[in Japanese]

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The patient was a 50-year old man who had various psychosomatic diseases, such as recurrent duodenal ulcer (stress ulcer), psychogenic impotence, psychogenic polakiuria, headache, and palpitation, complicated with parasomnia and nocturnal myoclonus snyndrome. At the age 7,his father died. Since then he was brought up by his mother alone. He was married when he was 27. During a few months after marriage he had a psychogenic impotence, but two children were born. He had been a manager of steelwork for ten years, when the presindent of the company changed. Because the new president was younger than him, the patient did not get along well with him. Since that time steelwork became inactive, stress around him became intensive. Some psychosomatic diseases, such as recurrent duodenal ulcer (stress ulcer), headache, palpitation and psychogenic polakiuria started to appear and impotence also reappeard. Since about two years ago he began to shout and throw things at midnight during sleep and sometimes he developed enuresis. After he awoke, he explained, "I had developed a terrible dream." Since this episode seemed to occur more frequently, he was admitted to our hospital for more complete examination of his sleep state. An all night sleep polysomnography test was recorded and a psychological test (draw a person test) was analyzed. We could find nocturnal myoclonus and insufficiency of his sexual identity. Subjectively he did not complain of insomnia and hypersomnia in spite of nocturnal myoclonus. It is recognized that nocturnal myoclonus and parasomnia (for example enuresis and night-mare) became worse by stress or psychological factors. But the pathogensis of nocturnal myoclonus and parasomnia is still unknown. We think that his stressful life and rigid character make this state worse, and at the same time abnormal behaviors during sleep make his stress more severe. On the other hand, this vicious circle disturbs the improvement of his various psychosomatic diseases (duodenal ulcer, etc.).

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A 33-year old single man with psychogenic vominting was referred to our hospital with complaints of general weakness and severe emaciation. Laboratory tests disclosed hypokalemic hypochloric metabolic alkalosis, hyperreninemia and aldosteronism. Other examinations showed sings of Bartter's syndrome, inculuding normotension, insensitivity to the pressor effect of angiotensin II. We diagnosed the patient as a case of Pseudo-Bartter syndrome. When the patient was 18-year old he vomited for the first time. Since then he vomited frequently because he could feel refreshed and encouraged to confront his stressful realities just after vomiting. Also he started avoiding salty meals and animal protein compulsively since he was missdiagnosed his orthostatic albuminuria as chronic nephritis. Later he became so obsessed that he thought these meals were wrong not only for his body but also for his mind and his human relationship. Before his admission to our hospital, he had received hospital care ten times. But unfortunately these hospital cares were just for his physical problems. During the hospitalization we tried to correct his irrational idea of the diet and applited a comprehensive approach, diet training, social skill training and so on. As the result he became able to take ordinary meals and gained weight and his serum electrolytes showed the normal range. However the renal biopsy revealed about a half of glomeruli in the specimen was hyalinazid and in each there was evidence of hyperplasia of the juxtaglomerular apparatus, and also there were sporadically organic destructions in the cortical collecting duct and renal tubules area, which may be due to hypokalemic nephropathy. In the clinical course, he became swollen under psychologically stressful situations, suggesting a decrease of glomerular filtration rate and renal blood flow and an increase of renal tubural reabsorption of water and sodium via increased sympathetic nervous system activity. What needs to be considered in this case is the fact that the patient received hospital care for his body ten times for the last sixteen years but not once for his irrational idea, which induced a miserable result that his kidney had organic destruction. We felt all the more strongly the neccessity of the psychosomatic approach in primary care.

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We reported a case of a 25 year-old woman weth Conversion Disorder (DSM-III). She had been unable to raise up her right hand, so she was diagnosed as having dystonia and had been treated with clonazepam by an internist. But after pregnancy, she showed a typical type of opishotonus and became unable to walk by herself after giving birth. Abnormal neurological findings were not seen but opisthotonus appeared suddenly and was exaggerated in the presence of observers. Behind the symptoms, there seems to be a conflict with her husband. She was admitted to our hospital. During treatment, narconalysis, hypnotherapy and continued-sleep therapy were conducted, which were not effective. However her symptoms diminished after her face became edematous with blood diffused from traumatic head ecchymoma which seemed to have been caused by herself purposely hitting her head against the floor. After this incident, we were able to employ behaviour therapy and the symptoms began to show gradual improvement and she was almost cured. We consider that her self-inflicted head injury and later regret of her conduct finally broke down her resistance to treatment and led her to accept the behaviour therapy.

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