Anxiety and depression, which are fundamental symptoms not only in the psychiatric field but a]so in the whole field of clinical medicine, are reviewed from a neurochemical and neuropharmacological viewpiont, and a few of current topics about these states are introduced briefly. On a basis of the above background a neural mechanism of appearance of depressive state derived from the chronic aversive stress is discussed with focus on the serotoninergic neuronal system, especially on imbalance between 5-HT1 and 5-HT2 subtype serotoninergic system, which is thought to appear from hyperglucocorticoidemia during the chronic stress. Vulnerability to be in this state is thought to depend upon resilience factors of an individual, such as a good social support, a good experience of bringing up by parents, great self-respect etc., and action of these resilience factors is also supposed to control by 5-HT1 neuronal system at hippocampus, which is named as the medial raphe - hippocampal serotoninergic resilience system.

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This paper introduces changes in the concepts of somatoform disorders and psychosomatic diseases using the international disease classification systems of ICD-10 and DSM -IV, which are the most widely used at present. Since these two systems were developed for different purposes, it is expected that it will take a long time before there is complete agreement between them, in spite of an attempt to incorporate one system into the other. In this paper, similarities and differences in the diagnosis of the above disorders between the two systems are discussed in detail. International frequencies of related disorders are also discussed. For the Japanese data, frequencies for those disorders identified in the outpatient clinics of internal medicine, obtained in our WHO collaborative study are presented. According to judgements made by psychiatrists, of those patients who attended the outpatient clinics of internal medicine in Nagasaki, about 15% had some kind of psychiatric problems. Major disorders seen included general anxiety disorder, neurasthenia and depression spectrum disorders. Somatoform disorders, although observed, were not common. It also was clear that recognition of mental disorders differed greatly between physicians and psychiatrists. Of those patients who were diagnosed as having depression by physicians, one fourth were diagnosed as being normal and another fourth as having somatoform disorders by the psychiatrists. In this paper, I suggest that such diagnostic disagreements should be openly discussed and resolved in the Society, in which specialists from the various fields gather.

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In order to clarify the current medical treatment system for eating disorders in Japan, we collected questionnaires from 444 members of the Japanese General Hospital Psychiatry Association. 95% of the respondents were psychiatrists (N = 420) with a total of 72% of these working at either general or university hospitals. 34% of university hospital -based psychiatrists, 38% of general hospital-based psychiatrists, and 15% of psychiatric hospital-based psychiatrists responded affirmatively to the item : "Treat eating disorders at both inpatient and outpatient settings at your facility". In response to the item : "Provide treatment for eating disorders as much as possible within the capacity of your facility", psychiatrists at the above facilities responded 79%, 62%, and 61% respectively. Looking at the desire to provide care for eating disorder patients for the group as a whole, 21% responded affirmatively to "I participate actively". 65% responded affirmatively to "I participate but not actively" and 14% responded affirmatrvely to "I like to avoid these patients". Age range differences were clearly seen on this item with more than 30% of the age group below 30 responding affirmatively to "I am quite interested in the treatment of eating disorders", and only about 20% for the 40 and older age group. Looking at the responses based on age then, the young physicians had much more interest in the treatment of eating disorders with many having a strong desire to treat this group. Considering that we can expect further increases in the number of eating disorder patients, it is desireable that the number of psychiatrists interested in treating this group also increase. We also looked at psychiatrists attitudes towards for illnesses which are thought to be difficult to treat in psychiatry and found that the responses to : "I participate actively" for these were 25% for "school refusal" followed by 21% for eating disorder 14% for alcoholism and 12% for borderline personality. The difficult treatment areas mentioned included, Iimitations in the staff, difficulties in team-treatment and difficulties in the treatments themselves. Additionally, Iack of time or manpower, unprofitability, inadequate understanding on the part of medical providers, and need to expand treatment facilities were noted. The future needs of the medical system include not only adequate reimbursement, but better administrative management. In addition, expanded treatment facilities along with specialty centers and team- treatment, adequate post-graduate training, and better understanding among general physicians are of great importance. Advancements in family therapy, group therapy, and self-help groups, as well as education of local clinics and schools are needed.

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It is necessary at first to improve malnutrition as soon as possible, then to introduce psychotherapy dealing with self-identity disturbance in the treatment of patients with anorexia nervosa (AN) . The authors have been using only liquid formula for nutritional rehabilitation in the initial treatment for inpatients with AN (Liquid formula therapy : LFT) . To begin with, the authors presented the first AN case who received LFT in our hospital. In this case, LFT resulted in a) favorable weight gain (4.8 kg/6 weeks) , b) improvement of her ritualistic behavior, c) marked reduction in the meal time, and d) enhancement of motivation for treatment. LFT was thought to be effective to conquer abnormal eating behaviors. Next, the authors compared patients who received LFT (LF group) with patients taking regular hospital meal (RM group) to examine the effects of LFT, and to determine the most suitable AN subtype for LFT. Compared with RM group, LF group showed a) steady increase in calorie intake and body weight, b) more stable defecation that avoided exacerbation of fat phobia due to gastrointestinal discomfort, c) promoted motivation to recovery. The most suitable AN subtype for LFT was found to be the restricting AN patients with long duration of illness. In terms of psychological implications, LFT enacts the separation-individuation process in infancy, and gives psychotherapeutically valuable findings. Finally, we discussed about the problems of LFT. The common obstacles for LFT is patients' resistance to LFT due to their disgust of liquid formula. However, this problem can be solved by therapist's consistent psychoeducatoinal approach. We conclude that LFT is very effective in the initial treatment for inpatients with AN.

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The number of patients with bulimia nervosa who consult a doctor on their own initiative is larger than that of patients with anorexia nervosa who consult a doctor by themselves. The number of patients suffering from bulimia nervosa and giving up their treatment by themselves is, however, also larger than that of patients suffering from anorexia nervosa who give up treatment arbitrarily. The treatment processes of patients with bulimia nervosa are liable to be prolonged and, what is worse, there would be many complications. Therefore, having the continuity of treatment, periodical clinical examinations, and constant strokes facilitating behavioral changes by guidance for patients' Iife and/or psychotherapeutic approach are the most important factors for the care of bulimia nervosa patients. Recently, pharmacotherapy with SSRI has been noticed as a treatment for bulimia nervosa. Thus, we have investigated the effect of the early administration of SSRI to bulimia nervosa patients on the continuation of treatment. A total of 19 patients of the Psychosomatic Department of Toho University Hospital who had beed daiagnosed as bulimia nervosa by DSM-IV, and had agreed to take SSRI clinical trial at the same time, participated in this study. The result was that 8 cases (42%) discontinued their treatment during the SSRI clinical trial, and 1 case (5%) discontinued right after the trial, while 10 cases (53%) continued to be treated after the trial. This result show that treatment continuity with use of SSRI is better than that of pharmacotherapy groups with other drugs, and inferior to that of hospitalization. Thereby, it is suggested that, treatment with SSRI could be helpful to increase the continuity of treatment which is essential to facilitate behavioral changes by guidance of patients' Iife and/or psychotherapeutical approaches. It should be emphasized, however, that the effect of written consent is indispensable effect of written consent should not be ignored.

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The object of this report is to show retrospectively how we dealt with eating disorder patients' refusal to receive or continue with our in-patient therapy. Thirty consecutive patients consisting of anorexia nervosa and bulimia nervosa with a history of anorexia nervosa were admitted in our hospital from 1994 to 1995. Ten of them had refused to receive or continue with our therapy and 6 of 10 patients took the refusal action two or three times during hospitalizatnon. The causes of patients' refusal or discontinuation of the therapy included discomforts of behavior therapy (33%) , anxieties for gaining weight (22%) , anxieties for starting behavior therapy (17%) , anxieties for returning to work or school (11%) , uncontrollable impulse to over-eat (11%) and conflict with another patient in the same ward (6%) . Whenever the patients refused the therapy, we coped with the avoidance behavior in the following manner. Initially, we asked the family members to come to the hospital and explained to them the reasons for the patients' refusal. Then, they were instructed to persuade the patients to receive the therapy. Following our advice, the family memders tried to persuade to do so. Some of them, however, failed to convince the patients and agreed to their discharge. Consequently, 3 of the 30 patients dropped out of therapy.

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The cognitive behavior therapy (CBT) for eating disorders has become prevalent in Japan as well as in western countries in recent years. The aim of this presentation was the demonstration and discussion of both advantages and shortcomings of CBT for eating disorders. The following are presumed advantages : I ) Behavioral techniques can be used whose effects were experimentally substantiated. 2 ) Cognitive techniques are expected to be effective at least for bulimia nervosa. 3 ) Treatment can be performed in a supportive atmosphere. These points were discussed further presenting a case of anorexia and bulimia nervosa who was treated by CBT and recovered from illness in about 1 year. The operant conditioning technique and the assertiveness training whose effects had been sufficiently validated were primarily effective for this case. However, the assertiveness training did not work well before Katzman et al's psychoeducational approach was introduced, and thus psychoeducation, self-monitoring, and cognitive restructuring method may have played a certain role in the whole treatment. Furthermore, the multifaceted treatment itself as mentioned above could be fairly supportive for the patient. On the other hand, the following are presumed shortcomings : I ) Standard strategies of CBT should be modified especially for anorexia nervosa patients because of lack of motivation and complex interactions between mind and body. 2 ) The grounds for effectiveness of cognitive techniques are insufficient especially for anorexia nervosa. 3 ) The validated concrete guideline for making a therapeutic relationship is not presented. While the second point means that the precondition for the use of CBT with eating disorders has not been established yet, as a matter of fact, how various cognitive variables lead to the onset and exacerbation of the disease has hardly been clarified yet. We presented one of our research findings in which 'beliefs on self-appraisal' played a critical role in the causal chain of various cognitive and behavioral variables. That is, if we can change 'beliefs on self-appraisal', other variables including symptoms of eating disorders such as excessive dieting behavior can also be changed sequentially, and we can assume that the effectiveness of cognitive intervention with eating disorders was supported by this result. It was then suggested that more relevant researches should be performed before the scientific grounds of CBT for eating disorders were sufficiently established.

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Recently, the association of personality disorders and eating disorders has received much attention since the establishment of the DSM-III criteria for personality disorders on Axis II. Several studies have examined the comorbidity of eating disorders and DSM-III-R personality disorders and demonstrated that 50〜70% of eating disordered individuals meet the criteria for at least one personality disorder. In this study, the prevalence of personality disorders was assessed in 22 patients with restricting anorexia nervosa (AN) , 20 patients with anorexia nervosa and bulimia nervosa (AN+BN) and 21 patients with bulimia nervosa (BN) using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID- II) . Fifty-four percent of all subjects met criteria for at least one personality disorder. Patients with personality disorders, especially borderline personality disorder had more severe clinical features in terms of bulimic behaviors, suicidal attempts, concurrent depressive, anxious and obsessive-compulsive symptoms, psychopathology related to eating disorders and social global functioning than patients without any personality disorders. Patients with personality disorders tended to be more often hospitalized. These results suggest that comorbidity of personality disorders in patients with eating disorders has a strong influence on a variety of clinical features and appears to be related to poor prognosis. With respect to the treatment of the eating-disordered patients with personality disorders, it is important to assess the individual for overall level of functioning, treatment readiness and environmental factors when determining treatment strategies. The importance of establishing a therapeutic alliance, preparing for destructive and counterproductive behaviors, use of psychotropic medications and supporting family members should be emphasized in the treatment of these patients.

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