Many studies have beent reported on Type A Nehavior Pattern in western countries. In Japan, studies on this subject have also been undergone in recent years and specific behavior patterns among Japanese patients with coronary heart disease were observed and reported. Although those nehavior patterns generally resemble the Type A Behavior Patterns of western countries, some very important differnces do exist. This study was conducted to determine the differences through factor analysis.Using the normal varimax method and 208 males with ischemic heart disease, three variables were found : (1) hard-driving, (2) hard-working, and (3) workaholic. The first two factors were characterized by a stronger job involvement and responsibility but a smaller competitive drive and time related stress compared to the variables found among the American males. These characteristics are consistent with the Japanese culture which encourages harmonious relationships rather than individualism and competitiveness. The third variable or workaholic factor should be specifically called the "Japanese workaholic tendency", because it is defined by the effort to develop one's identity by working hard for the company or society rather than pursuing individual achievement or success.Considering the results by factor analysis of Americans, Japanese-Americans, and the Japanese, Type A Behavior Patterns can be separated into two major components : competitiveness and strong job involvement. The former component is more prevalent among Americans while the latter is more characteristic of the Japanese.Type A Behavior Patterns may be determined by nationality and culture. In this paper, the authors discussed from cross-cultural points of view concerning the differences of Type A Behavior Patterns which were observed among western countries and Japan.

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It has been pointed out that a depressive state is present in Parkinson's disease. In the present study, Zung's Self-Evaluation Depression Scale (SDS) test was conducted to determine whether or not a depressive state is present in Parkinson's disease. Wechsler Adult Intelligence Scake (WAIS) test to determine whether or not there is any mental deterioration and YG character test to determine character patterns, and furthermore a study was conducted to examine the relation of the presence or absence of depressive state to the severity of physical symptoms, decreased intelligence, and the course of illness overtime. The subjects of this study were 73 cases of Parkinson's disease whose mean age was 66.0±7.2years, whose mean period of mobidity was 5.2 ±3.7 years, and whose severity of physical symptoms was according to Yahr's classification Grade I in 6 cases, Gade II in 28 cases, Grade III in 31 cases, and Grade IV in 8 cases. All were under drug therapy. A total of 48 normal cases having the mean age of 67.8±6.8 years were used as the control group. In addition, SDS test was concucted on 48 normal controls whose age ranged from 55 to 80 years with a mean of 67.8±6.8 years and on 40 patients with cerebral vascular damage whose daily activity disturbance was almost equivalent to that of Parkinson's disease patients of this study and whose age ranged from 48 to 81 years with a mean of 66.4±8.1 years. Comparison of the SDS index showed the index of 50.3±10.6 in the control group, 52.8±12.2 in the group with cerebral vascular damage, and 57.7±13.5 in the group with Parkinson's disease. SDS index in the group with Parkinson's disease was significantly higher than that in the normal group (p<0.01) and that in the group with cerebral vasculal damage (p<0.05). We have also observed that the higher the severity of Yahr's level, the higher tended to be the depressive index. In our study, mental deterioration was observed in Parkinson's disease cases, but no correlation between mental disturbance and depressive state could be observed. In the YG character test, Category E (unstable, inadaptive, and passive type) was greater in number in the Parkinson's disease group than in the control group, while Category D (stable, adaptive, and positive type) was smaller. Parkinson's disease patients tend to be emotionally unstable, socially maladaptive, inactive and introverted. The possibility is suggested that the depressive state in patients with Parkinson's disease is not only the response due to physical symptoms but also that a disorder of the amine metabolism is involved.

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Many patients have such feelings as anxiety, fear or strain toward dental treatments, which increase sympathetic nerve activity further breeded somatic anxiety like palpitation, tremor or sweating. Some dentists can not treat these patients. Therefore, diminishing these negative conditions is important to dental treatments and they usually give antianxietic drugs to their patients. On the other hand, for suppressing the patients' anxiety, a few dentists often use Autogenic Training (AT). Indicating plasma catecholamine, we investigated suppressive effects of AT and antianxietic drugs for the sympathetic nerve activity toward dental procedure. Subjectes consisted of 30 makes with ages ranging from 23 to 28. 11 males in the AT group, 9 males in the antianxietic drug group and 10 males in the control group.Lying on dental chairs, they were injected saline as pain stimulation as a dental procedure model in oral mucosa. For measuring plasma catecholamine, their blood samples were collected at ordinary times, before and after injection out of their subsking vein of arms.Result : Mean plasma adrenaline in the AT group before injection (0.025 ng/ml) was lower than the control group (0.032 ng/ml), and higher than the antianxietic drug group (0.017 ng/ml), and after injection (0.017 ng/ml) was lower than the control group (0.028 ng./ml) and the same as the antianxietic drug group. Mean plasma nordrenaline in AT group before injection (0.19 ng/ml) was lower than the control group (0.250 ng/ml) and higher than the antianxietic drug group (0.143 ng/ml), after injection (0.143 ng/ml) was lower than the control group (0.276 ng/ml) and the antianxietic drug group (0.161 ng/ml).These results suggest that increased sympathetic nerve activity due to dental procedure can be suppressed by practicing AT.

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Sand-play therapy as a psychosomatic approach was performed on children who were suffering from malignant disease. Four children, aged 5 to 14 years, were included in this report.They were not informed of the diagnosis until their final death.The characteristics of their expressions by sand-play were anger, aggression, isolation and religious world. They looked calm outwardly, however, from these expressions, they appeared to be aware of the seriousness of their illness in their mind. Furthermore, by making a religious world, they were obliged to consider their life seriously and this seemed to facilitate their psychological growth. They looked as if they had been prepared for their death.It is thought that this characteristic change occurs after they were disappointed losing their hopes for healing. We should conduct a medical treatment based on an understanding of their inner workd which is different from their outward appearance.

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The patients of the psychosomatic disease often tend to lack recognition of their mental conflict and emotion, and therefore have difficulty to express those experiences. This condition itself can be a cause of psychosomatic disease and also make the diseases more conplicated. In the therapeutic situation, verbal communication is often unsatisfactory between therapist and patient. In this report we present a successfull case of clinical application of landscape montage as a non-verbal therapeutic procedure.Case Presentation : A 26-year old male visited our outpatient clinic of Deoartment of Psychosomatic Medicine on February, 1986,complaining of general fatigue, appetite loss, epigastralgia and diarrhea. These symptoms were suspected to be caused by maladaptation in his company.The process of psychotherapy is devided into three stages according to the improvement of symptoms and social adaptability of the patient. 1) At the first stage, he suffered from various symptoms and could not gain an insight into his disease. He had difficulty of adaptation to the society and showed mental regression. 2) At the second stage, he gradually gained an insight into the psychosomatic relationship, but various symptoms remained unstable. He often expressed his positive attitude to ward the social life, but still showed hesitation to proceed his will. 3) At the third stage, he was fortunate to obtain the opportunity of re-employment. Every symptom remarkably improved and he gradually regained his confidence.The pictures of the landscape montage showed various states of escape phenomena, mental regression, volition, effort and anxiety for the social life with the change of the stage. He also learned to express his suppressed aggression and mental conflict through this therapy.Application of the landscape montage to the therapy of the psychosomatic disease seems to give a valuable information to understand the unverbalized problems of the patients and to estimate the improvement of the disease. We believe therapeutic value of the landscape montage is also expected in that unconscious aggression was effectively released and analysis of the pictures encouraged the insight of the patient into his disease.

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We encountered a 23-years-old male with anorexia nervosa complicated by pancytopenia.The patient developed body weight phobia, hyperacitivity, avodance of food, overeating, and vomiting after going on a diet. The condition fulifilled the diagnostic criteria of anorexia nervosa of the Japanese Ministry of Health and Welfare.On blood analysis, peripheral RBC was 342×10^4/mm^3. Hb was 11.1g/dl, indicating normochromic normocytic anemia, and WBC was reduced to 1,900/mm^3,glanulocytes to 880/mm^3,and lymphocytes to 1,144/mm^3. Thrombocytopenia of 6.1×10^4/mm^3 was also noted.Peripheral blood smears revealed anisocytosis, macrocytosis, and poikilocytosis. Bone marrow aspiratioon profile was markedly hypocellular, and three cell series were remarkably decreased. Gelatin-like degeneration was noted on aspiration. Histopathological studies showed a reduction in nucleated cells including megakaryocytes, but the hemopoietic series was relatively intact.In the blood coagulation test, the prothroumbin time and active partial thromboplastin time were prolonged to 13.9 sec. (control : 12.35 sec.) and 42.1 sec. (control : 30.1 sec.), respectively, and the euglobulin lysis time was notably shortened to 20 min. (control : 3-5 hr.).The serum transaminase levels were slightly elevated, and serum cholinesterase and albumin levels were decreased.Endocrinologically, GH was increased to 47.7 ng/ml, and cortisol to 29.0 μg/dl. As for thyroid function, T_3 was 0.4 ng/ml, T_4 was 6.3 ng/dl, and TSH was 10.7 μU/ml, a profile resembling that of primary hypothyroidism.After admission, the body weight of the patient was restored and maintained by cognitive behavioral therapy.All the above abnormalities were alleviated as the body weight recovered and nutritional condition improved.

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We observed two cases of hyperventilation syndrome (HVS) in the course of organic diseases.The first case, a 28-year old male complaining of epigastralgia, nausea, and palpitation, had an attack of dyspnea and anxiety accompanied by respiratory alkalosis before the diagnosis of hyperthyroidism was confirmed. He was worn out by his hard work and was anxious about his symptoms. Medication with antithyroid agents in combination with proparnolol and diazepam totally relieved him from his complaints.The second case, a 22-year old female, was referred to our department of critical care medicine, complaining of dyspnea with faintness. Remarkable respiratory alkalosis was evidenced by arterial blood gas analysis. She had severe anemia due to hypermenorrhea and needed blood transfusion, but even after the anemia convalesced, she showed emotional lability and recurred hyperventilation attacks. Psychological interview revealed that she was ambibalent towards her parents and her job. She was improved finally by intensive psychoterapy although the imaba lance in the autonomic nervous system remained.The HVS commonly occurs in the absence of physical disorder and is usually regarded as psychiatric or functional ; however, it is suggested from the cases described above that HVS might be seen in the course of various organic diseases. We would like to emphasize the importance of close inverstigation in patients with hyperventilation, somatically as well as psychologically.

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A 32-year-old woman was admitted to out hospital in June, 1985 with an affective disorder lasting for 4 years. She had been treated for depression in another hospital. The episode of depression was characterized by inability to sleep, poor concentration, loss of energy, sad affect and dismal outlook for the future. Before this depressive episode, the hypomanic episode has preceded including overactivity and distractivity. In April, 1985,the physician noticed that her face was puffy and she had a truncal obesity and stria with hypertension. Detailed endocrinological and radiographical examination revealed that her serum cortisol levels were elevated in spite of derceased levels of ACTH and there was no response of cortisol and ACTH to ovine CRF. Also 2cm diameter of tumor mass was found in left adrenal gland. She was diagnosed as Cushing's syndrome due to left adrenal adenoma. During the hospitalization, her psychiatric symptoms had developed, that is, a confusion, a presecution complex and ICU syndrome including a suicide attempt. After the total left adrenectomy, her psychiatric symptoms were rapidly decreased and abolished.It is emphasized that the physician must consider a case of Cushimg's syndrome when he treats a case of depression.

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We report a case of a 33-year-old man with neurofibromatosis who manifested hyperventilation. He was admitted to a surgical ward of this hospital because of anemia and bleeding of duodenal tumor. On the 4th and 37th hospital days, he was opearted on for duodenal tumor and postoperative ileus. Histologically, the duodenal tumor was benign (leiomyoma). During hospitalization, he was emotionally stable. He was discharged on the 78th hospital day, but a month after discharge, he was readmitted because of shortness of breath, chest pain, numbness of extremities and dizziness. By precise medical examination, he was diagnosed as hyperventilation, and placed under drug therapy. But he was emotionally unstable, and was transferred to our department. In a ward, his pattern of interpersonal relationship looked to be strongly infludnced by inferiority complex derived from neurofibromatosis. Under such conditions, he expressed various worries about neurofibromatosis. He and his family tended to avoid talking about neurofibromatosis each other.He had a history of neurofibromatosis as follows ; He became aware of tumors and pigmented spots when he was around 12 years. A diagnosis of neurofibromatosis was made at age 20. He has not received treatment, however, necause he has been asymptomatic. Only skin sysmptoms of neurofibromaosis were observed. There were Cafe-au-lait spots over the trunk, and multiple skin tumors were present all over the trunk, on the head and neck. No other remarkable symptoms were found. Personal history is described as below. He is the oldest son of 4 brothers and is the only single person in the family. Now he lives with his parents and the toungest brother and his wife who got married three month ago. He has been working at a confectionery after he graduated from senior high school. There was no history of neurofibromatosis in the family.Our discussion included the following points : (1) It was considered that the patient's anxiety about neurofibromatosis was an important factor which produced hyperventilation.(2) Family relationship centerng around neurpfibromatosis infulenced the progress toward recovery.(3)Finally we emphasized the need to treat emotional pains of the patients with neurofibromatosis and their family.

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