Although the relationship between vasospastic angina and stress has been pointed out, there are few studies focusing on this relationship. This study, therefore, explores the relationship between stress and the deterioration of vasospastic angina through four patients with vasospastic angina who showed alexithymia, over-adaptation and poor awareness of stress. Four patients with vasospastic angina resistant to treatment were followed for an average of three years. In these cases, coronary spastic obstruction without significant coronary stenosis was documented by ergonovine maleate infusion to the coronary artery. Various psychological tests including the MMPI Alexithymia Scale, CMI, SDS test, and a structured interview for type A behavior pattern were performed on these patients. These tests and clinical interviews showed the following psychological and behavioral characteristics : l) All of these patients had the alexithymic trait and the tendency to over-adaptation. 2) Case 3 was neurotic, and case 1 and 3 had depression. 3) Only one (case 4) showed type A behavior pattern. Case 1,2,and 4 were obviously under chronic stress and case 3 had a history of peptic ulcer and bronchial asthma, both of whom were resistant to treatment. All of our cases were supposed to be under chronic stress. Three (case 1,2,and 4) of them showed marked deterioration of vasospastic angina and preceding acutely stressful events were documented at almost all episodes. The remaining one (case 3) also showed marked deterioration, but acutely stressful event proceeding each of the episodes could not be documented. Case 1 had manic depressive disorder, and suffered four relapses of the disorder followed by marked deterioration of vasospastic angina. Though each of four patients showed poor awareness of stress, improving their awareness of stress seemed to be effective in preventing or suppressing the deterioration of vasospastic angina. It is supposed that the alexithymic trait, the tendency to over-adaptation, and poor awareness of stress play important roles in producing chronic stress. The alexithymic trait and the overadaptative tendency, combined with mental and/or physical strains, easily produced a chronic stress state in these patients. It is assumed that the addition of an acutely stressful event to patients with vasospastic angina under chronic stress leads to marked deterioration of vasospastic angina. It took more than several days for an acutely stressful event to evoke deterioration of vasospastic angina. When managing patients with vasospastic angina, it is important to know that the alexithymic trait, the tendencies to over-adaptation, poor awareness of stress, and stress itself play important roles in causing deterioration of vasospastic angina.

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The object of the present survey was to reveal the difficulties and stress experienced by the medical and paramedical staff caring for the terminally ill and their families both in medical cancer wards and in palliative care units. We sent questionnaires to 215 doctors, nurses and other paramedical staff working on the medical wards of the National Cancer Center and in the palliative care units of three general hospitals. 166 (77. 2%) of the subjects returned the questionnaires. The present paper analyzes the responses of 95 nurses in their 20's and 30's : 1. Our results indicated that 96. 8% of the nurses found it stressful to care for terminally ill cancer patients. 2. The types of stress experienced by the nurses differed between medical cancer wards where most patients are in intensive chemotherapy and palliative care units which aim at making the terminally ill as comfortable as possible. 3. Most of the nurses of the National Cancer Center found it difiicult to practice terminal care in medical cancer wards.

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We stated in a previous study that it is difficult to carry out advanced medical management and terminal care in the same ward and that it is necessary to separate medical oncology programs by specialties. The object of the present study is to reveal why the number of palliative care units and hospices is not increasing rapidly in Japan. We sent questionnaires to 327 doctors, nurses and other paramedical staff working on the medical wards of the National Cancer Center and of a general hospital as well as in the palliative care units of three general hospitals. 264 (78. 3%) of the subjects returned the questionnaires. The present paper analyzes the responses of 148 nurses in their 20's and 30's. The results may be summarized as follows : 1. Most nurses believe that terminally ill patients are best cared for in palliative care units or hospices. 2. The main reasons cited for the negligible increase in palliative care units and hospices are "the unsettled issue of whether or not to inform the patients of their illness and prognosis", "the lack of death education" and "financial problems in palliative care units which are unprofitable". 3. Over 60% of the nurses at the Cancer Center and in palliative care units consider it generally better to inform the patients and expect the number of palliative care units and hospices to increase in the future. However, approximately 35% of the nurses of the general hospital disagree with the latter opinion although they agree with the former.

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A large proportion of the general population are said to have bowel movement disturbances, but most of them do not consult doctors. Patients with irritable bowel syndrome (IBS) are more sensitive to their symptoms, and more distressed by their symptoms than non IBS patients. This may suggest that IBS patients are more psychologically disturbed than non IBS patients. We investigated the relations between the subtypes of IBS and psychological assessment based on DSM-III-R. A psychological assessment was made by the doctor who diagnosed and treated the patient, taking account of psychological tests as well as drug responses. The subjects included 53 male and 64 female patients with IBS who visited the Department of Psychosomatic Medicine, Kyushu University and the Department of Psychosomatic Medicine at the Saiseikai Fukuoka General Hospital during the period of April, 1985-June, 1991. We subdivided bowel movement disorders of IBS into 5 subtypes-diarrhea type, constipation type, alternate type, gas type, and unclassified type according to the dominant bowel movement disorder examined at the first visit. The results are summarized as follows : l) A depressive disorder accounted for about 70% of diarrhea and alternate types of IBS and about 60% of constipation type of IBS. 2) The gas type IBS was quite different from the other types regarding psychological features. 3) Maladjustment was most often recognized in the gas type of IBS while overadjustment was most often recognized in the constipation type of IBS. 4) Antidepressants proved to be most effective for all types of IBS.

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Patient was a 64-year-old male with lung cancer who underwent right upper lobectomy. Severe pain of surgical scar continued after this operation. Since the trials of local anesthesia and epidural block were not effective sufiiciently, electro-myographic (EMG) biofeedback therapy with a device of P 303 (Cyborg Company) was attempted to relax internal and external costal muscles contraction. The initial EMG Ievel before therapy was 30 μV. After one hour therapy, it dramatically decreased to 3 μV. The EMG level decreased to 1.25 μV by the further therapy. However, the level happened to increase to 160 μV as strong pain developed and became out of control. By 2 weeks therapy, the post surgical pain disappeared almost completely and the patient could control both EMG level and his pain with this therapy. This case suggested that EMG biofeedback therapy was one of the very effective treatment for the post-surgical pain intensified by the sustained muscle contraction.

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A sixty year-old woman was admitted to our hospital because of frequent belching. She began to complain of belching with chest pain from 6 months before the hospitalization, when she was stressed by her family. She maximally belched 1000 times per day. Video-analyzed upper gastrointestinal series after the admission revealed sliding esophageal hiatus hernia, gastro-esophageal refiux and turning back phenomenon of esophageal gas. Esophageal manometry showed decreased pressure of the lower esophageal sphincter and decreased amplitude of the esophageal peristalsis. Furthermore, the esophageal contraction amplitude decreased more under mental arithmetic task. Cisapride and clonazepam were administered for regulation of disordered esophageal motility via 5-HT 4 and benzodiazepine receptors. Autogenic training was performed to reduce the sympathetic discharge, which lowered the esophageal contraction amplitude. As a result, the esophegeal contraction pressure tended to increase with concomitant decrease in frequency of belching. Our case suggested that belching might be one of the important signs of esophageal motility disorder. Besides, autonomic dysfunction caused by stress was thought to worsen disordered esophageal motility and to trigger belching. A further study is necessary to clarify the relationship between belching and esophageal motility.

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It is well-known that some cases of food allergy are strongly influenced by psychological factors. Sometimes the presence of anxiety and/or fear prevents symptom relief during systematic desensitization, which is applied to such cases. We report a food allergy patient with successful desensitization under hypnosis after abreaction of her fear and anger toward her ex-husband in relation to the food allergies. Case : A 52-year-old female patient was admitted to our hospital complaining of urticaria after eating fish. Symptoms began about six months prior to admission. Single-blind food challenge tests were given to her using fish, which had seemed to cause her urtiearia, but consistent data were not obtained. She was treated with systematic desensitization under hypnosis, but started to resist imaging the fish during the sessions. When the therapist asked her about the reason under hypnosis, she answered that the fish reminded her of her ex-husband whom their children wanted her to remarry, and tearfully reproached her ex-husband for what he had done to her. After this abreaction she was able to move on to further steps in the desensitization program. After treatment, the previously positive intradermal reactions to various kinds of fish, as obtained just after admission, turned to negative, and urticaria did not reappear after eating fish. She also decided not to remarry her ex-husband and was discharged from hospital successfully. To conclude, these findings suggest that abreactive expression of emotions can improve the outcome when the patient does not progress during desensitization and symptoms remain. Abreaction also seemed to decrease this patient's allergic reactions, and to cause a change of her attitudes toward reality.

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We conducted a psychosomatic approach to a patient with refractory chronic urticaria (62-yearold female) , and obtained effective results. Although this patient had received various treatments at several hospitals, she had experienced strong drug side effects and therapy was thus not indicated. Her itch was so severe that she rubbed the skin until it bled. Consequently, the treatment was difficult. In a psychological interview conducted after she was discharged from hospital, her background was made clear in that as she had chronic mental tension to ward living due to her developmental history and also had strong feeling of mistrust with aggressiveness in medical care due to her daughter's death. When she received appropriate psychological treatment for her negative emotion, drug therapy became possible and her symptoms were relieved with reduction of serum IgE level.

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A 23-year-old woman was carried to our hospital as an emergency case by ambulance because of loss of consciousness at home. She had been suffering from anorexia nervosa since 1989,when she was 20 years old. She had admitted in other hospitals 8 times prior to this admission. She referred to the intensive care unit because she was in a state of coma and needed to control her respiration by respirator. Physical examination showed as follows ; blood pressure 110/76 mmHg. body temp. 33. 8℃, pulse rate 55/min, body height 153 cm, body weight 24. 1 kg. Neurological findings revealed that brain stem response was stable and focal signs were not detected. Laboratory data revealed severe hypoglycemia (blood sugar was 20 mg/dl), severe liver dysfunction and normal oxygen saturation of arterial blood. We diagnosed her as anorexia nervosa accompanied with hypoglycemic coma. In spite of intravenous injection of glucose, her consciousness level did not resume. Furthermore she had status epilepticus with tonic seizure. Her electric encephalogram on the second day showed slowing of the background activity and that on the fourth day accurately showed periodic synchronous discharges (hereafter PSD) . She showed responses to phenytoin so that PSD was disappeared and her consciousness level was rapidly repaired. Then she markedly regressed and rejected our therapy. So we received her supportively and recommended her father to participate in our therapy positively. Then she could take 1600 kcal diet without resistance and gained in weight while her father took care of her. Though she couldn't change her slender idea, she became able to establish a good relationship with us and leave hospital. Hypoglycemic coma and/or epileptic seizures in cases of anorexia nervosa are rare events. Furthermore PSD has never been reported. We guess our case fell into severe brain damage due to hypoglycemic encephalopathy because appearance of PSD is indispensable to diffuse damage of brain cortex. We found it later that the therapeutic course of this case was successful because insulin shock therapy was combined with reparenting therapy. Her father's acceptance of her regression brought back her psychic stability and basic trust between them.

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