In recent years, "Generality and Speciality" has been being discussed frequently and intensively in various fields of medical care. Some examples include one for cancer patients, another in infectious diseases, etc. However, when we compare these instances one another, it is not difficult to see some differences inbetween as to meanings as well as their back-grounds. In psychosomatic medicine particularly, its generality seems to be especially important, though its speciality can by no means be ignored. Concerning psychosomatic medicine, it seems to have strong relation with a certain, very large flow or change in the way of thinking existing not only in medicine but also in science and technology in general.Since I happen to be now in the position where the theme of "Science and Technology" is widely analysed and discussed to provide for the future policy in the government, I have many opportunities to think about medical care also, from such a view point. Now, I believe that the attitude seen in psychosomatic medicine really matches with the direction which is strongly requested by the public of all over the world.

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In this article, the recent trend and problems of behavioral medicine in Japan were reviewed. First, the definition and characteristics of behavioral medicine were discussed. As a result, it was pointed out that there were large individual differences in understanding of the definition, and five characteristics of behavioral medicine were identified. Second, the genealogy of behavioral medicine in Japan was summarized. Third, the recent trend of behavioral medicine in Japan was compared with that in the world. The results were as follows : (1) The number of members of the Japanese Society of Behavioral Medicine was small. (2) The fields of study were wide but the quality of studies was not very good. (3) It will take a long time to systematize behavioral medicine in Japan. Fourth, the approaches found in the main papers of behavioral medicine were discussed. And finally, two tasks in behavioral medicine were proposed. One was to arrange an educational system and a training system both in medical science and in behavioral science. The other was to arrange a system to carry out joint studies. Behavioral medicine is interdisciplinary, so that the accomplishment of these tasks is necessary to provide a common foundation and to produce good results in researches.

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The purpose of this study was to examine the effects of cognitive-behavioral intervention for diabetes patients. Forty-one non-insulin dependent diabetes patients with case histories of three years or more were randomly divided into either intervention group (n=20) or control group (n=21) . Subjects in the intervention group joined to a psychoeducational program including self-monitoring, homework assignment, selfreinforcement, and self-instruction for sixteen weeks. Changes in psychological stress responses, way of coping, self-efficacy, and social support were assessed during the training program. Changes in blood sugar level was also measured during the program. Subjects in the intervention group were divided into two groups according to the level of motivation for the program (n=11 in high motivation (HM) group and n=9 in low motivation (LM) group) . The major findings were as follows : (a) Patients in HM group showed a significant increase of knowledge about disease than patients in LM group after the program. (b) Patients in HM group could attain self-control of eating behavior and modify their eating styles. (c) A significant decrease of HbA_1c was found in HM group. (d) Patients in HM group learned to do adequate coping behavior with stress responses related to chronic disease. Clinical implication of the effectiveness of cognitive-behavioral intervention to chronic diseases was discussed from the viewpoints of psychoeducational program of self-control in order to promote health behavior.

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The disease structure has changed in recent years. The frequency of chronic disease, especially adult disease, has increased in each generation. Adult disease is_ called habitual disease and is strongly affected by the wrong life style Thus "behavior" rs one of the most important therapeutic factors. "Behavior" as used in this paper includes overt behavior, Ianguage, emotion, visceral function, etc. Behavior medicine can objectively evaluate complicated human behaviors based on the behavior theory.Very few doctors who rely on biomedical models can easily diagnose and treat psychosomatic disorders. Psychosomatic disorders can be easily recognized using a "behavior" model. Knowledge of behavior therapy also enables smoothly practice team therapy for psychosomatic disorders. The treatment of chronic disease is largely dependent on self-control, so, behavior medicine may become one of the most effective treatments in the future. Behavior medicine includes a detailed analysis of behavior by interview, psychological tests and somatic examinations. Following the behavioral analysis, we select the appropriate method (s) of treatment for the problem behavior. The basic principle of behavior therapy is to extinguish the inadaptive behavior and reinforce the maldaptive behavior. Mothods in behavior therapy include respondent conditioning therapy, operant conditioning therapy, aversion therapy, cognitive therapy, biofeedback therapy and muscle relaxation therapy. Generally speaking, the somatic component of the disorder is treated using some methods of internal medicine. It is necessary to confirm the therapeutic effect of both behavior therapy and internal medicine procedures during the treatment process. This paper describes a hypothesis of mechanisms of onset in psychosomatic disorders from the behavioral point of view and our practice of behavior therapy for internal disorders.

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We have been performing various treatment outcome researches as a trial of applying behavior scientific methodologies to the field of psychosomatic medicine. The purpose of this paper is to discuss the impact of such researches, based on the results of our controlled study of cognitive behavior therapy (CBT) for eating disorders and single-case study of photic feedback (PFB) . We have been doing a group outcome research comparing CBT with operant conditioning p]us brief psychotherapy for anorexia nervosa. Fifteen patients have participated in the study and six of them have completed the one-year follow-up for 2 years and 8 months since the start of this study. The following problems have emerged so far : (1) The number of patients introduced to each group was very different. (2) There have been many serious or atypical cases who could not participate in this study. (3) Therefore, much more time and effort will be necessary for the completion of the study, which will produce the problem of cost effectiveness and the deterioration of data quality. Some significance has been also noted : (1) We have learned to assess the seriousness of patients based on a certain criterion. (2) The common understanding about the treatment has been shared thanks to the treatment manual and supervision. (3) Whether the CBT has specific effects on anorexia nervosa will be clarified if the number of participants grows larger. PFB can enhance the alpha rhythm without subjects' own effort. We have applied it to 28 patients of various neuroses, psychosomatic diseases and depression following the single-case experimental designs. The precise case study of a 37-year-old neurotic depressive patient is presented. According to the changes of the MOOD, his depressive mood was clearly improved by this treatment_ Detailed data analyses of various autonomic measures indicated that the alpha enhancement may have produced parasympathetic suppression and sympathetic predominance, which then improved the patient's depressive symptomatology. The problems were as follows : (1) The generalization of one case is not necessarily possible. (2) Much effort was needed for data analyses. The significance was as follows : (1) We have learned to assess the treatment effects more objectively than before. (2) We could know something about the mechanism of action as mentioned above. (3) A means of studying the treatment process itself was obtained, which is a necessary condition for the optimal regulation of patients' mind and body. Thus, although the introduction of treatment outcome researches accompanies many serious problems to be solved, it may bring about the following promising fruits or by-products : the refinement of diagnosis and assessment methods, the common understanding about the treatment, the objective assessment of the treatment efficacy, the suggestion about the mechanism of action, and the establishment of a means of studying the treatment process itself.

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We reported the present condition of behavioral medicine practiced at The Department of Psychosomatic Medicine, Toho University School of Medicine in order to understand how to use a behavioral approach in clinical medicine, as we wish to make clear the role of behavioral medicine in the future. In our department we applied the behavioral approach chiefly to (1) functional diseases, (2) chronic diseases and (3) consultation-liaison services. We used behavioral theory to understand the meaning of patients' behaviors instead of using it for introduction of special treatment. We discussed some difficulty as we use the behavioral approach from the view points of treatment structure, treatment purpose, treatment course and treatment method. Finally, we have come to a conclusion that we have to manage several treatment modalities according to the state, intelligence, object-relationship of the patient instead of applying the behavioral approach to al patients.

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Since Freud, S. started studies on hysteria, a study of the linkage between psyche and soma has begun. From that time on, the explorations of psychosomatic disease have been tied with the development of psychoanalysis. Psychiatry in the US integrated psychoanalysis with dynamic psychiatry, which has activated psychosomatic medicine. Most of the researchers of psychosomatic disease have been interested in the associations between the development during the earliest period of life and the onset of psychosomatic disease. Recent advances in infant psychiatry is remarkable. In addition to emotinal mother-infant interaction, for example, emotional availability, it was found that in the process of the interaction, emotions were processed cognitively (primarily in the symbolism of language) and experienced subjectively as "feelings" and the cognitive processing of emotions fosters the creation of memories, fantasies, and dreams, which further help in containing and modulating states of emotional arousal. This self-regulatory function is taken notice in infant psychiatry, and some investigators have presumed that the failure of self-regulation leads to somatization. Moreover, in order to understand the therapeutic relationship, psychoanalytic group dynamics and study of object loss and so forth, psychoanalysis has made a great contribution to psychosomatic medicine.

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In this paper, I mainly try to illustrate the psychoanalytical psychotherapeutic process of a female psychosomatic patient. I present the case material because I want to show how and for what psychoanalysis/psychoanalytic psychotherapy actually works. Psychoanalysis and psychoanalytic psychotherapy would bring about one's psychic change, that is some transformation in patient's personality. This change in patient's mind leads not only to the improvement of physical symptoms, but also to the modification of excessively cruel ethics, the broadening of patient's personal relations, the promoting patient's quality of life and some understanding of the anxiety which seems to be an existential one. Recently in Japan, most fields of psychosomatic medicine seem to have repudiated psychoanalysis as an ancient relics, as if psychoanalysis were useless and anti-scientific. Then, so called scientific methods have eager]y introduced into the fields. However, it seems to me that no other method or technique of understanding the patients' mind is so deep as psychoanalysis really is. And I wonder this could be the firm and precise reason why we still need psychoanalysis and psychoanalytic psychotherapy in our psychosomatic medicine, even though these treatments require some long years and extraordinarily persevering devotion on the part of the both parties, namely therapist and patient.

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To consider the meaning of psychoanalytic psychotherapy in the treatment of psychosomatic disorders, the author presented a case who was in difficulty in going to school because of the hypotension-like symptoms was presented. A case was 21-year old female. She was unable to be aware of what she felt, and somatized easily when she had problems. In the therapy, she also somatized easily under the situation where her problems were reactivated in the relationship with the therapist. As the psychoanalytic psychotherapy proceeded, the patient began to know the existence of problems which used to appear as physical symptoms. That was the entry for her to solve her problems all by herself. Through this case, it can be said that one of the important meanings of psychoanalytic psychotherapy in the treatment of psychosomatic disorders is that the therapist helps patients become aware of their emotions through their presenting physical symptoms, and facilitate their mental growth.

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Somatic illness always involves some object loss for the patient, which means that each somatic patient has his own task of mourning work to do. In order to support this, psychoanalytically understanding of somatic patients is essential in psychosomatic medicine. This report illustrates its clinical application and some findings are noted. First, key concepts are reviewed, such as object loss, mourning work and escape from it, especially through manic defense. Based on them, two clinical cases are shown, which had been brought in from physicians. (1) Case 1 : Nephrotic syndrome (minimal change group). At the onset, she was a junior college student studying to be a kindergarten teacher. She was attacked by anxiety and apathy soon after giving up her course, and was introduced into supportive psychotherapy and later, psychoanalytic psychotherapy. The general understanding would be that the loss of aim and health had brought about her condition as a reactin to object loss. Nevertheless, another former object loss was revealed through psychotherapy ; the inner loss of parents in adolescence. Her diligence to become a kindergarten teacher could be considered a kind of manic defense against that object loss. The aim itself could be an identification with her mother from whom she was separating. Her defenses were broken down by physical illness, and her mental symptoms emerged. This individual understanding was made possible from the psychoanalytic view. (2) Case 2 : Diabetes mellitus. The patient was a middle aged, active housewife. She fell into a depressive state after severe diet regulation for DM. Pharmacotherapy was applied at first. She was gradually recovering from the depressive state, when she suddenly broke down and receded because of her inappropriate exertion. Then intensive interviews were set up to assess her psychological problems and reconsider the treatment. She had found it difficult to deal with her adolescent offsprings before the onset of DM, which was accompanied with increased consumption of food and beverages. This seemed to be a manic defense against inner object loss as a mother. Diet regulation caused her to give up the defense way, which brought on the depressive state. Further, she had had several deprivations from the early stage of her life. Her way of coping with them was mainly by manic defense, and mourning work for them had been unfinished. What was demanded therapeutically was introducing her to mourning work so that she could abandon manic defense. On this understanding, psychoanalytic psychotherapy was started. In conclusion, with somatic patients, the role of past object loss which has not been worked through is emphasized. Some may lose mental stability when somatic illness deprives them of their defense mechanism against that object loss. Psychoanalytic understanding of their life history and their degree of maturity to manage object loss would contribute to providing adequate care, and give them an opportunity for mental maturation.

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