There are two types of the abdominal distension to be considered from a psychosomatic point of view.One is so-called the gastrointestinal truct gasceous syndrome in which gas is filled in the stomach or intestine when the individual is under psydhological of mental stress, and the other type is a neurotic abdominal distension.In the latter case, abdominal distension is not caused by gas in the gastrointestinal truct, nor ascites, tumor, fat of the abdominal wall and nor pregnancy.The exacerbations and remissions of these symptoms are considered to be related to psychosomatic factors.We call this type of abdominal distension the neurosic abdominal distension. We experienced 57 cases of neurotic abdominal distension (44 females, 13 males), which were grouped into the following three classes.1) An abdomen suddenly distends ahead but this distention does not continue in existense.There were 11 cases (19%) of the 57 patients in this group.2) The abdominal distension continues long in existense and the degree of this symptom is affected by the psychosomatic factors. There were 30 cases (53%) of the 57 caess in this group.3) The abdominal distension is accompanied by the tension of the abdominal wall and continues long in existense. There were 16 cases (28%) of the 57 patiennts in this group.If doctors don't know the neurotic abdominal distension, they may pass these cases unnoticed as mysterious diseases.The cases of abdominal distension are frequently observed in middle age female patients and therefore when doctors examine the patients of abdominal distension, we suggest that they take into consideration of the neurotic abdominal distension.

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Hysterical symptoms are viewed by behavior therapists as learned maladaptive responses. So these therapists try to use the thechniques derived from learning theories. Conversion neuroses include hysterical anaesthesia, analgesia, deafness, muscular spasm, spasmodic torticollis and so on.At our out-patient clinic of pediatrics, the authors are asked to treat the patients of hysterical blindness several times a year, who were referred by opthalmologists. Usually they visit with the exclusive diagnosis because no organic pathologies were found.As already known, Brady-Lind or Grosz-Zimmerman reported a behabioral approach to hysterical blindness with an operant conditioning technique. Ohno, et al, however, criticized their methodologies. They insisted that such methodologies were sophisticated but not so useful in the situations of daily clinical practice. Ohno, et al, made a simpler approach using an aversive stimulus.We also treated patients of hysterical blindness using the operant technique. They were verbally praised whenever they gave the correct answers. We thought that the aversie therapy was not preferable because our patients were children. In this report we presented three cases of hysterical blindness which consisted of a 13-year old boy, a 12-year old girl and an 11-year old girl. The first 2 cases were urged to point out the big letters, which appeared in the settled distance and were gradually and syntematically changed into lesser sizes when the patients gave the correct answers.We noticed that all of the caess revealed some conflictual situations in their lives which were assumed to be the cause of blindness. So family therapy was concurrently tried and we believe our interventions were effective. In the case of the 13-year old boy, his father was an artist of surrealism and painted grotesque scenery in his work. So these pictures might have influenced the psychology of this boy in some degree. The father was a person of good sense and frankly admitted that those factors could induce his child's symptoms. He was able to handle the situation in such a way not to effect his son. We believe that the attitudes of the parents can lead to better prognosis.In this study the disturbance of visual acuity was treated using operant techniques, and psychological interventions were performed at the same times. The second of the 12-year old girl was treated almost in the same way as the first case and revealed a good result. In the last case the patient complained of poor visual ability but could study at shool. So we did not try operant conditioning techniques with her and only conducted family interviews with special focus on her mother because there seemed to be some conflictural situations in the family. The symptom itself did not improve markedly although her psychological problems wre solved.

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Nervous pollakisuria is a well-known psychosomatic disease in urological practice. Symptomatologically, the urinary frequency is not the type usually associated with urethritis or cystitis.It will cease at night and does not interfere with sleep. Also, it is often influenced by emotional changes, and relieved when the patient is at ease or interested in daily activities. Some investigators have emphasized the importance of sexual conflicts in women or obsessive traits in children. But, the reason why some persons should have such troublesome disturbances of the urinary bladder function in association with emotional conflicts is not clear.Generally speaking, the occurrence of the symptom is directly correlated to the previous experiences or illnesses of the patients. The complaints usually represent an expression of tension or anxiety, and is not due to any anatomical or physiological changes in the bladder.The anxiety of patients may not be apparently noticeable, but adequate consultation will reveal that he or she is quite concerned about the trouble and has a definite fear associated with it.It is therapeutically beneficial to detect a causative event for the development of symptoms in each subject.Clinical observation was performed on 5 adolescent cases of nervous pollakisuria. The results were as follows : 1) Nervous pollakisuria was usually intense at school, especially in classrooms, and non-existent at home. It means that the symptom is primarily influenced by emotional tension associated with life situations.2) All the cases were self-conscious and embarrassed by the presence of other people, particularly class-mates. They always felt intensive sense of shyness, self-reproach and guilt for leaving classroom for urination during school hours.3) They began to avoid their friends and school, and virtually withdraw themelves from social activities. They failed to make friends and achieve lively human relationships in their adolescent years.4) They were quite concerned about their pollakisuria and fearful of situations associated with it. They try various remedies and visit many physicians without success.5) The characteristics of their clinical features are similar in many respects to those of onthropophobia : a severe form of social phobia. They can be understood by adolescent psychology with particular emphasis on interpersonal relationship.6) We had obtained good therapeutical results by sympathetic listening followed by Morita-oriented instructions. Our main aim was to relieve fear and anxiety which are responsible for the illness. It seems important to investigate and treat pollakisuria of young generation from the standpoint of adolescent psychiatry.

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The author attempted to investigate the behavior pattern of patients with coronary heat disease (CHD) by Jenkins Activity Survey (JAS) which was translated into Japanese by the Department of Psychosomatic Medicine of Tohoku University.JAS is one of the most useful tests for specific behavior pattern determination in Western countries.To study the Japanese coronary-prone behavior pattern, JAS may be useful also to compare the Japanese behavior pattern with that of Westerners and to characterize the Japanese Type A behavior pattern.One hundred and eighty patients with the new onset of CHD(144 cases of acute myocardial infarction and 36 unstable angina pectoris) were analysed.The results were as follows.1) Type A scale and Factor H(Hard-driving and Competitive) scale showed significantly higher levels in CHD patients than in controls. In CHD patients, 63.3% were found to have Type A behavior pattern.In CHD patients, these were no significant differences of indicence of Type A behavior pattern between acute myocardial infarction and angina pectoris, under the age 59 and above the age 60.In regard to occupational positions, Type A behavior pattern appeared to be more closely related to the administrative class rather than to the non-administrative class.Incidences of hypertension, hypercholesterolemia and cigarette-smoking which were considered as traditional coronary risk factors in CHD patients did not seem to be related to behavior patterns.2) In comparison with the Western Collaborative Group Study (WCGS) report and the Belgian study, the mean Type A score and mean Factor H score in my study showed lower scores, particularly the latter showing markedly lower levels in the author's CHD patients.However, in the author's CHD patients, the mean Factor H score of administrative classes showed higher levels than that in WCGS report.So it was supposed that in Japan Type A scores and Factor H scores were closely related to the occupational positions.3) Cornell Medical Index (CMI) is widely used for determination of neurotic tendencies of patients in Japan. Many Type A patients belonged to the categories III or IV of CMI.According to the CMI criteria, the category III is diagnosed as probably neurotic and the category IV as neurotic.The reson why many Type A patients belong to CMI neurotic categories is that Type A patients get angry more easily and more sensitive than non-type A patients.Therefore, in case of CHD patients, it is necessary to analyse CMI results carefully from the standpoints of both neurotic tendency and behavior pattern.In conclusion, JAS can be considered useful for determining behavior patterns of CHD patients in Japan also.

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Previously, we reported the effect of the absolute bedrest condition in "Morita Therapy" on the psychological state of the patient and the relationship between teh psychological and psychophysiological changes under this condition. But the subjects of the past study were healthy adults. Now we aimed at learnign the similarity and/or difference of the psychological state between the neurotic patients and the healthy adults. Subjects were all male adults, 6 were healthy as control (20-28 years, mean 25.0+2.8), and 5 were neurotics (20-30 years, mean 25.8+3.2). No subject had significant medical illness, none was on drugs of any kind. The psychological changes were examined three times a day throughout the entire study period by a self-rating scale of mood. Sleep was evaluated by the polygraphic records every day.The results were as follwos : (1) Throughout the whole session both the neurotics and control expressed similar degree of the feeling of being isolated. At the mid third and later third of the session, the neurotics expressed significantly higher negative feelings and lower positive feelings. Some relationship was observed between changes on the self-evaluation of mood and changes on the polygraphic data in the control subjects, whereas disagreement was observed in the neurotics.(2) At the end of session significantly lower negaitve feelings and higher positive feelings were expressed in the control subjects. Especially they expressed higher sense of relief and sense of release. Also they expressed lower anxiety and depressive mood. These results suggest that their psychological state was more stable at the end of sesion.(3) At the end of session significantly lower feelings of being isolated and lower negative feelings were expressed in the neurotics. They expressed higher levels of self-confidence and self-esteem. Also they expressed lower levels of tension and adherence to inner conflict.(4) A significant positive correlation was observed between negative feelings and S3+S4/TST in the control subjects. And also a significant negative correlation was observed between positive feelings and S3+S4/TST in them. A significant positive correlation was ovserved between positive feelings and TST/1440 in the neurotics. The same tendency was also observed between feelings of being isolated and TST/1440. And also a significant negative correlation was observed between feelings of being isolated and S1-S2/TST in them.

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Emotional factors often influence bronchial asthma. CMI(Cornell Medical Index-Fukamachi method) has been utilized to assess psychological factors of patients with bronchial asthma.However CMI is one of methods to assess a neurotic tendency of patients but not psychosomatic disease perse. We think it is important to distinguish between neurosis and psychosomatic disease.The Comprehansive Asthma Inventory (CAI) which was originated by the Japanese Society of Psychosomatic Research on Respiratory Disease, is a questionnaire containing 22 questions designed to reveal emotional factors concerned with occurrence of astham attack. Using CAI, we find out psychosomatic disease and neurosis (including depression) in the patients with bronchial asthma. In this study we tried calculating the percentage scores of 9 psychological categories as "extent of conditioning, " "suggestibility, " "expected anxiety, " "dependency, " "frustration, " flight into illness, " "distorted life habits, " "negaitve attitudes towards prognosis, " " decreased motication towards therapy, " and taking average of total percentages (we call it CAI score).We applied five psychological tests (CMI, self-rating Depression Scale, Manifest Anxiety Scale, Yatabe-Guilford test, Seikenshiki Inventory) and CAI to 121 cases with bronchial asthma (50 males, 71 females; ages from 15 to 72,mean 39.8 years old) at the 1st Department of Internal Medicine, Nihon University School of Medicine.The results were summarized as follows;1. Numbers of neurotic cases were 53(43.8%), and that of depressive cases were 21(17.4%).In 28 cases (23.1%), no particular emotional factors were found by five psychological tests, but by the CAI, many emotional factors were found out.2. We devided 47 (38.8%) cases without neurotic or depressive states into two groups by the CAI. There were 14 (11.6%) cases with low-CAI scores, in which the mean CAI score was 9.3. There were 33 (27.3%) cases with high-CAI scores yet without in which the mean CAI score was 26.3.3. The high-CAI gropu with no abnormalities on CMI and SDS, comparing with the low-CAI group, had higher scores in the items as "extent of conditioning, " "suggestibility, " "dependency, " "frustration, " "distorted life habits" (p<0.01), "expected anxiety, " "flight into illness, " "negative attitudes towards prognosis, " "decreased motivation towards therapy" (p<0.05) on the CAI, and thus had higher CAI scores (p<0.01).4. The high-CAI score group without neurotic and depressive states answered "yes" to the questions as "Does your attack always lead you to the same condition? (p<0.01), "Do you often think that your asthma is incurable? (p<0.05) more often than the low-CAI group.

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A 19-year old Japanese man had shown episodes of binge eating and vomiting after two times of accident in Judo. At his 17 years of age, he had the first sport accidnent by Judo and sustained cerebral concussion. He had high fever above 39℃ and appetite loss. He had lost 10 kg during the 1 month after that episode. He spent several weeks in the hospital. Brain computor tomography (CT) and EEG showed the normal findings. However, his cerebral spinal fluid (CSF) was xanthochoromic. When he was discharged with no neurological deficits, xanthochromia in CSF was improved. One year after the first accident, he had the second sport accident. His CSF was also xanthochromic and its pressure was elevated. After the second accident, he showed some change in his emotion and personality. Three months later, when there was a trouble between his father and sister, he started his binge eating accompanied with vomiting. One year later, he got into heavy drinking and gradually developed generlized edema. When admitted to our hospital in June, 1985,he weighed 46.8 kg (ideal body weight : 57.4 kg). Laboratory examinations demonstrated hypoproteinemia and hypogammaglobulinemia with ECG abnormality, sinus bradycardia. Brain CT demonstrated mild cerebral atrophy. He had showed the low T_3 syndroem by endocrinological examinations. Cortisol circadian rhythm and dexamethasone suppression test were normal. However, TSH response to thyrotropin-releasing hormone (TRH) and GH response to insulin tolerance test (ITT) were depayed and no response, respectively. Compulsory feeding using the elementary diet, behavior control, personal psychotherapy, and family therapy were conducted . Thereafter, he became able to resume his social life.In the literature, only 5 cases with eating disorder associated with trauma including this patient (2 men and 3 women; mean age 21.8 yr.) were reported. Four of them suffered from traffic accidents and the remaining one from a sport accident. Mean per cent of ideal body weight at admission was 75% ranging from 64% to 82%. Most of the patients had mental and characteristic changes after trauma as well as changes in eating habit. Namely, the dysorexia nervosa type (bulimics and vomiting) was found in 4 of 5 these patients. However, the anorexia nervosa type (restricting) was seen in only the remainign one patient.It is considered that the minimum brain damage in hypothalamus and the change in personality caused by the accident might be correlated with eating disorder.

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Case : A 27-year old woman, para O, gravida O, who is married to her cousin, was anxious about delivery before gestation bacause of her intermarriage.In the seventh to eighth week of gestation, she developed hyperemesis gravidarum.In the tenth week of gestation, she drank much water after her gynecologist had told her to drink water for her fetus.In the sixteenth week of gestation, there were urinary retention, distension of abdomen and abnormalities of serum electrolyte values (hypokalemia, hyponatremia, hypochloremia). Moreover the anxiety about gestation increased and she developed amentia at last.After that, physical symptoms improved but she was still anxious about gestation together with her family. Therefore in consultation with gynecologist we tried to approach her family to give supportive psychotherapy. And she safely delivered a dauthter.Through the course of this case, we considered her psychological background and character features which produced amentia.With regard to her psychological background, we stated the following : The situation of gestation produced excessive anxiety under the psychologically prepared situation by intermarriage, and hyperemesis gravidarum, compulsive drinking water, urinary retention and distension of abdomen appeared. Moreover these symptoms increased anxiety and finally amentia developed by abnormalities of serum electrolyte.With regard to character features, we stated that immaturity and dependency are important factors which produced these symptoms.Through the treatment of this case, we made some discussion from the viewpoint of clinical psychiatry and emphasized an approach to patient and family as well as consultation with gynecologist. Lastly we briefly refered to side effects of psychotropic drugs on fetus.

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