In the last two decades, Psychosomatic Medicine in the USA has gone through a significant transition. Probably, the most notable of all is the elimination of the term "psychophysiological disorders" from DSM III. This has caused concern that DSM III has reduced the importance of Psychosomatic Medicine as an entity. More accurate is the fact that DSM III is reflecting change not only in Psychosomatic Medicine but also in psychiatry in general. Starting with a review of changes in the concept of, and approaches to, chronic pain in the last tow decades as a prototypic example, this paper discusses the current status of Psychosomatic Medicine in the USA and its implications for Psychosomatic Medicine in Japan.

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It is not rare that the patients with chronic hemodialysis suffer from various physical symptoms such as muscle pain, lumbago, fatigue, and also from emotional instabilities while receiving hemosialysis. These symptoms are often developed becaurse of 4〜5 hour restriction by hemodialysis. The purpose of this report is to present the results of indicated music listening to reduce the above mentioned symptoms throughout the whole course of hemodialysis. Subjects : Indicated for 13 patients, 4 males, 9 females who have been visiting to receive hemodialysis 3 days a week at St.Luke's International Hospital, Tokyo, Japan. Their age distribution ranges from 32 year old to 76 year old. The mean age is 53.3. Their hemodialytic experiences are from 11 months to 14 years since the beginning. Methods : A special reclining chair or bed pad with stereo and vibration called Body Sonic System was indicated for every patient throughout the whole procedure. The variety of musics were chosen by individual patient from whatever she or he wants to listen and also the patients can switch on or off whatever music they want by themselves during the listening. The questionnaire was handed out to all patients to ask their hobby of music and their impression of the music listening. Results : All of 13 patients have a hobby of listening music in their daily life. Eight of the 13 patients answered that they felt more comfortable with music listening while in hemodialysis than before without music. Five of the 13 patients answered that the music listening reduced or decreased their physical symptoms such as lumbago, back pain and general malais develooped in himodialysis. Six of the 13 patients answered that the music listening helped to induce natural sleep while in hemodialysis. Eight of the 13 patients answered that they were able to listen music more comfortably with vibration than without vibration. In one case, a 58 year old male who showed emotional instability with multiple complaints through the previous hemodialytic process, revealed dramatic recovery soon after the indication of music listening while in hemodialysis. Music listening was helpful for the patient to ventilate his negative feeling in theis case. Conclusion : Music listening during hemodialytic procedure with or without vibration was tried in this report. Music listening may reduce physical symptoms or emotional discomfort develop while in hemodialysis. Music listening with vibration, body sonic, heops patient listen music more comfortably than without it.

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In recent years, music therapy has come to be applied in the field of medicine, but few studies have focused on psychosomatic disease in senescence. Yet the number of such patients is increasing. A somato-psychological approach can be more effective than verbal communication for aged patients detective in the latter. Thus, in this report, music therapsy is applied for patients of psychosomatic ciseases in senescence. The subjects were 14 patients of psychosomatic diseases aged 65 to 81,or 75.4 on average. The mathod taken was as follows : patients were made to listen to music of their prefernece for 30 to 60 minutes with a body somic apparatus when they visited the hospital for consultation. The affects of therapy were recorded through interviews and questionnaires. Music was found effective for about 70% of patients at short intervals. In the most significant results, favorable chages were found between skin temperature before and after music therapy. "Enka", traditinal Japanese singing, was the genre commonly preferred by most patients. Music therapy was also applied for patients in terminal stages of somach cancer and patients of Alzheimer's disease, and showed favorable effects. Active music therapy involving singing and dancing was subsequently applied for 15 inpatients and outpatients at a hospital for the aged who requested such therapy. Seventy-theree percent of the patients reported feeling "good", while 13.5% of them felt "neither good nor bad" and the remaining 13.5% felt "bad". As described above, music therapy was applied for patients of psychosomatic diseases in senescence as well as gerontic diseases, and it was concluded that music therapy is useful. How to apply music therapy for patients of psychosomatic deseases in senescence and the effects of such application were also discussed and reported.

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In this paper, we discussed the application fo music therapy to the treatment for eating disorders. Also, we reported 10 cases suffering from eating disorders who had been treated with music therapy and two other clinical case studies. In our attempt, it was observed that music therapy was useful for most cases in establishing patient-therapist relationship, decreasing depressive moods, irritabilities, and increasing self-esteems and reality contacts. According to Winnicott's therapeutical theory, it seems true that music therapy acts as an transitional object and functions to provide a safe environment for playing and testing alternative interpersonal behaviors. And these facts impressed us with the importance of playing in the greatment of eating disorders to reinforce reality contact.

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Bronchial asthma is regarded as a disease thich has various causes such as allergy, autonomic nervous disturbances, psychological upset, air pollution, weather, sex and age. Therefore this disease demands a comprehensive treatment which includes environmental improvement, physical training, pulmonary rehabilitation, psychological therapsy and prophylactic drug therapy. These therapies should be combined according to the condition of the patient. When an asthmatic child, however serious his or her condition is, lives asey from home and is placed under residential therapy, the child will get better and grow up mentally. But it is not rare that the child gets worse when he or she goes back home to stay one or some nights leaving hospital. In order to maintain the effect of residential therapy, it is important to improve the relationship between patient and parent while the child is in hospital. I have been conducting a therapy by use of music to improve the relationship between an asthmatic boy and his mother. I had session with a patient and his mother. First the patient and his mother chose their own favorite pieces of music, and then they work together to find pieces of music which both persons like. A few days later, the mother listened to the music which her child had chosen, and vice versa. I had therapeutic sessions with them at imtervals of four weeks. I conducted the therapy with two asthmatic pre-adolescent boys and the results are as follows : 1. By listening to the same pieces of music, the patient and his mother found common topic for their conversation and a desirable change was observed in the unhealthy and too-close retationship between patient and mother whose interest used to be centered around his asthmatic condition. 2. Listening to the music the child had chosen helped the mother understand him empathetically and accept his wish to be independent. 3. Although an asthmatic child is generally gassive toward developing contact with others, he can learn to associate with other children of the same generation through their interest in music. The present approach to asthmatic children through music still needs more experiments, but as it looks worthwhile, I would like to continue at the present study.

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Recently we use art therapy at times for the patients with psychosomatic diseases. One of the reasons is that art therapy is deasy to use. Another reason is that it is a method of self-expression. We have heard that self-expression and self-realization have a good effect on pitients with psychosomatic diseases. Our department has used art therapy for diagnosis and treatment for 13 years. Now we conduct individual, family and group art therapies. We have known that psychosis and neurosis have different characteristics of drawing expression. We report these characteristics and explain the diagnosis and reatment of psychosomatic diseases by use of individual art therapy. We add the introduction of family and group art therapies. 1. Individual art therapy : Drawing expression is classified into three groups. Group 1 is unusual drawing expression in quality. Group 2 is unusual drawing expression in quantity. Group 3 is usual drawing expression. Group 1 shows strange figures, heterochromatic color, and so on. They are often drawn by the patients of schzophrenia and organic psychosis. Group 2 pictures are often drawn by the patients of manic-depressive illness. When they are depressive, they draw gloomy and poor works. But when they are manic, they ause many colors and draw thickly. Group 3 pictures are often drawn by the patients with neurosis and psychosomatic disease. We can find easily that Group 1 and Group 2 are unusual in form. So, psychosis's drawing has a great value for diagnosis. But Group 3 is usual in form. Therefore it is difficalt to use drawings done by neurotic and psychosomatic patients as the method of diagnosis. But we can find that Group 3 changes in content. In art therapist and a patient exchange views about the changes. This exchange functions as an effective reatment. This is because, in view of psychopathology, the art therapist helps the patient to express himself and the help can lead him to self-realization. II. Family art therapy : We use Conjoint Kinetic Family Drawing (CKFD) as a family art therapy. A therapist instructs all of family memberx to make their family drawng together. Each family member uses his or her own color and family drawing is done in conjunction. Using this method, we can intervene in family systems. III. Group art therapy : In our hospital ward, a group of patients draw monthly on panes by coloring sprays named 'pop snow spray'. The grou is made up of patients with neurosis. This therapy's effect is to increase the self-esteem of a worker by being praised for the work and to help him approach to the group more easily.

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Art therapy has not as yet found popularity in psychosomatic medicine. I have not specialized in art therapy but have tried some of its techniques in my eight years of clinical experience in psychosomatic medicine. In theis paper I would first like to report from my own experience on some of the useful aspects as well as some of the difficulties that may be incurred in the use of art therapy. Next I would like to report on the results of interviews I made with 17 clinical practitioners of psychosomatic medicine as to their experiences with art therapy. Their reports of useful aspects and difficulties are also included. Thus, by combining the data from all of these reports, those who are not as yet experienced enough in art therapy may find some useful imformation for their own practice. Art therapy's strong points are : 1) The practice of art therapy offers a therapeutic relationship, a therapeutic medium for bonding with the patient. 2) The practice of art therapy creates a situation in which both the patient and thrapist can be together in a therapeutically motivationg environment which the patient can appreciate. 3) In such a situation, the expression of inner world and emotional ventilation are made possible for the patient. These processes are somewhat similar to those of verbal psychotherapy but offer a new avenue of expression for those patients who find it difficaut to go through these processes without non-verbal techniques. Some patients would then be introduced to verbal psychotherapy afterward. In the same manner, the limitationa or limiting factors of art therapy are summarized : 1) As a psychotherapeutic technique there are not many opportunities to learn enough about it. It is not as theoretical as other methodologies and thus some clinicians find it uninteresting. The application of art herapy is rather limited and introduction to the patient is not always easy. Furthermore, considerable experience in psychotherapy is a necessity for full utilization of i. 2) It is requisite for an art therapist to have an interst in artistic expression and the capacity to interact ("play") in a therapeutic situation "holding" the patient. 3) Patients who have difficulty in expressing their inner worlds or who don't like the specific techniques are not good candidates for this type of therapy. 4) Concerning the therapeutic setting, suitable space and sufficient time are not always available. 5) Research in art therapy is not easy as evaluation is subjective rather than qualitative. Whether these limiting factors, as noted above, con be overcome successfully depends on one's own efforts to modify the techniques according to one's own clinical situations. Learning of art therapy in the psychiatric field and mastering the basic psychotherapy techniques are also necessary. Clinicians who are intersted in both artistic expressions and the internal worlds of their patients could find their own ways in the field of art therapy. Furthermore, it would be a valuable contribution to both art therapy works well.

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We often observe that psychosomatic patients have tendencies of suppression or alexithymia. Since their verbal expressions are emotionless, verbal approaches to them are less useful. So we also comduct sand play therapy as a non-verbal approach. We applied the sand play therapy to 24 cases for whom verbal approaches were not successful due to the following reasons : 1) less emotional expression 2) alexithymic tendency 3) tendency of mutism 4) mild mental retardation 5) lack of basic trust or excessive distorted perception By conducting the sand play therapy, we gained the following results; 1) The expression of patient's emotional states is promoted and it facilitates catharsis. 2) The patient's qwareness of emotional states is promoted. 3) It is important to catch a good timing between waiting enough and working on the patient during the sand play sessions by considering the therapist-patient relationship and the therapeutic process. 4) We can examine and modify our therapeutic attitudes by watching and talking with the patient about the sand play expressions, and that in turn helps us control our counter transference. 5) The sand play therapy facilitates to restore the patient's sense of reality which is excessively distorted. We conclude that the sand play therapy is useful and necessary for the patient for whom verbal approach is not successful.

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In recent years, patients who call on the department of psychosomatic medicine, are not always suffering from psychosomatic diseases of the narrow sense. Especially, in adolescent patients are found neurosis, depression, school phobia with somatic symptoms, violence to family with hypochondoriases, borderline case with somatization. Sand play, a kind of art therapy, is an image therapy. Inner emotion that is not defended and not intellectualized, is expressed by sand play therapy. The therapist is able to understand psychogical states of the patient who in turn becomes able to grasp self insight and control his impulses. We use sand play to make a psychological diagnosis as a psychological therapy on the basis of the theory of image therapy. In this study, I have presented 5 cases and probed on the cases. Three cases showed improvement and finished their treatment and 2 cases are getting well. In the patients whose psychological states were indicated in the sand play and in the patients whose self images were projected in the sand play, their psychological problems were reflected also in reality life and they actually succeeded in solving them. We should consider the indication of sand play. It is quite proper to use the sand play therapy effectively for the treatment of adolescent patients.

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