Psychosomatic study in Tohoku University was begun in 1919 by prof. S. Marui and its stream has been continuing via S. Yamagata and K. Kushima down to our department with a spirit of natural science which does not solely depend on psychological aspects. As a physician of internal medicine, the author has kept the attitude to conduct biological studies in order to clarify the mechanism of mind-body relations and is continuing to develop the diagnostic procedure and treatment methods from the standpoint of the following concepts. The diagnostic procedure of psychosomatic disease should have a stress-induced change of biological mediator such as blood catecholamines or cortisol in the human body. I can not agree to make a diagnosis of psychosomatic disease only by the psychoanalytic method that connects psychological stress and bodily symptoms directly. Since psychosomatic medicine is one of the branches of natural science, its diagnosis has to prove biological abnormality under the stress loading. The therapeutic method should has a scientific basis which consists of biological reasons. Also there needs to be an order range to pursue the schedule of medical psychotherapies as follows. 1. Complete explanation of the disease to patients until they can understand it, 2. discharge of frustration or stress by a non-directive interview, 3. cognition of reasons for unadaptation to their living environment including their behaviors and personalities by the method of self-instruction with NAIKAN meditation, which helps them to modify their own life style, 4. Regulation of imbalance of the autonomic nervous system and the endocrine system by the fasting therapy or ZEN meditation or autogenic training, as those bodily abnormal functions cause the bodily symptoms, 5. Modification of life style by group-life therapy utilizing balneotherapy which is conducted at resort hot spring hotel under the guidance of doctors and psychologists. This can call a psychosomatic rehabilitation to go back to general business. The result of above mentiond special therapies are successful in about 85 percent of the patients with psychosomatic diseases, neuroses and depressions. However, the most important factor in the success of therapy depends upon the personality of the attending doctor and not on his technical skill.

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We have analyzed the present situation in relation to psychosomatic education and its practice on the basis of our experiences at the Tokai University School of Medicine and its hospital which have been functioning for more than 10 years since their institution. Along with reporting the outlines and distinctive features of our program, we have studied serveral concrete counter measures which aim at an establishment of a far fuller pre- and post-graduate education with due considerations to the importance of psychosomatic approach in primary care. The author's opinions and programs are summarized as follows : I) It is necessary to help students have systematic understanding of lectures regarding psychosomatic medicine which are apt to be performed sporadically in each department, in addition to securing an opportunity for sufficient education in behavior science prior to specialized education. II) It is necessary to contrive the practice of psychosomatic study aid training including liaison psychiatry during the one-year rotation program in other departments which is assigned to all the residents in post-graduate education. III) It is needed to establish a closer cooperation system in education and learning among clinical departments on the basis of psychosomatic medicine. IV) It is desired to contrive extensive infiltration of general understanding of psychosomatic medicine into regional medical associations and nuclear hospitals through various medical and health seminars by strengthening of cooperational ties with them.

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Saiki Minamiamabe-gun, Oita Prefecture, is a local city with a population of 100,000. In connection with the regional medical care system in this area, we have been engaged in medical treatment and educatibn is based on the fundamental theories of psychosomatic medicine at Nagato Memorial Hospital since 1973. On the basis of this experience, we have reached the below-mentioned conclusions regarding the role of psychosomatic medicine in the regional medical care, the psychosomatic medical care system, and the prospects of psychosomatic medicine in the twenty-first century. 1. The basic model of psychosomatic disorders was useful in the elucidation of the cause of frequent outbreak of silicosis in tunnel workers who worked in this district away from home. It was also necessary for their medical care. 2. We have organized a care system for psychosomatic disorders in this district by giving psychosomatic training to a self-help group consisting of teachers and nurse-teachers who are in charge of school health, and of public health nurses and doctors are engaged in regional healthcare. 3. It is expected that self-care will become very important in public health and medicine in the 21 st century and psychosomatic medicine will play an essential role in these fields. For this purpose, postgraduate training hospitals appointed by the Japanese Society of Psychosomatic Medicine are requested to play a major role in the enlighetning of public on psychosomatic medicine.

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Althouth it is easy to advocate that the twenty-first century will be the time when all doctors are expected to have psychosomatic knowledge and skill, it is difficult to provide such doctors under the present conditions, where a few institutions have the programs to educate them. Recently the true value of critical care medicine has been recognized and the quality and quantity of critical care medical systems are continuing to improve than before through the establishments of critical care medical centers in various places. Medical treatments operated by such facilities particularly require psychosomatic knowledge and skill, because it is not too much to say that all the symptoms appeared in medical textbooks can be experienced in those facilities. Such examples include anxiety at night, psychogenic symptoms owing to both injury and admittance to a critical care medical center, suicidal attempts, psychiatric symptoms accompanied by somatic symptoms, psychiatric symptoms of patient's family, etc. It is almost impossible to accurately treat these complicated symptoms without a full understanding of psychosomatic medicine. The Critical Care Medical Center of Nippon Medical School has more than fifty doctor-trainees (including some doctors from other hospitals) annually and we educate them to have psychosomatic knowledge and skill. Part of the results has been already published. In this presentation we introduced the Educational Program of Critical Care Medical Center of Nippon Medical School which was in operation to provide the doctor-trainees with psychosomatic knowledge and skill, and discussed how the post-graduate education should be regarding psychosomatic medicine.

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As we think of education in psychosomatic medicine in the 21st century, it is important to learn from what is going on in this field overseas. I visited several units of psychosomatic medicine in West Germany and the U.S.A. in 1973 and 1986. I would like to introduce some of the things I learned in these coutries concerning the teaching of psychosomatic medicine. In West Germany a new law in medical education was enacted in 1970. There psychosoatic medicine is included in the subjects for the national license examination and also in the formal curriculum of medical education. Actually, independent units of psychosomatics exist in 22 of the 25 German universities which have medical faculties. In comparison, in Japan, departments of psychosomatic medicine exist in only 5 out of the 80 universities which have medical faculties. In the future, as in Germany, the number of psychosomatic units must be increased. My longest visit was at the Mannheim branch of the University of Heidelberg. Therefore, I will introduce the course of PSM training there, quoting from a paper by H. Schepank (Figure 1). In the basic course, medical psychology and sociology are included. In the clinical course, during the 3rd year, lectures on the general clinical examination of patients are given. And during the 4th year, after the main lectures on clinical pictures and psychosomatic disease therapy, the practical course on interviewing begins. Practical courses are most important in teaching psychosomatics and we need to induce these procedures into Japan. In the U.S.A., traditional teaching of psychosomatics is being continued by Professor Engel at the Rochester University (N.Y.). For instance, the combined class is held, which functions as a holistic educational system. Graduates of the Rochester University are somewhat different from others in that they look not only at the disease itself, but also at the person who has the disease. We are happy that the curriculum of medical education in the University of Tokyo has changed, and that a practical course of teaching psychosomatics has been established since this year. Table 1 shows the program of this course. As we have no inpatient ward in the department of psychosomatic medicine of Tokyo University, students learn by using their own data in lieu of patients' data in matters such as psychological testings. This experience also serves the student in cultivating his or her own therapeutic self. We are, however, in dire need of an inpatient ward to teach the students bed-side therapeutic techniques. In any case, we strongly desire to develop these systems and introduce them to other universities throughout Japan.

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がん患者の心理的適応の問題は医学心理学における重要な分野である。自分の持つがん性疾患または不明ではあるが悪性の疾患を思わせる症状に気づいた患者が, すぐにあるいは進んで医療のルートに乗るとは限らない。適切な治療を受けることをためらったり, 拒否する者さえいる。したがって, 症状に気づいてから医療を受けるまでの速さが, 悪性新生物に侵されたという困難な状況に対処するための重要な要因となる。そこで, 本研究はがん患者が治療のために病院を受診することに対する遅延に関する心理的要因を明らかにすることを目的として行われた。対象は国立がんセンター病院に入院し, 手術を受ける予定になっている90名の女性外科がん患者である。心理的要因は, RotterのInternal-External Locus of Contro1 (IE), 状態特性不安尺度(STAI), モーズレー性格検査(MPI)である。がん治療のための病院受診の遅延は, 異常に気づいた時からがん治療のための病院受診までの日数とした。 IE得点により, 患者を4群に分けた。遅延が最も長かったのは, 内的統制群であった。本知見はLocus of Contro1 が受療遅延の重要な心理的要因であり, 超内的統制群よりも内的統制群のほうが早く治療を受けに行くことをためらう傾向があることを示している。内的統制群で遅延が最も長かったのは, 彼らががんに侵されているという困難な状況にあることに加えて, 日常の場面では自分で状況をコントロールすることにより問題を切り抜けることができたために, 困難な状況に対処するだけの充分な防衛機制が発達していないためと思われる。したがって, 内的統制傾向の患者には特に心理的サポートが必要であろう。

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