gogram, Minnesota Multiphasic Personality Inventory (MMPI) and Jenkins Activity Survey (JAS) were administered to 89 psychosomatic patients. The responsiveness of the dopaminergic system of the hypothalamo-pituitary gland was measured in all psychosomatic patients by examining the effect of bromocriptine on serum growth hormone levels. Patients were classified as either responders or non-responders based on their secretion patterns of serum growth hormone levels. Forty-two patients were classified as responders and 47 patients were classified as nonresponders. Comparisons of scores of Egogram, MMPI and JAS between responders and non-responders showed no differences between them. Then multidimensional scaling techniques were applied to the answers of Egogram and JAS. These analyses revealed the differences between responders and non-responders only on the answers of JAS. The result indicated that non-responders have characteristics of hyperadaptation and an active coping style toward stress. In this study, the difficulty of measuring the behavioral characteristics related to the dopaminergic dysfunction using Egogram and MMPI was suggested. On the other hand, the usefulness of JAS to measure these characteristics was indicated.

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Since Sifneos and Nemiah pointed out the concept of Alexithymia, Psychosomatic disease (PSD) is characterized by Alexithymia and Over-Adaptation. Furthermore psychodynamics of PSD have been discussed in these days. Especially Denial defence mechanism is highlighted. From this point of view, we studied personality and adaptation of PSD patients in this article. Then, in order to investigate Over-Adaptation and Alexithymia, we discussed 2 studies by using Psychological tests. At first. we discussed Over-Adaptation. Our results provided strong support for former studies. They showed the patients' over-involvement in relationships with others and also meant their over identification to their social roles. With the psychological test, we could find that most of PSD patients avoided to express their aggression and assertiveness even when their self-esteem was wounded. On the other hand, some studies considered the psychodynamics of Alexithymia as a result of Denial denfence mechanism. So we conducted to study on Alexithymic tendency of PSD patients. In this study, differing from former studies, our results showed that Negation was the characteristic defence of Alexithymia. According to Sifneos's definition of Alexithymia, the lack of imagination and disability to verbalize inner conflict was the most important characters. In this point of view, Negation, which is one of the primitive defence mechanisms, may disrupt the Alexithymic patients to confront with their immature emotions.

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We payed attention to the psychological test that diagnosed personality traits of patient, and studied if these data showed the significant index of psychosomatic therapy. We conducted PDE to 50 PSD patients, and the results showed PDE was a reliable method for diagnosis of personality traits. Next, we conducted PDE to 14 Anorexia Nervosa patients (AN group), 13 Bulimia Nervosa patients (BN group), 8 Dysorexia patients (A+B group) and 13 controls. AN was significantly more diagnosed as obsessive compulsive, BN was significantly more diagnosed as histrionic, and Dysorexia was significantly more diagnosed as borderline than controls. These findings suggested that eating behaviors related personality traits. The last study was conducted with case reports of IBS. Psychosomatic therapy for IBS patients with personality disorder was more difficult than those IBS patient without it. Therefore, it was meaningful to examine PDE considering the prospective effect of psychosomatic therapy.

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Many asthmatic patients lapse into a worse condition, as they come to regard attacks as inevitable, irrespective of their own will or efforts. This appears to represent the condition that develops in individuals under repeated stimuli recognized as occurring regardless of their behaviors. It makes them see themselves ineffective and helpless in the environment. In the presents investigation, we studied this sense of 'helpless' in asthmatic patients and compared the findings with the results of psychological exminations conducted on them. The subjects consisted of 37 psychosomatic patients with bronchial asthma who visited our department of psychosomatic medicine (17 males and 20 females, aged 18-65) . They were interviewed to determine whether they felt 'helplessness' associated with their disease, and the relationship of these findings with the results of the Cornell Medical Index (CMI) and the Comprehensive Asthma Inventory (CAI) was examined. Those patients acknowledging a sense of helplessness were subjected to general psychosomatic treatment for a year and studied for the resultant clinical improvement and changes in cognitive attitudes. The results obtained were as follows : l. The subjects were classified into three groups : 16 patients felt 'helpless' ; eight who did not ; 13 who were not classificable. 2. When the CAI findings were compared with those of the patients who did not feel 'helpless', a significantly greater proportion of the 'helpless' patients thought that their disease was incurable and that they would remain incapacitated until they were cured of it. Their scores were significantly higher in suggestibility, anticipatory anxiety, disease evasion, pessimistic views of their prognosis, and loss of therapeutic efforts. 3. As the result of general psychosomatic treatment, 14 of the 16 'helpless' patients showed a significant improvement in their severity of bronchial asthma and pulmonary functions, along with improved scores in all CAI items mentioned in #2. It was thus concluded that the CAI was useful in evaluating the 'helplessness' in asthmatic patients, as it is tailored specifically to suit those patients. Furthermore, the condition appeared to improve with pychosomatic treatment, whose effectiveness could be evaluated again by means of the CAI.

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Rheumatoid arthritis (RA) is an intractable disease with continuous severe pain and functional disturbance in the advanced stages. The RA patients have many types of stress, such as pain, limitation of activities of daily living (ADL) , and anxiety about joint deformity in the future. The purpose of this study is to grasp the concepts of stress and stress-coping, factors which may influence the behavior pattern of RA patients. The subjects were 19 RA patients (5 males, 14 females) who were receiving regular outpatient treatment at our department. The controls were 17 patients with somatoform pain disorder but with no organic lesion (P group) (4 males, 13 females) . 111 normals (N group) (63 males, 48 females). For the study, we used Stress and Stress Coping Questionnaire (SSCQ) including character, factors as well as other variables. We administered Cornell Medical Index (CMI), Self-rating Depression Scale (SDS) and Self Grow-up Egogram (SGE) to the RA patients and P group as well. The results of the SSCQ were as follows : In life events and daily hassles, stress factors, the RA patients showed a lower total of points than the P group. In uplifts, of all the stress-coping factors, the RA patients showed higher points than the P group, but lower points than the normals. In hardiness, another stress-coping factor, both the RA patients and the P group showed lower points than the N group. The results of the CMI and SDS of both the RA patients and the P group showed neurotic tendencies and mild depressive states. The average egogram pattern of the SGE of the RA patients also resembled that of the P group. The behavior pattern of the RA patients, however, was greatly influenced by the depressive state. The practical conclusion is that the RA patients have difficulty coping with stress, and they are aware to a minimal degree that they suffer from stress. Furthermore, great care should be directed to the evaluation of quality of life (QOL) of the RA patients because their behavior pattern influences their depressive state. Therefore, it seems to be important for us to understand the characteristics of stress-coping of RA patients in our medical treatment.

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Psychological tests were administered to patients 2 months after the initial diagnosis of diabetes to determine personality traits characteristic of diabetics and to study the psychological aspects of diabetes control. The patients studied were diagnosed for the first time as having non-insulin-dependent diabetes mellitus (NIDDM) at this hospital, and were all under the age of 65. Subjects with HbA_<1c> of 7. 5% or more at the time of initial diagnosis were considered as having diabetes mellitus (the DM group). At 6 months after diagnosis, those DM patients who had HbA_<1c> under 7.5% were classed as well-controlled (15 cases) , and those with HbA_<1c> of 7.5% or more were classed as poorly-controlled (13 cases). For comparison, a group of 12 healthy subjects were also studied. Methods : The DM group was subjected to a physical examination, family history, and study of the patient's life style. Two months after the initial diagnosis, a psychological evaluation was conducted, using CMI, YG, TEG, MAS, Baum test, and Rorschach test. Results : Obesity was more commom in the well-controlled group than in the poorly-controlled group. However, there was no notable difference between the two groups in insulin secretory ability. There was also no significant difference in terms of family history or alcohol and tobacco use. There was no difference between the well- and poorly-controlled groups in the written responses to the psychological tests : however, significant differences did emerge in the Baum and Rorschach tests. Based on these results, it seems that early diabetic patients experience few subjective feelings of struggle or anxiety in their approach to disease. In terms of deep personality structure, however, despite the fact that they differ little from healthy controls in terms of problem-solving or problem awareness, they lack sensitivity, maturity, personal strength, a sense of self, adaptability. This combination of traits forms a distinct trend in the diabetic personality, indicating there is indeed a possibility that personality plays a role in the onset of diabetes. The results of psychological testing for the poorly-controlled groups also show that, in terms of deep personality, such patients tend to be stubborn and less adaptable, lack will power and self-motivation. In some cases psychological therapy may be advisable as an adjunct to medicinal. Therefore, we conduct psychological evaluation of diabetics with emotionally-caused obesity and those with family problems, and inform them about cases of clinical improvements in diabetes controls. In the course of psychological treatment of diabetic patients, it is first necessary to relieve their anxiety about functioning normally in society. Patients with poorly-controlled disease are inherently less able to cope with such anxiety. Continuing psychological therapy may thus be an effective tool towards allowing diabetics to find psychological relief.

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To discuss the diagnosis and treatment of eating disorders, we presented 2 cases which came to a good outcome, against the early prospect. Then we picked up several symptoms of inpatients of eating disorders, and examined the relationship between these symptoms and outcome. 1. We presented a patient with anorexia nervosa (dysorexia type) who came to our hospital eight years after the onset. Her minimum body weight was 22 kg. Her impulse control was poor. We performed a psychotherapy in which we believed in her ability to recover and supported her mother, and we got a good result. 2. We presented a bulimia patient who had a tendency of obsessive compulsive personality, and who had much concern with her body shape. We performed structured psychotherapy. She has improved in her eating behavior, cognition, and social adjustment. 3. We examined the relationship between symptoms and outcome of 62 inpatients. There were significant differences in the controlling tendency, isolation, relationship with their mothers, and motivation for therapy. Above all, the authors conclude that it is not appropriate to predict a poor outcome easily even if the patient has some symptoms which were reported as predictors of poor outcome. If there are some factors which can promote therapy (especially factors related to therapeutic relationship). a good outcome can be expected through appropriate therapeutic intervention.

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There has been no systematic research done on children with eating disorders in Japan up to this point. We, the physicians at the branch of pediatrics of Osaka University Hospital, Schousinen, and The Psychosomatic Children's Clinic investigated our subjects with eating disorders bet. ween April 1976 and May 1993 (17 years and 2 months) to know the characteristics of childhood eating disorders. We have examined 123 subjects who met diagnostic criteria for anorexia nervosa from the Ministry of Health and Welfare and for bulimia nervosa from DSM-iii-R. There were very few subjects below the age of 9,several subjects between the ages of 10 and 12,but the numbers increased gradually for subjects over the age of 13. We devided the subjects into three groups according to age : childhood, pre-puberty, and puberty in pediatrics. The subjects below the age of 12 showed no evidence of secondary sexual development. Therefore we considered that subjects below the age of 12 were typical pre-pubertal characteristic samples in childhood. There were 20 samples below age of 12 (18 girls and 2 boys) . Most of them had nearly the same characteristics as the adolescence cases except for binge eating and vomiting. Therefore, therapy for "under-age-twelve" samples was the same and equally difficult as therapy for adolescents.

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One of reasons for difficulties of recovering from eating disorders (E.D) is switching from one type to another in 3 types of E.D, namely, (1) Anorexia Nervosa Type, (2) Bulimia Type, (3) Bulimia Type through Anorexia Nervosa conditions ("switched Bulimia Type"). It is necessary to predict the type of the E.D patient with the symptoms of anorexia ; namely, whether the patient is Anorexia Nervosa Type or switched Bulimia Type, before examining a treatment plan. We gathered significant data on differential diagnosis of E.D type according to the results of a research (n=123) on family pathology and of psychological tests (Baum test ; n=59,Landscape montage technique (L.M.T) ; n=51). The family pathologies include inadequate quality of family functions and maternal problems. The Bulimia group has those traits (family malfunction or/and maternal problem) more significantly as compared with the An. N group. The Bulimia group showed significant results of Baum test and L.M.T. Concerning the Baum test ; pressure of drawing, the thickness of a trunk, form of Baum crown, etc. are important. Concerning L.M.T ; position of a river, existence of a bridge, figure of a person, etc. are important. As to the treatment for Bulimia Type, a re-parenting method was applied which was based on D.W.Winnicott's theory. We presented a case to which this method was applied.

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This report deals with the long-term prognosis of anorexia nervosa (AN) patients, particularly in the case of drop-outs. The main feature of our AN therapy is behavior therapy consisting of group therapy and behavior counseling during hospitalization. Family members are also instructed regarding our therapeutic goals and methods in order to enlist their help as co-therapists during to critical stages of treatment. The most critical stages are a) when the patient obstinately refuses to cooperate during the early stages of therapy and b) when the patient drops out of therapy against medical advice (AMA). Of 112 consecutive AN cases admitted in our hospital, 109 were followed by phone or interview at least 4 years after discharge. They were classified as follows : Group A (n=68) consisted of patients who completed treatment without significant rejection of our therapy, Group B (n=22) were patients who rejected our therapy and left the hospital AMA but, with the help of family members, were persuaded to complete the treatment and Group C (n=19) were patients who, after dropping out, were not successfully persuaded to resume treatment. The Global Clinical Scores (GCS) of Garfinkel et al. and the production of children after inpatient treatment were used to compare the outcomes. The proportion of patients with 'excellent' outcome in their GCS was 70. 6% in Group A, 59.1% in Group B, and 10. 5% in Group C [A vs. B, ns ; A vs. C, p<0.OO1 ; B vs. C, p<0.O1]. Thus, 'obstinate' Group B patients had statistically similar prognosis when compared to the 'tractable' Group A patients. Among the patients, 20. 6% (Group A), 45. 5% (Group B), and 5. 3% (Group C [A vs. B, p<0.05 ; A vs. C, ns ; B vs. C, p<0.05] had children after inpatient treatment. Thus, Group B patients had significantly more children than the other groups. Therefore, we believe that family therapy (family members as co-therapists) is the key to the successful treatment of drop-out patients.

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In recent years, cognitive-behavioral therapy has become prevalent not only in Western coun. tries but also in Japan. There are some reasons for this. First, cognitive-behavioral methods are directly concerned with thoughts and feeling that are imporatnt in psychiatric and psychosomatic disorders. Secondly, these methods have scientific basing and are more amenable to evaluation in clinical trials. Thirdly, cognitive-behavioral therapy is comparatively easy to use. It can be applied to depressive disorders, anxiety and obsessive disorders, eating disorders, and certain somatic problems, etc. Our research group made a manual of cognitive-behavioral therapy for anorexia nervosa supported by the Ministry of Health and Welfare in 1991. We also revised a manual for clinical study of anorexia nervosa in 1992. The aim of this study is to compare cognitive-behavioral therapy with an operant conditioning treatment with brief psychotherapy. This is a multi-center study that was begun in October, 1992. In this paper, we will outline our manual of cognitive-behavioral therapy, and the revised one for clinical study, and make an interium report of the study in our department.

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The author reports here on group therapy for the mothers of eating disorders patients, which has become extremely significant since it was incorporated into the overall treatment of such disorders in February 1991. 109 cases (73 patients) were hospitalized and treated in this manner at the Second Tokyo National Hospital over the past five years (from 1988) , accounting for 140/0 of the total psychiatric patients in a 26-bed ward. Group therapy for the mothers is run once a month for 90 minutes. As the treatment does not involve a set number of sessions, the mothers of new patients just join the pre-existing group. The mean number of participants has been 7. 3 per session although the optimal number would be 10. Besides a psychiatrist, the staff includes highly experienced professionals from various fields : 2 psychotherapists, 2 nurses, as well as pediatricians and psychiatric residents who joined the group later. The topics cover all the problems involved, in eating disorders. First discussed were symptom-related problems, but this gradually gave way to more psychological issues as the number of sessions increased and recently the group psychotherapeutic character has become stronger. This attempt has provided the mothers with : 1) catharsis ; 2) knowledge and understanding of eating disorders : what other mothers have experienced has a big impact and helps mothers realize that it is not that simple, that it will take time and patience ; 3) a lesser degree of anxiety : as the mother's attitude stabilizes, the atmosphere at home becomes more relaxed, which favorably influences the patient ; 4) personal insights as well as insights into the mother/child relationship or the intrafamilial dynamics. The unity and nature of the staff, their eagerness, their knowledge and understanding of eating disorders, are all important to the success of group therapy. This attempt has proven more efficient and more effective than individual family therapy. It is also excellent training for the staff, significantly raising the quality of the therapeutic team. As far as the author knows, there are presently 10_facilities in Japan that provided group therapy for mothers of eating disorder patients. These can be divided into two types : 1) not only educational but also psychotherapeutic groups, and 2) self-help groups, or educational groups. The former, psychotherapeutic groups of 10 or so members, are run by psychiatrists or psychotherapists, whereas the latter are run in internal medicine or psychosomatic medicine units and are much bigger groups. The needs for such groups is very great and we hope that more facilities will see the importance of this endeavor.

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