I. Terminal Care in Japan, past In the 1970 s, a small number of physicians who had a special interest in palliative care and in hospice care initiated a team approach to the dying patient. In Yodogawa Christian Hospital a team called OCDP (The organized Care of the Dying Patient) began work in 1973. This was the first palliative service in Japan. The year 1977 has a very special meaning in the history of Terminal Care in Japan, because of the fact that (1) The Japanese Association for Clinical Research on Death and Dying (JARD) started, (2) the word, hospice, was introduced to Japanese public for the first time, and (3) hospital death exceeded home death. The first hospice to open was Seirei Hospice in 1981 with 30 beds, followed by Yodogawa Christian Hospital Hospice in 1984 with 23 beds. II. Terminal Care in Japan, present Almost all terminal cancer patients die in the general hospital. However the general hospital is not a good place for the dying patient because of following reasons : 1. Physicians are strongly cure-oriented. 2. It is difficult to establish a good team in the general hospital. 3. It is difficult to provide an appropriate environment for the dying patient in the general hospital. In April 1990,the Japanese Government made a decision to give medical insurance benefits to three hospices and one palliative care center. As of 1992,there are seven government approved hospices. A daily payment of 30,000 yen is designated for each patient regardless of the cost. There is a new tendency that interested physicians and nurses start terminal care meetings in the general hospital. In several university hospitals also terminal care meetings have been started. III. Terminal Care in Japan, future Terminal care in Japan will take the following direction : 1. Increase in the number of hospices and palliative care units. 2. More hospice-minded care in general hospitals. 3. More home care service.

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Over the past twelve years, the Terminal Care Study Group at Itabashi Hospital, Nihon University, has been holding a terminal care meeting (TCM) once a month. For the most part, participants report on and discuss cases involving terminal illness. Detailed information about the cases is recorded by a reporter in two formats : one is a TCM case report, and the other is a TCM checkpoint form. Both reports are printed and distributed to the participants of the meeting, where free discussion proceeds among participants under the direction of the chairman. In our discussions of cases, we have often addressed problems associated with terminal care in university hospitals. Most of the 77 patients were 50-60 years old, and most were suffering from lung cancer. The data from the TCM checkpoint forms were summed up and analyzed, and yielded the following results. 57.1% of the subjects had occupations when hospitalized, 11.7% had financial problems, and 11.6% belonged to some kind of religious sect. 11.0% had been properly informed of their disease, and 73.8% felt that communication with their medical care practitioners was satisfactory. Of those who found the communication with medical care practitioners insufficient, some complained of not being informed of the true name of their disease, and others complained that their pain was not being properly controlled. Complaints regarding QOL (quality of life) were summed up as follows. 71.0% complained of meals and related items, 65.2% of insufficiency in excretion, 59.4% of having trouble sleeping, 82.6% of poor sanitation, and 76.8% of insufficient motor function. This strongly suggests that at the terminal phase of disease, it is often difficult to maintain the quality of life to a normal level. 85.9% of the subjects suffered pain, and 23.4% had their pain properly controlled by medical means. 73.9% suffered mental instability, including anxiety, depression, loneliness, irritation, or confusion. 20.1% had problems of social adaptation. Next we transferred our attention from problems related to the patients to requests made by the patients and their family members. The most urgent requests (sought by the patients and their families) was related to pain control. In this study we focused our attention on patients who had been discussed at the TCM on account of their having unique problems, and through the investigation of such patients, we think we could reveal the current status of patients requiring terminal care in university hospitals. Lastly, we indicated a number of points appropriate for counselling with the patients with terminal illness, and touched upon them briefly.

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In recent years, the use of music therapy in terminal care has become more prevalent, especially in Western countries. In trying to analyse the complexity of pain in cancer patients, Dr. Cicely Saunders coined the phrase "total pain", which she described as having physical, psychological, social and spiritual components. Finding ways to treat the total pain of the terminally ill is a very difficult task. Music therapy has been introduced in terminal care as an approach that aims to alleviate some of this "total pain" and to improve the "quality of life" of the terminally ill. The potential of music therapy in terminal care is outlined through our experience in our hospice. Music is indispensable for the patients and their families in our hospice. Concerts are sometimes held. Occasionally a patient performs on a musical instrument at a program attended by staff, patients and their families. Ambulatory patients, patients on wheelchair and even patients in beds can gather in the hospice lobby for such programs. Frequently our hospice staff visit the rooms to sing together the favorite songs of a patient. In addition cassette tape players or CD players are available for use by the bedside, and for this a library of music tapes and CD's are available. Two cases in which music therapy was useful and effective in our hospice were outstanding. In the first case, the patient had physical, psychological and social pain, and in the second case, spiritual pain. Music therapy has the potential for multidimensional influence on the physical, psychological, social and spiritual aspects of a patient's life. Physically it promotes muscular relaxation, helps to relieve pain and facilitates physical participation. Psychologically it can alter the patient's mood including the easing of anxiety and the lessening of depression. It provides a nonverbal means of expressing feelings. Music enhances communication and helps the patient to recall past significant events. Socially it provides an opportunity to participate in a group and to lessen isolation. It can be used as a bond promoting a sense of community with family members and others ; it can also promote healing during the family's grief process. Spiritually it provides an avenue to search for the meaning of life and helps the patient to accept the dying process by easing the fear of death. Music can inspire hope. Music therapy has a great deal of potential for meeting the needs of the terminally ill and their families. In the future, music therapy is expected to be used more widely and more effectively not only in terminal care but also in the field of psychosomatic medicine.

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We experienced our terminal care in 96 patients with head and neck malignant tumor. The terminal care for patients with head and neck cancer was discussed to involve psychosomatic medicine. Especially, we found the following factors from our retrospective case study on familiar care ; 1. Lightening the patient's pain control deceases the psychological stress of the family 2. It is necessary that the patient and family spend time together. If the patient wants to stay home, it is important to grant the request. 3. Understanting their feeling helps to maintain patient-doctor relationship. It is important to gain quality of life for head and neck cancer patients for terminal care.

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We studied the clinical features of alexithymia in the field of internal medicine, and obtained the following results. (1) During the course of chronic pancreatitis, the severer the physical conditions become, the severer the psychological symptoms develop. The problem of alexithymia in patients with pancreatitis is reflected on the behavioral patterns and life styles, and is deeply associated with the onset and development of disease. (2) Patients' favorite commodities are closely related to alexithymia and involved in the onset and clinical course of the disease. (3) In bronchial asthma, alexithymia and alexiscmia are interrelated. (4) In ulcerative colitis, the primary and secondary alexithymia should be differentiated. In comparative analysis of MMPI-AS in neurotic syndromes such as bronchial asthma, pulmonary carcinoma and hyperventilation syndrome, it was evident that the incidence of A, C, D in YG and MMPI-AS were higher in patients with severer physical symptoms. Furthermore, MMPI-AS was higher in patients with A, C, D than those with B, E in YG.

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In order to investigate the alexithymic personality disorder of psychosomatic patients, I conducted three studies on this subject using psychological tests. The first study was conducted to compare the personality of the subjects according to good and poor control of fasting blood level with YG-test analized by factor analysis. The results showed that alexithymic patients did poorly than well controlled diabetics. The second study was conducted to study the alexithymic aspects of severe diabetics comparing with mild subjects who were matched with age, duration of diabetes. The results suggested that the severity of diabetes was related to the patients' alexithymic characteristics measured by the state and trait anxiety inventory and YG-test. That is, there were less anxious and abnormal patients in the severe diabetics, which was discussed that the alexithymic personality contributed to the severity of diabetes. The third study was conducted with the subjects of "character psychosomatics" and neurotic patients using Egogram. The results supported the 1st and 2nd studies, in that character psychosomatics were factor-analytically shown as alexithymic than neurotics. These studies maintained that alexithymic characteristics neglect one's somatic sign so as to aggravate the disease as well as develop psychosomatic diseases.

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A1exithymia, which has been introduced to Japan by Ikemi in 1977,became popular in Japanese psychosomatic medicine, but not in psychiatry. Furthermore, the relationship between alexithymia and psychosomatic illnesses has been criticized by some psychiatrists. Since alexithymia is not so well recognized in psychiatry as in psychosomatic medicine, we investigated alexithymia in psychiatric disorders by MMPI alexithymia scale. Subjects are 106 patients (56 males, 50 females) whom the author presumed more or less alexithymic from the clinical point of view. We subsumed the subjects into the following three groups according to the scores of MMPI-A. Group A : A1exithymic group with the scores of 17 or more. Group B : Borderline group with the scores of 13〜16. Group C : Nonalexithymic group with the scores of 12 or less. There is a tendency for nonbipolar depressed patients and schizophrenics to belong to groups A and B, while bipolar depressed patients and neurotics to group C. To be more exact, 63.6% of schizophrenics end 55.8% of nonbipolar depressed patients belong to groups A and B. On the other hand, 75% of bipolar depressed patients and 62.2% of neurotics belong to group C. Thus we can find more alexithymia in schizophrenics and nonbipolar depressed patients, which implies that there is some relationship between alexithymia and melancholic type personality (Tellenbach) as well as schizoid personality. To our surprise, alexithymia in schizophrenia has not been referred in the literature within our knowledge. Although this had better be called as pseudo-alexithymia, it may give us some implications for the pathogenesis of alexithymia. Considering the discrepancy between clinical impression and MMPI-A scores in some cases, dissociative symptoms and histrionic personality may have anti-alexithymic factors in contrast to conversion symptoms, which are related to alexithymia with such somatoform symptoms as somatization and chronic pain. For psychotherapy of alexithymic depressed patients, some modifications are necessary for overcoming the communication barrier and preventing them from taking the chronic course. In liaison psychiatry, consultation work for cancer patients or patients under long standing hemodialysis cannot be carried out sufficiently without the knowledge of secondary alexithymia. Hence, it can be said that the concept of alexithymia is as important in psychiatry as in psychosomatic medicine.

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Alexithymia is the concept characterized by difficulties in the capacity to verbalize affect and a lack of fantasy. The phenomenon was recognized as clinical characteristics specific to psychosomatic disease. However, many studies have shown the existence of alexithymia in psychiatric disorders such as substance use disorders and posttraumatic stress disorder and somatic diseases which were placed under severe stressful conditions such as dialysis, terminal cancer, organ transplantation. There have been attempts to explain the etiology of alexithymia from many points of view including (1) genetic, (2) neurophysiological or neuroanatomical, (3) developmental, (4) psychodynamic, (5) social, and (6) intellectual. In particular, the etiology of alexithymia was discussed on the basis of our studies and several references. In our studies, secondary alexithymia was positively associated with denial of physical illness in patients with dialysis, severe burn, myocardiac infarction. It was suggested that secondary alexithymia might be derived from strong defense mechanisms. In addition to historical backgrounds and possible etiology of alexithymia, the authors also reviewed clinical significance and therapeutic intervention.

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The concept of alexithymia has been intensively studied in the field of psychosomatic medicine in Japan. These studies, however, mainly focused on the pathologic or pathogenic aspects of alexithymia of psychosomatic patients rather than on the treatment implications of this concept. As a psychotherapist, the author discussed the treatment implications of this concept from an integrative psychotherapeutic point of view. Clinicians should assess the cognitive. behavioral, and physical areas as well as the affective area. It is also important to formulate the problems based on the understanding of underlying schema or representations of self and objects. In order to understand the communicative aspects of emotion it is useful to tune in the patient's emotion from two points of view, categorical and gradient. The strategies are decided by various factors, which are determined by features of the patient and therapist, the nature of therapeutic relationships, the treatment phase, and the treatment environment.

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