We encounter indeed those patients who are called "problem patients" in our clinical practice at general hospitals; they manifest such characteristics as, 1) a discrepancy between complaints and the severity of the disease, 2) chronic complaints, 3) a clinging, demanding or aggressive attitude towards the doctor and nursing staff, etc. However, I don't think that they are by nature problem patients. The "problem" should be understood in the context of the doctor-patient relationship. The clinical case presented is a 53 year old female worker, who is also a housewife. She was referred to the psychiatrist, because her frequent abdominal pain was easily alleviated by a placebo injection, and her complaint of vomiting didn't seem to be real. In the first session, the patient told the psychiatrist that she had been suffering from abdominal pains for almost 30 years. No doctor could find the origin of those pains ; she expressed negative feelings towards the former internist in charge (Dr.A), but she idealized the current internist in charge (Dr.B) and the professor internist in the university hospital (Dr.C) with whom she sometimes consulted. She further told the psychiatrist about her stressors which consisted of problems caused by her family members (her son, her daughters and her husband). She also expressed negative feelings towards the nursing staff. During the 2 years when the psychiatrist saw her, Dr.B and his nursing staff encountered many troubles caused by the patient. Although she was hospitalized for 4-5 times and also received outpatient treatment, there were many exaggerated somatic complaints, frequent demands to stay out at home or to be discharged, along with her clinging, demanding and aggressive attitudes towards the hospital staff : there was also no cooperative attitude on the part of family members. Indeed, the very internist-patient relationship was in crisis and being broken. On the other hand, the psychiatrist couldn't play the expected role of arranging the troubled relationship, although he tried to listen to the patient and successfully empathized with her traumatic experiences. Eventually, only after the patient's psychological stressors had been almost all resolved, was the relationship re-established and the patient's panicky state diminished. However, I don't think the favourable result was brought about only through the improvement on the patient's part, but also through the re-stabilization of the internist's feelings towards the situation. In the "problem patient" phenomenon, it is crucial, I believe, that the doctor in charge should work through any negative feelings he may have towards his patient or the patient's characteristics mentioned above.

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Vomiting is a common gastroenterologic symptom which is particularly pernicious in diabetics because of their precarious metabolic homeostasis. However, the severity of abnormal gastrointestinal motility is not necessarily caused by the diabetic state, but by psychosocial factors that we should address when dealing with diabetic patients whose symptoms include severe vomiting. In such cases, the psychosomatic approach is very important for treatment. We treated a 33-year old diabetic woman who had received hospital care about 50 times due to vomiting attacks before her admission to our hospital. She suffered from NIDDM when she was 17-years old. She vomited with motion sickness for the first time at the age of twenty. She married at 24,but was divorced at 27 after aborting artificially 3 times because of severe emesis. When she was 28-years old, she started working at an office and was admitted for treatment approximately once a month due to her vomiting. At the age of 31,she began to cohabit with a man and her vomiting attack slowly increased in frequency and severity despite several evaluations and courses of treatment. As vigorous medical management failed to control her vomiting, she was introduced to our hospital in September, 1987. On admission, her weight was 39 kg and her height 159.6cm. She was 22% under the standard weight and suffered from diabetic triopathy, especially severe nephropathy and gastropathy. On the 5th day after her admission, she requested to be released from the hospital, but we did not comply with her request. The next day, vomiting occurred throughout day and night, continuing for 5 days and subsiding on the 6th day. A similar attack occurred during a TRH test. In the intermittent period between the episodes, there was no vomiting and meals were taken normally, and she requested discharge repeatedly. It was difficult to persuade her to continue the therapy. On November 27th, she left the hospital without having been discharged. Ten days later, she was readmitted on an emergency basis due to vomiting and systemic edema. Once the attack subsided, she again left without formal discharge, but came back to the hospital within a few days due to a vomiting attack. In April, 1988,we contracted with her for a three-month admission. For the somatic aspect, we guided her through self control exercises to control her diabetes, and, for the psychological aspect, we dealt with her conflict with the man she cohabited with and the causes of her anxiety that resulted in vomiting attacks. The patient gradually improved on this regimen and was discharged after three months. After discharge, she did well for five months. By the sixth month, she had had no recurrence of vomiting, but her renal function had deteriorated, so she was started on dialysis.

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The present study was undertaken to investigate various factors in chronic eating disorders, namely anorexia nervosa and bulimia nervosa. The duration of illnesses and their characteristic features were evaluated in a total of 174 patients. Subjects in this study were patients who admitted to Kyushu University hospital between 1972 and 1986. Subjects were devided into 4 groups according to duration of illnesses, their clinical features and results of psychological testing. There were no significant differences in the age of onset of the illnesses and the extent of weight-loss at the time of hospital admission ; however bulimia, vomiting and denial of illness were related to durations of illness. No significant differences were found in the following clinical characteristics in the 4 groups : stealing food, hyperkinetic activity, past history of emaciation, frequency of depression, frequency of amenorrhea, frequency of laxative abuse. There was no significant relationship between the duration of illness and the results of psychological testing (CMI, YG and PF study). The duration of hospitalization correlated with the duration of illness. Three of the patients whose illness were longer than 10 years are described in this study. Case 1 whose illness was longer than 25 years had good therapeutic results with the cooperation of her family. Cases 2 and 3 who had vomiting associated with their eating disorders because of fear of obesity did not have good therapeutic results due to lack of family supports. The patients whose illnesses were of a long duration and who denied their illness, had very frequent vomiting and bulimia, and required long term therapy.

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Psychosocial factors and their reference to middle-term and long-term courses were investigated in the patients with anorexia nervosa (AN) and bulimia nervosa (BN). The subjects were three males and 33 females with the mean age of 25.6 years referred to the neuropsychiatric clinic of Fukushima Medical College Hospital and its related hospitals. Based on the criteria of DSM-III-R, they were classified into three groups; 14 cases of typical AN group (typical group), 11 cases of atypical AN group (atypical group), and ll cases of BN group. The typical group fulfilled the whole criteria, but the atypical group fulfilled only some of them. Among the evaluated psychosocial factors (personality trait, serious family pathology, psychosocial stressors, and precipitating factors), obsessive compulsive personality trait and precipitating factors on the body image of patients were characteristic of the typical group. On the other hand, serious family pathology and severe psychosocial stressors were more remarkable in the atypical group. Important psychosocial factors in the BN group were borderline, obsessive compulsive, or dependent personality traits and precipitating factors on self-supporting ability. The middle-term outcome (five years after onset) was favorable in 71.5% of the typical group, 54.5% of the atypical group, and 45.5% of the BN group. In the unfavorable cases, there were relatively long duration of binge eating and severe mental symptoms such as suicidal attempts and self-mutilating behaviors. Concerning psychosocial factors, unfavorable outcome could be connected mainly with borderline personality traits in all of the three groups. Fourteen cases were examined on the long-term outcome (more than ten years after onset with the mean term of 12.5 years). In both the typical and atypical groups, the outcome of eating behavior tended to be good. However, a few cases in the both groups showed severe mental symptoms which were mainly attributable to personality disorders. The outcome of the BN group was relatively good not only with eating behavior but with mental symptoms. Like middle-term prognosis, personality trait played a major part for deciding long-term prognosis. Namely, the patients with obsessive compulsive personality trait were led to good outcome, while borderline, dependent, or narcissistic personality traits could become worse and develop into personality disorders, and therefore might be related to poor outcome. These results suggest that personality trait might influence the course and outcome of eating disorders.

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Seventy nine females with anorexia nervosa (AN) were followed up by postal questionnaire 2-12 years after their first consultation at Kyoto National Hospital. Their outcome was assessed using the global clinial score of Garfinkel et al. Scores of 0 to 3 were defined as "improved", 4 to 13 as "intermediate" and greater than 14 as "unimproved". The outcome showed improved in 31 (39.2%), intermediate in 29 (36.7%) and unimproved in 19 (24.1%). Sixteen of the unimproved, whose duration of illness was over 5 years were defined as having chronic AN. These patients had poor psycho-social adjustment as well as long lasting low body weight, amenorrhoea, and other physical conditions such as hypokalemia, elevated hepatic enzymes, parotid enlargement, arteriomesenteric duodenal occlusion and alopecia, and poor eating behavior. The factors that were significantly correlated with poor outcome were older age at first consultation, longer delay from onset to consultation, lower minimum body weight and bulimic behavior. Of the family background that we investigated, alcohol abuse and social mal-adjustment in the patients' fathers were significantly correlated with poor outcome. The personality characteristics of AN were examined using the Rorschach test in 13 patients with chronic AN and 15 improved patients. The Rorschach variables in chronic AN were found to have a greater number of responses scored "F-" than in the improved group The patients were classified into five groups according to their levels of ego-strength, which were determined by both form levels and how much they employed their primitive defenses. Ten of the 13 with chronic AN were categorized as belonging to group IV (suspected serious neuroses) or group V (suspected borderline personalities). On the other hand, 13 in the improved group were categorized as belonging to group I (suspected mild neuroses), group II or group III (suspected moderate neuroses). It is suggested that the borderline personalities and family background of AN should always be taken into account when deciding the method of treatment, as well as when assessing the final outcome of the patients. And counselling of the patients' mothers is also recommended as part of the treatment.

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In an attempt to elucidate major prognostic factors, a follow-up study was performed using 40 female patients with anorexia nervosa. The patients fell into the following outcome categories : 1) fine 12 (30%), 2) moderate 10 (25%), 3) slight 9 (22.5%), and 4) poor 9 (22.5%). The authors selected the following factors and investigated the influence of each of them on outcome : 1) support system by family, 2) anthropophobia, 3) autonomy, 4) cognition, 5) control of eating, and 6) management of time. The following results were obtained. 1) There was little difference between the fine and moderate outcome groups. Any factor was not so risky in these groups except for control of eating. It was more difficult for the latter to control eating than the former. Mild anthropophobic feature in the latter tended to increase in incidence compared with the former. 2) There was also little difference between the slight and poor outcome groups. Any factor was risky in these groups. The more serious the outcome was, the more difficult was to control eating, the more ineffective was the support system and the more severe was anthropophobia. 3) There was, however, a marked difference between the moderate and slight outcome groups. The latter was dramatically discriminated by lack of autonomy, distortion of cognition and incompetence of managing time from the former. These results indicated that major prognostic factors included autonomy, cognition and management of time. It was thought, however, that the other factors were only as modulators in the clinical course. This study was supported by the Research Grant for Intractable Disease from the Ministry of Health and Welfare of Japan.

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In 16 cases suffering from Anorexia Nervosa (AN) for 10 years or more, we examined their physical and mental symptoms as well as prolonging factors. The results were as follows : 1) Most of these prolonged cases changed into bulimic types, and showed not only various abnormal eating behaviors, but also other abnormal behaviors, physical symptoms, and psychotic symptoms. Most of them were socially withdrawn and isolated. 2) Frequency of irreversible or life-threatening symptoms in these prolonged cases were higher than that in the cases previously reported by Fujita and others (1987). 3) In the prolonged cases, long time was spent from the onset of the disease to intial examinations and treatment. 4) Many of these cases were complicated with psychosomatic diseases or neuroses and were not obese before the onset. It was suggested that they were also socially immature. 5) Their fathers were gentle but did not exercise leadership, and most of their mothers became symbiotic with them after the onset. It was supposed that these attitudes reinforced their symptoms. 6) The results of our cognitive-behavioral treatment for the prolonged cases were fairly successful, though much energy and time were required. 7) In cases of poor prognosis, most of their families could not play a role of co-therapist because of alcohol dependence, social maladjustment or broken homes, etc.

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Eating disorder is regarded as a syndrome or spectrum disease, and so it is difficult to evaluate the long-term prognosis because of its different psychopathologic levels. We studied 20 chronic eating disorder patients (more than 10 years duration from the onset) with regard to weight, eating behavior, menstruation, psychological functioning, psychosocial functioning and clinical course. 16 patients (80%) shifted from anorexia to bulimia with vomiting in their eating behaviors, and their bulimia with vomiting continued. Body weight was still persistently below 85% of the average in 65% of the subjects. Menstrual dysfunction (persistent amenorrea, sporadic, irregular) was reported in 16 patients (80%). The most common psychological symptoms were depressive, obsessive-compulsive tendencies at follow-up. The common personality traits were obsessive-compulsive, avoidant, and borderline features. In particular, patients who were associated with bulimia and vomiting, often act out and abuse. They were diagnosed as borderline personality disorder. Most patients remained poorly adjusted socially. Their relationships with families and with other people were quite impaired.

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