I solve the clinical ethics case on the site. I resolve it with the medical staff in the field. The clinical ethics education is shown to achieve these purposes. In the following, I explain about the awareness of clinical ethics problems, that is, what a good ethical problem is and what a wrong ethical problem is, using a case study sheet and having a case study group, etc.

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As cancer is a life threatening disease, patients feel extreme distress and sometime manifest psychiatric diseases such as major depression. The needs for psychological care and psycho-oncologist are increasing. Psycho-oncologist is the specialist who has specialty concerning psychiatry or psychosomatic medicine, and also oncology, and can facilitate communication among the medical staff, and enables total care including bio-psycho-social-spiritual aspects. This is in the spirit of psycho-somatic medicine.

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The prevalence of delirium is very high in patients with cancer. Therefore, doctors in psychosomatic medicine are frequently asked to treat delirium in those patients. In order to make a plan for treating delirium, it is necessary to evaluate whether the delirium will be reversible or not. With regard to pharmacological treatment, antipsyhoctic drugs are used. In addition, non-pharmacological approach and explanation to patient's family is important.

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Denial is a clinically relevant concept in cancer patients and their families. Serious conflicts owing to a denial, one of the defense mechanisms, have used to arise frequently among cancer patients, their families and the medical stuff. A case of a 60-year-old terminal cancer patient with her families who have strongly expressed anger and used a denial will be presented in order to discuss our problems among medical participants. In order to learn difficult communications between patients and medical stuff, we need not only a knowledges of defense mechanisms but should have such simulated experiences as this case study.

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Background : We experience many cases complaining of chronic dizziness in our Department of Psychosomatic Medicine. In many of them, we find a physical disorder like secondary hypertonic contraction of neck muscles. However many cases tend to suffer from alexisomia and lack subjective symptoms. In these cases, physical feedback is suggested to modulate their cognitive ability. We investigated the usefulness of intervation of experience-based awareness which makes the cases with chronic dizziness be aware of the existence of hypertonic contraction of neck muscles by hypnosis-induced muscle relaxation. Method : Fifty-six cases complaining of dizziness and hypertonic contraction of neck muscles for longer than 3 months were enrolled to the study. On the first visit, they were divided into two groups, alternately, in the order of entry, i.e. 28 hypnosis vs 28 non-hypnosis cases. Thereafter, we explained that hypertonic contraction of neck muscles was one of the causes of dizziness and progressive muscle relaxation was introduced. In two groups, the degree of dizziness was monitored chronologically by Numerical Rating Scale. Results: In both groups, significant changes in Numerical Rating Scale were observed (p<0.001) In both groups, changes between the first visit and the state 1-month later were significant (p<0.001). In contrast, changes between the first and the third month were not significant. In the hypnosis group, Numerical Rating Scale of dizziness between the first visit and the state 1-month later was not significantly lower than that in non-hypnosis group (p=0.029). Numerical Rating Scale of dizziness between the first visit and the third month was significantly lower (p=0.005). Conclusion : In the hypnosis group, the improvement was greater than that in the non-hypnosis group. This implies that experience-based awareness by hypnosis on the first visit leads to the improvement of dizziness. Experience-based awareness is supposed to stimulate the cases to recognize a relation between subjective physical disorder and chronic dizziness and may be a beneficial approach to treat alexisomia.

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Objective: This study aims at investigating the present condition about cooperation between schools and medical institutions to support students with eating disorders and their guardians. Subjects and Method : We conducted the questionnaire for school nurses and the effective replies of 362 were obtained (valid response rate was 56.9%). Results : (1) Although school nurses thought that support for the students with eating disorders by school nurses was necessary, the rate actually supported was low. (2) Although school nurses of elementary schools (85.2%), junior high schools (92%), and high schools (93.7%) thought that cooperation of schools and medical institutions was necessary, the ratio of actual cooperation was low, 20.9% for the elementary schools, 50.7% for the junior high schools and 31.7% for the high schools. (3) Almost of all school nurses who experienced cooperation with medical institutions thought that actual cooperation was effective and little in trouble. (4) When cooperating with medical institutions, 80% or more school nurses answered that support was necessary for guardians, but the actually supported percentage was 40% or less. The ratio of "support is effective" was high (90% or more) and that of the troubles are low (less than 15%). Conclusion : Validity is realized on actual cooperation between schools and medical institutions by the school nurses although problems exist. It was indicated that we had better come up with various things in order to develop school-medical institution cooperation.

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The patient was a 19-year-old male. After consulting emergency room for severe abdominal pain and getting relieved by enema in the year X-5, his obsessiveness with defecation became strong and he came to use many purgatives. After he quit his after-school sport-related club activity in the year X-2, he began to skip meals and to lose body weight from BMI 18.1. Since he began to live alone after he entered a university in April in the year X-1, he lost his weight furthermore. He was referred to our department as an eating disorder patient by a practicing internal medicine doctor in May in the year X (BMI 14.1). Because he indicated neither fear for gaining weight nor distorted body images, he was diagnosed as a case of "eating disorder not otherwise specified". Soon after he started to study abroad in an English-speaking country in April in the year X+1, his rhythm of defecation was disordered and his tendency to skip meals became strengthened. Finally at the end of June of the year, his BMI was 12.1 and he came back to Japan to be admitted to our department. Because he was conscious about the significant interference in his daily life due to his excess obsessiveness with defecation, he was diagnosed as a case of obsessive-compulsive disorder (OCD). After starting combined therapy of exposure and response prevention with fluvoxamine, his obsession calmed down gradually and he continued to eat the hospital meal completely. After being discharged, he took a leave of absence from school and lived with his grandmother. He reduced rituals gradually and his BMI exceeded 18.5, and finally at April in the year X+2, he returned to school. He began to live alone again, but no significant interference has occurred. In a case of atypical eating disorder whose obsession is particularly strong, it may be important to suspect OCD proactively.

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