It has been well recognized that psychosomatic disorders(PSD_s), especially persistent cases are increasing remarkably in number. Also both ends of thee age parameters of disease onset are gradually expanding, because the psycho-social environment in our daily life has been changing yearly in complicated and diverse ways. Thus these medical topics are mentioned as the social problems of today. It is suggested that such a transition of the disease structure from the past to the 21 st century will 'demand more speciality in psychosomatic medicine on the part of the doctors who wish to participate in it, and also that the general physicians are becoming aware of how important the psychosomatic approach is in general practice. Therefore, from the psychosomatic point of view, the authors are attempting to establish diagnostic and therapeutic systems in general practice which include our explanation of the present situation of PSD_s, diagnostic criteria for PSD_s and psychosomatic treatment and prevention, mainly based on our findings of psychosomatic diagnosis and treatment, and of psychosomatic primary care, which has been already reported in the Japanese Journal of Psychosomatic Medicine, etc. The main points of psychosomatic diagnosis and treatment in general practice are as follows; First, it is very important for the patients with PSD to be systematically treated with a common and basic treatment, and to be fully aware of the psychological part of such a treatment, that is, basic psychotherapy advocated by the authors. Secondly, psychosomatic diagnostic criteria, which rely on pathophysiological examinations, Diazepam test for the measurement of anxiety-tension in the cerebro-limbic system, circadian rythmus of serum cortisol levels for the marker of thalamo-hypothalamic function, and Bromocriptine test for the marker of central dopaminergic function in hypothalamo-pituitary gland, are indispensable by which to select the adequate treatment for PSD_s; and psychological and behavioral characteristics may be useful as the global clinical markers. Finally, in psychosomatic treatment and prevention, it is important for the patients with PSD to correct their inadequate habits in daily and to be made aware of how to control themselves from the point of view of psycho-somatic correlation.

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In cardiovascular field of psychosomatic medicine, the following points will be requested toward 21st Century. 1) On the vase of scientific advanced knowledge in cardiology, psychiatry or sociology, the guideline, nomenclature or the standardization for diagnosis and management of psychosomatic diseases, which is easy to understand and easy to practice, and which is an acceptable whole in the country, have to be established by the society of psychosomatic medicine. 2) These guidelines for clinical use on psychosomatic medicine have to be focused into following separate 3 points of view, (1) the advanced scientific part in medicine, (2) the technical part for diagnosis and treatment, (3) the social part. 3) Physiological responses to stress are different according to the sort, stage, severity or duration of stressful stimulation and also to the background of patients. Therefore, these factors have to be considered for making these guidelines. 4) Social factors have been emerging as important factors for the pathogenesis of cardiovascular diseases. Besides, these social atomospheres will be changeable year by year. It will be important to study how to standardize these social factors.

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Today complicated paychological, social and environmental factors factors are pressing down adolescents causing abnormal conditions. The author has been taking active part in the treatment of adolescents and learned that many of them who manifest behavior problems such as school refusal bullying violence in the family and delinquency, etc, are shut out of the present society which is full of distortion. Therefore, for their treatment, it is of vital importance to turn the children's social environment into warmer and more accepting one. For the prospect of the paychosomatic approcach to adolescents toward the 21st Century, the following points need to be considered. 1. It is indispensable to seek after the value of paychosomatic medicine as social medicine. 2. Holistic care needs to be provided by facilitating cooperation in the community and from people in every walk of life surrouding children. 3. A tram approach including doctors, social workers and public nurses is important. In addition, cooperation of medical specialists with parents and teachers will have added significance. 4. It is important to put into practice holistic medicine in the form of the patient's rehabilitation, prevention of illness and the individual's health management in addition to diagnosis and treatment of illness proper.

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Recently, the number of patients complaining chronic pain are increasing. Sometimes pain is untolerable and hoped to suicide for the patients. With chronic pain the quality of the patient's life will go down very much. In the 21st Century, it will be one of the biggest themes of psychosomatic medicine to diagnose and treat chronic pain. Originally pain is a personal sensation and a psychological reality and in chronic pain no abnormalities were found by all clinical examinations concerning pain. Therefore nowadays, by using the method of diagnosis, chronic pains cannot be classified for their treatment. In this study, the classification of chronic pain is attempted by using the figure which is made according to the degree of effect of medicines and of methods of treatment for chronic pain. This figure is changed from flat to solid in number by checking the effect of treatment. After the separation of acute pains from chronic pains by the classified types of these figures, the useful treatment of chronic pain will be found. It will be one of the most useful medicines in the 21st Century to cure pain in the human life.

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Terminal care involves many problems in the field of psychosomatic medicine and medical psychology. Psychosomatic medicine plays an important role in terminal care, which is now being re-evaluated, as seen in the hospice movement, in response to recent remarkable improvement in medical science and technology and socio-economic changes. In Japan also, the Society for the Study of Dying Patients was launched in 1977 to learn and discuss the problems of dying patients. The Society's main theme is to study how one can live a higher quality of life when one faces remaining days toward death. Today terminal care deals with right to self-determination, treatment approaches such as meaningless prolongation of life or alleviation of symptoms, cure or care, revival and life-saving treatment at the time of death, medical economics, the place to die as for example in the hospice at home and the management of gief of families left behind. In order also to seek for better terminal care, an emphasis has placed upon the necessity of bio-ethical evaluation of death and of education to prepare for death. There are also some hot topics in relation to the practice of terminal care such as organ plantation, brain death and the use of artificial organs. Along with further impovement in medical science and technology toward the 21st Century, new and difficult proplems will occur in the field of terminal care. It is impossible, however, to stop death no matter how much improvement medical science and technology may make. Today terminal care needs to establish itself under a new paradigm which is different from that of the old theory and practice of treatment medicine aiming at cure. The purpose of this new approach is not to fight against death, but to harmonize with death which is the fate of human life. It is therefore necessary to develop holistic medicine by integrating ethics, medical psychology, sociology and other related disciplines.

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Cass : A 49-year-old house-wife, Diagnosis : Chronic renal failure and hypertension, Chief complaints : headache, anorexia, nausea, vomiting generalised fatigue. Present history : Since Nov. 1983,she complained of fatigue and was diagnosed as suffering hypertension & chronic renal failure and treated by hemodialysis since Jan. 7 1984. Since March 1st, of the same year, she has been treated with hemodialysis twice a week on an outpatient basis in our hospital. On Aug. 22nd, she gained weight and her CTR increased. We thought it was because of insufficiency of water control and placed her on a 3-time/week treatment regimen. Her dry weight over 5% and insufficient control of water balance contintinued. In Sept. 1985,we instituted guidance to change her lifestyle so that the Adult egostate factor on Egogram would elevate. In Sept. 1986 we again evaluated her Adult ego state factor and found an improvement in the presence of a 4.9% in dry weight. Future efforts will be made to expand our series of treatment in an attempt to substantiate the results obtained in this case study. Disussion : We found that there is a 5% difference between the well controled group and the poorly controled group. The Adult egostate factor by Egogram of this case was low and we thought that we would be able to assist her by promoting this function. However, control was not easy because her life style from childhood was more physically oriented than mentally. She was marrid with a plumber and present is involved in a very busy life with work and house care. We advised her to decelerae her life style to allow more time to spend leisurely and to think about alleviating her symptoms. Therapy was continued for about 1 year and we were able to obtain good clinical results. We learned that management of these specific patients and their symptomology is not only time consuming but also very complex. Thus, we, as clinicians attermpting to help these patients with a multiplicity of symptoms, might be able to use the results of this case study as a guideline in the management of these patients.

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