Morita therapy, which originally began as inpatient treatment, has developed outpatient treatment measures now. Though its original therapeutic target was neurotic patients with “trapped mechanism by vicious cycle”, it has expanded the therapeutic targets to various diseases, including psychosomatic disease, or medically unexplained symptoms. In this paper, we explained the concept of Morita therapy, illustrating some examples. Morita therapy focuses on the attitude to the symptoms, but a symptom itself. It aims to release patients from the trapped situation by vicious cycle. On the other hand, every patient with psychosomatic disease or medically unexplained symptoms visits our clinics for getting rid of their symptoms immediately. So it is not easy to apply Morita therapy to such patients. It requires some ingenuity. First we should focus on the patient’s physical symptoms and understand his suffering. Secondly, we should propose more adaptive behavior or daily habits, that is, “Do as you will do with the symptoms, and leave the symptom as it is.” Morita therapy focuses on daily life and considers it important to regulate daily life as possible. It will lead to the improvement of the symptoms.

Anorectal function tests are essential in the diagnosis and treatment of patients with functional anorectal disorders. Although these patients often experience comorbid depression or anxiety disorders, adequate attention has not been paid to these patients and the aforementioned procedures, in the field of psychosomatic medicine in Japan. Functional anorectal disorders include fecal incontinence, functional anorectal pain, and functional defecation disorders satisfying the Rome Ⅳ criteria. These disorders co-exist each other and are associated with high comorbidity rates. In our hospital, we use anorectal function tests to evaluate the pathophysiology of functional anorectal disorders and accordingly treat the patients with functional anorectal disorders. A representative treatment method applied through an anorectal function test is intra-anal pressure biofeedback (BF) training. A patient is guided to fasten and relax his anal sphincter muscle while the intra-anal pressure is monitored on a display. Anal excretion training involves the excretion of a silicon-balloon inserted in the rectum. Defecation sensation training increases the maximum rectal tolerance volume using an adequately inflated silicon-balloon indwelling the rectum.

These treatments are often insufficient for patients with functional anorectal pain, and multidisciplinary treatment involving a psychosomatic approach is required. We present the results of these treatments and report a case of functional anorectal pain with depression to demonstrate the treatment procedures. BF training was applied to the patients with olfactory reference syndrome with malodor of flatus.

In conclusion, it is useful to combine anorectal function tests providing treatment benefits and the psychosomatic approach to treat patients with functional anal pain or olfactory reference syndrome.

Psychosomatic medical care also plays the role of helping patients who slip between psychiatry and internal medicine, by re-evaluating their bio-psychological and social aspects and readjusting their diagnosis and treatment process with those factors in mind. When examining psychological and psychiatric factors, the evaluation of the brain is important. CT and MRI are used for morphological evaluation, but this is not a functional source of information. Electroencephalography is the only prevailing examination that can objectively evaluate brain function.

It is a low-invasive examination which uses electrodes attached to the scalp to record minute electrical activities in the brain and it can be found in most hospitals. The test is mainly used when epilepsy or disturbance of consciousness is suspected, but it is also used when judging brain death, and can be called the test which checks ‘whether the brain is operating normally.’ We also believe EEG can be used to evaluate if symptoms are from psychological aspects or from disturbance in brain function, which can help evaluate senile depression, delirium, vascular epilepsy, and dementia, or differentiate panic disorder from epileptic seizures. Here, we will report the practical use of electroencephalography in psychosomatic medicine, including a case report.

In the treatment course of eating disorders (EDs), therapists sometimes encounter resistance or even complete refusal of treatment. While we can understand these issues given the pathophysiology of EDs, therapists may feel despair and impatience on encountering patients with such behavior. We previously reported the case of a woman in her 30 s with severe and enduring anorexia nervosa (SEAN) who did not respond effectively to psychotherapy and ultimately received nutritional therapy under physical restraint. Among the questions that should be considered, we need to understand how therapists can develop treatment strategies to increase the willingness to undergo treatment among such patients.

In this article, we introduce our research on patients with SEAN and discuss therapeutic options and strategies for its treatment.

Inpatient treatment and physical management of underweight eating disorders are very difficult for the therapist. They are often hospitalized urgently and the therapist often has to start treatment without treatment contracts. Even though the therapist explains to them the need for hospitalization, it could be difficult to obtain hospitalization consent. The therapist should carefully explain the condition to their family and ask the family for help with the treatment. Physical complications are more likely to be severe if they are underweight. It is desirable to proceed with treatment as multidisciplinary approaches, mainly while exchanging close information with ward nurses. It is important to flexibility for medical treatment, such as creating both the medically necessary treatment and decision making of patients for their treatments. In addition, it is necessary to devise ways to increase motivation for treatment.

Strict physical management by hospitalization is indispensable to save the lives of starving patients with eating disorders, but it is often difficult to introduce hospitalization due to lack of symptoms and treatment resistance. Psychiatric institutions can also enforce compulsory medical treatment under the law, but the criteria for adaptation are not clear. Therefore, it is necessary to address various conditions such as the severity of the symptoms, opinions of both the patient and the family, family background, and their economic situation. Moreover, even after hospitalization, treatment measures such as behavioral restrictions, isolation, and physical restraint require careful judgment not only on medical ethical considerations but also on their ultimate therapeutic value, including the impact to the doctor-patient relationship and any psychological damage. In addition, physical management is often a burden for psychiatrists. Even though the psychiatric ward of a general hospital can provide treatment in conjunction with internal medicine, the characteristic physical problems of eating disorders are not easily confronted, so thorough understanding and experience with treating the entire disease are required. This chapter discusses the appropriate mental and physical treatment of patients based on care provided at Osaka City University Hospital.

A treatment of anorexia nervosa is difficult when refusing to intake despite being extremely lean. In addition, the presence of physical illnesses such as hypoglycemia associated with extreme weight loss, disuse syndrome, and the presence of refeeding syndrome require long-term rehabilitation and significantly increase the duration of inpatient treatment. When a patient with anorexia nervosa is transferred from another medical facility due to physical complications, etc., there is no choice but to perform inpatient treatment before establishing a good therapeutic relationship. We are treating patients with anorexia nervosa while thinking about what a medical practitioner can do in order to get rid of the skinny mantle of anorexia nervosa. Many patients with anorexia nervosa find meaning in losing weight and are anxious and afraid to take off their skinny mantle. Setting a target for recovery body weight is important, but sometimes the treatment may become stuck. In that case, it is necessary to discuss measures such as the goal of being able to maintain a living and measures for gaining self-compassion.

Many aspects of irritable bowel syndrome (IBS) in childhood and adolescence remain unclear, though it is one of the most common functional gastrointestinal diseases. However, IBS is known to be affected strongly by psychological stress. Elucidation of its psychosocial background can lead to appropriate therapeutic intervention. Therefore, this study was conducted at the Okayama University Hospital Pediatric Department to clarify characteristics of child and adolescent patients with IBS by analyzing gender and comorbidity of 69 patients with IBS for whom onset occurred at 18 years of age or younger. Of 35 male and 34 female patients, 59 patients had refused to attend school. Some patients couldn't get out of their house. Many cases had orthostatic dysregulation and allergic diseases as comorbidity : 24 patients were diagnosed with autism spectrum disorder. Results show that sensory hypersensitivity and attention and obsessions of autism spectrum disorder might engender prolongation of symptoms and increased complaints. Apparently, it is necessary to conduct medical treatment while devoting attention to developmental characteristics. Seven male patients had restricted their own behavior. Especially in such cases, environmental adjustment and psychotherapy were effective.

Objectives : Recently, subthreshold autism spectrum disorder, which is noticed only after complaints of physical and mental disorders in adolescence and adulthood, has become a focus of attention. Early assessment of ASD characteristics presenting in the background of comorbidity is most important to provide appropriate support depending on the characteristics. Although P-F study is originally a personality test based on the reaction tendency to frustration scenes, it is easy to reflect problems in interpersonal situations, and its possible usefulness has been shown as a means to specifically grasp the characteristics of interpersonal interaction in ASD. In this study, it is a purpose to examine the possibility of assessment towards adolescents and adults with subthreshold ASD using quantitative and qualitative analyses of P-F study.

Subjects and method : The subjects were 31 patients who visited a psychiatric unit. They were divided into two groups according to the presence or absence of subthreshold ASD. The group with subthreshold ASD fell under one or more of the diagnostic criteria A or B in DSM-5 (11 patients). The control group was a clinical group without ASD (20 patients). We conducted P-F study for adults, and performed quantitative and qualitative analyses.

Results : As a result of quantitative analysis of the P-F study, unscorable responses were more abundant in the subthreshold ASD group than in non-ASD clinical group. In the qualitative analysis of the unscorable responses of the subthreshold ASD group, four characteristics of “difficult to cope”, “situation approval”, “self-oriented”, and “misidentification of situation” were recognized. The qualitative analysis of responses for 24 scenes also showed four characteristics “excessive displacement of responsibility”, “self-assertion with less empathy”, “inappropriate remarks to situation” and “using words with discomfort”. In the subthreshold ASD group, “misidentification of the situation” in the unscorable responses, and “inappropriate remarks to situation” and “using words with discomfort” in the responses of 24 scenes, were recognized more frequently than in non-ASD clinical group.

Conclusion : The P-F study is likely to reflect interpersonal interaction issues that are difficult to recognize at first glance, and there is a possibility of being able to distinguish subthreshold ASD in the background of comorbidity.