Studies on somatization are numerous in western countries, but scanty in our country. The purpose of this study is to examine whether or not somatization is common in primary care, and to find the types of somatization that are most common in Japan. Method : 2060 consecutive new outpatients at primary care outpatient clinic in Kawasaki Medical School hospital were analyzed during the period of December 1,1989 and March 31,1992. The 4 important questions about illness behaviors, explanatory model, personality and changes of environment, in addition to ordinary medical history were asked in the interview. The Zung's self-rating scale for depression was used when necessary. Then, the medical records of these patients were analyzed after six months at the least. Psychiatric diagnoses were made by using the DSM-III-R as a criteria. Results : 1) The prevalence of somatization was found is 742 cases (36.0%), and organic diseases in 1194 cases (58.0%). 2) There were many mild cases of somatization. 3) The study revealed that many different kinds of patients, such as schizophrenia and cenesthopathy, visited our clinic although the number of them was very small. Conclusion : Even though this study had some selection biases, it can be concluded that the prevalence of somatization in a primary care setting in Japan was as high as that of the western countries, and that although there are many different types of somatization, the mild cases seem to be more prevalent, which can possibly be taken care of by the primary care physicians.

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The purpose of this report is to present of primary health care with a psychosomatic and behavioral approach to university students. The subjects of my study are 13,000 students of Rikkyo University, Tokyo, Japan. Our health center has a close teamwork among doctors, nurses, dieticians and other university staff to promote students'health as well as to treat their illness. We studied basic habits of these students, freshmen to juniors, regarding eating, sleeping, smoking and drinking. As the result the data revealed that they skip breakfast (over 50%) from the second year of university life and cut their sleeping time (to midnight to 1-2 AM). To skip breakfast is closely related to the delay of their sleeping time. Smoking and drinking start from the beginning of university life. These results suggest the changes of their life style after entering university. In addition to these changes of life style, they began to confuse how to adapt to university life. The reasons for their confusion include the following : First, the entrance examination is extreme as if it were a battle in Japan since more than 30 years ago. Then, students have to work like a memory machine since primary school until high school. These extreme situations give heavy pressure on them and take away their chance to experience humanistic growth. Consequently, most of them do not know how to communicate each other with their poor self identity, poor patience and poor emotions on the campus (so-called Adultchild). Secondly, parents and school teachers have not paid enough attention to children's humanistic or spiritual education because of money- or material-centered attitudes which contaminated Japan since after the second world war. We also have a medical clinic on the campus. More than 3,500 students visit us during the school year (about 85% of them) with common diseases (flue, gastrointestinal trouble etc.) About 8% of them visit us with the complaints of mental problems such as maladaptation, anxiety or depressive state and psychosomatic reactions. Others are skin diseases, bronchial asthma and anemia etc. Conclusion : To practice the health care or treatment for the university students, it is necessary to indicate psychosomatic, behavioral and primary care approach because of the above mentioned reasons. We also have to recognize and make an approach to them as growing models.

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The aim of this study was to examine Primary Care and Psychosomatic Medicine from the standpoint of Informed Consent by giving the questionnaire to both medical doctors and patients. Doctors thought that they were satisfied with the information from their patients. Also they did not have trouble to have Informed Consent with their patients. On the contrary, the patients were not so familiar with the term"Informed Consent." Up to 44.0% of the patients thought that the explanation from the doctors was not well understandable or not sufficient. Three reasons were categorized as to why the patients thought explanation could not be understood well or not adequate. (1) Communication problems : 1) There was no explanation or even if there was, it was not enough. 2) Doctors' explanation was not adequate or not patient-oriented, the terms they used were too difficult to understand, and doctors spoke too fast or stammer. (2) Difficulty in understanding the medical or physical examination and treatment plan : 1) Purpose of and reasons for the medical examination were not understandable. 2) Effects and prognosis of the treatment were not clear. 3) Names of the disease, diagnoses, side effects of the medicine were too difficult to understand. (3) Complaints of relationship with the doctors : 1) Personality of the doctors was not reliable because they lost their temper and became displeased when the patients asked questions. 2) Patients thought it was hard to trust the doctors. Up to 44.0% of the patients who answered the questionnaire thought that the explanation was not well understandable and not sufficient. This meant that the doctors should more realize what the patients really want from the doctors. Also they should be more open to the patients to give information and receive questions from their patients. These results show that the patients want not only reliable medical doctors as specialists but also more open and friendly doctors. It is possible to say that compliance and effect of the treatment largely depends on the quality of Informed Consent. That is why Informed Consent should not be a mere method of reporting the result of medical examination and the name of the disease. It should also be a major start of treatment. It should be recognized as a part of primary care.

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Basic concept of psychosomatic medicine is very important, but the Ministry of Health and Welfare has not made proper evaluation of psychosomatic medicine especially from the economical point of view. Most doctors have little time to talk to their patients about their problems and patients themselves always complain that they are not satisfactorily cared for. I believe that one possible way of solving this problem is to provide a chance to let the people learn about their body and mind in a correct and interesting way. Japan Health Service Center where people can get up-to-date information about human body and mind might hold a tremendous potential for achieving a deeper understanding of ourselves.

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The specialization of medical discipline has been established and qualification of specialty is almost necessary to practice in the U.S. The physicians who mainly practice in primary care field are general internists, pediatricians and family practitioners. Family Practice was approved as the 20th specialty of medicine by the Accreditation Council for Graduate Medical Education in 1969. American Academy of Family Practitioners is the second largest academic society next to American College of Physicians and had 50,969 members as of January 1992. The curriculum for residency training in family practice is for 3 year duration and contains behavior science as well as internal medicine, pediatrics, and emergency medicine as a chief component of the curriculum. The curriculum for residency training in family practice in the U.S. almost covers that of Japanese psychosomatic medicine. The term "primary care" is not uniformly recognized by physicians in Japan. The survey to interns of 8 major teaching hospitals in Japan showed that about 40 percent of the trainees regarded "primary care" as emergency care and/or resuscitation. In the U.S., pre-graduate medical school education includes behavior science, and psychosomatic medicine is thought to be a major component of primary care, but not an independent specialty. For the purpose of improving the status of Japanese psychosomatic medicine, the following suggestions would be made through a review of development and educational system of primary care in the U.S. : 1) education of psychosomatic medicine and behavior science would be offered to medical students, 2) requirements for training of psychosomatic medicine specialists should contain basic medical specialist training in order to obtain broad based medical knowledge and skills, 3) outpatient oriented postgraduate medical education should be emphasized to meet the needs of primary care.

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Chlordiazexide was the first anti-anxiety agent marketed in Japan for the treatment of neurosis and psychosomatic disorders in 1960. And the treatment of neurosis and psychosomatic disorders was revolutionized by the clinical use of Chloradiazepoxide. Flutazolam was the first anti-anxiety agent in Japan that exclusively applied to the treatment of psychosomatic disorders in 1984. This report deals with a new therapy of anti-anxiety drugs for the treatment of psychosomatic disorders. It is based on the results of our clinico-pharmacological studies of anti-anxiety agents. 1. Cases with psychosomatic disorders display physical disorders, dysfunction of the central nervous system and social maladaptation. Anti-anxiety drugs have achieved improvement in clinical conditions through stabilizing and regulatory actions on the function of the central nervous system as shown in following case. Improvement in clinical symptoms and ulcer healing achieved by Clotiazepam treatment for 4 weeks satisfactorily paralleled the reduction of anxiety scores in the Manifest anxiety test and the normalization of circadian rhythms of blood corticosteroid in a psychosomatic case with gastric ulcer. Therefore, the drugs considered as subsidiary are now used as the primary medication in the treatment of psychosomatic disorders. 2. Anti-anxiety agents with selective action on specific organs have been developed and marketed after Flutazolam. For one thing, Alprazolam has an antiulcer action, Mexozolam has a hypotonic action, Etizolam has a muscle relaxant action, and Tofisopam has a regulatory action of the vegetative nervous system. We investigated the investigated the influence of three anti-anxiety agents on blood pressure in a psychosomatic case with essential hypertension. and a new effect of Ethyl loflazepate, a hypotonic action, was established as demonstrated in this report. Successively a new family of anti-anxiety agents, non-benzodiazepine derivative, is being investigated as a medication for vegetative dystonia. This agent improved low TII waves of the standing ECG as shown in a case with vegetative dystonia. Accordingly it is simple to select the anti-anxiety agents above mentioned to correspond to specific organ or organic system-disorders of psychosomatic patients. This is similar to drug therapy of essential hypertension with hypotonica. In Japan anti-anxiety drugs for the treatment of psychosomatic disorders have to show effects on both psychic symptoms and physical disorders of psychosomatic patients. For example, Etizolam has proved to improve anxiety symptoms and the healing process of ulcers in psychosomatic cases with gastric ulcers in our recent study. 3. The clinical effects of a daily 2mg of Ethyl loflazepate has been shown by the relationship between its plasma concentrations and its efficacy in cases with psychosomatic disorders. In conclusion, non-benzodiazepine anti-anxiety drugs display selective action of specific organs enabling a medication with low, once-daily dosages as a new pharmacotherapy for psychosomatic disorders.

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Many patients with depression visit at the department of psychosomatic medicine. It is characteristic of these patients that their symptoms are milder than the patients in psychiatry and they have more somatic symptoms than psychological. The therapeutic approach to depression may have to be modified by the patients' psychological status, because the genesis of depression is varied and depression is a heterogeneous disorder. We studied the features of these patients and their therapeutic procedures in our department of psychosomatic medicine. Eighty percent of all first-visit patients had depressive disorders (classified by DSM-III-R), and 30.2% of them were major depression, 11.8% were dysthymia and 58% not otherwise specified (NOS). The severity of depression was milder. The recent general adaptation function (GAF) of major depression was lowest in the three subtypes of depressive disorders, even though the mean GAF score of major depression was 55.4. The comorbidity of somatic disorder shows a high rate. Forty percent of patients with depressive disorders have functional somatic disorders, such as irritable bowel syndrome, migraine, tension type headache, hypertension etc. As to pharmacotherapy, many of the patients with depressive disorders in our department of psychosomatic medicine, received plural drugs such as antidepressant, anxiolytics, sulpiride, hypnotics. Antidepressants were prescribed most frequently in the major depression group. Anxiolytics and sulpiride were used commonly in all groups. As to the reason why anxiolytic and sulpiride were prescribed frequently, we have concluded that these phenomena raised from those usual antidepressants need the long period of time before main effects appear and they have various undesirable side effects. The selective serotonin reuptake inhibitors (SSRIs) are developed and emerging already as a new class of antidepressant in USA and Europe. The SSRIs have equivalent efficacy to standard antidepressant treatment such as the tricyclics, but with improved safety, a more acceptable side-effect profile and reduced risks with overdosage. Treatment expectations will be raised and a broader spectrum of patients will be able to receive treatment.

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To clarify the actual state of insomnia and use of hypnotics in internal medicine and psychosomatic medicine, (1) the prescription of hypnotics to outpatients of Kansai Medical University was analyzed at the Computer Center of the Hospital, (2) insomnia in outpatients and inpatients of the Department of Internal Medicine and Department of Psychosomatic Medicine of the Hospital was analyzed, and (3) physicians' approach to these issues was determined by the questionnaire method. The results are summarized as follows. : a) Hypnotics were prescribed to 7 to 8% of all patients of the Department of Internal Medicine : b) Insomnia was noted in 23% of the patients who were examined by the Department of Internal Medicine for the first time and in about 49% of the patients who were examined more than one time. Of these, 50% were using a hypnotic, and about a half had some anxiety about using the medication : c) 62% of the inpatients complained of insomnia, and it had begun after their hospitalization in 57% of them : and d) Psychiatrists are knowledgeable about hypnotics and have abundant experiences in using these drugs. This study revealed that the psychiatrists' approach to their patients with insomnia is appropriate, including selection of the somnifacient and the method of administration.

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