It is well known that the bronchi of asthmatic patients are very sensitive to many factors. Emotional stress is especially well established as an important trigger factor of asthmatic attacks. There are many clinical studies concerning the psychological factor in asthmatic patients, but there have been very few papers which report that psychological stress alters the bronchial sensitivity in asthmatic patients. We used SMR (self monitoring relaxation) methods to asthmatic children and observed improvement of bronchial response to acethylcholin. From these data, we conclude that the psychological problem is very important to asthmatic children, but sometimes psychologists used technical terms which are not understandable to medical doctors. In the near future, it is hoped that many easy explanations will be used in the clinical field and physicians must always talk about emotional factors to each patient.

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It is thought that 3 factors, namely 1) disposition (latent bronchial hypersensitivity, atopic disposition), 2) environmental factors (infection, allergen, psychosocial factors) and 3) the biological defense mechanism which maintains the homeostasis, may play important roles in the process of the onset and clinical course of bronchial asthma. From the standpoint of psychosomatic medicine, we have proposed the hypothesis that chronic psychosocial stress may disturb the biological defense mechanism and make the "pre-asthmatic state" in the individuals who have an asthmatic disposition. In this state, any one of triggers as respiratory infection, allergen or psychological stimulus can cause the first asthmatic attack. These triggers and psychosocial factors may become precipitating factors after the onset of asthma and make a vicious cycle with sencondary factors attendant upon asthmatic attacks. In order to investigate the role of psychosocial factors on the onset mechanism and clinical course of bronchial asthma, life changes (or life events), personality profi1es and coping behaviors of 74 asthmatics were compared with those of 51 normal controls. The following characteristics were observed. i) As compared to the controls, more asthmatics, especially severe patients, answered that they were busy and left with a heavy task prior to the onset of asthma. ii) In contrast to controls severe asthmatics showed more scrupulus character and tendency to want perfectionism, and to suppress their own feelings and adapt to other people. iii) In the coping behavior relating to difficult situation, as compared with the controls more patients answered that they don't ask for other people's helps or advice and don't consult with reliable persons rather. These results suggest that much more asthmatics, especially severe patients, may have difficult expressing their own feelings, they are overadaptive and have no effective coping behaviors inspite of their heavy tasks, and have a tendency to create a stressful situation and subsequently the "pre-asthmatic state" or intractable state after the onset of asthma. In animal experiments, recent studies have provided considerable evidence to support both morphological and functional nerve/mast cell interaction. In the present study, we observed that restraint stress increased the severity of the bronchial reaction to antigen provocation, anterior hypothalamic lesion decreased it, suggesting that the central nervous system may have a modulating effect of bronchial reaction. The results of studies about capsaicin treated guinea pigs and electrical stimulation of the cervical vagus nerves suggest that the autonomic nervous system and sensory neuropeptides may play important roles in bronchial reaction. On the basis of these studies, the onset mechanism and pathophysiology of adult asthma were discussed from the standpoint of psychosomatic medicine.

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These are many factors that make it difficult to treat the patients with bronchial asthma in adolescence. From the psychosomatic point of view, we paint out some problems from which they are suffering and propose the treatment considering the aspect of their psychological development as well as that of somatic care. We interviewed in detail 22 intractable asthmatic patients in adolescence and found the characteristics of psychosocial backgrounds as follows. 1) Many of them rarely received affectionate breeding, especially maternal care in infancy and/or childhood, so that they tend to lack emotional stability and to keep poor relationship to other persons. 2) When in adolescence, they get strong negative feelings such as anger or resentment toward their parents. However, they not only repress their emotion in stead of expressing it frankly but also behave in overadapted manner. This may be due to the fact that many fathers are almost unconcerned about their family, and so mothers consequently feel themselves standing alone, and have to play a role of father as well. Interview with the patients suggests that parents react unpleasantly during athmatic attacks and dominantly during non-attack ; they reject their asthmatic children when the patients really need gentle care (i.e. dependency), and behave dominantly when the children need to act freely (i.e. independency). These parental contradictory attitudes induce the result that asthmatic patients get the negative feelings toward parents, but they suppress these emotions because they believe their mother have received a great deal of trouble, and because they must be taken care of during attack. Therefore, conflict between dependence and independence are unsolved in their inside, which makes patients emotionally unstable when confronted difficult problems, and then go into malajusted state in their social environment. We suppose that this state of malajustment may, in turn, run them into frequent episodes of asthmatic attack. On the basis of those psychosomatic consideration, we must practice not only appropriate drug therapy and prompt care for attack, but also family therapy or psychotherapy for their inner conflicts in the treatment of adolescent asthma.

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1) It is well known that the feature and prognosis of bronchial asthma are often modulated by psychosociological factors which consist of various psychopathological conditions. With a view to evaluating the diagnostic criteria for bronchial asthma influenced by psychosociological factors, the psychopathological conditions were classified into the following groups; a) The group with less psychosociological factors (Somatic asthma ; cases with no need of psychosomatic therapy), b) The group with confirmed psychosociological factors related to the initiation or physical condition (Psychosomatic asthma), (a) The group with emotionally disturbed state, but not neurotic or depressive conditions, (b) The group with neurotic conditions, (C) The group with depressive conditions. 2) The resulting classification was applied to 700 patients with bronchial asthma (356 males, 344 females, ages ; from 15 to 83,mean 47.8 years old) to assess the psychopathological conditions involved and the underlying factors was investigated. The results were summarized as follows ; a ) Psychosociological factors were found to be involved in 600 cases (86%) of the subjects. They comprised psychosociological factors without neurotic or depressive conditions (41%), neurotic conditions (26%), and depressive conditions (19%). b) Psychosociological factors, mainly neurotic and depressive conditions, were significantly associated more frequently with female than with male patients. The years of suffering were significantly longer in the psychosomatic asthma groups, mainly with neurotic and depressive conditions, than in the somatic asthma group. When the subjects were classified according to disease severity, the severe cases were present more in the psychosomatic asthma groups, mainly with neurotic and depressive conditions, than in the somatic asthma group. Furthermore, the FEV_1.0% and %VC of spirogram were significantly lower in the depression group. c) The incidence of psychosociological factors involvement did not differ according to ages and the presence of allergic factors. 3) We applied three psychological screening tests, such as Self-rating Depression Scale (SDS ; to 201 cases), Manifest Anxiety Scale (MAS ; to 197 cases) and Yatabe-Guilford test (Y-G ; to 197 cases), and two psychophysiological screening examinations, such as Cornell Medical Index (CMI ; to 700 cases) and Comprehensive Asthma Inventory (CAI ; to 700 cases). CAI which was originated by the Japanese Society of Psychosomatic Research on Respiratory Disease is a questionnaire designed to find out emotional factors concerned with asthma attack. The results obtained were summarized as follows ; SDS, MAS, and Y-G were valuable for checking the neurosis and depression, and CMI and CAI were very useful for detecting all pychopathological conditions.

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The pathophysiology of bronchial asthma is quite complex. So it is often unavoidable to depend on steroids to treat intractable asthma despite many types of treatment. Nevertheless, some reports have demonstrated that severe asthma improve by means of psychosomatic approach. This finding suggests the importance of psychosomatic approach to the treatment of bronchial asthma. For this reason, we reported the assessment of quality of life, actual treatment of an outpatient, effectiveness of autogenic training, and outcome of a kind of consultation approach to asthmatic patients. The results were as follows : 1. The more frequently asthmatic attacks occur, the more impaired quality of life patients have. Such a tendency was intensely observed especially in the psychological factors such as anxiety, depression or hypochondriacal tendency among ten items of quality of life. 2. It seems useful to apply psychosomatic approach including brief psychotherapy to asthmatic outpatients in order to improve their quality of life. 3. Autogenic training is also useful for the treatment of bronchial asthma. It is occasionally observed that mild asthmatic attacks are improved or cured by this procedure. So we might expect autogenic training can bring an immediate effect on asthmatic attack. 4. It is worth while for the psychosomaticist to make a kind of consultation approach cormplying with a physician's request. This maneuver contains two meanings : one finds it easy to carry out the holistic approach in this manner and the other is that education can be given to a physician as to psychosomatic approach. The practice of psychosomatic approach to an asthmatic outpatient composes the basic part of his treatment, that is, to perform a brief psychotherapy based on good patient-doctor relationship along with physical treatment. The advantage of psychosomatic approach to asthmatic patients at the outpatient department includes, first, that they can maintain their daily life to some degree ; i.e., they can receive treatment while keeping their quality of life going on. Secondly, it is easier for both patient and doctor to become aware of the mind-body relationship of the disease.

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For the past 5 years, 42 inpatients have been placed on the graduated psychosomatic treatment which was systematized by Ago. Their treatment course is reported in the present study. The subjects were 17 male and 25 female asthmatics (age : 18-63). All the patients irrespective of the type of asthma showed the improvement of their symptoms after the graduated psychosomatic treatment. This technique might also be effective for asthmatics requiring hospitalization. In the course of graduated psychosomatic treatment, asthmatic patients can possibly be classified into 3 types. Determination of optimum treatment based on this classification leads to the increase of treatment effects. Graduated psychosomatic treatment is applied to asthmatics so that the organism fulfills its preventive function and attains self-control of asthma by coping efficiently with psychosocial factors providing pre-asthmatic conditions. The purpose of this treatment in its course is the change of the patient's behavior on the basis of solution of his emotional problems, leading to better treatment effect which can not be obtained only by physical treatment. The graduated psychosomatic treatment systematized by Ago is expected to be applied as a basic therapeutic technique not only to the treatment of asthmatics, but also to other patients in various clinical fields.

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