Twenty six rheumatoid arthritis (RA) patients and 31 healthy controls were studied to determine the effect of mood on the neuroendocrine and immune systems. Neuropeptides. catecholamine, CRF, ACTH, cortisol, Iymphocyte subsets, cytokines, and NK activity were examined prior to and following mirthful laughter induced by "Rakugo" (traditional Japanese comic stories) While plasma levels of Met-enk, ACTH, IL-6,and IFN-γ changed after "Rakugo" in RA patients, plasma levels of Met-enk, substance P, norepinephrine, ACTH, CD4/CD8,%CD57,IFN-γ changed in controls. It wvas remarkable that IL-6,which is significantly related to RA activity, decreased to one-third of the pre-Rakugo level. These results suggest that mirthful laughter may influence the neuroendocrine and immune systems, and may reduce the activity of RA.

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[in Japanese]

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Many patients experience anxiety, fear and tension at the time of dental treatment. These responses accelerate the sympathetic nervous and endocrinal functions. It is important to inhibit such states, but the anxiolytic agents which are generally administered also cause somnolence, dizziness, etc. Some dentists use autogenic training (AT) instead. In this study, we reviewed the inhibitory effect of AT and anxiolytic agents on the endocrinal system with indices of serum ACTH, cortisol and beta-endorphin. Twenty-six volunteers were studied, namely. 9 cases of the AT group, 8 cases of the anxiolytic agent group and 9 cases as a control. 0.3 ml of physiological saline solution was injected as a stimulant to the right side maxillary premolar of the subjects seated in the dental chair. AT was conducted by three clinical psychotherapists once a week up to the second formula. Learning was confirmed according to the introspection of the volunteers by using a bio-trainer made by OG Engineering Corp. The anxiolytic agent, 0.5 mg lorazepam, was administered 60 minutes prior to injection. The results showed lower serum-ACTH and cortisol values in the AT group than in either of the group treated with anxiolytic agent or the control before and after the injection. Prior to the injection, betaendorphin was higher in the AT group than in the group treated with anxiolytic agent, but lower in the control. After the injection, beta-endorphin in the AT group showed a lower value than those in the two other groups. A significant difference was observed in the control group, with a level of significance of less than 5%. The AT group showed a lower value after the injection than before in groups treated with cortisol and beta-endorphin. These results suggest that learning AT is effective for inhibiting the elevation of the endocrinal function at the time of dental treatment.

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Diffuse esophageal spasm (DES) is a motor disorder of the esophagus characterized by multiple spontaneous contractions and by swallow-induced simultaneous contractions with large amplitude, Iong duration, and repetitive occurrence. DES is known to cause symptoms such as dysphagia or chest pain, however, the cause and therapy of DES are not clearly established. There were very few reports of psychological therapy for esophageal motor disorders. We report three cases of DES remarkably improved by psychosomatic therapy ; autogenic training, supportive psychotherapy and antidepressants. Our experience shows that psychosomatic approaches are effective in treating DES patients. We suggest that psychosomatic therapy is an effective therapy of esophageal motor disorders, which are mostly induced by psychosocial stress.

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A seventeen year old female had developed severe emaciation, purpura and altered level of consciousness due to dietary deprivation for 3 months prior to admission. Pancytopenia and pneumonia were also pointed out by further clinical examinations. Intravenous hyperalimentation (IVH), antibiotics injection and blood transfusion were not effective, thus 75 /μg/day of human recombinant granulocyte colony-stimulating factor (GCSF) was administered for 4 days continuously. At the 20 th hospital day, pancytopenia and airway infection improved and body mass index (BMD increa_sed to 16.7 from 10.5. But two months after discharge, she was admitted again due to dyspnea and drowsiness. She wanted psychotherapy by a clinical psychotherapist in the intensive care unit in which Heimlich valve method and steroid therapy were performed for reexpansion pulmonary edema following pneumothorax. Then bedside session was performed 1 hour/day, based on non-verbal approaching theory. After the above combined intensive care for 4 weeks, she was discharged and an alliance was built up successfully between therapists and her. Such intensive psychosomatic care was thought to be effective for initiating continuous outclinic management of a case with anorexia nervosa who had no clear insight into her illness.

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We can find several reports on epileptic convulsion observed in the course of anorexia nervosa and bulimia nervosa, but the mechanism of this convulsion is not clear. A case of a 25-year-old bulimic female revealing grand-mal seizure due to hypoglycemia after selfinduced vomiting is presented. Initially, her eating disorder began at age 18 as indicating typical figure of anorexia nervosa, then turned to bulimia nervosa (DSM-III-R) with self-induced vomiting. She was admitted to our hospital on April 1991 because of worsening of her eating behavior and emaciation (152 cm, 28 kg) . During admission her bodyweight recovered up to 39 kg by psychotherapy and drip infusion of glucose. One evening in September 1991,she lost her consciousness and had generalized tonic-clonic seizures after self-induced vomiting following binge eating. At that time, her blood glucose level was 46 mg/dl, and she was awaked soon after 20 ml injection of 40% glucose. It was considered that the cause of her convulsion was due to hypoglycemia, thus the patient was asked the following day to perform the same eating behavior as the day before and traced the blood glucose, IRI, IRG, cortisol, GH, adrenalin, and noradrenalin level during binge eating and after vomiting. Serum IRI Ievel after binge eating was higher than expected as compared to the blood glucose level, and reactive hypoglycemia was observed after self-induced vomiting. No responses of counter regulatory hormones was detected. Her EEG showed intermittent 5-7 Hz θ-wave on a slow background frequency. The CT scan of her brain indicated normal. She complained prolonged headache until next morning after hypoglycemic attack. This is the first case report that indicated the correlation between the convulsion seen in bulimia nervosa and the reactive hypoglycemia after binge eating followed by self-induced vomiting.

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There are many reports on seasonal affective disorder (SAD) , which is characterized by depressive symptoms, hypersomnia and social withdrawal. We experienced one case of SAD following alopecia areata. She was a 27-year old part time offce worker. She had no family history of psychiatric illness. In the winter of 1983,she developed depression, hypersomnia, overeating and carbohydrate craving, but gradually recovered from her symptoms the following spring in the course of nature. After that, her symptoms of SAD appeared repeatedly every winter. On the other hand, in the spring and summer seasons, she became very happy and sometimes felt there was nothing she couldn't do. In October 1990,Ioss of her hair in a 2 cm diameter circle in the occipital area of her head was found for the first time. Continuously she suffered from a common cold with high fever, and then developed nausea and vertigo. She was diagnosed as being in a neurotic state and was prescribed medazepam, but she became more depressive. She came to our hospital in November 1990 with the complaints of alopecia areata, depressive moods, hypersomnia, overeating and carbohydrate cravings. We prescribed etizolam and amitriptyline, but no change was seen in her symptoms. Again she gradually recovered from her symptoms with the return of spring. In November 1991,she became depressive again and the symptoms of SAD reappeared, so she was admitted to our hospital in January 199Z for the bright light therapy. We started the bright light therapy (2500 Iux. 06 : 00-08 : 00) for 1 week, after which her symptoms of SAD and alopecia areata improved, although daytime sleepiness remained. Also in the polysomnographic study, REM sleep increased, frequent sleep disruption decreased and sleep efficiency was increased. After she was discharged from our hospital, she continued the bright light therapy at home for a week. Since then her symptoms of SAD reappear in winter, and we then use the bright light therapy. We need to notice the fact that her preceding symptom of alopecia areata and the symptoms of SAD improved immediately after the bright light therapy. Some reports said that psychogenic stress caused alopecia areata, and other studies said there was no relationship between psychogenic stress and alopecia areta and the immune systems took part in the pathpathogenesis of alopecia areara. In our case, she had no psychogenic stress before the onset of alopecia areata, and her symptoms appear every winter, so it is assumed that there is some kind of abnomality in her immune system that might be related to seasonality.Her psychotic Symptoms of SAD and somatic symptom, like alopecia areara, improved immediately after the bright light tyerepy. We suggest that a psychosomatic approach is needed in the treatment of SAD.

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We have experienced a 33-year-old female case who had severe, recurrent vomitings without any other somatic obstacles. Though we could neither find abnormalities in her intelligence and character nor psychiatrical problems were revealed by various psychological tests, we diagnosed her masked-depression under her unvigorous outlook. After administration of anti-depressant, amoxapine, she has become active and has had no vomiting. This case shows psychosomatically two important problems. First, some psychological tests may have little use when patients do not recognize their psychological state. Secondly, the neurological mechanism of vomiting induced by depression is still unknown. More intensive researches in these problems are needed.

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Although Post-traumatic Stress Disorder (PTSD) has seldom been discussed in Japan, it is lately becoming remarkable with reference to dissociative disorder, borderline personality disorder and any other psychopathies. A 62-year-old female met with a large earthquake in the Hanshin area of Japan, known as the Great Earthquake of Hanshin. She was shocked a great deal. After that, she had been mute, hvpoactive and apathetic state, having difficulty in eating. Eighteen days after the earthquake, she was admitted to our hospital and showed disturbance of consciousness. Her laboratory data revealed severe dehydration and hypernatremia. We gave her drip infusion and an intensive treatment. Then her general condition gradual]y recovered in two or three days, but was still suffering from anxiety, irritation, phobia, depression, obsession, sleep disturbance, nightmare and other mental disorders. We diagnosed her as PTSD by a criterion of DSM-IV and gave her some sedatives. Of all those medicines, drip infusion of clomipramine hydrochloride and bromazepam was efficacious. At present, an appropriate treatment of PTSD has not been established, but as suggested in this article, we think that medication of clomipramine hydrochloride and bromazepam is effective for the patients to recover from mental disorders caused by PTSD.

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