The so-called vegetative dystonia is a disorder characterized by the absence of tissue pathology which explains the origin of symptoms complained by patients in general. Accordingly the patients with functional symptoms are diagnosed occasionally as the so-called vegetative dystonia by the general practitioner. In this presentation, 132 patients who were , diagnosed to have functional symptoms at our psychosomatic clinic were analysed. The major diagnoses included 32 cases of depressive state or depression, and followed by irritable bowel syndrome, anxiety neurosis, hysteria in that order. From the study of psychological etiology in these patients, conversion reaction which was a similar condition to hysteria, was found most frequently which was 35%, The second highest, that is 32%, was anxiety and tension reaction, followed by depressive state or depression which was 28%. The responses of the autonomic nervous system to the mecholyl test were classified into Types S, N, and P according to Okinaka's criteria. In these patients Type P was found to be 65% while Type N (normal type) was in only 13%. Beside the Cornell Medical Index (CMI), which is a widely used personality test with questionnaires in our country, was performed. Grade 4 and grade 3 in Fukamachi's classification were considered to indicate neurosis and neurosis suspect respectively. 63% of these patients was diagnosed as neurosis or neurosis suspect. From the above results, autonomic disturbances seem to occur as comcomitant symptoms of psychogenic illness, such as anxiety neurosis, hysteria, and depressive state or depression. Therefore, the term psychoautonomic dysregulation syndrome should be chosen primarily because the functional symptoms may not only occur as an integral clinical picture but also as an accompanying symptom of many different disorders, particularly psychogenic illness.

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We examine our classification using DSM-III, a psychological test(TMI), the autonomic nervous system function test and time course of diagnosis. Our material includes 88 cases with unidentified clinical symptoms who visited our clinic of Psychosomatic Medicine Toho University. Generalized anxiety disorders counted the greatest number of 'cases in our subjects according to DSM-III. The second largest were psychological factors affecting physical conditions. The third included somatization disorders. The fouth were panic disorders. The fifth was a group of hypochondriasis. The last were dysthymic disorders. The patients with panic disorders complained more symptoms than other 5 diseases. The number of somatic symptoms of somatization and panic disorders was significantly higher than psychological factors affecting physical conditions and hypochondriasis. Psychological symptoms of dysthymic disorders revealed 3.0 complaints whereas the other 5 diseases below 1.0. Psychological symptoms of dysthymic disorders were significantly higher than somatization disorders and psychological factors affecting physical conditions. Psychological factors affecting physical conditions found many abnomalities ' of MV and orthostatic ECG. This was followed by somatization disorders. We made a comparison between our classification and the 3 type classification (Abe's method) of 6 diseases using DSM-III, which, however, showed no significant differences. There was no significant difference between TMI classification of 6 diseases. Concerning Case l, we learned after seeing him seveval times that he manifested an illness prone behavior in order to get compensation money. The second case with so-called vegetavive syndrome was reported. He was diagnosed as pathological gambling after treating several times. Thus so-called vegetavive syndrome turned out to be a different disease after having clarified psy.chosocial backgrounds during treatment. The diagnosis of so-called vegetative syndrome is much different from the diagnosis of malignant tumor by biopsy. So-called vegetative syndrome can be understood as a tentative diagnosis which depends on the amount and nature of the patient's information. A new diagnosis different from so-called vegetative syndrome can be confirmed after treating the patient for some time. Thus it would be more adequate to apply the diagnosis of vegetative syndrome tentatively, and not as a unit of disease entitity.

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So called vegetative syndrome has been very popular in the daily practice. However, its clear definition is not established yet. The main reason will be focused on the vague subjective symptoms and transitional functional disorders in this syndrome, which presumably have led to the confusion of diagnosis and the retardation of the treatment. In any way, it is worthy of special mention that in most cases suffering from vegetative syndrome, acute or chronic stressful experience or life events were outstanding as a trigger or (and) prolongation of it. In another word, psychological stress as well as physical stress could be suspected as a potential impact for this pathogenesis. This may suggest the dysfunction in the central nervous system including neocortex and hypothalamus, will result in the unbalance of the function in the peripheral autonomic nervous system, i. e. vegetative syndrome may be the reflection of impaired brain function on the periphery. The main patho-physiological mechanism in the periphery will be hyper-or hyposecretion of neurotransmitters (mainly catecholamines and acetylcholine) and incidential reactions in the receptor sites, which consequently could lead to the local dysregulation of the sympathetic or (and) parasympathetic nervous system. Therefore, the therapy of this syndrome should firstly be aimed at the decrease in stress in the brain, handling very often with anxiety, depression, and distress as well as fatigue and tension. The author insists on the importance of psychotherapeutic approach, especially support and guidance for the elimination of symptoms throughout the cases. The dysrhythm in the physical level should also be readjusted in the same way. In drug therapy, psychotropic drugs, mostly enough with benzodiazepines and tricyclics should be the first choice. For the peripheral manipulation several receptor blockers (ex. β-adreno-recepter blockers and cholinergic blockers) could be recommended. The author thinks the systematic and dynamic combination of drug therapy with psychotherapy should be essential. This is why psychosomatic approach should be the best for the therapy of vegetative syndrome at this point in time.

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Kushima and Hasegawa have conducted rather a complete research on vegetative syndromes found in the field of obstetrics and gynecology. In their study, they proposed the definition of vegetative syndrome and analyzed its pathology. The author's work in this paper is to add some data to their study. In the field of obstetrical clinic, although any autonomic function test is not conducted in most cases of pregnancy, about 20% of pregnant women are accompanied by some kind of autonomic imbalance which tends to result in dystonia. Much is already known regarding vegetative syndromes in the women with menopausal syndrome, but the author likes to emphasize that the process of gynecological disorders, such as inflammation, tumors and operation, often induces autonomic imbalance in the form of complaints.

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From the viewpoint of clinical neuropsychiatry, so-called "vegetative-dystonia" is a ten-tative diagnosis, which bears some resemblance to "unidentified clinical syndrome (Abe)" in the field of internal medicine. This vegetative dystonia can be devided into the following five categories : l) Psychophysiologic vegetative-dystonia (psychophysiological autonomic and visceral disorders, psychological factors affecting physical condition) 2) Neurotic vegetative-dystonia (vegetative neuroses, generalized anxiety disorder, somatization disorder, etc.) 3) Depressive vegetative-dystonia (vegetative depression, mild depression, masked depression, etc.) 4) Essential vegetative-dystonia (orthostatic dysregulation, hyperhidrosis, climacteric disorder, premenstrual tension syndrome, etc.) 5) Others : a) Iocal vegetative-dystonia ex.) Barre-Lieou syndrome (posterior cervical sympathetic syndrome) "cervical sympathetic dysharmony" (imbalance between the right and left sides of cervical sympathetic functions) b) transitory vegetative-dystonia......initial symptoms of neoplasma, etc. c) symptomatic vegetative-dystonia The treatments of "vegetative-dystonia" depend largely upon the pathogenesis of the dystonic state of the autonomic nervous system and, therefore, the causes of the alterations in autonomic balance should be clarified.

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On the pathophysiology of "autonomic imbalance" symptom, the theme of this symposium, there is still much room for debate. And presentations by various speakers at the symposia show subtle differences in expression. When, however, we study a group of patients showing this pathophysiology we learn, in our daily clinical practice, that many of them come under a group of patients who present functional disorder of the autonomic nervous system in a certain type of neurosis, depression and psychosomatic disease, with exceptions of a small number of patients whose pathophysiology is due to organic factors and a group of patients who are constitutionally and genetically predisposed to develop functional imbalance. We have studied changes in the psychosomatic symptoms and their mutual relations for the last several years through the clinical feedback training and polygraphical study on neurosis, depression and psychosomatic diseases that present anxiety and hypochondriacal state. At this symposium we have reported results of EEG Biofeedback Training aimed at enhancement of a activities and a part of polygraphical study thereof using a group of 23 patients with neurosis who present anxiety and hypochondriacal state as the subjects. The results obtained are summarized as follows. 1. Generally, the mean value for the percent time of α-activities (PTA) was always low in the neurosis group compared with that in the healthy adult group. 2. Sufficientα-enhancement was not always obtained in. the Biofeedback Training using the conventional fixed threshold level. When, however, the method of shaping threshold level was employed, sufficientα-enhancement was obtained in a relatively short time even in the neurosis group. 3. Subjective improvement almost consistent with a sharp increase in the PTA value was noted in 5 out of 23 patients in the neurosis group. Subjective improvement was seen progressively with changes in the PTA value in 13 patients. On the other hand, there were two cases in which high PTA values were obtained by the Biofeedback Training, but corresponding subjective improvement was not seen. The relationship betweenα-enhancement and clinical improvement was not necessarily uniform. 4. Prominent prolongation of ECG R-R interval time, an increase in the peripheral blood flow volume in the antebrachial reg ion and change of microvibration to low frequency are seen as interesting polygraphical characteristics during the Biofeedback Training. With clinical improvement, various physiological indicators for patients with neurosis tended to become stable in a certain fixed direction, albeit with many individual variations. 5. Our impression is that cases showing distinct autonomic nervous symptoms, when compared with cases showing only psychiatric symptoms as the chief complaint, are positively responsive to the Biofeedback Training. The results above suggest that the Biofeedback Training may serve as one of the effective therapies for neurosis, particularly one showing functional disorder of the autonomic nervous system. Further studies on this therapy are needed.

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Though the pathogenesis of autonomic nervous dysfunctions (AND) is not completely understood, it is also true that many patients with various kinds of psychosomatic complaints are diagnosed as having an AND and are treated psychosomatically. To ascertain whether this is the practice, a questionnaire was sent to 15 primary physicians and it was found that 93% of these physicians diagnose psychosomatic patients as having an AND and that 80% Of these physician consider this diagnosis useful. The criteria they apply is that they can find no organic changes which could explain the patient's complaints or that the patient vaguely complaints about various autonomic nervous dysfunctions. When faced with such patients, rarely do these physicians perform psychometric and/or autonomic nervous function tests. The many AND outpatients seeking treatment at the author's hospital has led him to examine these cases in depth. Thus, a retrospective study was made of all new patients treated during 1987. The number totaled 301 (103 males and 198 females) and, in most instances, no more than two diagnoses were made per patient. Out of these 301 patients, 125 (54 males and 71 females) or 41.3% were diagnosed as suffering from depression or being in a depressive state. Additionally, 84 patients (37 males and 47 females) were diagnosed as having an AND. Statistically, the AND cases represented 27.7% of the total number of patients and their average age was 35. 2 years. The most common AND complication was depression, followed by conversion hysteria, psychogenic reactions, and anxiety neuroses in that order. Of this total of 84 AND patients, however, only five had no other complications nor a second diagnosis. As for previous treatment, 13 were first time patients, while 28 (34%) had visited more than two other clinics previously indicating a tendency to shop around for a cure. Treatment for AND cases most commonly consisted of pharmacotherapy with brief sessions of psychotherapy and 61 patients (71%) were handled in this way. Six other patients received autogenic training and music therapy, conducive to relaxation and the prevention of AND. Eight other patients, manifesting complicated and severe AND conditions, were given fasting therapy. In conclusion, though AND may be a transient diagnosis, it nevertheless is useful for primary care physicians, and it is essential to treat AND patients by employing a psychosomatic approach.

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