Panic episodes were described as a distinct form of anxiety by Freud almost 100 years ago, and the recent publication of the Diagnostic and Statistical Manual of Mental Disorders, third edition (D.S.M.-III), has provided the basis for the separate diagnostic entity of panic disorder. A panic attack is characterized by the abrupt onset of apprehension or fear accompanied by symptoms such as dyspnea, palpitation, chest discomfort, dizziness, sweating, feeling of unreality, and fear of dying. Panic discover, defined as four panic attacks in a four week periode, has a lifetime prevalence of 1 to 2 percent of the general population. In these patients, panic disorders can be provoked by pharmacologic challenge with sodium lactate, isoproterenol, yohimbine, caffeine and carbon dioxide inhalation. In this study, we showed the historical review of research and the result of our clinical study of panic disorder in 6 patients. The following results were obtained : 1)Abnomal DSTs were observed in only two of 5 patients. 2)Five of 6 patients showed high concentration of adrenaline and noradrenaline in urine. 3)Anxiety was provoked by caffeine in two of 5 patients. 4)Depression of T-wave was shown in three of 5 patients with orthostatic E.C.G. 5)Sinus tachycardia was gained in one of 3 patients with Holter E.C.G. 6)Abnormal respiratory functions were observed in all two patients with Tredmill. 7)Only one small heart was observed on a chest radiograph. 8)Panic attacks were provoked by sodium lactate infusion in all 6 patients.

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Cardiac neurosis (CN) and neurocirculatory asthenia (NCA) are the most widely used diagnostic terms for non-organic cardiac symptoms in Japan. Although general agreement on these terminology has not been established, NCA is used for the patients indicative of autonomic function disorder whereas CN is used for mere neuroses such as anxiety neurosis or hypochondriasis in our clinic. Recently, DSM-III based criteria for anxiety disorder is gradually accepted in Japan and the relationships among these criteria need to be clarified. The present study was made to investigate the differences of our criteria and DSM-III in reference to epidemiology, reactivity to stress or drug infusion, and pharmacological treatment. Epidemiology : Out of 2461 patients who have visited our clinic from 1984 to 1988,105 patiens had non-organic cardiac symptoms. With our criteria, 50 were diagnosed as NCA and 55 as CN, and 59 were diagnosed as panic disorder (PD) and 46 as others (nonPD) according to DSM-III-R. It was turned out that about a halh of NCA belonged to PD and about the remaining half to CN. This result indicated that our criteria and DSM-III-R based criteria had little in common in diagnosing non-organic cardiac patients. Reactivity to stress : Cardiovascular reactivities to a psychological stress test (mirror drawing test : MDT) were examined in 48 patients. When NCA (n=19) and CN (n=29) were compared, NCA showed greater increases in systolic blood pressure, heart rate and plasma norepinephrine, and a greater decrease in CV_R-R than CN. However, no sinificant differences in those variables were obtained between PD (n=28) and nonPD (n=20).Reactivity to drug infusion : Serial intravenous of isoproterenol and atropine were given to 20 patients. NCA (n=9) showed higher heart rate and lower CV_R-R than CN (n=11) during infusions of each drug. Again, no significant differences were observed between PD (n=11) and nonPD (n=9). Pharmacolcgical treatment : Clinical assessment of effective drugs for non-organic cardiac symptoms was made in 87 patients (NCA=40,CN=47 and PD=51,nonPD=36) who have recieved pharmacotherapy in our clinic. A combination of β-blocker and benzodiazepine (BZD) was effective for 58% of NCA and 26% of CN whereas BZD alone was effective for 30% of NCA and 55% of CN. However, BZD alone or combination with β-blocker were almost equally effective for both PD or nonPD. Present results indicated higher sympathetic and lower parasympathetic reactivity in NCA which might have accounted for higher efficacy rate of β-blocker in pharmacotherapy. It was concluded that our criteria is more focused on the physiological basis and is more useful in selecting pharmacological treatment.

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Irritable bowel syndrome (IBS) is a typical functional disorder in the gastrointestinal tract that frequently develops under psychologically stressful conditions including panic. In relation to panic disorder, we first described a few interesting clinical aspects of IBS that were mainly based upon our clinical study on 152 refugees at the time of Takachi Earthquake in 1968. Many refugees dedveloped abnormal bowel movements and related abdominal symptoms, and their disturbed patterns of defecation showed a significant change during a course of time. In brief, diarrhea was predominantly manifest during the early period, and constipation or alternate diarrhea/constipation became evident in later periods. A follow-up study carried out a year after the earthquake revealed that some refugees had developed into clinical states which could be diagnosed as IBS. We next demonstrated the results of an animal stress experiment that was performed, using a newly-developed stress model, in order to address an neuroendocrine mechanism for IBS. The results in the study strongly suggest that corticotropin-releasing factor, a neuropeptide which regulates various stress responses, is closely involved in the development of stress-induced bowel distrubances similar to IBS. These findings indicate that it is possible that the pathophysiology of IBS may be elucidated from a neuroendocrine point of view, as well.

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Recently there have been several significant findings of panic disorders concerning their reactions to medication of their neuro-biological studies. Indeed there is no doubt that a severe emotional change by a panic attack induces neuro-biological changes in the brain and this process could be a target for drugs of efficacy. However, many retrospective studies showed poor prognosis. Intensive psychotherapy would not be effective for the chronic panic disorder, leading to the state of chronic anxiety which is caused by anticipatory anxiety infolded with hypovhondriachal, depressive or phobic symptoms. We discussed the problem of panic disorder in relation to its personality tendencies, condescriptive analysis of our clinical data, case reports and non-subjective cluster analysis with following results. 1)The patients of panic disorder have, in general, complex, personality features showing a bilateral traits of nervous and introvert character such as hypersensitivity, considerateness towards other people and introspection, and extravert character such as gaiety, liveliness and sociability. 2)The patients with this twofold character which is manifested such traits as gentleminded, obedient, mild and good-natured had a good prognosis. 3)On the other hand, we could points out that a group of patients with bad prognosis showed sthenic factors such as little self-examination and considerateness, being rather extraverted, strong-minded, short-tempered and active.

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Since panic disorder was separated from generalized anxiety disorder in DSM-III (1980), panic disorder has become a current topic especially in American phychiatry. Along with such a trend, the relationship between panic attack and depression became a subject of investigation from various points of view. This subject, however, is historically rather old, because depressive cases with thoracic discomfort had been called "Pneumomelancholy" in the 19th century. The Great Debate in England is famous for a long controversy between unitarians and binary theorists. Unitarians like Lewis, A. assumed anxiety neurosis as a minor variant of manic-depressive illess and agitated depression as its major variant. Binary theorists like Roth, M. strictly distinguished anxiety state from depressive illness only by their clinical symptoms. In 1979 Hirose, T. proposed "panic attack-retardation" type of depression as some evidence of the unitary view, based on his clinical experiences of the cases with panic attacks followed by long intervals and subsequent retarded depression. Some bipolar courses may be seen among such cases, which imply endogenous origin excluding the possibility of secondary depression. Now it is known that several course patterns of depression with panic attacks other than the above-mentioned one can exist. Panic attacks may occur without interval just before or after and during a depressive episode. Hence, panic attack can be a prodromal symptom or a symptom of depression per se. It can also change to depression by syndrome shift. Panic disorder is distinctly different from generalized anxiety disorder and is more closely related to depression as regards drug response and hereditary characteristics. Tricyclics and MAO inhibitors are effective against both panic disorder and depression. Depression with panic attacks seems to be located nosologically in between panic disorder and depression without panic attack, according to some data of clinico-genetical investigations as well as several data of biological experiments such as lactate infusion provocation, polysomnography and dexamethasone suppression test. Thus, clinically, it is reasonable to treat a patient with panic attacks by tricyclics with or without alprazolam and we should take it into consideration that a depressive episode may come later. Theoretically, the endogeneous nature of panic attack, as indicated by Sheehan, D.V., et al., should be taken more account, since panic attack is closely related to depression as mentioned above.

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We conducted a study on the rehabilitation problems of 50 dialyzed uremic patients at Hiroshima City Hospital. The rehabilitated group (engaging in work or in housekeeping for 5 or more days) consisted of 23 patients and the non-rehabilitated group of 27 patients (rehabilitation rate : 46.0%). Fifteen patients (65.2%) had physical complications in the rehabilitated group and 18 patients (66.7%) had physical complications in the non-rehabilitated group, demonstrating no significant difference between the two groups. Zung's Self-rating Depression Scale (SDS) test was conducted on all patients to classify them into depressed (SDS index &gnE; 50) and non-depressed (SDS<50). SDS index was 53.4±13.2 in the rehabilitated group and 57.7±9.9 in the non-rehabilitated group, the difference being not significant. Twelve (35.3%) rehabilitated patients and 22 (64.7%) non-rehabilitated patients were depressed, while 11 (68.7%) rehabilitated patients and 5 (31.3%) non-rehabilitated patients were non-depressed, demonatrating that a significantly higher rate of the patients were depressed in the non-rehabilitated group (χ^2=3.648,p<0.005). In the non-rehabilitated group, SDS indices of the patients with physical complications and without physical complications were 60.4±8.0,52.2±11.0,respectively, demonstrating that SDS index of the patients with physical complications was significantly higher than without them (p<0.005). In the patients with physical complications, 17 (84.4%) patients were depressed and one (5.6%) patient was non-depressed, while in the patients without physical complications, 5 (55.6%) patients were depressed and 4 (44.4%) patients were non-depressed, demonstrating that the proportion occupied by depressed patients was significantly higher in the patients with physical complications(χ^2=6.014,p<0.05). Depression was considered to play an important role as the factor which disturbed the rehabilitation of dialyzed uremic patients, and the presence of depression was considered to be influenced by physical complications, indicating that a psychophysiological approach might be important in coping with the rehabilitation of dialyzed uremic patients.

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Egogram has been known as avaid proven psychological test based on the theory of transactional analysis. An egogram of children was standardized on the basis of healthy children in primary, junior and senior high schools and their parents (Shinshin-Igaku 25 ; 36-44,1985 and 27 ; 319-327,1987). One hundred and seventy parents filled their own egogram check lists and evaluated the egograms for their 3 to 5 year old infants separately, and 119 parents who evaluated their infants together were added to this study. The total numbers of infants, their fathers and mthers were 289,281 and 290 respectively. The ego-profile for infants showed that the points of the Critical Parent (CP) and the Nurturing Parent (NP) increased, and the Adult (A) remained at the same level, and the Free Child (FC) fell down with age. The range of the Adapted Child (AC) became wide at the age of 5. The total points of CP, NP, A, FC and AC, being considered to be the activity of the ego, increased at 5 yrs of age. No statistical difference of these patterns was found in infants with different ages. athe fact that the infants with different ages. The fact that the infants presented the ideal form of "Bell shaped" type more often than the worst form of "V shaped" type indicates that we have possibly traced parents' wishful thinking. To correct this bias, we compared the patterns of infants with those of their parents. The agreement of patterns of infants evaluated by parents was 29.2% at 3 yrs and no difference was found among parents themselves, and between infants and their fathers and mothers. But the incidence of agreement increased to 50% at 4 and 5 yrs and was higher than those of between infants and parents and between parents themselves (p<0.005). Although the patterns of the egogram of infants evaluated by their parents were different from those of the parents themselves, a half of parents showed the agreed patterns with their infants, and this standardized egogram could tell us the development of the ego in infancy.

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This study was performed to collect baseline data on the life events occurring in Japanese families with infants. The author gave a life event questionnaire to mothers who attended routine infant health checkups at three district health cecters in Tochigi. Coddington's questionnaire with some modifications was used. There were 1528 families at the 3- or 4-month checkup, 1498 families at 8- or 10-month checkup, 1541 families at the 18-month checkup and 790 families at the 36-month checkup. The means and standard deviations for life events were 0.50±0.89 at 3 or 4 months of age, 0.49±0.93 at 8 or 10 months of age, 0.73±1.20 at 18 months of age, and 1.84±2.0 at 36 months of age. Some significant differences in the mean number of life events were found for different regions of Tochigi Prefecture. The average scores of the life change units (LCU) were also calculated. There were significant differences in the mean number of life events between group with different infant birth orders, with different maternal ages and with different paternal occupations. When the infant was the first child, the family tended to have more life events. The younger the mother was, the more the family tended to have life events. Families in which the father was a farmer had less life events. These findings have not been reportde previously. The mean number of life events did not consistently increase with the age of the infant. It decreased when infants were 8 or 10 months old, and increased with age thereafter. The average scores of life change units showed a similar pattern with one exception. When the sum of the data of the first 18 months and the data at 36 months of age were compared, there was no difference in the number of life events, but a significant difference in the LCUs. This seemed to reflect the fact that many families had had their next child by the time these infants became 36 months old. "The birth of a younger sibling" is usualy associated with another more stressful event, that is, "the hospitalization of the mother". This finding suggests that both the number and the LCU of a life event should be considered in the study of life events. It was also found that families which had many life events had a tendency to consistently have many life events. These families had common features such as a mother having a new job and a father being young.

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The Type A behavior pattern attracts many researchers' attention, because it increase the probability of coronary heart disease (CHD). The Type A behavior pattern is a situation-induced pattern, and thus differs from typologies or trait theories that have been used in the studies of personality. However, it is important for us to make clear the relation between Type A and other traits in order to know more concretely "what is Type A." Moreover, Type As are said to use some types of cognitive defenses in stressful situations. These kinds of defenses are thought to be very important from the clinical point of view. In this study three kinds of personality tests were used : Yatabe-Guilford Personality Inventory (YG Test), Rosenzweig Picture-Frustration Study (P-F Study) and Jenkins Activity Survey (JAS ; devised at Doshisha Univ.). Subjects of Type A and Type B (the opposite pattern of Type A) were selected according to their AB scores (clinical scale of JAS) from the students of Hyogo College of Medicine. In YG Test, Type As showed significantly higher scores on Ag (lack of agreeableness or aggressiveness), R (rhathymia), G (general activity), A (ascendancy) and lower scores on I (inferiority feelings) scale than Type B. High positive correlation was found between Ag and AB scores in all subjects.Comparing the numbers of each personality type between groups, we found many Type As belonged to the "B"type in YG (black list type : emotionally unstable, socially inadaptable and extraverted) and no Type A belonged to the introverted type ("C" or "E" type). In P-F Study, Type As had less "i" (need persistence-intraggression), less "N-P" (total need persistence), less "I-A" (total intraggression), more "E" (ego defense-extraggression), and more "E__-" (super-ego factor of "E") response than Type B. From these results we can conclude that Type As are more active, aggressive and extraverted but emotionally unstable and that they try to protect themselves from the accusations of others and guilt feelings using denial and projection mechanisms.

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The patient was a 74-year-old male. He had suffered from severe lumbago since Mar. 1984. Furthermore, he had a trouble with a neighbor concerning his estate. He became insomniac, and gradually grew more agitated and depressed. Finally, he had delusions of injury and attempted suicide. He was admitted to Kokubu Hospital on Sep. 8,1984. He experienced remarkable depressive mood changes in spite of the administration of antidepressants and antiaxieties. In Oct. 1987,after being informed that his case was at a disadvantage concerning the trouble of his estate, he indicated night delirium for several days and gradually developed remarkable dementia symptoms. His agitaton and the depressive mood were, however, improved and he was discharged from the hospital on Jul. 6,1988. We discussed the relationship between the occurrence of DAT and stress levels and concluded that both maximal and minimal stress levels would promote the occurrence of DAT.

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