adult population and said that it cannot be applied to children bacause of immaturity of their ego.Since we now know that the ego can develop at any age, we have made an egogram questionnaire for school children. The egogram questionnaire originally designed for adults by the Departments of Psychosomatic Medicine of University of Tokyo and University of Kyushu was transformed and reconstructed so as to be understood by elementary school children. Fifty questions were analyzed to measure the ego states, the Critical Parent (CP), the Nurturing Parent (NP), the Adult (A), the Free Child (FC), the Adapted Child (AC) and their Total.In order to standardize the egogram for children, 136 boys and 152 girls in the first to third grades and 122 boys and 172 girls in the fourth to six grades were selected from elementary school children, and 54 boys and 53 girls from junior high school children on the basis of health questionnaire.The standardized egogram profile was described as "high abnormal" (T score over 68,or 95 percentile), "high borderline" (T score 58-67,or 79-94 percentile), "normal" (T score 43-57,or 23-78 percentile), "low borderline" (T score 33-42,or 7-22 percentile) and "low abnormal" (T score less than 32,or 6 percentile). Twenty nine severe asthmatic children divided into two groups, 11 stable and 18 unstable progress at a residential hospital, and they performed the egogram 3 to 5 times to compare their clinical course.The unstable group showed lower T score for "Total" (P<0.1 at the second test), "NP" (P<0.01), "A" (P<0.01), "AC"(P<0.1) and "Total" (P<0.01) than stable asthmatics. These results suggest that severe and unstable asthmatic children might have some difficulty in developing healthy ego states.We concluded that the standardized egogram questionnaire for children should be reliable and valuable as a psychological test in pediatric practice.

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As the mental state and the physical state in children are immature and undifferentiated, and their defence mechanisms are not developed enough, they are apt to show extreme, strong and sometimes inadequate reactions as a whole.On the other hand, the ways in which symptoms (reaction), various kinds of conditions and problem behaviors manifest themselves depend on the developmental stage of mind and body, on the grade of combination of psychological and physical factors and on the environmental factors includinhg their developmental histories.So, when we diagnose a child's state as a psychosomatic (physiologic) symptom or disease, it will be more reasonable to diagnose on the basis of the extent in which psychological factors exert significant influences and on the effects of analyzing the mechanisms which make up symtoms or diseases, than on the names which diseases are usually called.In this paper, I have arranged the psychosomatic symptoms (reactions) frequently seen in children by classifing them into several groups, and displayed the ways of healing, guiding, and educating them, according to the mechanisms of symptoms (reactions).When we discuss psychosomatic symptoms in children, we must pay attention to the facts that children are more seriously influenced by the circumstances than by adults, because their defence mechanisms in mind and body are not yet fully developed.If we notice this facts, we are able to find that symptoms or reactions of childhood include a lot of reactions caused by mallearning or misslearning. So educational efforts must be made more frequently and effectively in treating children's psychosomatic problems.The necessity of providing the adequate circumstances for educating children and guiding parents should be stressed more eagerly.

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Recently gastric and/or duodenal ulcers, irritable bowel syndrome and other various psychosomatic symptoms began to show an increasing tendency in children of the infantile and adolescent stage.The major cause is pressure from various, especially metnal stresses imposed on the children under the present complicated social environment.Adolesence is an unstable stage for children to develop into adulthood both physically and psychologically, and therefore they easily suffer from mental stresses.Phychological understanding and trust based on the doctor-patient relationship is among the key factors, on the basis of which we simple provide pertinent guidance including helping to develop their attitudes toward life in accordance with individual conditions.So, we need to be slways ready to take the trouble in helping these patients consistently.

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Eating behavior plays a very important role in one's life style and its irregularity causes various psychosomatic disturbances. Recently, abnormal eating behaviors are increasing in number especially in adolescent patients. In order to investigate the psychosocial background of such behaviors, a retrospective research has been conducted on 357 inpatients during the past 15 years and 407 outpatients during the past three years. Their ages ranged from 12 to 25 years old.The results were summerized as follows : (1) New diagnostic criteria in relation to the motivational factors at the onset were introduced for the patients with anorexia and extreme emaciation who had no organic or psychotic disorders. Classical anorexia nervosa (AN) inclueded the one group who refused to eat by willful desire to be thin, whereas the other who developed emaciation with appetite loss caused by psychosocial stress was diagnossed as psychogenic anorexia (PA). A statistical study showed that AN had more serious somatic conditions, psychological and family conflicts than PA. These criteria were thought to be useful in selecting therapeutic procedures. Strict behavioral therapy involving other members of the family was effective for AN, whereas psychotherapy focusing on the psychosocial stress was successful for PA.(2) The adolesent psychosomatic patients with eating disorders had more disturbed family background such as parental conflicts, divorce, mother's dominancy, father's unemployment etc.in compatison with other psychosomatic diseases and neuroses.Irregular taking of breakfast was a most frequent abnormality found in their eating style.The main problem existed in the decrease of their mother's eagerness to prepare hand-made foods for the family.The background factors of eating disorders in adolescence have various aspects. However, the role of parents played in the life style of the family was thought to be the most essential cause.

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Adolescence is a period when biological and psychological developments occur quickly and drastically in several years. In this period psychosomatic and/or psychobiological disturbances arise in many adolescents. At the same time adolescents must overcome several psychosocial tasks. So we should call above mentioned disturbances as "psycho-bio-sicial disturbances in adolescence". If we recognize the period of adolescence as such a stage of the way of life, could we easily use the term "psychosomatic disease" for adolescent cases ? This is a big problem in the field of adolescent psychiatry. The authors consider that almost all adolescent cases are of psycho-somato-social disturbances and the term of psychosomatic disease should not be taken too lightly in adolescent psychiatry.In the psychiatric department of our university hospital we saw 38 cases diagnosed as psychosomatic diseases during ten years from 1968 to 1977 and followed then up over 5 yeaars.In these cases 36.8% complained headaches, 28.9% tic, 7.9% abdominal pains, 5.3% psychogenic fever, and so on. In these ten years we experienced 80 cases severenes of school-attendance (male 40 and female 40-4.7% of adolescent outpatients in our clinic) in our university hospital. In these 80 cases 24 male and 22 female cases complained somatic symptoms. But we found no statistic differences between the two sexes. When examined the 80 cases from age differences, we find age-linded specific differences. The 31 of 45 cases from 10 to 14 years old and 15 of 35 cases from 15 to 19 years old showed somatic complaints. The younger group had more somatic complaints than the elder group. Then we fiind a statisticd difference of 0.1% level with x^2 examination between two age groups.From these findings, how should we understand the relationship between servereness of school-attendance and psychosomatic disease in adolescence ? Adolescents express frequently their psychopathology with somatic behavioral features rather than psychic or psychological features.We think that somatization and behanioral expression of one's psychopathology and/or inner conflicts are equivalent from the viewpoint of adolescent psychiatry. Of course pathological features of somatization in adolescence means more than so-called psychosomatic disease. And besides, pathological features of behavioral expressions imply many patterns in adolescence, such as wrist-cutting syndrome, eating disorders, delinquencies, etc. The authors consider the severeness of school-attendance as one of psycho-behavioral disturbances. Then we can conclude that pathological features of somatization including psychosomatic diseases and severeness of school-attendance are the alternative ways of somato-behavioral disturbances in adolescence.

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At out adolescent clinic, we frequently face psychosomatic problems. The somatic symptoms in adolescence are very variegated and appear differently in compliance with each age group.With regard to psychological aspects, they can be classified into 3 groups; (1) failure in human relationship in family, school or their place of work (46.3%), (2) sexual problems (31.3%), such as misapprehension for menses, troubles of sexual intercourse, and (3) stress of school work (21.3%). At our gynecological clinic, we find that sexual problems often cause somatic symptoms, as for instance, dysmenorrhea, amenorrhea, vaginal itching, suprapubical pain, vaginismus, etc.These sexual problems ofen relate to juvenile delinquency and the teen ager's pregnancy. Therefore, bio-psycho-socio and ethical approach is essential to manage these patients.This approach can not be realized without a comprehensive medical care in which psychologists, social-workers and educators participate.

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A case of intractable asthma (a 14-years old girl), who had once been dependent on corticosteroid, was reported.Her asthmatic attacks were present every time she attended school and disappeared when she was absent from school. Furthermore her attacks continued while she seemed to be anxious about her life after graduating from junior high school, but they disappeared when this anxiety was gone.The classical conditioning mechanism was applied to interpret her anxieties causing varius manifestations, but the operant conditioning mechanism must be introduced to understand her desire to escape from school performance.

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