We have recently revived our activities of respiratory psychosomatic medicine.

In this article, we reported a program of our network meeting with the focus of clinical experience, search and education in respiratory psychosomatic medicine.

Bronchial asthma is a typical respiratory disease that can include psychosomatic factors. However, psychosomatic treatment is rarely done in respiratory departments practicing EBM. In order to encourage psychosomatic treatment by clinicians, it is necessary to elucidate the pathological condition of bronchial asthma as a psychosomatic disorder and to show scientific evidence about effective psychosomatic treatment. This can be partly achieved through animal experiments. We used an asthma model which showed that mice exposed to stress early in life exhibited a significant acceleration in airway inflammation and hyperresponsiveness as adults, compared to unstressed mice.

In recent human brain imaging studies, the activities of the anterior cingulate cortex and the insula cortex were altered during a stimulus task of “words related to bronchial asthma”, after bronchial asthma patients were exposed to allergens. It was reported that these changes in brain activity were correlated to the change of eosinophils or forced expiratory volume 1.0 (sec). In addition, we reported that the anterior cingulate cortex and the insula cortex were closely related to emotional autonomic nervous activity. These reports suggest that brain activity and autonomic nervous activity are changed due to the interaction of allergens and stress, which causes inflammation and contraction of the respiratory tract.

Psychotherapies, such as active listening (actively listening to another person’s story), cognitive reappraisal (techniques underlying cognitive therapy), and mindfulness (to pay attention to your own experiences at the moment and to accept reality as it is), affect the anterior cingulate cortex and insula cortex of bronchial asthma patients, which can improve the symptoms of bronchial asthma.

Further research is needed to show scientific evidence about effective treatments and the cost effectiveness of psychosomatic treatment for bronchial asthma.

Asthma is a heterogeneous disease with varying molecular, biochemical, and cellular inflammatory features. Based on these, an asthma “endotype” has been proposed as a subtype characterized by a distinct pathophysiology. This endotype-based therapeutic strategy will be important for treating asthma with personalized medicine. Asthma is a respiratory psychosomatic disease, wherein patients can be easily influenced by psychosocial stress. Since responses to stress may differ among individuals, personalized medicine for stress-induced asthma is expected to be highly effective. Stress Resilience is to maintain normal psychological and physical functioning and avoid serious mental illness when exposed to unusual traumatic stress. Recently, resilience has been shed light on the field of neurobiology and reported to be involved in the pathogenesis of respiratory psychosomatic disease, such as asthma. For instance, Chen et al have reported that genomic or epigenomic regulation of ADCYAP1R1, which is one of the stress resilience-related genes, might involve in the pathogenesis of childhood asthma. Interestingly, the stimulation of the ventral tegmental area (VTA) in the mouse brain, a part of the brain’s reward circuitry and resilience-associated lesions, can activate innate and adaptive immune response. There might be a direct link between stress resilience and asthma endotype. Further studies will be needed to clarify this issue. Here, we discuss the future prospects of personalized medicine for respiratory psychosomatic disease, such as asthma based on stress resilience.

・At first, we should discriminate chronic cough and respiratory discomfort against many biological diseases.

・Patients with chronic cough, such as cough variant asthma, are more depressed and anxious than classic asthma patients.

・A psychosocial evaluation is needed to patients with respiratory discomfort, such as emphysema.

・The evaluation of biological, psychological and social problems is very important to control respiratory symptoms such as chronic cough and respiratory discomfort.

Recently, while the prognosis of lung cancer has improved, the patients have to suffer from distress for a long time. Palliative care prolonged the survival in the patients with non-small cell lung cancer. Communication training for the oncologist improved cancer patients’ prognosis. In lung cancer patients, depression and suicide are highly prevalent and dyspnea is associated with anxiety. Topics such as myofascial pain syndrome, chemical coping, and alexithymia are drawing attention in the palliative care field. Thus, psychosomatic medicine plays an important role in medical practice in lung cancer.

One of the most marked features of asthmatic patients may be that they repeat two opposing stages of asthmatic state, that is, asthmatic attack and non-attack. When they have an attack, they fall into the state of dependence, both physically and psychologically. On the other hand, they get into the state of independence during the non-attack period. We usually treat their attack promptly, which means fulfilling their dependence. Besides, we contribute to the improvement of their adherence or inhalation therapy during the period of non-attack, implying to aim for their independence. Therefore, I emphasize my contention that careful medical examinations and treatments could be directly connected with psychotherapy, namely aiming to deal with the problems of dependence and independence for asthmatic patients.

Finally, recently many reports have revealed that some psychiatric disorders, depression or panic disorder etc., involve complication of asthma significantly. Given the mechanism of relationship between classical psychosomatic aspect as stress-induced asthmatic attack and the increase of asthmatic morbidity in some psychiatric disorders is not illuminated, I would like to hope that researchers of the next generation will resolve those mechanisms. Those are two of my messages for the coming psychosomatic researchers.

Referring to the results of The Japanese Society of Psychosomatic Research on Respiratory Diseases (abbreviated to the Society), I mentioned the activities expected in the field of respiratory psychosomatic medicine in the next generation. In the meeting of the Society, the research for bronchial asthma was mainly presented and active discussion was held. Unfortunately, the Society was closed in 1996 due to unavoidable reasons. After the Society was closed, the number of presentations relating to respiratory psychosomatic research sharply decreased at the meetings of the Japanese Society of Psychosomatic Medicine. The possible reasons for it were mentioned.

As to the activities required for developing respiratory psychosomatic medicine, I consider it important to increase the seminars and lecture meetings for respiratory psychosomatic medicine, to use Comprehensive Asthma Inventory and “Questionnaire relating the onset and clinical course of bronchial asthma” and to present respiratory psychosomatic medicine at the meeting of respiratory medicine.

I also discussed the difficulty in practicing a psychosomatic approach at the department of psychosomatic internal medicine, and the underlying problems of psychosomatic medicine in Japan.

Objectives : Many studies have demonstrated that individuals with social phobia focus their attention on internal information, such as their thoughts, feelings, and bodily sensations, to construct an impression of how they appear to others. This impression can take the form of a mental visual image experienced from an “observer perspective,” wherein individuals perceive themselves from another person’s viewpoint. It was shown that the observer perspective causes negative self-evaluation. Subsequently, the intervention has been developed to adjust the observer perspective with the field perspective. In addition, it is shown that the importance of a perspective to oversee both internal and external information objectively. However, there has not been developed the scale comprising multiple items that measure these mental perspectives. Hence, in this study, we developed the Mental Perspective Scale for Social Anxiety Disorder (MPS) and investigated its reliability and validity.

Subjects : Two hundred and eighty-three undergraduate students were included in the study.

Method : We created the Mental Perspective Scale for Social Anxiety Disorder (MPS) comprising 17 items and used a three-factor structure. Subjects completed the MPS, the Focused Attention Scale (FAS) (Yamada et al., 2002) that measured self-focused attention, the Short Fear of Negative Evaluation Scale (SFNE) (Sasagawa et al., 2004) that measured social anxiety, the Detached Mindfulness Mode Scale (DMMS) (Imai et al., 2012) that measured the function of the detached mindfulness mode, and the Voluntary Attention Control Scale (VACS) (Imai et al., 2015) that measured attentional control. To examine whether the MPS indicates a three-factor structure, a factor analysis was performed ; further, Cronbach’s α was calculated for examining internal consistency. The reliability of the MPS was then verified by the test-retest method within a two-week intervening period. Further, the correlation analysis between each variable was conducted to examine construct validity.

Results : The factor analysis extracted the following three factors from 13 items : Factor 1, Field perspective (5 items) ; Factor 2, Observer perspective (4 items) ; and Factor 3, Detached Mindfulness perspective (4 items). Cronbach’s α was sufficiently high, and each subscale demonstrated good or fair test-retest reliability. The construct validity was indicated for each subscale.

Conclusion : These results demonstrated that the reliability and validity of the MPS were acceptable. It may be helpful to assess the degree of each mental perspective (before and after the intervention of social phobia) by using the MPS.

Aims : Brain-gut interaction plays an important role in the pathophysiology of irritable bowel syndrome (IBS). Anxiety is one of exacerbation factors in IBS, which increase the hypersensitivity to external stimuli and may influence colonic motility. We investigated the correlation between anxiety and alternation in the colonic motility induced by colonic distension in IBS.

Methods : We analyzed the data from 20 patients with IBS who underwent colonic manometry and barostat examination. We investigated whether alternation in motility index (ΔMI) correlate with the anxiety score evaluated by State-Trait Anxiety Inventory (STAI).

Results : IBS subtypes were diarrhea (n=10), mixed (n=7), and constipation (n=3). All of IBS-C patients had depression, one IBS-D and IBS-M patient had obsessive-compulsive disorder. The mean trait anxiety score was more than 50 points, indicating most of patients were high trait-anxious individuals. A significant positive correlation was detected between ΔMI and trait anxiety (p=0.040), while there was no significant relation between ΔMI and state anxiety (p=0.170).

Conclusion : These results suggested a pathophysiological relationship between increased colonic motility and exaggerated trait anxiety in IBS patients. Although the increased colonic motility against colorectal distention in IBS patients was considered to be due to intramural reflex, its association with central nervous system might be present.