I joined the First Department of Internal Medicine after graduating from Nihon University School of Medicine in 1976 and had the opportunity to receive training of psychosomatic medicine in Kyushu University in 1978. Since then I have devoted my whole life to psychosomatic medicine. I have been involved in the clinical investigation of chronic pain, fibromyalgia, rheumatic diseases, bronchial asthma, COPD, and chronic fatigue syndrome. With a background of specialty of internal medicine, rheumatology and respiratory medicine, I was also involved in the basic research in the stress related physiological responses and biological defenses as a main theme of the study. From 1982 to 1985, I studied as a research fellow at the Cleveland Clinic in the United States and confirmed the value and importance of basic research for psychosomatic medicine through the study of molecular biology and immunology. I have sought to build up my professional skills of medical psychology such as autogenic training, transactional analysis and cognitive-behavioral therapy. I also had good opportunities to learn together with many psychology experts. I was inspired by the most important basic principle of psychosomatic medicine “Therapeutic Self” which has been sublimated into a treatment philosophy based on Japan’s unique culture. I was strongly encouraged by the belief that psychosomatic medicine is the pioneer in the future of medicine. On the other hand, times have been transforming drastically, and variable issues not covered by the traditional concept and model of psychosomatic medicine have been revealed. We must investigate more widely and deeply the possibility of development and contribution of psychosomatic medicine required by the modern society as the times change. We need to work from a global perspective on the pathologies of recent social problems and events associated with computerization and rationalization. We must also focus on vast mental deterioration such as depression, lacks of empathy, cooperation, emotional response and weakened relationships. With the use of advanced latest technologies, fundamental researches in the field of psychosomatic medicine are also unlimited such as seeking the differences in DNA sequences and gene expression modulated by environmental factors, analysis of protein-metabolite proteome and metabolomic analysis, immune modulation by oral bacterial flora in the gut and brain, neuroimaging studies on neural activity and discovery of biological markers. These accumulations of knowledge may be contributory to elucidation of the pathogenesis and mechanisms of many stress-related phenomena and disorders such as chronic pain, chronic fatigue, MUPS (medically unexplained physical symptoms) and FSS (functional somatic symptoms). I believe the congress was closed fruitfully and gave us a good opportunity to think of a new era of psychosomatic medicine.

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Firstly I would like to refer to personcentered care and personhood from Dementia Reconsidered published by Tom Kitwood in this manuscript Of all the branches of work with older people, dementia care is probably the most challenging. It is the one which makes the greatest demands on relatives care staff, people who typically receive little support and recognition for their efforts. In this paper, the work of Professor Tom Kitwood, Bradford University, UK, developed the entirely new standard of dementia, personcentered care which has been currently main stream of dementia care. In the main ethical discourses of western philosophy, one primary theme has been the idea that each person has absolute value. We thus have an obligation to treat each other with deep respect ; as ends, and never as means towards some other end. This is the important theme : the concept of personhood. We would like to apply in the areas of physicians’ clinical practice as well as other paramedical fields. It must be stressed at the outset that the bulk of the caring for patients with dementia is done by a network of family, friends and neighbours. In areas where such traditional links have weakened, the gaps may be partially plugged by voluntary organizations. We have currently four anti-dementia drugs : donepezil (aricept), rivastigmine, galantamine and memantine. This situation has been favorable for the patients suffered by Alzheimer’s disease. We hope that the better pharmaceutical approach will be available in the near future. In conclusion I expect our academic association of psychosomatic medicine might be a nuclear power to increase support the person with dementia, frail elderly and children in the communities throughout our country.

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Central sensitization and descending facilitation may play important roles in the pathogenesis and maintenance of pain in fibromyalgia (FM). Brain imaging MRI scans of FM patients are characterized by 1) augmented brain responses to experimental pain stimuli, 2) changes in brain morphology (atrophy) in brain regions of pain processing, and 3) changed resting-state functional connectivity. Characteristic functional connectivity of brain networks in FM patients is summarized from the literature as follows ; FM patients had more positive and negative correlations within the pain network than healthy controls. FM patients displayed enhanced functional connectivity of the anterior cingulate cortex (ACC) with the insular cortex (IC) and basal ganglia. On the other hand, functional connectivity of the ACC/IC/thalamus with areas involved in the descending inhibitory system, such as the periaqueductal gray matter (PAG) and the rostral ventromedial medulla (RVM) was reduced in FM patients. Increased insular connectivity to the default mode network (DMN), a network whose activity is increased during non-task resting states, was also observed in FM patients. The reduction of DMN-IC connectivity following acupuncture therapy was correlated with diminished pain. Moreover, FM patients treated with Cognitive Behavioral Therapy showed improvement of brain connectivity and reported less pain. These findings strongly suggest that the brain network connectivity measures could potentially be used in studies elucidating mechanisms of pain in FM patients or clinical settings to evaluate the effective therapeutic strategy for FM. Exercise is commonly recommended in the management of people with FM. In FM patients, positive relationships between physical activity and brain responses to pain were observed in regions implicated in pain regulation, suggesting that physically active FM patients appear to maintain their ability to modulate pain.

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Pregabalin was first approved of pain relief to fibromyalgia (FM) in 2012, and then duloxetine in 2015. Medications for FM are gradually evaluated in Japan. In this symposium, clinical experiences were introduced in 300 FM patients with the main emphasis on medication. In usual drug therapy, pregabalin and neurotropin^® are used as the first choice. Pregabalin will not be chosen in children, students, drivers, and instructors of precision machine. In these cases, usually high doses (double doses) neurotropin^® are used at first, which are followed by combined use of clonazepam, duloxetine, mirtazapine, tramadol, and regnite^®. The author, however, does not rely only on medications, and practices trigger point injection, warming therapy, alternative therapy, exercise, consulting therapy, and cognitive behavior therapy depending on different situations. In conclusion, tailor-made medicine is necessary for FM patients because they are heterozygous.

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Though pain is experienced by everyone, it is not well understood because pain is the most unpleasant feeling for all living creatures. It is not something that is to be sympathized with or shared with others. Thus, there is a lack of understanding about pain because pain is something that nobody desires. It is a natural instinct for all living creatures to fear pain and not want to know about it. However, to explore the reason for the existence of complex pain, it is necessary to elucidate and comprehend each of the mysteries concerning the background of patients with fibromyalgia. If this is not explained, patients will feel as if their complaints are difficult to understand and place a burden on the physician, especially when they hear responses such as ‘This clinic cannot handle your case’, ‘Go to a specialist’, or ‘This is an incurable disease’. It is indeed difficult to understand such complicated cases. However, there are always clues within the words of the patients, because, even when they are confused, patients always express what they intend to communicate. Patients who desperately desire to be understood, but are sometimes unable to express their feelings well, especially when they are overloaded with ‘excessive explanations’, think that their efforts to explain their situation are failing. Patients grow tired of explanations, and it is impossible for the therapist to offer them any treatment. In contrast, some patients remain quiet. In their social life, patients are forced to come to terms with their pain through the processes of ‘normalization’, ‘pacing’, ‘perseverance’, and ‘reshaping of the body’. Moreover, the author’s opines that ‘reshaping of perception and awareness’ may also occur in such patients. However, this makes their disease difficult to understand, even for the person offering treatment. Thus, they become ‘silent patients’. Although it is certainly difficult to instantly cure fibromyalgia, I believe that when any patient understands the background of the pain and obtains a sense of improvement in his condition through the amelioration of each cause, it is possible for the patient to continue treatment and not lose hope. It is reassuring for patients that such attempts have begun. Here, I will introduce some case studies of patients who reported complex pain and other concerns. I hope to work together to attempt to solve such cases.

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Fibromyalgia is characteristic for its complicated physical symptoms of pain alongside an array of psychological symptoms including anger anxiety and depression. It requires specific treatment drawing on the specialized knowledge of clinical professionals with appropriate psychological support from a psycho-therapeutic perspective. This study examines the context in which FM patients experience the occurrence of pain and proposes a new framework for psychological support in clinical practice. Based on the results of investigations and clinical practice, we focused on the interconnected factors that are the likely causes of the pain, identifying four such factors. In the treatment of pain, we not only considered the patients’ complaints on the excruciating nature and frequency of the pain, but also emphasized the physical and psychological preparedness to cope with pain. A case in point is one in which interviews with family members brought about a significant amelioration of pain symptoms.

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Although fibromyalgia is not well known on the pathology, recent researches have proved that patients with fibromyalgia have unique psychological characteristics, abnormalities in immunology, brain function, and autonomic nervous system function from multimodal aspects. Here we present that fibromyalgia patients have displayed abnormal pacing, passive self-image induced by background and over-adaptation and hyperactivity, and abnormal resting state brain connectivity to enable readers to understand the psychosomatic relationship and holistic approach for the disease. The default mode network (DMN) showed greater connectivity to the insula cortex and secondary somatosensory cortex (S2) in fibromyalgia patients. The DMN change as a centralized pain and the abnormalities in musculoskeletal system and autonomic nervous system as peripheral pains constitute complicated psychosomatic pathologies. It is desirable that holistic approach in normalizing the pacing and increasing in accessibility among consciousness, preconsciousness and unconsciousness should be developed in the clinical psychosomatic practice for fibromyalgia patients.

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Objective : Eating disorders (ED) are chronic, intractable conditions with various physical manifestations. One manifestation that is often noted is renal dysfunction. This study retrospectively examined renal dysfunction in inpatients with ED at our hospital. Methods : The subjects were 149 patients with ED (77 with anorexia nervosa, binge-purge type〔ANbp〕 ; 38 with anorexia nervosa, restricting type〔ANr〕 ; 26 with bulimia nervosa, purging type〔BNp〕 ; and 8 with an ED not otherwise specified〔EDnos〕who were admitted to our department of Psychosomatic Medicine from April 2010 to November 2013. Subjects consented to participation in this study in writing. Aspects such as the type of ED, age upon admission, body mass index (BMI) upon admission, duration of disease, and biochemistry results were examined using medical records. Statistical techniques were used to examine these aspects by the types of ED. Results : Examination of the number of patients with chronic kidney disease (CKD) indicated that 38.3% of the total patients (57/149) had CKD. The proportion of patients with CKD by the types of ED was 58.4% (45/77 patients) for ANbp, 18.4% (7/38 patients) for ANr, 19.2% (5/26 patients) for BNp, and 0% (0/8 patients) for EDnos. The median estimated glomerular filtration rate (eGFR) of each type was as follows : ANbp, 54.3 (interquartile range, 39.4 to 74.8) ; ANr, 76.8 (interquartile range, 62.2 to 92.0) ; BNp, 77.7 (interquartile range, 61.7 to 89.8) ; and EDnos, 78.7 (interquartile range, 74.2 to 92.9). Patients with ANbp had a significantly lower eGFR compared to that of patients with ANr, BNp, or EDnos (p≤0.05). In patients with ANbp, a significant correlation was noted between eGFR and BMI and between eGFR and duration of disease (eGFR and BMI : r=0.38, p<0.01, eGFR and duration of disease : r=0.44, p<0.01). In patients with BNp, a significant correlation was noted between eGFR and duration of disease (eGFR and duration of disease : r=−0.60, p<0.05). A Mann-Whitney U test was used to compare patients with different types of ED in terms of the presence or absence of hypokalemia (K<3.5 mEq/l). Results revealed significant differences in the eGFR between patients with ANbp and those with BNp. Discussion : Patients with ANbp had a significantly lower eGFR than did patients with other types of ED. In addition, results indicated that low BMI, prolonged duration of disease, and hypokalemia can place patients with ED at risk for CKD. Conclusion : Renal dysfunction is often found in patients with ED. These patients need treatment to protect their kidney function. Patients with ANbp in particular have a high risk of severe renal dysfunction, so they should receive early assessment and intervention.

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A 14-year-old girl was admitted to our hospital with 26.6 kg of body weight and 12.0 of body mass index and was diagnosed as the restricting type of anorexia nervosa. She had already been treated in a psychiatric hospital from age 11 because she exhibited school refusal at age 10 and social phobia at age 11. Her food intake was 500 kcal/day or less in the first half of hospitalization and body weight did not increase. It was difficult to provide psychotherapy and psychosomatic treatment for her because her social communication skill was too poor. Autism spectrum disorder was also diagnosed in this patient. Her food intake behaviors were strongly associated with autism. Therefore, we decided to utilize the characteristic behaviors of autism to improve her eating behaviors. She stuck to one meal a day but had neither interest in food calories nor cooking methods. We modified the food menu to increase the calories per capacity. Finally, her intake calories increased from 800 kcal/day to 1400 kcal/day. Her weight increased up to 33.5 kg (15.2 of body mass index) when she was discharged from hospital after 4 months. This case suggested that it is important in the treatment of patients with intractable anorexia nervosa accompanied by autism spectrum disorder to utilize their own characteristics behaviors.

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