The therapeutic guideline for psychosomatic disorders, which was edited by the Medical Strategy Committee of the Japanese Society of Psychosomatic Medicine in 1970,has been cited and utilized on many occasions. Hewever, following the progress of medicine, there have been increasing numbers of opinions, which insist on the necessity of revised criteria of psychosomatic disorders and introduction of new therapeutic approaches to the guideline among the members of the above-mentioned Society. Under such circumstances, Dr. Ikemi, the chairman of the Board of Directors and also the chairman of the Committee of Medical Education and Training, started working on the revision of the therapeutic guideline. After consulting with the members of the Board of Directors and councillors several times, he pointed out the fundamental problems concerning the revision of the therapeutic guideline in December, 1989. As the chairman of the Committee of Medical Education and Training, succeeded to Dr. Ikemi, I proceeded with the work and at the 31st Congress of the Japanese Society of Psychosomatic Medicine I would like to propose the outline of newly revised guideline for diagnosis and treatment in psychosomatic medicine as the presidential address. The main items of the new guideline are as follows. 1. The concept of psychosomatic medicine 2. The developmental background of modern psychosomatic medicine 3. Behavioral medicine and psychosomatic medicine 4. Consultation-liaison psychiatry and psychosomatic medicine 5. Classification of mental disorders by DSM-III and DSM-III-R. 6. Psychosomatic disorders 7. Doctors who engage themselves in the practice of psychosomatic medicine 8. General principles in the practice of psychosomatic medicine 9. Psychosocial evaluation a) Interviews b) Psychological tests 10. Psychophysiological examination 11. Psychosomatic diagnosis 12. Psychosomatic treatment modalities 13. Summary of psychosomatic treatments 14. Terminal care From now on, after discussing and arraging the proposed draft for the new guideline with the members of the Comittee of Medical Education and Training, I will announce the final form of the revised guideline for diagnosis and treatment in psychosomatic medicine to all the members of the Japanese Society of Psychosomatic Medicine. Ideeply appreciate many constructive opinions and supports by the councillors of the Japanese Society of Psychosomatic Medicine and the present and former staff members of our Department of Psychosomatic Medicine.

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It is familiar to us that humans emotional stress affects the cardiovascular system. However, the relationship between emotion and arrhythmias is not clear within the human brain. Choronic experiments were carried out in cats because emotional behavior and arrhythmias were elicited by the electrical stimulation of the hypothalamus. Hypothalamic stimulation produced at least five kinds of emotional behavior in cats. It was found that the simultaneous recordings of the ECC's showed arrhythmias frequently accompanied with unpleasant emotional responses such as restlessness and rage. These sites in the hypothalamus were located in and close to the anteromedial and ventromedial nucleus. The arrhythmias induced by the stimulation of the anteromedial hypothalamus were due to the excitation of both sympathetic and parasympathetic nerves. In addition, the rapid exchange in excitability from sympathetic to parasympathetic nerves was one of the requirements for the occurrence of the arrhythmias. Catecholamines released from the adrenal medulla seemed to be related to the duration of the arrhythmias.

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Marked advances have been made recently in neuroscience, and it is important to apply these advances to psychosomatic medicine. The brain is composed of numerous neurons, and information is chemically transmitted between neurons by neurotransmitters. In other words, the function of the brain is the sum of synaptic transmission phenomena. Therefore, to clarify brain function, quantification of neurotransmitters alone is inadequate, and evaluation of their receptors is neccesary. Neurotransmitters and their receptors in the catecholamine and neuropeptide systems markedly change with stress, and this had important implications in psychosomatic medicine. Especially, changes in the neurotransmitter system under chronic stress highly resemble those following antidepressant administration, suggesting biological adaptation. The brain is closely associated with the endocrine system and immune system, which is mediated by the neurotransmitter system. These three systems cooperate to maintain homeostases and regulate biological reactions to stress. Therefore, evaluation of one of these three systems alone is inadequate. It is impossible to discuss the status of the body only by evaluating changes in the amount of neurotransmitters. In analytic studies on the neurotransmitter system for psychosomatic medicine, results should be evaluated in termas of the entire body.

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The hypothalamus plays important role in neuro-humoral control of food intake, sexual behavior and relevant visceral functions. (1) The lateral hypothalamic area (LHA) has been known as the "feeding center". Electrical and chemical stimulation of the LHA elicit feeding behavior. This area contains a specific group of neurons which are sensitive to glucose, metabolites and hormones which are involved in fedding control. The majority of LHA glucose-sensitive neurons of the monkey decreases in activity during bar-press (food acquisition) and/or reward (food consumption) periods, while glucose-insensitive neurons mainly show excitatory response to cue signals which guide task performance. The task-related firing patterns are differentially regulated by catecholamines and opiod : β-adrenoceptors and opioid receptors are involved in modulation of bar press- and reward-related firing decrease, respectively, while dopamine is related to cue recognition and initiation of food acqusition. (2) The LHA is also involved in promotion of male sexual behavior, however, the medial preoptic area (MPOA) is the main neural substrate of male sexual behavior in the vertebrate. Neuron activity of the MPOA during sexual behavior is intimately related to the level of sexual arousal in the male monkey. Some MPOA neurons of the female monkey also show similar activity pattern during sexual behavior and activity of female MPOA neurons are affected by male's mating acts. (3) The dorsomedial hypothalamus (DMH) is involved in execution of mating acts in the male monkey. DMH neuron activity shows synchronized excitation during mounting and thrusting. (4) The ventromedial nucleus of the hypothalamus (VMH) has been thought as the center for female sexual behavior and as the "satiety center". VMH stimulation fascilitates female sexual behavior but suppresses feeding behavior in the monkey as well as lower mammals. VMH neurons are excited during presenting that is female sexual behavior of the monkey. A particular type of neurons in the VMH which is characterized by large cell soma and well developed dendrites shows excitatory response to glucose as well as to estrogen, which suggests neural substrates to cntrol feeding and sexual behaviorlind functionally and morphologically. In a hungry state, neural circuit promoting male sexual behavior may be activated, while female sexual activity may be fascilitated in a satiety state.

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Cytokines released from activated T lymphocytes effect not only immune circuit but also the nervous system. Neurotransmitters or neuropeptides released after nervous stimulation transmit signals to the nerve system as well as to the immune system. Therefore, bidirectional signal interactions are found to be acrossed between the nervous and immune systems. Various reports have been accumulated the facts that different forms of stress influence immune regulation either up or down in immune response. In general, the immune response is known to be decreased after various forms of stress applited to mice, and the altered immune response was returned to the normal level by the exposure to aromatic fragrances in the stressed-mice. Furthermore, the alteration of the immune response was not able to recover by the pretreatment of the stressed mice with procain before the exposure to the fragrance. The results indicate that the sensory system of the body may regulate immune function, and the effect of the fragrance on the stressed mice with decreased immune response was proved to be recovered via the olfactory system. Further sudies on the effects of the olfactory system by a variety of fragrance which reflect to immune responses together with other sensory systems are expected to be carried out.

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Deep involvement of the psychological stress is found in the relapse or recrudencene of gastroduodenal ulcer indeed, but no objective index thereof has been available yet. On 22 cases of gastroduodenal ulcer which showed relapse or recrudescene during observation and which were taken from among periodically followed-up patients with gastroduodenal ulcer, we recently determined so-called "stress markers (serum indicators of stress)" such as cortisol, free fatty acid, uric acid before and after relapse or recrudescene of ulcer and examined comparatively pre- and post-values, together with serum gastrin and MAS. After the relapse or recrudescence, all of cortisol, free fatty acid, uric acid, gastrin, and MAS values tended to be higher, and especially free fatty acid showed significant higher post-values when relapsed or recrudescened ulcer was still in the active stage and cortisol in the case of duodenal ulcer. These findings suggest positive involvement, at blood level, of the psychological stress in the relapse or recrudescene of ulcer.

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