This paper reported psychosomatic problems after organ transplantation. There are several kinds of psychiatric symptoms after transplant : (1) organic brain syndrome such as delirium; (2) immunosuppressant-induced neuropsychiatric symptoms ; (3) anxiety and phobia for rejection responses in a transplanted organ; and (4) psychogenic reaction due to isolation in a laminar air flow room in bone marrow transplantation. Moreover, various psychological characteristics and responses observed in a recipient, i. e. (a) euphoria, (b) denial of physical illness, (c) noncompliance of immunosuppressants, (d) alexithymia, and (e) posttraumatic stress disorder, were demonstrated. In this paper, the importance of consultation-liaison psychiatry, which is so called organ transplant psychiatry, was discussed on the basis of several references.

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We studied the psychiatric problems after kidney transplantation of the recipients at Kitasata University Hospital from 1972 to 1988. We were considering that psychiatric disturbances were induced by distortion or lack of feedback function in cerebral and/or interpersonal communication. This thought was affective to understand these disturbances for recipients, family and the medical staff, and to take care and prevent these problems. Depressive state was the most important problem and observed in 61 recipients (24.1%). Most of them were related to a guilt-shame feeling toward the donor, loss of future, discouragement, and high dosage of steroid. Some of them were related to the donor's demand of independence and better social adjustment. A markedly dependent and withdrawn state was observed in 5 adolescents after severe rejection, but they fell into depression after decision of removal of the gifts, several years later. A markedly dependent and regressive or symbiotic state was observed in 31 child, adolescent and young single adult recipients who were gifted from their mothers. A delirious state was observed in 21 adult recipients, but in no child and adolescent recipients in spite of more dosage of steroid per kg. This state was related to cerebral arteriosclerosis, hypertension and discouragement. A markedly anxious, irritable and hypochondriacal state was observed in 46 recipients. Many of them who had been experienced acute rejections suffered from Damocles syndrome. Conversion hysteria was shown in 8 young recipients who were suffering from fear of abandonment from their donor and family. Body-image disturbance was observed in 16 adolescent and young adult recipients. Many of them were suffering from Cushingmoid appearances and strange sensation of abdomen or wound of operation. A delirious and illusional state was observed in two young recipients. One was only in the hospital for delivery, the other had been paranoic and injured the doctor with persecutive illusion. With regard to the causes of the postoperative psychiatric problems, there were many possible factors; physically, renal rejection, complications, high dosage of steroids; psychologically, fear of rejection, guilt-shame feeling toward the donor intrafamiliar conflict, stress of school and social lives, demands for independence and changes in appearance due to steroid. Psychiatric problems were induced in complicated combination with multiple factors, and developed by distortion of communication with the donors and medical staffs. From this point of view, multidimensional and comprehensive approaches should be taken in management of post-operative psychiatric problems. Moreover, we are expected to consider quality of lives of patients and mental development of the child and adolescent patients, having better and reciprocal communication with patients and their families.

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Recent progress of surgical techniques makes it possible to save the lives of the patients who have fairly severe disease. Consequently the patients who suffer secondary postoperative disturbance have been increasing. In these cases it seems that the accepting process of the disturbance is rather complex. I made a research of the cases who had had renal failure postoperatively and had to receive hemodialysis more than one month in our renal center. According to the results, I would like to discuss the factors influencing the accepting process from the point of view of a 1iaisonist. Main results are as follows : l) Hemodialysis patients initiated postoperatively are 7.7% of the total ones initiated newly and its ratio has been obviously increasing with the expansion and repletion of highly advanced medicine and emergent medicine. 2) Nine (six males and three females) of the hemodialysis patients initiated postoperatively were treated more than one month. Mean age of them was 56.1 years old. 3) The original diseases include 6 cases of cardio-vascular, and 3 cases of acute abdomen disorders. 4) Three of them have left hemodialysis, another three have received mairtaining hemodialysis and remaining three were dead. 5) As to the contents of psychosomatic problems, it was noticed as a remarkable point that the dominant problems were in the area of behavior, such as being aggressive to the medical staff or low compliance of medication and the daily-life guidance, and of "situationalization", such as confusion of the relationships among family, nursing stag, doctors of HD center and surgical team. Then I discussed some factors as follows influencing the accepting process, using the "container/contained model" by Bion, W. : the problems of the patient's personality, informed consent the sensitivity of the medical staff to the subjective experience of the patients, the function of the medical staff as a team to support the accepting process, and the importance of the 1iaiso service supporting these problems.

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Psychosomatic medical treatment is considered as important as physical treatment. Especially in case the patient is an infant, similar mental treatment to the patient's parents has been thought to be necessary to alleviate their anxiety. This is based on an idea that the patient's recovery process will be affected by a degree of the parent's anxiety. In this paper, we studied how the degree of the mother's anxiety after the operation would be affected by a different approach in consultation which was made to the mother before the operation. This is part of our study in identifying a better consultation approach to the patient waiting for the operation, that may keep the patient at a better mental condition after the operation. In this study, the mothers were picked up whose child had been receiving hospital treatment and waiting for the operation. Then, they were divided into two groups. The first group received medical consultation in advance of the operation in the anesthesiology consultation room for the out-patients. The same consultation was held to the second group at the patient's sickroom. After the operation was performed, the degree of the mother's anxiety was evaluated, and then data of the first group and second group were compared. We used a questionnaire sheet when questioning the mother regarding the consultation, etc. in advance of the operation. We applied MAS (Manifest Anxiety Scale) to a survey of the mother's anxiety after the operation. For comparison purposes, either doctor or nurse in charge was questioned on what degree of the patient's anxiety 3ad appeared. In comparing the mothers who showed more than the medium degree of anxiety in MAS, the number of those who belonged to the bedside consultation was less than that of those who belonged to the out-patient consultation. In addition, those who showed more than the medium degree of anxiety in the MAS had been judged as either "no anxiety" or "a little bit anxious" by the doctor or nurse in charge. These comparison data indicate that the anxiety on the patient's side may be possibly more sophisticated than it appears to the doctor's side. The anxiety of the patient waiting for the operation can grow in the whole process from the out-patient examination to the operation, and not at a limited period after notification of the operation. Although the study is not an overall one on the said anxiety, it was confirmed that even consultation before the operation performance would nevertheless affect the patient's anxiety. If one of the family members becomes sick, all the family members become "mentally sick". The situation will become even worse in case the patient is an infant. In this situation, it is very important to alleviate the parents' anxiety, so that the sick child's mental security can be maintained. This approach will surely have a positive effect on the recovery process after the operation.

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Gastrectomy of gastric cancer is stressful to laborers. Their complaints and postoperative working conditions were analyzed to evaluate how they rehabilitated themselves and returned to their preoperative jobs. Early gastric carcinomas are often asymptomatic and such asymptomatic operative cases have been increasing lately. In such cases, postoperative complaints and changes of their life-style are very important to their psychophysiological conditions. It is necessary to grasp the personality traits of these laborers as well as the degree operative damages as we make our hotistic approach to them.

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Important roles expected of psychiatrists working in general hospitals include the matter concerning the Consultation-Liaison psychiatry requested by the clinical departments. Among others, psychiatric symptoms, indefinable complaints and behavioral abnormalities in post-operative patients are often referred to the consultation as the direct problems. The number of in-patients referred to the consultation during one year in 1990 averaged 4 to 5 a day in the Tokai University Tokyo Hospital where one of the authors works as a liaison psychiatrist. One fourth of them or 46 were post-operative patients. Of the post-operative patients, 13 presented problems due to pathophysiology directly related to the surgical operation concerned, but remaining 33 had problems attributable to reasons which are not necessarily associated directly with the surgical operation concerned. Detailed studies of these cases show that various factors such as anxiety about hospital admission-surgery, fear of death, apprehensions about the post-operative life, dependent ways of living learned from experience with hospital stay-surgery, obsession about the physical function lost and absence of correct understanding of pathophysiology with the physician-patient relationship not established fully are intricately entangled with the unstable character of the patients and environmental factors. Needless to say, therapists including physicians and nurses must give careful consideration to such cases. But the way family members supporting the patient shoud be, careful understanding of the family dynamics and the way of coping with it lead to the resolution of the problems in not a few cases. While presenting some concrete examples, the authors have described changes in the problematical symptoms and behaviors as well as participation of family members in thy treatment and its role.

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The patient was a 27-year-old female. She had been diagnosed as suffering from ulcerative colitis (UC) at 21 years of age. There was continued exacerbation and palliation. The symptoms of UC became aggravated upon her marriage at the age of 25. UC remained in remission for a period of 1 year from 1987. Mucobloody diarrhea occurred in August, 1988 and she was hospitalized because of strong left pygalgia on the 20th of September. Bone scintigram revealed a high uptake in the left sarcoiliac joint, diagnosed as sarcoiliitis. Balium enema and colonoscopy showed the findings of active UC of a left-sided colitis. Pygalgia became relieved and UC improved following the administration of steroids and intravenous hyperalimentation. The patient had spent her life in a dormitory during her junior college days, being very anxious about personal relationships and studying hard regardless of whether she had sufficient sleeping time or not. Psychological stress at this time was thought to have brought about the onset of UC. Her overadaptive behavior was noted in her new working environment and in her marriage. The recent worsening of her UC occurred just when she was planning to become pregnant and problems concerning living with her mother-in-law arose. These events made her stressful and her UC worsened. The patient had an overadaptive, alexithymic and alexisomic personality and psychosocial stress was found to influence the clinical course of her UC. We gave her supportive and sympathetic therapy and discussed problems arising from their domestic life with her husband and adjusted the conflicts between the couples. Therefore their psychological stress extremely decreased. We thought that it was one of the factors which UC has remissioned for more than three years.

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There are many cases of chronic dehydration in babyhood. In adults, however, there are few cases other than those caused by disorders of the thirst center or endocrinological diseases. We treated a patient with a rare case of gastrointestinal neurosis with hypernatremic hyperchloremia caused by chronic dehydration. This 22-year-old male university student visited my clinic complaining of weight loss, loss of appetite (restrictions in dietary intake), sense of abdominal fullness, constipation and general fatigue. He had undergone medical treatment for chronic gastritis for two years. He weighted 40.0kg and was 173.0cm tall. Laboratory findings at his first visit showed serum natrium at 164mEq/l and serum chlorine at 122mEq/l. His weight loss and abnormal levels of serum electrolytes were due to his intentional ristriction of fat and water intake in his diet. These results were explained in detail to make him understand his errors in taking water and food. As he was prepossessed with the symptoms of stomach and intestines and tended to have a nervous temperament (Morita shinkeishitsu), he underwent modified Morita therapy as an outpatient. As he became able to take water and fat freely, serum electrolyte levels normalized and his symptoms disappeared gradually. He gained 16kg in six months. This case shows that in treating chronic diseases it is important not only to prescribe medication and general dietary instructions, but also to carefully monitor the patient's lifestyle, eating behaviors and personality.

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A patient who underwent surgical treatment for obesity was observed as suffering from depression in spite of a successful reduction in weight. A case study was performed, and the following significant features were recorded : 1) patient had previous experiences of easily falling into depression when subjected to difficult circumstances in regular life ; 2) patient had a firm belief that it was not possible to reduce weight through own free will ; 3) patient was opposed to being overweight and desired to become thin ; and 4) patient believed that surgery would produce a completely new (perfect) person. As a result, the patient fell into depression because the surgical procedure did not produce the end-result expected. It was concluded that close attention must be paid to the psychological state of the patient when determining surgical treatment for obesity.

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