Physicians from many medical societies within the Japanese Society of Psychosomatic Medicine (internal medicine, gynaecology, dentistry, and anaesthesiology) have questioned how to appropriately diagnose psychosomatic patients in these different disciplines, and how to then determine the varied therapeutic response each patient may need. Another question of importance is whether individual disciplines require their own personalized systems of psychosomatic diagnosis or a common psychosomatic diagnostic system designed by an individual discipline may work for all other disciplines. Considering the latter, what does it then mean when a discipline such as psychiatry has the sole authority to present definitions for psychosomatic disorders in all disciplines depending on the quality of studies that have been published in that field over the last five to ten years? I will endeavour to discuss with you the redefinition of new concepts of psychosomatic disorders in Japan and call attention to the complications arising from the diagnoses of “bodily distress disorder/somatic symptom disorder”, “functional disorders”, “physical diseases with a psychosocial cause”, “depression” or “anxiety”, which exacerbate the course of physical disease via psychosocial triggers. From a psychosomatic viewpoint, we can describe these disorders as a psychiatric mind or neurological brain dysfunction, or a complex mind-brain-body interaction, including an internal medicine perspective, as has been demonstrated in irritable bowel syndrome (IBS). I reject the idea of the predominant view of psychiatry, neurology, sociology, and internal medicine in order to understand and treat these disorders. High-level international scientific representatives for classification systems (ICD-11, DSM-5), patients, society, and the country’s health system must decide on this important issue of psychosomatic disorders.

I recall my pearls and pitfalls of anorexia nervosa (AN) treatment. Illness education for the patients and their families begins with an interview. The most important purpose of clinical laboratory tests is to exclude other diseases that cause emaciation. Primary care requires urgent medical hospitalization and exercise restrictions depending on body weight to prevent aggravation of illness and death. Because ordinary clinical laboratory tests do not show abnormalities until patients become seriously ill, inspection items that can frequently provide abnormalities, including hormone values or bone mineral density, should be considered and used for psychoeducation. The prevention of hypoglycemic coma as a fatal complication involves supplementary food intake after self-measurement of blood sugar. The primary treatment for hypokalemia accompanied by vomiting or laxative abuse is rehydration by consuming water and salt. The prevention of short stature involves shortening the low-weight period to less than a body mass index (BMI) of 16 kg/m² when the secretion of insulin-like growth factor-I (IGF-1) decreases. Decreased bone mineral density is the primary complication of AN. The recovery of body weight and menstruation are the most effective treatments for osteoporosis. Medical therapies to normalize bone mineral density (BMD) in severely emaciated patients have not yet been established. Patients with AN tolerate body weight gain when they recognize that the advantage of body weight gain is superior to the psychological merits of emaciation and avoidance as stress coping, and through psychoeducation based on impactful medical information. The period of gluttony during the recovery process is the most difficult for patients. Family is a resource for recovery, and interventions to promote adaptive coping styles reduce the caregiving burden and improve mental health. We emphasize the need to increase patient resilience for recovery. The cooperation of medical experts, family members, and school officials supports patients on the difficult treatment path of AN.

Because psychosomatic correlation is redefined as a bidirectional interrelationship between the center of the brain and the periphery of the body, the significance of the function of the autonomic nervous system (ANS) as a mediating variable for this relationship is gaining renewed attention. From this perspective, the “polyvagal theory” presents a novel view of the ANS through psychophysiological studies of the heart. Based on the anatomical fact that the efferent pathway of the vagus nerve is divided into two sections in mammals, the ANS is considered to exist as three components: the dorsal vagus complex, sympathetic nervous system, and ventral vagus complex. This theory shows that (1) there are two types of defense reactions: the mobilization system of the “fight or flight” system through the sympathetic nervous system (SNS), and the immobilization system of “freezing” to “collapse” through the dorsal vagal complex; and (2) the social engagement system of a “feeling of safety” through the ventral vagal complex presents a unique social function at the autonomic level and contributes to the elucidation of the mechanisms of (1) “onset” and (2) “recovery” of stress and trauma. This article examines the significance and challenges of this approach to psychosomatic correlations.

Orexin, a neuropeptide produced by neurons in the lateral hypothalamus, has been shown to promote feeding behavior; however, subsequent studies have revealed that it plays an essential role in the regulation of sleep and wakefulness. In addition, orexin is involved in the behavioral preference for more rewarding meals instead of baseline feeding, and functions as a negative regulator of energy metabolism and the prevention of obesity. This study discusses the regulation of feeding, sleep, and energy metabolism by orexin via the central nervous system.

Numerous patients with eating disorders visit the Department of Psychosomatic Medicine at Kyushu University Hospital annually. However, there are cases in which treatment is interrupted before completion of the process. Furthermore, when patients with eating disorders are admitted to psychosomatic medicine, persuasion by medical personnel and family members often requires considerable time and energy. Fukamachi stated that if hospitalization is achieved after sufficient time is spent on persuasion and consent, the hospitalization goals have been halfway achieved. This achievementis important in treatment because it indicates that the patient has taken a significant step toward recovery by confronting the psychopathology of eating disorders, including avoidance.

However, there are cases in which persuasion for treatment is not reached or in which the patient refuses all treatments even after hospitalization. Within the framework of psychosomatic medicine, which lacks legal coercive power, challenges persist in guiding patients toward treatment and saving lives.

This article discusses the ethical challenges in treating eating disorders in the field of psychosomatic medicine.

Ethical issues related to eating disorders sometimes emerge in civil and criminal litigation.

In civil litigation, when physical restraint is applied to a hospitalized patient with an eating disorder, a lawsuit can be filed to claim damages, and the legality of physical restraint is questioned to ensure fair sharing of damages. Medical professionals are allowed to exercise discretion in determining the necessity of the physical restraint.

However, in criminal proceedings, when a patient with an eating disorder shoplifts, the question of whether to impose punishment or its appropriateness is complicated. In this regard, if we consider the concept that the justification for punishment is to prevent the criminal from committing the crime again, it may seem inappropriate to impose punishment in such cases. However, in reality, no court precedent was found in such cases in which the defendant was acquitted. Notably, for patients with eating disorders, even if they shoplift again during their suspended sentence, they tend to be awarded another suspended sentence and probation and are subject to social treatment.

Objectives : In recent years, bariatric surgery has become a popular treatment option for obesity in addition to medical treatment. As the procedure involves removing the factor of emotional eating, which may be significant for stress reduction, careful presurgical psychosocial evaluation is important. Candidates for bariatric surgery were evaluated based on the presence or absence of psychiatric disorders, stress status, and personal characteristics that lead to obesity.

Method : We evaluated the psychological characteristics of candidate patients for bariatric surgery using the Beck Depression Inventory (BDI)-Ⅱ, State-Trait Anxiety Inventory (STAI), and Bulimic Investigatory Test Edinburgh (BITE), and assessed the relationship between obesity, eating behavior (binge eating), and depression and anxiety.

Results : Significant correlations were observed between BITE and BDI, STAI status, and STAI characteristics ; however, no significant correlations were noted between obesity and BITE.

Conclusion : These findings suggest that the more severe the bulimic symptoms, the more likely the patient is to experience depression and anxiety. As a treatment team, we consider it necessary to observe patients undergoing treatment for obesity for potential eating behavior problems and accompanying depression and anxiety while using mental indicators such as BITE for guidance, irrespective of the severity of obesity.