At the introductory stage of treatment of P.S.D., psychiatric diagnosis should be performed based on three factors : symptoms or nosology, psychodynamics, and the patient's attitude toward his sickness and treatment.Accurate determination of symptomatic features and diagnosis of disease are necessary in order to choose suitable drugs. Every psychotropic drug has some target symptoms. The benzo-siazepine anxiolytic drugs, which are used in the treatment of psychosomatic disorders, have some common characteristics, but have also some differences. They differ in acting duration, absorption time and potency of taming effect.Estimation of psychodynamics is necessary for a combined use of psychotherapy and drugs.Each psychopathological state has psychodynamic causes, and the psychotherapeutic approach should be chosen with these causes in mind. The author believes that there are some formulas relating psychopathology to psychodynamics.For example, P.S.D. can often be explained by a collapse of the introjected mother in the patient's bodily ego. Anxiety neurosis often begins in some emotional isolation. Hypochondriacal patients usually have defensive attitudes toward fear of becoming weak and being rejected. Depressive state follows object-loss experiences. Hysterical neurosis is an escape into disease and also represents a seeking of the mother's breast. Phobias are attempts to displace real anxiety. Obsessive compulsive neurosis is due to self-distrust and desire to control other people. And boderline personality patients have a splitting tendency in their object relations due to a divided self made by unconsistent experiences with praise and rejection from his mother.Finally, the author would like to point out the importance of an objective attitude toward prescribing psychotropic drugs.

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We studied an applicatino of psychotropic drugs to the field of psychosomatic medicine including evaluation of the precautions and problems of these drugs.Actually, when psychosomatic diseases are treated in the field of psychosomatic medicine, self-control based on the re-integration of mind and body becomes an important aim of therapy; therefore, the treatment goal can never be achieved with only drug therapy.First, as to the precaution for the use of psychotropic drugs, the patients show either positive or negative attitudes towards drug therapy when they visit the department of psychosomatic medicine. Therefore, an appropriate identification of selection in these attitudes in an infallible point for the start of drug therapy for psychosomatic disease. This indicates that the treatment of psychosomatic disease has to be conducted on the individual basis.Secondly, the correct conduction of increase and alteration of drug is important in drug therapy.Thirdly, it is a problem of administration method. Recently, the determination of the concentratino of drug in blood has become possible and the administration of drug once a day is practiced in drugs with long blood half-life stage from the results of pharmacokinetic studies. Especially, antidepressants relieve side effects due to the administration at the time of going to bed, and have the advantages of the patient not forgetting to take them as compared to divided administrations.Fourthly, the problem of drug dependency is indicated. An attention should be paid to the increase of dose in drug therapy, and it is desirable to approach this problem by combining other psychological therapies in an attempt for gradual increase and eventual succession.Fifthly, we indicated some problems relating to the combined use of other drugs in anti-anxiety drugs and antidepressants.

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Psychotropic drugs used in the area of internal medicine include almost always antianxiety drugs. However, the patients who should be treated with antidepressants are prone to increase gradually in recent years.In the analysis of psychotropic drugs used in the psychosomatic clinic of our department, antianxiety drugs were most frequently used in 88% of all patients, whereas antidepressants were used in 37%.Beside, 25% of all patients were treated with combination of antianxiety drugs and antidepressants, and 24% of all patients were treated with psychotropic drugs (antianxiety drugs or antidepressants) and somatic drugs such as anticholinergic drugs, Domperidone, Metoclopramide combined. According to our experience, antianxiety drugs such as Diazepam, Cloxazolam, Flutazolam, Oxazolam, Clotiazepam, Etizolam, and antidepressants such as Amitryptiline, Dibenzepin, Imipramine, Maprotiline, Sulpiride seemed to be effective and useful for psychosomatic diseases in the area of internal medicine.The side effects were recognized in 0.3% of the patients treated with antianxiety drugs, in 0.7% of those treated with antidepressants. The incidence of side effects of these drugs was lower than that of these drugs in premarketing period respectively.Next, we studied the clinical efficacy of various antianxiety drugs on irritable bowel syndrome (IBS), because this syndrome is one of the most important psychosomatic disease and a disturbance occurs in the function of the digestive tract.Flutazolame, Prazepam, Oxazolam, Etilozam seemed to be effective and useful for this syndrome. However, there was no antianxiety drug which was effective for all patients with this syndrome.Moreover, we studied the clinical efficacy of combined use of an antiulcer drug (Gefarnate) and an antianxiety drug (Alprazolam) on the patients with gastric ulcer.This combiantion therapy was effective not only for an early improvement in subjective symptoms but also for the healing of ulcer.Furthermore, the patients with gastro-duodenal ulcer once healed by medication were treated with maintenance therapy to prevent recurrence and they were followed up endoscopically for more than two years.Analysis of the contents of maintenance therapy showed that the relapse rate of patients who had used antianxiety drug alone or some antiulcer drugs, especially stimulants to mucosal defensive factors, with antianxiety drugs were lower than that of those who had used many kinds of antiulcer drugs without antianxiety drug.That was to say that the combined use of antianxiety drugs and antiulcer drugs seemed to be very effective in preventing relapse of gastro-duodenal ulcer.

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In the field of obstetrics, psychotropic drugs are in principle, used as little as possible (other than specific cases) due to serious concern about influences such as tetragenecity to the fetus. But there are cases when small quantities of anti-anxiety drugs are prescribed for a short term or in regular doses, together with an anti-epileptic drug for long term control of epilepsy for pregnant women with epilepsy.In cases of slight depression or neuropsychosis in the puerperium anti-depressants and anti-anxiety drugs are used together with psychotherapy and regulation of environment without lactation.There is an exceptional case of a patient having been laboring a healthy male infant, dosed with a small quantity of anti-depressants and anti-anxiety drugs during pregnancy, since the patient and family had been most anxious for her to complete her pregnancy even if there was some possibility that the anti-depressants would have an effect upon the fetus. This patient had been in a state of depression and become pregnant during treatment. We have been following this case until now. The boy is 11 years old, healthy in body and mind, and well grown.In the field of gynecology, climacteric syndrome, (as well as so-called vegetative syndrome and unidentified clinical syndrome) is a typical condition requiring anti-depressants and anti-anxiety drugs. However, there has a growing preference to towards Chinese traditional medicine; anti-depressants are prescribed only for the state which comes up in climacterum. There are many successful cases of anti-depressants, and anti-anxiety drugs regularly prescribed for premenstrual tension. This might be due to psychological changes during luteal phase.There are cases when small quantities of a psychotropic drug is prescribed for dysmenorrhea to release anxiety, impatience or pre-anxiety of apin. They have a strong effect on these psychogenic conditions.There are cases when anti-depressants, anti-anxiety drugs or sometimes psychotropic drug are used to relieve chronic pain syndrome (including that of vulva and vagina), vulvar pruritus, pslvic infectious disease, tumors, functional uterine bleeding, sexual disorder, endometriosis during the period when danazol is dosed or psychological complaint caused by those disease in the field of gynecology.

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In time of major surgical operation, psychotropic drugs are not normally used;however, to patients who suffer from fear and sleeplessness before operation, diazepam, a kind of psycho-analeptica drug, is mainly given.After the operation, opipramol, which is a kind of anti-depressant and very often used in the field of surgery, is given to patients who have non-specific complaints or a dumping syndrome.However, some patients, after the operation, turn hysterical, at which time psychotropic drugs have very little effect on them. So that it is nessessary that the surgeon tries to treat them by other therapies such as interviewing the patient for his psychological behaviors.For the patient with disturbance of postoperative mental state, it is likely that the disturbances are diagnosed as only an emotional change and he is given unsuitable psychotoropic drug without any suitable examinations. Thus the surgeon hould just diagnose the disturbance by the PSM approach after excluding organic genesis from causes of the disturbance.Surgeons at times may misdiagnose, not realizing that the patient is mentally ill and perform polysurgery. This practice must be avoided.

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The use of psychotropic drugs in pediatric practice is discussed. Anti-anxiety drugs are widely prescribed for psychosomatic disorders and behavior problems in children. Although anti-psychotics are not widely used in pediatric practice, haloperidol is very effective on Gilles de la Tourettes tics. Antidepressants are used on nocturnal enuresis. Psychostimulants are very effective on hyperkinetic syndrome in children. Calcium hopantenate and pentoxifylline are also used in behavior disorders of brain demaged children. It is important that psychotherapy for children and counselling for their parents are combined with the use of psychotropic drugs.

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We report on six cases of anorexia nervosa associated with Graves' disease. The relationship between the two diseases and the pathogenesis of anorexia nervosa are considered.Case 1 was an 18-year-old female, one of monozygotic twins : Both twins suffered from Graves' disease and underwent thyroidectomy at the same time. Six months after the operation, one of them developed anorexia nervosa. From this case, it would seem that the hereditary factor is more important in Graves' disease but it does not play a main role in anorexia nervosa. We observed five cases of twins only one of each set of twins was suffering from anorexia nervosa.Case 2 was a 13-year-old female. At first she suffered from Graves' disease. During her recuperation her body weight increased in spite of a normal diet. She showed a fear of becoming obese, and started to reduce her intake of food.Case 3 was a 25-year-old female who followed a similar clinical course as case 2.Case 4 was a 25-year-old female. Anorexia was associated with a stressful life situation after marriage. One year after the onset of anorexia, her condition was diagnosed as Graves' disease. In spite of a high level of serum thyroid hormone, she did not show the syndrome of hyperthyroidism. The hypermetabolic state of Graves' disease seemed to be suppreassed by the hypometabolism occasioned by anorexia.Case 5 was a 19-year-old female who suffered from both anorexia nervosa and Graves' disease at the same time. She showed a tendency toward low T_3 syndrome in spite of her hyperthyroidism.Case 6 was a 20-year-old female. Due to anorexia her body weight once decreased from 55kg to 35.2kg. After a turn from anorexia to bulimia, her body weight increased to 80kg, in spite of an association with the hypermetabolic state of Graves' disease.From the above cases, it is concluded that the hereditary factor does not necessarily play a main role in anorexia nervosa, and the increased body weight during recuperation of Graves' disease is a trigger cause of anorexia. Further, the clinical picture of Graves' disease is usually hidden by the clinical symptom of anorexia nervosa.

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"Taken" Diagnostic Test for Child-Parent Relationship was re-standardezed (Part I) and used to compare the incidence of abnormal (less than 20 percentile) and borderline (21-40 percentile) relationship between children and their parents among 478 healthy control, 65 asthmatic children (non-institutionalized) who joined our Ashma Summer School in 1983 (Group A) and 56 institutionalized asthmatic children (Group B).The incidence of abnormal and borderline (less than 40 percentile) relation viewed by children toward their fathers was higher in interference (p<0.1) and blind love (p<0.05) of healthy control than those of asthmatics. When viewed by children toward their mothers it was higher in negative refusal (P<0.01) of asthmatic Group A than healthy control. When viewed by fathers toward their children it was higher in interference (P<0.05) of healthy control and in negative refusal (P<0.05) and disagreement (P<0.05) of fathers to asthmatic Group A than the other. From mothers to their children it was higher in negative refusal (P<0.01), positive refusal (P<0.01), interference (P<0.01), blind obedience (P<0.01) and inconsistency (P<0.05) of mothers to asthmatic Group A than healthy control.The incidence of abnormal relation from boys to their parents was lower in interference (P<0.1) of asthmatic Group A and higher in negative refusal (P<0.1), anxiety (P<0.005), blind love (P<0.025) and blind obedience (P<0.05) of Group B than healthy control. The Group B was higher in interference (P<0.01) and anxiety (P<0.01) than Group A. When viewed from girls to their parents it was lower in interference (P<0.1) of asthmatic Group A and higher in negative refusal (P<0.05) and blind obedience (P<0.05) of Group A than healthy control, and lower in disagreement (P<0.1) of Group B than healthy control. The Group B was lower in negative refusal (P<0.025) and disagreement (P<0.05) than Group A. From fathers to their children it was higher in blind obedence (P<0.05) and disagreement (P<0.01) of fathers to Group A, and lower in interference (P<0.005) and higher in positive refusal (P<0.05), blind love (P<0.025), blind obedience (P<0.005) and disagreement (P<0.005) of fathers to Group B than healthy control. The fathers of Group B were higher in strictness (P<0.1), blind love (P<0.025) than the fathers of Group A. From mothers to their children it was higher in negative refusal (P<0.01), positive refusal (P<0.01), interferenre (p<0.01), blind love (P<0.05), blind obedience (P<0.05), disagreement (P<0.1) of mothers to Group A, and higher in expectation (P<0.025), interference (P<0.005), blind love (P<0.005) and disagreement (P<0.05) of mothers to Group B than healthy control. The mothers of Group B were lower in negative refusal (P<0.1), positive refusal (P<0.05) and blind obedience (P<0.1), and higher in anxiety (P<0.1) than the mothers of Group A.We concluded that the relationship between children and parents should be evaluated by re-standardized "Taken" Diagnostic Test and compared asthmatic children who joined Asthma Summer School and institutionalized asthmatic children to healthy control in order to characterize their relation.

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Recenthy there is a rapid increase in the number of children with school refusal in Japan. Children with obesity symptom accompanied with school refusal were oftern seen in child psychiatric outpatient clinics.In order to investigate the relationship between obesity and school refusal, own subjects were divided into the following three groups and a psychosomatic analysis was carried out by taking into consideration of their main clinical symptoms, family backgrounds and personality features.(A) the group of children with obesity as well as school refusal.(B) the group of children with school resufal but with no obesity.(C) the group who suffered only from obesity Forty-one cases consisting of 25 males and 16 females, ages 9 to 14,were examined at the outpatient clinic at the Dept. of Psychiatry and Neurology of Osaka Children's Medical Center during the period of 1977 to 1981.These subjects were divided into the above-mentioned groups, the number of the groups A, B and C was 15,15 and 11 repectively.The results were as follows : (1) 8.3% of the examined children with school refusal were obese, and this percentage was equal to that of all pupils and students in Japan.(2) All cases of the Group A were of the chronic school refusal type, whereas in Group B we found some with the acute type besides those with the chronic type.(3) Concerning the family environment, about a half of the group A had such problems as divorce of the parents, father's alcoholism and the other half were apparently from the typical latent destructive families.(4) With regard to eating habits, all of subjects the Group A showed hyperphagia, while none showed it in the Group C.(5) As a result of GAT, the order of total anxiety tendency grade was B>A>C.The members of the Group A obtained high scores in somatic signs and anxiety about human relationship. The Group B tended to feel isolated fearful and hypersensitive; however most of the Group C members were in the normal range.According to our investigation being obese in infancy did not cause feelings of rejection or contempt on the part of their parents or playmates. But in childhood, obesity was rejected and despised by their school mates and even their parents. So they got inferiority complex and distorted body-image.Growing fat in childhood was caused by hyperphagia which was affected by underlying parental discord, and being obesity hurt their body-image. It was assumed that these children tended to develop neurotic characters and escape from the society, resuling in their refusal to go to school.

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