Objectives: To investigate the prevalence of a self-reported low-grade fever in patients with depression and the association between self-reported low-grade fever and major depression. Subjects: 914 new outpatients, who consulted the clinic of the Department of Psychosomatic Medicine at Kyushu University Hospital in the course of a year. Method: A multivariste questionnaire was used to survey whether or not subjects experienced a low-grade fever, in addition to determining their chief complaints and the diagnosis. Logistic regression analysis was used for the statistical analyses. Results I Self-reported low-grade fever was found in 37% of the subjects with major depression and 22% of the subjects without major depression. Major depression (OR 2.40, 95%CI 1.35-4.25, p<0.005 in males; OR 2.09, 95%CI 1.34-3.24, p<0.005 in females) and high Self-rating Depression Scale (SDS) scores in females (OR 1.82, 95%CI 1.40-2.35, p<0.0001) were associated with self-reported low-grade fever. Conclusion: Major depression in both genders and a high SDS score in females were associated with low-grade fever. When treating patients complaining of fever, testing for depressive disorder in differential diagnoses may contribute to proper diagnosis and treatment of depressive disorder, which can reduce medical costs.

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We conducted a questionnaire survey for 98 lung cancer patients to examine perceived support network size and to explore variables predicting the support size. As a result, the median of support size is 3, the average of support size is 4.3±2.8 (male4.6±3.1: female 3.5±2.8), the range is 0-20. As for variables, only self-efficacy affected significantly the support size by hierarchical multiple regression analysis. Then, mental status (HADS) , physical status (subjective pain, PS, typical side effects) , age, gender, consultation style, and marital status were not. It is suggested that perceived support size has been affected by patient's style of perception.

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Diabetics with serious somatic disease complications often lapse into a depressive state because of anxiety, anger, despair and remorse. We encountered a 58-year old man in a depressive state with serious somatic disease complications. We did non-structural interviews with the patient. In this study, we report the process of psychotherapy. In interviews, we found distorted cognition peculiar to the patient and his tendency to make extremely negative evaluation of his memories of past experiences. Therefore, we started searching intervention, in which we used reminiscences. The therapist gave him homework and suggestions because he became able to remember past situations objectively. The patient's chief concern changed from past to present after the intervention. As a result, the patient came to feel less negative about undergoing diabetic treatment. As the patient began to recognize his situation objectively, the therapist urged him on to recollect positive reminiscences. Thus, the patient was able to make proper revaluation of the past events. Consequently his depressive state improved along with recovering his self-esteem. In addition, we could discuss the improvement of this case from the viewpoints of both cognitive and narrative theories. This study suggests we can improve the depressive state and self-esteem of diabetics with serious somatic disease complications by helping them to recollect positive reminiscences with objective cognition.

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The purpose of this study is to clarify the concept and differential diagnosis among neurasthenia, chronic fatigue syndrome (CFS) and depression by observing the treatment and course of three cases. Some suggestions for further research, aimed at improving the treatment, will be offered in this paper. Case 1: A 48-year-old female primary school teacher was referred to our psychosomatic outpatient clinic with excessive fatigue and sleep disturbance for the past 6 months. Although she suspected herself to have CFS from the Internet information, our diagnosis was probable CFS. On the basis of her symptoms of headache, concentration impairment, dizziness, auditory hypersensitivity, irritability and inability to relax, she was diagnosed as neurasthenia by ICD-10 criteria. She was treated with Maprotiline and Alprazolam and graded exercise therapy (GET) for 3 months and returned to work. During the following year she still complained of easy fatigability. Case 2: A 32-year-old unemployed female was referred with back and abdominal pain, general malaise, insomnia and menstruation irregularity for more than one year. She thought she had CFS, but somatoform disorder was provisionally considered on the basis of objective findings. During the treatment with SSRIs, however, delusions of persecution and reference became obvious. She became well soon after her drug treatment was changed to Perospirone with a change of diagnosis. This case showed to us that sufficient attention is necessary not to mistake delusion for CFS. Case 3: A 25-year-old female office worker was referred with multi-joint pain, easy tiredness of 8 months' duration and irritability and inability to work for 6 months. She was suffering from cervical lymph nodes tenderness, multi-joint pain, sore throat and post-exertion malaise which were emerged before depressive episodes, and was diagnosed as CFS. She improved in health with GET, cognitive behavioral therapy and administration of Paroxetine. She found a new job one year later. Neurasthenia and CFS are often considered to be the cultural variance of the same illness in different countries. The diagnostic label of neurasthenia was also used in some countries to avoid the stigma associated with mental disorders. Considering the present condition and history which may imply diagnostic abuse of neurasthenia, we think it useful to the welfare of patient and family to make a positive diagnosis of CFS instead of an ambiguous diagnosis of neurasthenia. This therapeutic approach will contribute greatly to the elucidation of the brain function of fatigue.

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We report a case of urticaria induced by psychosocial stress. A 35-year-old woman was referred to our hospital because of intractable systemic urticaria. She developed urticaria when her company urged her to return to her job. She had been working as an insurance saleswoman since 22 years of age and married at the age of 30. Last year, she was assigned a new manager, but could not get along with him. She has suffered from her husband's infidelity, but did not express her negative emotions at home because she lived with her parents-in-law and behaved as a good wife of their son. Soon she began to feel distressed and took sabbatical leave from her employer. She developed chronic urticaria soon after she returned to her job against her wishes. The urticaria was resistant to anti-histaminergic or anti-allergic drugs. Urticaria appeared and was easily exacerbated when she became emotional. However, she did not notice such an emotional effect on the development of urticaria. When she was admitted to our hospital, sweating was evident on her palms and resting plasma noradrenaline level (589pg/ml) was high, suggesting chronic activation of the sympathetic-adrenomedullary system and increased arousal level. Her blood eosinophil ratio was 1.9% and IgE level was 105IU/ml, both of which were normal. There was no specific allergen found. Urticaria was not induced by physical stressors such as exercise or immersion of her hands into hot (42℃) or cold (5℃) water. However, urticaria was reproduced by stress interview, especially when she was asked to talk about her husband, parents-in-law, and her manager. Furthermore, urticaria appeared induced by psychological stressors such as mental arithmetic stress and mirror-drawing test (MDT) , which increases arousal. We therefore treated her with the following multidimensional psychosomatic approaches. Psychosomatic treatment included (1) separation from her family by hospitalization, (2) reducing sympathetic tone by practicing autogenic training, (3) self monitoring to facilitate awareness of the relationship between her emotional state and urticaria, (4) assertion training and emotional exposure to the doctor in charge, and (5) asking for help for her family and workplace situations. The effects of stress and psychosomatic treatment on plasma histamine levels and urticaria were evaluated by MDT. Before treatment, her baseline plasma histamine level was 2.30 nmol/l, which was higher than the normal range (0.74-1.54nmol/l). Twenty minutes after MDT, plasma histamine level increased dramatically to 10.0nmol and urticaria appeared all over her body. Three weeks after multidimensional psychosomatic treatment, MDT-induced increase in histamine was attenuated to 3. 60 nmol/l at 20min. After treatment, her tension and anxiety decreased and urticaria hardly appeared even when she talked about her family and manager. This case clearly demonstrates the mind and body interaction of urticaria; that is, its appearance and exacerbation by psychosocial stressors and improvement by multidimensional psychosomatic intervention.

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