Recent development of the research on the chronobiology has revealed that clock mechanism may cause some types of disorders, such as sleep-wake rhyihm disorders and seasonal affective disorders (SAD). Bright light therapy has been demonstrated to be effective in treatment of these rhyihm disorders. In human, bright light has been shown to advance the phase of the endogenous rhythms, when the subjects are exposed to light early in the morning. Such phase advance of the rhythm may cause amelioration of rhyihm disorders. Besides light therapy both methylcobalamin (vitamin B_<12>) and melatonin are reported to be beneficial in some cases of sleep-wake rhythm disorders, although their effectiveness has not been well established yet. One possible action of methylcobalamin responsible for sleep-wake rhythm disorder is to increase sensitivity to light. This was suggested by the fact that subjects given methylcobalamin showed more suppression of melatonin release by bright light immediately after wake up during night sleep compared to subjects without methylcobalamin. Melatonin has three different modes of action which are beneficial to amelioration of sleep-wake rhythm disorders. First, it shifts the phase of the rhythm according to the time of melatonin intake, in other words, evening melatonin advances and morning melatonin delays the phase. Second, melatonin accelerate sleep itself. Third, it decreases body temperature, resulting in deeper sleep. Longitudinal follow up study of seasonal affective disorder revealed various types of course. About half of patients with SAD examined maintained consistently regular course of autumn or winter time episodes. Such patients with regular course often showed atypical symptoms, such as hypersomnia, hyperphagia, carbohydrate craving, weight gain and so on. Furthermore, it was very interesting that patients with atypical symptoms responded better to bright light therapy than those without atypical symptoms. The author postulates that patients who show three major characteristics, atypical symptom, good response to light therapy and consistent seasonality, are composing the core group of SAD.

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Gender role is determined by socio-cultural factors based upon biological sex. Also, one's belief in gender role decides how he or she should be in the psycho-social context. Therefore, confusion, damage or loss of gender role causes an identity crisis, which could become a stress, triggering a psychosomatic disease. While modern society does not expect the individuality strictly defined by biological sex, both men and women are still required to play their gender roles according to the expectancy of society where men are traditionally dominant. Thus, it is often hard for an individual to establish his or her belief in gender role nowadays. In middle adulthood, one's relationship to society changes and his or her identity is disturbed so that the person's belief in gender role is often perplexed and even harmed. In this symposium, I introduced two cases of the middle-aged : one case was a man whose belief in gender role was confused by "restructuring" and the other was a woman who lost her belief in gender role at her climacteric. Confusion and loss of belief in gender role became the stress which caused psychosomatic diseases in these cases. The influence of one's belief in traditional gender role was especially examined by referring to the Bem's gender role scale and physiological, psychological and sociological factors that the middle-aged face.

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The concept of "gender" gives us a vague impression. The term"gender role" rs usually deflned as the role people are expected to play in the community based on their sex, but how to interpret the phrase is disputable. When gender role is considered from the standpoint of ego identity, as expressed by the term "I am myself", it is not simple. Female identity should be studied with a view to the position of a daughter, wife, mother and woman who experiences ovulation and menstruation. The same approach may be applied to male identity. Marriage is the union of man and woman who have such ego identity, as well as background differences. This study describes 4 cases entitled "Psychosomatic Medicine applied to Middle-aged and Elderly People from the Viewpoint of Gender Role" : 1) a couple who have problems in the bond between husband and wife : 2) a woman who has lost confidence regarding her sexuality after a gynecological operation : 3) husband and wife in climacterium, and 4) a woman with psychosomatic pruritus vulvae. As a result, in 1), the couple was confused about their gender roles. In 2), the woman lost her sexual identity after an operation, causing inner confusion about her gender role. In 3), they had different ideas about their gender roles and little willingness to compromise. Finally, in 4), the woman had too strong a role both as a man and a woman as she defined her identity, and faced a crisis in identity choice. Such anxieties were thought to have been expressed in various symptoms. It is suggested that in the three cases above, reading a full understanding between husband and wife by exchanging their views, which I summarize as 6 points, is essential to remission and resolution of these symptoms. In any patient with psychosomatic disease, especially when it is related to gynecological issues, gender and gender role should not be overlooked.

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The author examined 402 cases of menopausal women whom he treated in our psychosomatic outpatient clinic for a period of twenty years. The results were summarized as follows : 1) The incidence of a decrease in sexual desire was 58% on the menopausal women. 2) The incidence of sexless couples was 25% by the age of fifty and 80% by the age of sixty. 3) However 27% of the patients who complained of sexual disturbances were those at the ages of fifty and sixty. 4) Hormone replacement therapy (HRT) was given to 65% of the menopausal women and as a result of this their prognoses were better than the women in other therapy groups (p<0.01). 5) The prognoses of psychosomatic patients with HRT were especially better than those without HRT (p<0.01). 6) A symptom of genitalia was most frequently found among their somatic symptoms. And the psychological factors observed were related to feelings of loneliness, attitudes towards the value of life and family relationships. In conclusion, it was clearly shown that sexuality was of great importance for menopausal women.

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It is important to consider gender role and life-style when we examine psycho-social factors in psychosomatic medicine. It also helps to understand the patient's current situation, behavioral pattern and the way to relate to other people. Purpose : The purpose of our study is to find out what the important themes of psychosomatic medicine are for middle age to old age patients from the viewpoint of gender role. Subject : Our subject was composed of new 297 patients (male : 85,female : 212) who have visited the psychosomatic department and new 32 patients who have visited the gynecological department (the psychosomatic clinic) of International Goodwill General Hospital in 1995. 193 (male : 56,female : 137) patients were at age or above 40 of the 297 psychosomatic department patients. 18 patients were 40 years old or over of the 32 gynecological department patients. Method : We studied the following items retrospectively from the charts : 1) number of patients in each age-group, 2) diagnosis by using DSM-IV, 3) existence of psycho-social factors. Result : 1) Mean age of patients was 45.74 (male : 49.54,female : 44.87) . The male group had 2 peaks, which were the group of 41-50,and that of 56-65. The female group had 3 peaks, which were the groups of 21-30,41-50,and 71-75 respectively. 2) Diagnosis : 22% of all the patients of the psychosomatic department have mood disorders, 19% have anxiety disorders, 16% have somatoform disorders, 9% have psychosomatic disorders, and 8% have brain organic illnesses. In the group who were above age 40,mood disorders, anxiety disorders, and somatoform disorders were predominant, but more patients have psychosomatic disorders, brain organic illnesses. 42% of the patients of the gynecological department (the psychosomatic clinic) have somatoform disorders, 16% have psychosomatic disorders, 13% have anxiety disorders, and 11% have mood disorders. In the group who were above age 40,somatoform disorders and psychosomatic disorders (including menopausal syndromes) were predominant. 3) Many of middle to old age male patients listed "work" as a psychosocral factor. Many of them identified it as change of social life rather than as change of gender role. It meant, however, that they didn't tend to realize that they were expected to play his gender role as husband, father and son by women. Many of female patients listed "home". They considered it directly related to the change of gender role as daughter, mother, and wife. Conclusion : Middle to old age is the time when weakness of the individual tends to come to the surface along with the decline of life. It is suspected that when change of biological gender role and that of psychosocial gender role are not well-balanced, psychosomatic disorders and neurotic disorders tend to appear. We must deal with this theme.

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The authors discuss the psychosomatics concerning male gender role among middle and old age in this article. Psychosomatic treatments for male sexual dysfunctions, such as HRT (hormone replacement therapy), VCD (vacuum constriction device) for penile erection, intracavemous injection with vasoactive drugs such as papaverine hydrochloride, prostaglandine E1,surgical operations for vasculogenic impotence, invasive operation with implantation of penile prosthesis for organic impotence, psychotropic medications, medication of cavemosal smooth muscle relaxating agents such as trazodone hydrochloride, sildenafil, medication of cerebral activating agents such as indeloxazine hydrochloride etc., are useful and available for effective recovery from impaired or disturbed invalid consciousness of male gender role and male gender identity of middle and old age, in the meaning of supportive psychotherapies. Furthermore, psychologically "the existential and ethical insight" with an active attitude to accept the aging itself under recognition of one's natural providence for oneself improves own subjective well-being in life in the viewpoint of mental health. And the elevation of mental health with high level of subjective well -being will activate a prohomeostatic autonormalization of brain function. Psychosomatically the regulation both of the antonomic nervous system and the endocrine system and the activation of the immune system will be improved under psychoneuroendocrinoimmunomodulation. These mechanisms mean health promotion (salutogenesis). The authors discussed and tried to prove these important and interesting concepts under our several surveys by using assessment scales such as LSI-K (life satisfaction index-Koyano), PGC moral scale (Lowton), PIL-test etc. in Okinawa. According to the result of our surveys the increasing of LSI-K scores with recover from consciousness of invalid male gender role and male gender identity after giving adequate psychosomatic treatment for male sexual dysfunctions was examined in some cases. In addition, the authors examined socio-cultural gender role in the community at the holy sublime ceremony named "Hatiguati umati" held by the maidens called "Nuru" or "Noro"with "Nrral Kanal"worship in the Kudaka-jima Island, the holy historical place of the beginning of the country in Okinawa.

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To investigate differences between children's self-recognition and their parents' recognition of the child's physical and mental symptoms and life events, we conducted a survey of primary school and junior high school students and their parents. Objectively evaluative and realistic physical and mental symptoms could be easily detected by the parents and there were few differences in recognition between children and their parents. However, regarding subjective symptoms that were difficult to detect by others including parents, there was a great difference in recognition between children and their parents. As these symptoms included those closely related with psychosomatic disorder such as orthostatic dysergulation and initial symptoms of school refusal, such symptoms would provide important information to prevent or diagnose infantile psychosomatic disorder early. Life events that showed a significant difference in recognition between children and their parents were mostly trifling events that caused less concern among others. They tended to be less noticeable by parents. Thus, children may get less social support when they are confronted with such life events. These life events should be regarded as risk factors for psychosomatic disorder.

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