ACT (Acceptance and Commitment Therapy), developed by Hayes et al (1999) in USA, has spread rapidly as a contemporary psychotherapy in the world. In Japan, it has gradually been recognized. ACT consists of six components in psychopathology, each of which corresponds to the therapeutic process. Following this model, we applied the model of Morita therapy to ACT and discussed considerable similarities. Consequently, both therapies address avoidance behavior and attachment (Toraware) in psychopathology and emphasize the acceptance and purposeful action in the therapeutic processes. Morita therapy, developed in the 1920s, is now moving into the international spotlight.

Stress is one of important issues to be solved by psychosomatic researchers in the 21st century. Irritable bowel syndrome (IBS) is a prototype of functional gastrointestinal disorders (FGIDs) which are one of typical stress-related disorders. IBS patients usually show dysfunction of the colon and/or small bowel which are/is evoked by the efferent signal from the brain. Corticotropin-releasing hormone (CRH) is released from the paraventricular nucleus (PVN) of the hypothalamus by stress loading and it switches exaggerated colonic motility by way of sacral parasympathetic outflow. Released CRH also degranulates mast cells, increased permeability of the gut mocosa, and cause visceral hypersensitivity. Visceral hypersensitivity is important pathophysiology of IBS with dysregulation of brain-gut interactions. Dysregulation of regional brain at visceral stimulation is seen in the anterior cingulate cortex, mid cingulate cortex, insula, amygdala, hippocampus, hypothalamus, dorsolateral prefrontal cortex, medial prefrontal cortex, orbitofrontal cortex, striatum, and periaqueductal gray matter in IBS patients. Gut microbiota is also involved in the pathophysiology of IBS and composition of gut microbiota is influenced by psychosocial stress. IBS is highly related to depression, anxiety, and alexithymia. These features are based on molecular and neural changes. In another words, functional (and psychosomatic) disorders would have structural and organic changes which can be detected by advanced technology. Therefore, fine and quantitative measurements are important to explore pathogenesis of stress-related disorders. Severe stress induces methylation of the promoter gene of the glucocorticoid receptors and impair negative feedback of CRH systems and pathological hypothalamic-pituitary-adrenocortical axis. IBS research provides typical phenomena of gene-environmental interaction and plausible candidate genes including CRH receptor genes for IBS has been detected. Advanced therapies including psychopharmacotherapy, psychotherapy, and neuromodulation are developing. To cope with IBS, it is important to find the law of stress and brain-gut interactions. Moreover, practical use of psychosomatic approach including cognitive behavior therapy is recommended for clinicians. Similar activities to find the law of stress and brain-gut interactions can be applicable to the other areas of medicine.

Cell-specific gene expression is largely regulated by combinations of DNA-binding transcription factors and various chemical modifications of histone and DNA. Epigenetic regulation is often considered as a stable regulation of gene expression conferred by some of these chemical modifications. Since acetylation of histone and methylation of histone and DNA utilize metabolic intermediates, acetyl-CoA and S-adenosylmethionine (SAM), respectively, it is becoming increasingly appreciated that metabolic status and nutritional conditions affect epigenetic regulation. Methionine adenosyltransferase 2 has recently been shown to form a protein complex with histone methyltransferases and DNA binding transcription factors to regulate genes for oxidative stress response. Conceptually similar complex has been also discovered in yeast cells. Therefore, such protein complexes containing metabolic enzymes may couple metabolism and epigenetic regulation. Recently, undernutrition during embryonic stage has been shown to affect an incident of various diseases in the adult phase, raising the possibility that such conditions alter epigenetic regulation. However, detail epigenetic alterations and mechanisms behind remain still elusive.

Gastroesophageal reflux disease (GERD) is defined as a condition which develops when the reflux of gastric content causes troublesome symptoms and/or complications. GERD is categorized into erosive reflux esophagitis, defined as the presence of esophageal mucosal breaks, and nonerosive reflux disease (NERD), defined as the presence of reflux-associated symptoms without esophageal mucosal breaks. Proton pump inhibitor (PPI) is generally the first choice of treatment for GERD. However, some GERD patients experience persistent and troublesome symptoms despite PPI therapy and they reduce health-related quality of life (HRQOL). We examined the relationship between efficacy of PPI and HRQOL to evaluate predictive factors affecting response to PPI, in Japanese GERD patients receiving PPI therapy. In this study, we used of the gastroesophageal reflux disease questionnaire (Gerd Q), 8-item Short Form health Survey (SF-8), Pittsburgh Sleep Quality Index (PSQI) and Hospital Anxiety and Depression Scale (HADS) to 145 GERD patients receiving PPI therapy. Using Gerd Q, we classified them in well controlled patients to PPI therapy (responders) and not well controlled patients (partial responders). Using SF-8, PSQI, and HADS, we evaluated HRQOL of responders and partial responders. Sixty-nine patients (47.6%) were partial responders. Partial responders had significantly lower scores in five of eight subscales and in mental health component summary in SF-8 than those of responders. Partial responders had significantly higher scores of PSQI and HADS including anxiety and depression than those of responders. Non-erosive reflux disease and double PPI dose were predictive factors of partial responders. In conclusion, Persistent reflux symptoms despite PPI therapy caused mental health disorder, sleep disorder, psychological distress in Japanese GERD patients.

The brain-gut interaction is considered as one of the most important mechanisms of IBS, after dietaly habits and gut microbiota have clarified its role for IBS. We extracted IBS by RomeⅢ and considered dietaly habits by BDHQ Questionnaire in a health promotion project (Iwaki Health Promotion Project). All participants of this project involved 1,167 people and IBS were 5.2% of all. We classified all participants in 3 groups ; Healthy dietary pattern, Western dietary pattern and Alcohol and accompanying dietary pattern. We compared each group as to IBS or not IBS participants, but there was no significant difference in each group. We also investigated gut microbiota in this study by examing fecal specimens with metagenomic analysis, and evaluated gut microbiota about 4 strains considerd to associate with IBS until now. Also in the evaluation of gut microbiota, there was no significant difference in each group. The mechanisms of dietaly habits and gut microbiota have not been well clarified and still unknown. We will have to consider the optimal evaluation methods about dietaly habits and gut microbiota in IBS.

Patients with eating disorders may engage in avoidance behaviors and act out during therapy due to the character of the disease itself. Typically, these behaviors are expressions of dissatisfaction that result in refusal to communicate with or difficulties in communicating with the nursing staff, speech and behavior that attempt to manipulate the therapists and caregivers, and running away from the ward. Based on our experience, our nurses have developed methods to create an atmosphere of an effective caregiver/patient relationship, as follows : 1) A treatment manual was developed by the nursing staff that presents possible answers to the patient actions, 2) Our nurses participate in lectures, given by doctors, that help them better understand the diseases, and 3) The nursing staff hold study meetings in which they engage in “self-learning”. 4) In addition, once a week we have a joint conference for the various types of specialists who deal with our eating disorder patients in order to succeed with a team approach. The chief physician, nurses, pharmacists, and nutritionists share their opinions. Our inpatient treatment program is based on a therapeutic frame called “cognitive-behavioral therapy using behavior limitation”. The staff deal with psyco-social problems that emerge during the course of treatment. Observing and structuring the daily life environment are indispensable to the therapeutic framework of this treatment. Our nurses play an important role in creating an environment conducive to effective inpatient treatment. We report these attitudes with a typical case report.