Seishin shinkeigaku zasshi = Psychiatria et neurologia Japonica最新文献

Psychotherapies have developed closely associated with cultures. The 21st century was the era during which Western intellect, or scientific thought, was by far the predominant influence in the world. Under the influence of such scientific thought, psychoanalysis, behavior therapy, and cognitive therapy were developed, from which various psychotherapies have been derived. These can be regarded as control models with which ego enhancement is aimed at by control- ling symptoms or conflicts. Morita therapy is a psychotherapy which lies at the other end of the spectrum. The thera- peutic mechanism of this psychotherapy is based on the oriental understanding of human beings, which include naturalism or one embodiment theory for mind, body, and nature, consid- eration of human ego and language as definite, and relational theory (a Buddhist idea that every phenomenon arises in mutual relationships). In this paper, I would like to : 1) clarify the characteristics of Morita therapy related to eastern views of nature, and 2) discuss the characteristics of self and acceptance/behavior change. As for self, contrary to mind-body dualism, nature lies at the bottom of all of us, on which the body exists, on which the mind exists. These are mutually related and inseparable, while being open to one another. In Morita therapy, the mind (consciousness) is understood only to a limited extent in relation to nature and the body (unconsciousness). It therefore strongly questions the omnipotent interpretation of thought mediated by lan- guage, which the other psychotherapies sometimes present. Morita therapy aims to be in touch with body and nature in different approaches. The above is what "following nature" means. It is the understanding that fears (inner nature) have to be accepted as nothing but fears, and desires (also inner nature) cannot be given up. By awakening to the fact that there are things that are out of our control, one realizes the presence of desire for life that self-pos- sesses, and its exertion becomes a possibility. This is what we call the state of "Arugamama (being as-is) ", being comprised of the tension between the two poles of desire and fear, which is highly dynamic. Arugamama is the same as the concept of mindfulness to accept fear/anguish as it is. Aru- gamama remains from the concept of desire for life, to assume a dynamic recovery. This is a very useful concept to resolve the narcissism in modern times.

There are psychotherapies in a narrow sense that are systematized as a theoretical model and there are also psychotherapies in a wider sense that provide foundations to the former. This paper first discusses that the latter underlies the former and delineates the features of one of such psychotherapies. Recently, the nature of psychological problems has become so complex and diverse with multiple layers of contributing factors interacting with one another that it is necessary to employ an integrative framework that allows idiographic yet multiphasic observation and multi-axial judgment. The paper contrasts this type of integrative psycho- therapy with other more common approaches and then argues that psychotherapy integration needs to go beyond the integration of theoretical models and the eclectic adoption of different techniques and aim for the personal integration of psychotherapists, which will contribute the most to the betterment of psychotherapy.

In the present case, the subject was a 31-year-old woman with obesophobia who restricted her energy intake and repeatedly induced vomiting and misused laxatives after binge eating, which caused a sudden weight loss of 29 kg in approximately 5 months. In January 20XX, the subject was first examined as an outpatient at our psychiatric department at the recommendation of her eldest son. Upon diagnosis of anorexia nervosa, the subject underwent outpatient treatment ; however, there was no improvement in the disturbance in self-per- ceived weight or shape, and the subject voiced her desire to lose weight. In May 20XX, the subject complained of chest pain, pharyngeal pain, and respiratory distress after self-induced vomiting and was, thus, examined at the psychiatric outpatient services. Chest X-ray and chest CT revealed pneumomediastinum and subcutaneous emphysema. Spontaneous oesophageal rupture, a fatal condition, was suspected and, therefore, the subject was transferred to a more advanced medical institution capable of esophageal surgery. After admission, spontane- ous oesophageal rupture was ruled out based on the results of upper gastrointestinal endos- copy with esophagography, and spontaneous pneumomediastinum was diagnosed. The pneu- momediastinum disappeared with conservative treatment ; however, after approximately 8 months, spontaneous pneumomediastinum recurred, following self-induced vomiting. For patients with eating disorders and who are involved in self-induce vomiting, we believe that the vomiting can cause pneumomediastinum, and it is assumed that continuation or recommencement of vomiting can potentially increase the risk that pneumomediastinum will recur. We, therefore, report recurring pneumoediastinum as a physical complication caused by self- induced vomiting that should be noted in clinical practice of the psychiatric department.

The Japanese Society of Psychiatry and Neurology has been discussing what a Psychiatric Specialist should be for a long time. Although the so-called 'Yamauchi Report' eventually determined the professional accreditation system in 1994, it was not until 2006 that the first Psychiatric Specialist was accredited. Recently, the system that has been operated for 10 years is markedly changing. The Ministry of Health, Labour and Welfare (MHLW) launched an explanatory committee to discuss what a Psychiatric Specialist ought to be, and published a report in April 2013, which led to the inauguration of The General Incorporated Association of Japanese Medical Specialty Board as a trusted third party in May 2014. Thereafter, it set up a new training and accreditation system for Psychiatric Specialists, which is starting in 2017. With such situation in mind, in this paper, I explore the qualities a Psychiatric Specialist needs to acquire and the sort of professional training they shall undertake. I discuss reforming educational programs in medical schools, a clearer picture of a Specialist that the Psychiatric Specialist Investigative Commission at the MHLW and the Japanese Medical Specialty Board suggested, and the way a Psychiatric Specialist ought to be, which the Japanese Society of Psy- chiatry and Neurology has been considering. I emphasize that the methodology to achieve the goal is changing markedly along with the globalization of medical education; however, the phi- losophy, mission, and outcome of the Psychiatric Specialist system should not change.

It is essential to develop a good therapeutic relationship with a patient. However, it is not always easy. There are various factors that make the therapeutic relationship difficult. Being unaware of a change in the therapeutic structure and also being unaware of countertransfer- ence are some of those factors. It is difficult for trainees to realize them by themselves. Suffi- cient opportunities for supervision and case conferences should be made available.

Psychotherapy is an essential component of psychiatric treatment. Although appropriate training including supervision is essential to become able to conduct psychotherapy skillfully, supervision has not been performed in the training of Japanese psychiatrists. In this article, we explain how to utilize supervision in psychiatric training.

Psychiatric residency training programs in the United States are based on regulation by the ACGME (Accreditation Council for Graduate Medical Education). They basically consist of a four-year course (six years if the child program is included), with a variety of didactic courses as well as clinical assignments in different clinical settings affiliated with the local resi- dency program. Each resident is closely supervised by his/her supervisor during his/her clini- cal assignment. Clinical training opportunities are supplemented by on-call duties which require each resident to apply the entire repertoire of skills of a fully-fledged psychiatrist, with intake assessment for hospitalization as well as acute psychiatric coverage in emergency rooms. The author participated in one of these programs at the Menninger Clinic in Kansas in the early 1990s. He discussed one of his own anecdotes, which depicts a potential pitfall for inexperienced psychiatric clinicians.

The roles of university hospital psychiatric departments are: 1) the development and pro- vision of advanced psychiatric treatments unique to university hospitals, 2) the provision of psychiatric intervention models for patients with physical diseases, and 3)the provision of real- world environments for young psychiatrists to learn the principles and experience the practice of such innovative care. As for 1), our facility offers a hospitalization for examination program, which uses near-infrared spectroscopy as a biomarker useful for the auxiliary diagnosis of psy- chiatric disease and selection of the treatment method. University psychiatric departments also play a major role in neuropsychiatry, such as through the use of Epilepsy Monitoring Units (EMU) to differentiate between epilepsy and psychogenic non-epileptic seizures (PNES). Additionally, hospitalizations for examination programs are being implemented for psychosocial and employment support for psychiatric patients, and the diagnosis and evaluation of develop- mental disorders. With regard to 2), our facility has a psychiatric liaison-consultation team. In addition to providing consultation for all departments on delirium, anxiety, and depression, they are actively committed to various transplant treatments. There is also a strong cooperative relationship between the critical care center and psychiatric department. Of the patients hospi- talized for physical conditions and emergencies, over ten percent require psychiatric support, and without the psychiatric department, many patients with severe physical diseases cannot be treated. As such, the medical fees for psychiatric departments in universities and general hospitals should be evaluated appropriately. We would like to propose an "Advanced Psychiat- ric Treatment Development Management Center" (tentative name) to manage the following cycle : a) every university psychiatric department will develop and offer model projects utiliz- ing their respective expertise and specialties ; b) after collecting information on best practices, they will establish evidence through multicenter research, Diagnosis Procedure Combination (DPC) data, and others ; c) they will progress to advanced medical treatments and insurance coverage ; and d) they will continue to improve quality. Finally, I emphasize the role of univer- sity psychiatric departments as the center of education where young psychiatrists learn the principles and experience the practice of such an advanced care model, which will innovate and reform future mental health care.

Cognitive dysfunction such as body-image disturbance and undue influence of body weight on self-worth is a conspicuous feature of eating disorders. The cognitive problems are known to be extremely difficult to treat. Why and how, therefore, is cognitive behavioral ther- apy (CBT) recommended, with high quality evidence, in clinical guidelines such as the NICE guidelines in the UK? In reverse direction to the history of eating disorders, namely anorexia nervosa first and then bulimia, CBT was developed for bulimics first and then after its establishment, the skills were applied to anorexia nervosa. Anorexia treatment whether behavioral or familial, has tended to place patients in a passive mode. The CBT technique, on the other hand, invites patients to participate fully in the treatment, via formulation-making and symptom self-moni- toring. This is particularly important because, unlike in the early days of adolescent anorexia 'epidemic', the number of adult patients has increased. Behavioral and family treatment is less applicable to adult patients who are expected to be more independent than early adolescent anorexics. CBT for bulimics consists of two parts. The first part, the normalization of eating pattern, is largely behavioral. In the enhanced CBT (CBT-E) by Fairburn, a standard CBT in the field of eating disorders research, patients are obliged to make two outpatient visits a week for the first four weeks in order to install a regular eating pattern. The cognitive work is added later on the basis that the patient has successfully achieved a regular meal schedule. This behav- ioral change through two sessions a week may be difficult in a Japanese clinical setting. Some modification such as a brief in-patient treatment may be considered. Also, the number of CBT therapists in Japan is lacking. Collaboration with clinical psychologists is necessary. The CBT for anorexia is a challenge. Fairburn has expanded the application of CBT to anorexia via his 'transdiagnostic' approach. Likewise, Pike et al started to use CBT-AN for relapse prevention for the patients who acquired sufficient weight through inpatient treatment. The research data is promising. In particular, Touyz et al show that CBT-AN had effects on severe and enduring AN (SE-AN), a category of AN which is often thought to be resistant to any type of treatment. It is of note that for both anorexics and bulimics, the effect of 'behavioral only' techniques expires early. By contrast, treatments which deal with psychological elements such as CBT and interpersonal psychotherapy (IPT) have a lasting effect. The time courses of CBT and IPT treatment effect seem sufficiently different that the matching of patient characteristics and the type of treatment should be investigated further. Another important aspect of cognitive dys- function among eating disorder patients is 'denial of illness'. More research should be per- formed with regard to how patients, on improvement from eating disord

Diagnostic and treatment guidelines for childhood attention deficit/hyperactivity disorder (ADHD) were first released in Japan in 2003. Since then, there has been numerous changes in how ADHD is treated, such as the approval of slow-release methylphenidate and atomoxetine for use from childhood to adulthood. Demand regarding adult ADHD has also risen, as the symptoms of ADHD can persist into adulthood, and due to problems with high prevalence rates and comorbidities. Moreover, the DSM-5 recognized the coexistence of ADHD and autis- tic spectrum disorder (ASD), which further raised the level of concern. Yet at present, treat- ment guidelines have not been established for ASD with ADHD symptoms, so it is hoped such guidelines will be created quickly. This article provides a brief summary of recent findings on pharmacological therapy for ASD with ADHD symptoms.