An through assessment of the frail elderly in the at-home care needs to include measurement of the burden and the quality of life on the part of caregivers. Nevertheless, we have not yet arrived at a so-called golden standard for measuring the burden on caregivers. In order to evaluate the reliability, the validity and the clinical usefulness of the instruments for assessing the care burden and the quality of life, the results of the Caregiver Strain Index(CSI) and a revised self-completed questionnaire for quality of life(QUIK-R) in 64 at-home caregivers(mean age 63±12 years) were cross-sectionally analyzed. 1.The results of the CSI: The CSI(Robinson, 1983) consists of 13 items, and is scored by summing the no(point 0) and yes(point 1) responses for the items. a)The internal consistency of the CSI was α=0.70. b)Significant correlations were found between the CSI and other assessments on care burden(CSI vs.Costs of Care Index:r=0.513, CSI vs.Caregiver Burden Index:r=0.576, respectively, p<0.001). c)The result of mean and standard deviation was 3.9±2.8. Among 13 items, item No.6 "There have been changes in personal plans." had the highest response, conversely, item No.9 "Some behavior is upsetting." did the lowest incidence. d)The CSI wss correlated with the caregiver's health, and patient's age and dysurination(p<0.05). 2.The results of the QUIK-R: The QUIK-R covers four domains, including physical functioning, emotional adjustment, social relation-ships and attitudes toward life, totaling 50 questions, and five check items. A lower QUIK-R score reflected a higher QOL level. a)The internal consistency of the QUIK-R was α=0.88. b)The QUIK-R showed a close correlation among three instruments;namely, r=0.424 for CSI, 0.501 for CCI and 0.454 for CBI, respectively(p<0.0001). c)The mean and standard deviation of the total score excluding the five check items was 10.6±8.3(3.36±3, 47 for 164 age-matched not ill healthy elderly in the general population). The results of the mean and standard deviation of the QUIK-R total score were much worse than those in the age-matched healthy elderly group with no illness(3.36±3.47, P<0.0001). d)The QUIK-R had close linkage with the caregiver's age(p<0.05), the number of caregivers(p=0.02), family relationship(P<0.05), caregiver's health(P<0.05), the severity of the patient's disorders and comprehensibility(p<0.05). In this study it should be concluded that the CSI and the QUIK-R were very excellent tools for assessing the care burden and the quality of life despite having some clinical limitations, respectively.

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The purpose of this study was to develop the scale of self-efficacy on illness behavior for terminally-ill cancer patients. The sample was consisted of 50 patients(20 males and 30 females) with terminal cancer who were outpatients under hospice care or in the hospice ward. Structured interview was conducted with some measurement scales, which included our original self-efficacy scale, and Hospital Anxiety and Depression Scale(HADS). Thirty-five items relating to self-efficacy on illness behavior for terminal cancer were from the previous studies and through discussion with palliative care unit staff. Exploratory factor analysis revealed that the scale had following three factors:'Symptom coping efficacy', 'ADL efficacy' and 'Affect regulation efficacy'. Stepwise exploratory factor analysis made each factor have six items with best fitting(χ^2(9)=8.65, GFI=0.93, CFI=0.99;χ^2(9)=5.52, GFI=0.96, CFI=1.00;χ^2(9)=5.65, GFI=0.95, CFI=1.00). Path analysis also examined three models about the relationship among three factors in the self-efficacy scale, and anxiety and depression in HADS. The analysis revealed that the data best fit the model in which affect regulation efficacy was directly associated with symptom coping efficacy, anxiety and depression, and ADL efficacy mediated affect regulation efficacy and depression(χ^2(4)=1.32, GFI=0.98, CFI=1.00). Overall, these findings may offer the validity for the scale of self-efficacy on illness behavior for terminally-ill cancer patients and explanation for causal relationships among self-efficacy, anxiety and depression. Especially, it becomes clear that affect regulation efficacy plays an important role, and this implies that supporting patient's coping efficacy is effective for enhancement of psychological adjustment and QOL in advanced cancer patients. For achieving this, development of effective intervention programs for terminal cancer is needed.

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Long-term outcome in patients with the constipation type of irritable bowel syndrome(IBS) was examined by two-time postal questionnaire. Between 1982 and 1990, 205 patients with the constipation type of IBS visited our hospital. A questionnaire asking about abdominal, somatic and psychological symptoms was sent on 1990 and 1997, and 48 patients(recovery 30.3%) completed. Almost every symptom was significantly improved at both the 1st and the 2nd follow-ups compared with those of the first visit. However, there were no significant defferences between the 1st and the 2nd follow-ups. Factor analysis of our research questionnaire using the data at the first visit revealed 5 factors, namely Abdominal pain-Tension, Easy defecation, Sleep disturbance, Preoccupation with the symptom and Vigor. Multivariable analyses were executed to compare long-term prognosis with these 5 factors. Subjective improvement at the 2nd follow-up was significantly correlated with the Vigor factor on the first visit. Overall improvement of abdominal symptoms at the 2nd follow-up was negatively correlated with the Abdominal pain-Tension factor, and positively with the Easy defecation factor at the first visit. These results suggest that psychological factors are involved in the clinical course of constipation type of IBS.

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Irritable bowel syndrome(IBS) is one of the most common psychosomatic diseases, and is often accompanied with autonomic nervous system dysfunction. We studied body temperature circadian rhythm in IBS patients. Subjects were consisted of 16 patients with IBS (5 males and 11 females, 46.8±15.0 years old) and 20 normal controls (5 male and 15 female, 41.7±13.9 years old). In July, subaxillar body temperature was measured with an electronic thermometer by each examinee seven times a day (on wake up, 9 am, 0 pm, 3 pm, 5 pm, 7 pm and before sleep) for seven days in their routine living setting. Times of each meal and sleep were recorded. Nine in 16 IBS patients and 8 in 20 controls repeated the same procedures in November of the same year. Temperature was averaged through a week at each time of a day in each examinee, and statistically compared between the two groups by ANOVA with repeated measures. In summer, body temperature of IBS patients was significantly lower than that of controls(p<0.01). A significant difference of body temperature between male and female subjects was seen only in the control group(p<0.05), but not in the IBS group. In IBS patients, body temperature of the constipation-predominant type was significantly lower than that of the diarrhea-predominant type and the alternating diarrhea and constipation type(p<0.05). Although seasonal alteration was insignificant in the control group, IBS patients showed significantly lower body temperature in winter than in summer(p<0.05). Amplitude of body temperature did not significantly correlated with either the number of fasting in a week or the length of sleep. Abnormal circadian rhythm and seasonal alteration of body temperature were observed in IBS patients, suggesting that the body temperature regulation is inappropriate.

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This paper discussed the significance of consultation service by a team composed of a psychiatrist, a clinical psychologist, and two psychosomatic physicians in Tokyo Metropolitan Ohkubo Hospital. Our team regularly visited all nurse stations of the wards with 300 beds, the ICU, the rehabilitation room and the hemodialysis room once a week from April 1994 to March 1999, and 923 cases (the ratio of male and female was equal) were consulted regarding psychological, sociological, somatic or behavior problems. The number of consultation was 253 in the first year, 175 in the second year, 173 in the third year, 158 in the fourth year, and 164 in the fifth year. For these five years, 35.3%(326 cases/923 cases) were directly referred to a psychiatrist, 14.3%(132/923) to a clinical psychologist, and 22.1%(204/923) to psychosomatic physicians. 28.3%(261 cases/923 cases) were consulted with by our team, when our team was visiting the wards. The number of consultation with our team included 215(82.4%) by the nursing staff, 25(9.6%) by doctors, and 19(7.3%) by the rehabilitation staff. Our team consulted with nursing staff more frequently than any other staff because it was easy to consult them when we were visiting the wards and no special procedure was required. When our team and the medical staff were able to discuss the problems on the spot during our visits, 65.9%(172 cases/261 cases) of the problems were solved. When this was not possible, we selected someone to be in charge and follow up the case. When a direct interview was needed, we made it a rule to consult with the doctor in charge of the patient. Among the 261 cases who asked for consultation with our team, the percentage of reference to a psychiatrist was 18.0%(47 cases/261 cases), to a clinical psychologist was 6.5%(17/261), and to psychosomatic physicians was 9.6%(25/261). We needed to form a consulting team by including a psychiatrist, a clinical psychologist, and two psychosomatic physicians because of a shortage of staff for mental care. Since our team members have their own stance, we could discuss varied problems with one an other and cope with requests from medical staff in the general hospital. It was confirmed that our team was functioning as a nice support system to ourselves.

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We experienced two cases of conversion disorder with pseudoptosis who were suspected of having myasthenia gravis because of unilateral blepharoptosis. One patient was a 23 year-old woman with quadriparesis and left unilateral blepharoptosis and another patient a 33 year-old woman with right unilateral blepharoptosis and right unilateral hypesthesia. Both patients showed negative edrophonium test, negative anti-acetylcholine receptor antibody, and normal neurological examination except blepharoptosis. Their neurological symptoms were fluctuated by psychological stress. As these reasons, we diagnosed their disease as conversion disorder. Diplopia, low vision, and visual paresis are known as the ophtalmic symptoms of conversion disorder. There are only five reports about conversion disorder with pseudoptosis. The psychological factors often exert a strong influence on the onset and exacerbation of symptoms of conversion disorder. In case of the inconsistency with the neurological signs or laboratory data, it is necessary to treat patients with pseudoptosis by the psychosomatic approach.

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Some children with psychogenic fever advance to school refusal. Psychogenic fever is thought to be caused by inappropriate verbal expression. If this is true, sandplay therapy may be an effective treatment method, since it is a non-verbal method that promotes verbalization. We report our experience with a child demonstrating psychogenic fever who showed marked improvement by sandplay therapy. The patient was a ten-year-old boy. Growth, past history and family history were unremarkable. The family consisted of the parents, the patient and two younger brothers. Psychological testing showed the patient had tendencies toward introversion, high psychological tension along with a loss of self-confidence. In the family, he experienced sibling rivalry. In school, he had few friends and was often isolated. We suggested that psychogenic fever was due to stress caused by these problems. In an early interview, he was tense, silent and had difficulty in verbal expression. Therefore, in every interview we encouraged him to talk about school and family, and tried to praise him to increase his self-confidence. We used sandplay therapy adjunctively as a non-verbal approach. In early sandplay, he hardly spoke and his works were not integrated. The contents of his works were many animals rested at a glassland. It was thought that such a content projected his own desire to get away from many stressors and rest mentally. Gradually, his works became aggressive, energetic, and were integrated as a whole. At the same time, verbalization was promoted, and in later interviews he spoke extensively about his family and school of his own accord. At last, psychogenic fever stopped and he began to go to school cheerfully. In this case, by using ssandplay therapy, emotional catharsis and verbalization were promoted, his frustration was worked off and psychogenic fever disappeared. Judging from the above, sandplay therapy may be an effective treatment for psychogenic fever to prevent deterioration.

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