In order to study the meaning of a data base (DB) of medical records in Psychosomatic Medicine, computerized DB of discharge summaries was developed from the mark-card system which had been used in our department for many years. The DB includes many items such as name, gender, age, diagnoses and chief complaints. The process of developing it revealed some problems, which were divided into two groups, that is, the problems concerning its contents and its management. In particular, the classification of psychosomatic disorders is considered to be one of the most important problems. After developing the DB, we analyzed the basic items of 1,417 inpatients who had been admitted to our ward for the first time from 1974 to 1985. Common diagnoses in these patients were bronchial asthma (158 cases), eating disorder (152 cases), irritable bowel syndrome (140 cases) and so forth. In terms of residential areas, more patients with some diseases like eating disorder, had come from outside than inside Fukuoka Prefecture, where our hospital is located, as these diseases are considered difficult to treat by local general physicians. Treatments frequently applied to deal with patients included medical drugs (775 cases), interviews (734 cases), autogenic training (569 cases) and others. Interestingly, patients treated with transactional analysis (including psychoanalysis) were decreasing and those with behabior therapy were increasing, from the end of 1970's to the beginning of 1980's. The results of analyzing ev en the basic items clarified objectively some of the clinical roles that had been played by our department. This fact is considered to show the importance of developing a DB of medical records. Many issues, including relationship between the DB and the total information system of a hospital, still remain to be studied, some of which must be solbved by Japanese Society of Psychosomatic Medicine.

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To prove the benefit of psychosomatic treatment for asthmatic patients from an economical point of view, we compared medical expenses which were spent before and after psychosomatic treatment. The subjects were 10 asthmatic patients who had been having one or more attacks a week despite of their taking bronchodilaters (Xanthines and β_2-stimulants). Psychosomatic treatment was performed for about 3 months through individual and group interviews for a half-hour to an hour at a time for twice to four times a month. Medical expenses consist of the fee for re-consultation, guidance on chronic disease, medication per os, injection and inhalation. Average monthly medical expenses were compared before 3 months after 3 months of psychosomatic treatment. The result was that 4 patients showed a decrease not only in the number of attack but also the dose of medication (remarkably effective cases), 3 patients showed a decrease in the number of attack (effective cases) and 3 patients did not show a decrease in the number of attack (non effective cases) after psychosomatic treatment. The medical expenses of 7 patients, whose treatment was remarkably effective and effective, 3 months after psychosomatic treatment, decreased to an about half on the average as compared with before the treatment. This result shows that psychosomatic treatment is beneficial for the treatment of bronchial asthma in general hospitals from an economical point of view. But effectiveness psychosomatic treatment is not well appreciated by the present medical system in Japan. It is thought, that in order to popularize psychosomatic treatment, its further appreciation is indispensable.

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Psychosomatic diseases in the field of ophthalmology were classified into three groups by Kato, such as ocular conversion symptoms, ocular symptoms due to neurotic psychization and ocular vegetative neuroses. Hysterical blindness is the most representative disease of ocular conversion symptoms, therefore many clinical reports have been published. However, there were no clinical reports discussed in detail from the viewpoint of psychoanalytic theory. In this paper the recognition gained from a 21-year' old girl suffering from hysterical blindness, who was given supportive psychotherapy based on psychoanalytical understanding, will be described. As a result, the author has pointed out the psychopathology which involved Oedipal as well as Pre-Oedipal ambivalence in this case.

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This study consisted of 47 inpatients diagnosed as psychogenic vomiting. These patients were divided into 5 types : the continuous vomiting type, the habitually postprandial vomiting type, the irregular vomiting type, the nausea type, and the self-induced vomiting type. These patients were classified according to their psychiatric diagnosis : the conversion disorder type, the depressive disorder type and other rypes (generalized anxiety disorder and obsessive compulsive disorder). We observed the relation between the patterns of vomiting and the psychiatric diagnosis. Most cases of the continuous vomiting type showed conversion disorder while many cases of the habitually postprandial and the irregular vomiting type showed depressive disorder. These are the most important psychological mechanisms involved in psychogenic vomiting. The psychiatric mechanisms and the patterns of vomiting often alternate during the clinical course of psychogenic vomiting. We would like to emphasize that assessing the psychiatric diagnosis as well as the patterns of vomiting is important in the diagnosis and treatment of psychogenic vomiting.

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In this study, psychiatric symptoms and secondary alexithymia of the patients on hemodialysis were investigated using the MMPI Alexithymia Scale and the 30-items General. Health Questionnaire(GHQ). The subjects of this study were 47 patients on hemodialysis. They consisted of 24 patients of the introductory stage and 23 patients of the stable stage. The results were as follows. By MMPI Alexithymia Scale, 37.5% of the introductory stage and 31.1% of the stable stage were judged as alexithymia. By GHQ, 62.5% of the introductory stage and 73.9% of the stable stage were judged as neurotic tendency. In neither GHQ nor MMPI Alexithymia Scale, there were no significant differences between the introductory stage and the stable stage. The cases which did not indicate any problems in both of GHQ and MMPI Alexithymia Scale were only 2 cases out of 47 (4.3%). Therefore, it was suggested that the care and consideration are necessary not only for psychiatric problems such as depressive, neurotic state, frequently observed in the patients on hemodialysis but also for psychosomatic aspects including secondary alexithymia.

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Bulimia nervosa is an episodic pattern of chaotic eating that is accompanied by several other symptoms. The patient generally engages in binge eating-the rapid consumption of a large amount of food in a discrete period of time, usually less than 2 hours. Other symptoms include an awareness of the disordered eating pattern with the fear of not being able to stop eating voluntarily, depressive moods and self-depreciating thoughts after the episodes of binge eating, and repeated attempts after binging episodes to lose or control weight through severely restricted diets or purging behavior such as self-induced vomiting or laxative abuse. The patient has a persistent overconcern with body shape and weight. Bulimia nervosa has long been recognized as one aspect of the disordered eating habits of patients with anorexia nervosa or obesity. Some investigations have demonstrated that the development of bulimic symptoms among patients with anorexia nervosa has important etiological, prognostic and clinical implications. But bulimia nervosa also appears to be occurring at an alarming rate among women of normal weight who do not have histories of anorexia nervosa. Despite the increased incidence and seriousness of bulimic behavior, there were no studies in Japan which have reported on the situational and psychological problems as precipitating factors of bulimia nervosa. We studied fifty patients (48 females and 2 males) who satisfied the diagnostic criteria for bulimia nervosa of DSM-III-R. The mean age at the onset was 19.1 years (SD±3.6). Patients were divided into four groups according to their disordered eating behavior observed at or before the onset of bulimia nervosa. 1. Binge eating group (N=5) Recurrent episodes of binge eating occurred form the beginning of bulimia. 2. Appetite loss group (N=7) Appetite loss which was not based on voluntary dieting has continued for considerable periods of time (mean 12.0 months; SD±18.7) before the onset of bulimia. 3. Voluntary dieting group (N=29) Voluntary restriction of food intake aiming at slim figure has continued for considerable periods of time (mean 9.9 months; SD±5.9) before the onset of bulimia. 4. Self-induced vomiting group (N=9) Self-induced vomiting which aims at slim figure has continued for considerable periods of time (mean 9.0 months; SD±9.0) before the onset of bulimia. Patients of the binge eating group and the appetite loss group had often psychological stresses in their life situations; interpersonal problems with family, friends or colleagues, persistent worries about achievement in school or company, etc. Cases of the voluntary dieting group and the self-induced vomiting group had such psychopathological problems as distorted body image, intense fear of becoming obses, dysmorphophobia, social phobia, narcissistic or borderline personality disorder. We concluded that bulimia nervosa is a paradigmatic psychosomatic disorder and that anorexia nervosa and bulimia nervosa are not the two separate dichotomous syndromes, but the extreme counterparts of the same disorder. It will be shown that these two conditions can alternate in the same person and that the same psychological factors play important etiological roles in both conditions.

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We reported on twelve children from nine years to 15 years of age who were diagnosed as having a psychogenic visual disorder. Three were males and nine were females. Except for two cases, all were aware of a deficit in visual acuity at school and were suspected of having a psychogenic visual disorder by the ophthalmologist because of the absence of a corresponding ophthalmological disease. They often showed a positive response to a trick test using ±0 lens. We interviewed mother and child and used some psychological tests. In all cases, we noted some kind of psychological mechanism or background information related to visual disorder. In five cases, bullying was the main cause of the visual disorder. But the teacher or parent was not aware of this fact. In four cases, poor schoolwork or maladaptation in social relationships was noted. In other cases, there were suppression, a genuine desire to wear glasses, or other causes. We thought that these psychological conflicts were converted into visual symptoms. We finished the psychiatric consultation after the first interview because the families of patients did not seem to like to come to the regional psychiatric hospital. Nevertheless, the first visit was thought to be very insufficient as treatment. To examine the prognosis of the visual problems subsequent to the consultation, we distributed questionnaires inquiring the course of the disorders to the teachers of the children at their schools. Five of the twelve cases improved, but in seven cases, symptoms continued or recurred after temporary improvement. Restricted visual acuity did not seem severe as a symptom, but was difficult to improve by only one psychiatric consultation or by itself. We stress the importance of continuous psychotherapy or improvement of conditions at school according to the circumstances contributing to the disorder.

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We investigated the role of emotional stress in the relationship with plasma catecholamines and platelet function in patients with ischemic heart disease. The degree of subjective stress, plasma catecholamines, whole blood platelet aggregation and plasma β-thromboglobulin (βTG) were determined in 45 patients with angina pectoris (AP group), 40 patients with old myocardial infarction (OMI group) and 50 healthy individuals (control group). The degree of emotional stress was measured by recording subjective stress of 4 degrees (0 : without stress, 1 : with mild stress, 2 : with moderate stress, 3 : with severe stress) every one hour and these values of every hour of the day were summed up. Subjective stress (stress score) were determined by average values of 6 days. The levels of epinephrine (EP) and norepinephrine (NE) were determined by high-performance liquid chromatography with an electrochemical detector, and βTG by radioimmunoassay. Whole blood platelet aggregation was measured by impedance method. Stress scores of AP group and OMI group (7.86±6.43,8.95±5.03,respectively) (mean±SD) were significantly higher than that of control group (4.08±2.90). There was no significant difference of the contents of EP and NE between these three groups. Whole blood platelet aggregation of AP group and OMI group (17.4±4.7,16.9±3.8,respectively) were significantly elevated compared with that of control group (13.4±4.4). The contents of βTG of AP group and OMI group (32.9±18.3 ng/ml, 33.3±16.4,respectively) were also increased significantly compared with that of control group (22.5±12.5). Then plasma catecholamine levels and platelet function were compared between the high stress group (stress score above 7) and the low stress group (stress score less than 7) of AP and OMI patients. The content of EP of the high stress group (0.036±0.015) were significantly higher than that of the low stress group (0.025±0.013) but there was no significant difference in the contents of NE of the high stress group and the low stress group. Whole blood platelet aggregation of the high stress group (19.3±5.1) was higher than that of the low stress group (14.5±4.0) significantly, and the level of βTG of the high stress group was also higher than that of the low stress group. These results suggest that emotional stress in patients with ischemic heart disease is higher than that of the control group and platelet function is accelerated. In the high stress group, plasma EP level and platelet function were elevated compared with the low stress group. So it was concluded that emotional stress is closely related to the development of ischemic heart disease at least in part by influencing the catecholamines and platelet function.

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Apraxia of lid opening is an insufficiency of initiaating lid opening that was termed by Schilder in 1927 and has been described as supranuclear abnormalities (i.e. the levator neurons are inhibited). This disorder is tended to be easily confused with blepharospasm or blepharoptosis. Though the latter two diseases are thought to be caused by a conversion mechanism, it has not been reported that apraxia of lid opening is owing to that mechanism. The following case, to our knowledge, is the first report of a patient suffering from apraxia of lid opening as a conversion symptom. Case : A 62-year-old woman was referred by her neurologist because of laryngeal discomfort, and saying that she can't open her eye lids smoothly. The patient had been healthy with no serious diseases until she noticed her illness about a year before. When she was admitted, she looked healthy and had no problem except for her chief complaints. In addition, she had received no medical treatment. After every possible examination, she was diagnosed to be suffering from apraxia of lid opening with globus hystericus and differenciated from blepharospasm or blepharoptosis by superficial EEG or clinical symptoms. There were no organic abnormalities that could cause this disease. It was revealed, however, that she was under psychosocial stress at the time of onset of her illness. After admission, her lids' symptoms improved gradually by client-centered psychotherapy without administration if any psychotropic drugs and finally she was cured in two and a half months. Judging from the process of therapy, her psychosocial characteristics and her globus gystericus as a complication, it is clear that her illness is Apraxia of lid opening due to a conversion mechanism.

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The patient was a 13 year-old girl with chief complaints of phobia of swallowing food and weight loss. She entered junior high school and soon caught a cold. After that, she felt continuous sore throat. Because of her fear of swallowing food, she ate only a little. Her weight decreased from 32kg to 25kg within 4 months. On admission, she wanted to gain weight, but she was not able to swallow. She was diagnosed as having anorexia nervosa with phobia for swallowing. In her family, her mother did not get along with her grandmother, and the patient was affected by this bad relationship. Her inability to relax worsened her neurotic predisposition. She was treated by enteral hyperalimentation, counseling, and cognitive behavior therapy. As a result, she became aware of her overadaptation, and she learned to relax. She gained weight and became mentally stable. For her swallowing phobia, she received autogenic training, followed by sysytematic desensitization using swallowing images. After 3 months, she was able to swallow food.

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A case of the recurrent anastomotic stricture after esophageal transsection in need of psychosomatic approach is reported. A 60-year-old Japanese woman was admitted with dysphagia, regurgitation, heart burn, tachycardia attack, insomnia, and anorexia. Soon after esophageal transsection for massive hematemesis from esophageal varices at the age of 58,she developed severe difficulties of food passage. In spite of conservative treatments with dilatation using bougir or endoscopic cutting for a period of two years, her complaing of dysphagia was not improved. X-ray studies on admission demonstrated severe stricture at the lower esophagus, She had in addition numerous clinical problems as cholecystitis, paroxysmal sinus tachycardia, unknown paralysis of lower extremities, and constipation. The patient was depressed and anxious about the prognosis of her illness. Psychosomatic treatments were conducted on admission. We first tried to correct her depressive and negative cognition by frequent interviews with her. At the same time, intensive dilatation using bougie was undergone on early days of her hospitalization. It appeared that altered cognitions had not a little influence on esophageal passage. On discharge she required bouginages only two times a month. Four years after discharge, she became able to resume her social life without bougienage. The lower esophageal stricture itself at the time of discharge, however, was not improved significantly in X-ray study. This fact may indicate that esophageal passage is frequently influenced by emotional factors in human.

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