The New Training System for the Fellow of the Japanese Society of Internal Medicine (FJSIM) got started since 2018. The certification of FJSIM will be required to become a Board Certified Fellow of Psychosomatic Medicine in Japan. This FJSIM training system requires the acquisition of psychosomatic treatment. The trainees must experience the treatment for sleep disturbance using hypnotics and anxiolytics and need to understand about functional dyspepsia, irritable bowel syndrome and somatic symptom disorder during the training. Because the trainees of psychosomatic medicine also experience patients with psychosomatics from viewpoints of internal medicine, they may become familiar with understanding the biomedical processing of diseases at the state-of-the-art levels. Therefore, mentors will be asked to explain the patient’s condition on the bases of the physical-mental mechanisms and should consider their trainees’ preferences to attract trainees’ interests in psychosomatic medicine. This new training system should be a great opportunity to help the trainees of internal medicine become the Board Certified Fellow of Psychosomatic Medicine in Japan.

To the enforcement of Fellow system of the Japanese Society of Internal Medicine (FJSIM) program, the psychosomatic medicine does not still reach the realization while having a possibility admitted as one of the subspecialties in internal medicine in Japan. As a result, it may not be denied an enhancement to the residents “Psychosomatic medicine is one of the internal medicines” has been weakened.

Even some residents who would like to be psychosomatic internists in the future, may not receive training practically in their own department for the internship. On the other hand, a curriculum to be psychosomatic internists who will be associated with FJSIM program is necessary not only for some residents who hope to expertise psychosomatic medicine but also for others who will expertise a different internal medicine specialty to expand the knowledge of psychosomatic medicine. Additionally, we should discuss about an educational system to expertise not only psychosomatic medicine generally but also the subspecialty in psychosomatic medicine such as psychosomatic gastroenterology etc. In this article it is suggested that an ideal educational model for the scheme development of psychosomatic medicine in the future.

The training of psychosomatic medicine mainly focuses on pre-postgraduate education in medical schools. Our hospital, which is a community hospital without medical schools, had provided the psychosomatic training in the part of internal medicine residency program since 2004. In the earliest years, residents who are interested in psychosomatic medicine received training in a traditional apprentice system. However, the effects of this training were unknown. Therefore, we improved our training methods on reffering to U. S. educational systems of psychotherapy and family medicine. The new one-month training has a goal of making our residents gain confidence in assessment, initial intervention and referral as the same level as U. S. residents. Although this eclectic and systemic training breaks away from the traditional one, our training have received a high evaluation from residents. As a result, the psychosomatic training was made indispensable in our internal medicine residency program. Furthermore, a few residents from other departments got psychosomatic training. Recently, some residents applied our psychosomatic medicine specialist program.

In April 2018, senior residents, who wanted the qualifications of both new internal medicine specialists and psychosomatic medicine specialists, started training.

Conventionally, after they were trained only at the department of psychosomatic medicine for a year in the third year of medical doctor, they could take the exam of a Board Certified Member of the Japanese Society of Internal Medicine. Then, if they acquired the certification, they could take the exam of a psychosomatic medicine specialist. On the other hand, in the new specialist system, it is necessary to have three to four years of additional training in various departments of internal medicines after training as a junior resident, because the qualification of psychosomatic medicine specialists cannot be obtained without the qualification of a new internal medicine specialist. While there is an advantage that they can experience the training of internal medicine for a longer time, the timing of the start of training for a psychosomatic medicine specialist is delayed. With the introduction of the new specialist system, there is also a need for significant change of the training system of psychosomatic medicine. This article outlines the training system of psychosomatic medicine corresponding to the new specialist system at the University of Tokyo hospital. In addition, we discuss how to convey the essence of psychosomatic medicine and the evaluation method to young doctors.

Even through psychiatric diseases are not included in psychosomatic diseases, it is difficult to distinguish the somatic symptom as a part of psychiatric disease from physical disease accompanying psychiatric disease. Somatic symptom disorder (SSD) in DSM-5 is a psychiatric disease which cannot be excluded by existence of physical disease. Therefore the patients with SSD often come to the department of psychosomatic medicine. Excessive thoughts, feelings, or behaviors which the SSD patients have are related to the somatic symptoms, hence it is not appropriate for psychosomatic medicine to reject SSD, and actually a psychosomatic approach is frequently effective to SSD. Patients occasionally take multiphasic communication so dealing with not only the surface but the depths is necessary to make the effective relationship between the patients and doctors. Doctors should be cautious about having negative affection against the patients complaining various symptoms and control their inference and affection.

I outlined the characteristic and historic changes of Somatic Symptom Disorders and Related Disorders reconstituted as a new category using DSM-5. When patients with somatic complaints (functional somatic symptoms, hypochondriac symptoms) visit us general practitioners, our therapeutic intervention proves difficult. In the Biopsychosocial model, somatosensory amplification, proposed by Barsky AJ, is overlooked as one of the cognitive factors of expressed somatic complaints (functional somatic symptoms, hypochondriac symptoms). Barsky AJ targeted somatosensory amplification and developed it as an approach to manage functional somatic symptoms, hypochondriac symptoms functioned by himself. Then I introduced a cognitive-behavioral therapy program for somatic complaints that my colleagues and I translated. When considering the economics of medical care, major problems are foreseeable in the future for the treatment of the patient group troubled by somatic symptoms at home or abroad. In the domain of psychosomatic medicine, searching from both the mind and body to fully comprehend “functional somatic symptoms and hypochondriac symptoms” is possible, including the development of a comprehensive approach utilizing medical, psychological and social support staff.

From a pharmacotherapy perspective, the pathologies classified under somatic symptom and related disorders (somatoform disorders) include obsessive-compulsiveness, anxiety or fear, and anger.

Selective serotonin reuptake inhibitors (SSRIs) are effective in obsessive-compulsiveness. When the effect of SSRIs is inadequate, augmentation therapies with antipsychotics, especially those that have high D₂ receptor affinities, may be effective. When an immediate improvement is needed, combination therapies with noradrenergic and specific serotonergic antidepressant (NaSSA) may be effective.

Both benzodiazepine anxiolytics and SSRIs are effective in anxiety or fear. When these are not adequately effective, antipsychotics, especially multi-acting receptor-targeted antipsychotics (MARTAs), may be effective. α₂δ ligands can also be one of the alternatives, because it can alleviate the hyperactivity of amygdala, the nucleus associated with anxiety and fear.

In some cases of anger, prescription of Japanese Kampo Medicines, particularly Yokukansan, or antipsychotics, especially MARTAs, may be considered.

Introduction : Binge-eating and vomiting are the most common cause of dental complications in patients with eating disorders. However, we recently treated a patient in whom almost all teeth had been ground down to the roots solely as a result of disordered eating behaviour Chew and Spit (CHSP), even though the patient had no history of binge-eating and vomiting.

Case Report : A 25-year-old woman diagnosed with post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, and anorexia nervosa and binge-eating/purging subtype (AN-B/P) was undergoing psychiatric treatment with a selective serotonin reuptake inhibitor (SSRI) at a psychiatric department. She presented at a local dental clinic complaining of tooth pain that appeared as soon as she started CHSP, and was referred and presented to our center because her repeated hospitalization and discharge made treatment at this local clinic difficult.

On initial examination in our center, almost all her teeth were ground down to the roots, and occlusion had broken down. We therefore focused on improving what she was chewing and instructing her on oral hygiene after CHSP.

Discussion : The patient’s oral environment during CHSP was kept acidic by sweetened beverages and similar, suggesting that the dental complications had developed due to a long-maintained caries-inducing environment. Side effects of the SSRI were also suspected. Personalized dental treatment is required in such cases, and widespread awareness of this behaviour is also required to prevent such cases from becoming severe.