The State of Psychosomatic Medicine in Japan

Chiharu Kubo Director, Kyushu University Hospital President: Japanese, Asian Societies of Psychosomatic Medicine

Kyushu University Hospital

Fukuoka

The State of Psychosomatic Medicine in Japan

1. What is Psychosomatic Medicine? 2. The development of Japanese Psychosomatic Medicine 3. The Research of Psychosomatic Medicine 4. World Congress on Psychosomatic Medicine 5. Asian College of Psychosomatic Medicine

1. What is Psychosomatic Medicine?

Psychosomatic medicine can be defined as a holistic medicine which considers not only physical, but also psychological ,social and existential aspects of illness and which offers a more general and integrated approach to medicine.

Definition of Psychosomatic Disorders

Pathophysiological state of somatic disorders that have been closely affected by psychosocial factors in their onset and development, and in which organic and/ or dysfunctional lesions are found, Rule out psychiatric disorder, anxiety disorder or depression accompanied by mainly somatic symptoms

Stress
Psychological factors affecting medical conditions
DSM-V Axis-I

Healthy ventilation Hobby, Sport, etc.

Alexithymia Overadaptation Disease-prone personality DSM-V Axis-II

Acting out

Absent from school and Anti-social behavior

Psychological dysfunction Anxiety disorders, Depression, etc.

DSM-V Axis-I
Physical dysfunction

Psychosomatic diseases DSM-V Axis-III

Psychosomatic treatment
1. Physical therapy in internal medicine and other clinical fields 2. Pharmacotherapy (psychotropic drugs, Chinese herbs) 3. Life guidance 4. Social casework 5. Psychotherapy

Psychotherapy
Counseling, Behavioral (cognitive) therapy, Autogenic training, Muscle relaxation, Hypnosis, Psychoanalytic therapy, Transactional analysis, Gestalt therapy, Biofeedback therapy, Cognitive therapy, Family therapy, Occupational therapy, Play therapy, Music therapy, Group therapy Oriental psychotherapy : Herbal Medicine(Kampo therapy), Acupuncture moxibustion therapy, Qi-gong therapy, Fasting therapy, Morita therapy, Naikan therapy, Yoga therapy,

2. The Development of Japanese Psychosomatic Medicine(1)

1959 1961 It was established in Kyushu University as The Japanese Society of Psychosomatic Medicine. The magazine " Psychosomatic Medicine " was published. The Faculty of Medicine of Kyushu University attached Psychosomatic Medicine Research Institute was established. The Department of Psychosomatic medicine, Faculty of Medicine of Kyushu University was established The name The Japanese Society of Psychosomatic Medicine was changed. The name of the magazine Psychosomatic Medicine was changed. Joined The Japan Medical Association.

1963 1975 1976 1979

The Development of Japanese Psychosomatic Medicine(2)

1985 A system for the authorization of doctors began. 1990 Psychosomatic medicine therapy permitted by the insurance system. 1991 Treatment guidelines for psychosomatic medicine were completed. 1996 Governmental approval of specialized departments of psychosomatic medicine. 2004 A medical psychological care system was started. 2008 Changed from the authorized doctor system to a specialist system. 2013 3,300 doctors are members of the Japanese Society of Psychosomatic Medicine.

Member of Psychosomatic Medicine in Japan

In June 2009, the Japanese Society of Psychosomatic Medicine celebrated our 50th anniversary. Since its foundation by Prof. Ikemi and approximately 100 colleagues, we have grown rapidly and currently have 3,300 active members, including internal medicine specialists, psychiatrists, psychologists, and co-medical staff members.

Prof. Yujiro Ikemi

The Establishment of Psychosomatic Medicine Departments at Universities in Japan

1961 1972 1974 1979 1980 1993 1994 1999 Kyushu University Tokyo University Tohoku University Nihon University Toho University Kansai Medical University Kagoshima University Kinki University

2007/5/16 Department of Psychosomatic Medicine, Kyushu University

Sub-association of Psychosomatic Medicine

We have five associated sub-associations: 1. pediatric psychosomatic medicine 2. women psychosomatic medicine 3. psychosomatic internal medicine 4. dermatology 5. dentistry

In addition to the national society, we have seven regional psychosomatic medicine societies.

Psychosomatic Medicine Department and Journal

There are eight universities with psychosomatic medicine departments.

There are two journals of psychosomatic medicine. 1. Shinshinigaku (Japanese language) 2. Biopsychosocial Medicine (English) : Impact Factor 1

Psychosomatic Education in Japan

Most medical schools include psychosomatic medicine as part of their basic educational program for doctors, and continuing education is provided by the many medical societies that focus on such areas as allergy, pain disorder, eating disorders, irritable bowel syndrome, psychooncology, depression, et al. Our doctors are licensed by the Ministry of Health and can receive board certification by the Japanese Society of Psychosomatic Medicine.

Psychosomatic care in Japan

Psychosomatic care for Japanese patients with mental health problems has progressed dramatically over the past few decades. The health ministry has included most psychosomatic diseases for coverage under the national health insurance system, and most hospitals have sections that deal specifically with psychosomatic diseases.

3. The Research of Psychosomatic Medicine

Cutting edge basic research is being done in areas such as psycho-neuro-endocrineimmunology and brain imaging. Clinical research is being done in the fields of eating disorders, pain disorder, diabetes, bronchial asthma, IBS, depression, and cancer (psychooncology) all supported by specialzed professional organizations.

Psychosomatic Medicine Research

1. Research into the psychosomatic relationship at the body, organ, tissue, cell and gene levels

2. The relationship of host and environment

(internal and external stress) 3. The relationship of psycho-neuro-endocrineimmunology

The Relationship of Host and Environment

Hypothalamus, Pituitary, Peripheral endocrine External environment Nutrition, Exercise, Sleep, Stress, Internal environment Temperature, Radiation Carcinogen, Bacteria, Virus Genetic Program molecular, cellular, organ

Physiological aging Pathological aging

Cardiovascular disease Myocardial infarction Periarteritis Hypertension Atherosclerosis

Endocrine disease Diabetes Obesity

Immunological disorder Autoimmunity Cancer Infection

Neurological disease Cerebral infarction Alzheimer disease

Respiratory disease Pulmonary fibrosis Pulmonary emphysema

The Current Status of Psychoneuroimmunology : Basic Research Using Animal Stress Models

1. Stress and cardiovascular diseases

2. Stress and Autoimmune diseases 3. Stress and Allergic diseases

Sustained Elevation of Serum Cortisol Level Causes Sensitization of Coronary Vasoconstricting Responses in Pigs In Vivo: A Possible Link Between Stress and Coronary Vasospasm
Takatoshi Hizume, Keiko Morikawa, Aya Takaki, Kohtaro Abe, Kenji Sunagawa, Mutsuki Amano, Kozo Kaibuchi, Chiharu Kubo and Hiroaki Shimokawa

Background
1. Vasospastic angina pectoris is known to be induced by various mental stress. (Jiang W et al. JAMA. 1996;275:1651-1656. ) Cortisol secreted by the activated hypothalamopituitary-adrenal axis, may play a key role in mental stress. (McEwen BS. Biol Psychiatry. 2003;54:200207.)

2.

3. Rho-kinase, an effector of the small GTP-binding protein Rho, plays an important role in vascular smooth muscle contraction. (Kandabashi T. Circulation. 2000;101:1319-1323. )

Serotonin-Induced Diffuse Coronary Hyperconstriction in the Cortisol Group Before 5-HT IC After 5-HT IC

Control group

Cortisol group

(Hizume T, Kubo C et al. Circ Res. 2006;99: 767

Acute Inhibitory Effect of Rho-kinase inhibitor on Serotonin-Induced Hyperconstriction in the Cortisol Group
5-HT IC Hydroxyfasudil + 5-HT IC

(Hizume T, Kubo C et al. Circ Res. 2006;99: 767

Summary
1. Sustained elevation of serum cortisol levels caused sensitization of serotonin-induced coronary hyperconstriction both in vivo and in vitro.

2. Serotonin-induced hyperconstriction of coronary arteries under sustained elevation of serum level of cortisol was inhibited by hydroxyfasudil, a specific Rho-kinase inhibitor, both in vivo and in vitro.

Conclusion
Sustained elevation of the serum level of cortisol is a key mechanism in the link between mental stress and coronary vasospastic activity in which Rho-kinase activation is substantially involved.

Basic Research
1. Stress and cardiovascular diseases

2. Stress and Autoimmune diseases

3. Stress and Allergic diseases

4. Stress and liver diseases

5. Stress and respiratory diseases

6. Stress and gastrointestinal diseases

The Current Status of Psychoneuroimmunology : Basic Research Using Animal Stress Models

1. Stress and cardiovascular diseases

2. Stress and Autoimmune diseases 3. Stress and Allergic diseases

MRL/lpr mouse (Lupus autoimmune animal model)

Lymphadenopathy

Social isolation stress

Cardboard walls

Control group (5 mice/cage)

Isolation stress group (1 mouse/cage)

Material & Methods

5w Isolation stress

Body weight / 2w Serum corticosterone Urinary protein/ 4w Survival rate Serum dsDNA IgG/ 5w

Control (5 mice/cage)

Isolation stress (1 mouse/cage)

20w
Cytokine production of in vitro anti-CD3 Ab-stimulated splenic cells (IFN-g, IL-4, IL-

The effect of isolation stress on the body weight Control

60 Body weight (g) Stress (n=15) (n=15)

50
*** *** *** *** ***

40
***

30

20 5 9 13 1 7 2 1 25

2 (wks ) < 0.001) 9 (*** p

The effect of isolation stress on the serum corticosterone levels Control

Serum corticosterone (ng/ml) 120 ### 110 ## (n=8) Stress (n=8)

100
90 80 70 60 50

## ###

###

14

19

(wks)

(* p < 0.05 vs Control; ## p < 0.01, ### p < 0.001 vs 5 wks d

The effect of isolation stress on the survival Control

100 80 Survival (%) 60 40 Stress (n=12) (n=12)

20
0 5 15 25 35 45 (wks )

The cytokine production of in vitro anti-CD3 Ab-stimulated splenic cells Control Stress (n=8) (n=8) IFN-g IL-4 (pg/ml) IL-10 (ng/ml) ** (pg/ml) ** * 700 350 400 600 300 300 250 500 200 400 200 150 300 100 200 100 50 100 n.d. n.d. 0 0 0 aCD3(- aCD3(+ aCD3(- aCD3(+ aCD3(- aCD3(+ ) ) ) ) ) )

(* p < 0.05, ** p < 0.001)

Conclusion (Stress & Autoimmune disease)

1. Social isolation stress was shown to exacerbate the autoimmune disease of MRL/lpr mice. 2. This stress also promoted a Th1/Th2 balance shift toward Th1 predominance and inhibited the blood corticosterone response to chronic inflammation, both of which may be associated with stress-induced exacerbation of autoimmune disease.
(Chida Y, Sudo N, Kubo C. J Neuroimmunol 158: 138-144, 2005)

The Current Status of Psychoneuroimmunology : Basic Research Using Animal Stress Models

1. Stress and cardiovascular diseases

2. Stress and Autoimmune diseases 3. Stress and Allergic diseases

What is a communication box

Electrical foot-shockPsychological stress (FS) (CS)

Psychological stress in childhood & Asthma in adults

Stress 1hr timesW
3W OVA 10mg + Alum 2mg i.p. 2% OVA nebulizer 30min/day 3days

24h 8W 10W 11W

Balb/c mice Control (CON) Communication box-induced stress (CS)

Airway inflammation Total number of MNCs in BAL Subpopulation of MNCs in BAL (MNCs: mononuclear cells, BAL: bronchoalveolar lavage) (Wright-Giemsa)

Result 2Subpopulation of MNCs in BAL

60

Cell number (103)

50

CON CS

40
30 20

10
0
Eosinophil Neutrophil Monocyte Lymphcyte

* P < 0.05

Effects of RU-486(steroid receptor antagonist) on Bronchoalve

200

80 70 *

CON+RU (n=11) FS+RU (n=9)

CS+RU

(n=8)

150

60 50 40 30

Cell number (103)

100

50

20 10

CON +RU

FS +RU

CS +RU

Eosinophil Neutrophil Monocyte Lymphcyte

* P < 0.05

Conclusion (Stress & Asthma)

1. In a mouse model of asthma, psychological stress by communication box at the age of 3 weeks significantly exacerbated airway inflammation at the age

of 11 weeks.
2. Pre-treatment with RU-486, a glucocorticoid receptor antagonist, before the administration of OVA mist completely eliminated stress-induced exacerbation of airway inflammation in BAL. In addition, the stressed mice exhibited a significant increase in blood glucocorticoids after the administration of OVA mist in comparison with the control mice. 3. These findings indicate that hyporesponsiveness of the HPA axis mediates

such stress-induced exacerbation of asthma.

The Relationship between Stress and Neuro-EndocrinImmune systems

Stress
General sensation (Skin, Muscle)
Special sensation
(Vision, Audition, Smell) Sense of equilibrium Autonomic nervous system

Central nervous system Cerebral cortex

Association areas (Cognition)

Thalamus Limbic system (Emotion)

Hypothalam us

OVLT

Pituitary gland

Endocrine system

Hormone Cytokine

Immune system

Internal organs

Metabolic material

4. World Congress of Psychosomatic Medicine

year The 1st The 2nd The 3rd The 4th The 5th The 6th The 7th The 8th The 9th The 10th The 11th The 12th The 13th The 14th The 15th The 16th The 17th The 18th The 19 The 20
th th

Place (Country) Guadalajara Mexico Amsterdam Netherlands Rome Italy Kyoto Japan Jerusalem Israel Montreal Canada Hamburg Germany Chicago USA Sydney Australia Madrid Spain cancelled Bern Swiss Jerusalem Israel Cairns Australia Athens Greece Gothenburg Sweden Hawaii USA Kobe Japan Quebec (Canada) Torino (Italy) Seoul(Korea) Lisbon(Portugal)

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013

The 21st The 22nd

5.Asian College of Psychosomatic Medicine

The 1st The 2nd The 3rd The 4th The 5th The 6th The 7th The 8th The 9th The10th The11th The12th The13th The14th The15th The16th 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 TokyoJapan New DelhiIndia Kuala LumpurMalaysia SendaiJapan TaipeiTaiwan FukuokaJapan DalianChina SeoulKorea TokyoJapan TaipeiTaiwan Okinawa (Japan) Melbourne(Australia) SeoulKorea Beijing China Ulaanbaatar Jakarta
Yujiro Ikemi Singh A.N. Mahadevan M. Jinichi Suzuki Hsien Rin Chiharu Kubo Liu Zengyuan Byung Il Min Sueharu Tsutsui Ming-Been Lee Hiroshi Ishizu Lorreine Denerstein
Bong Yul Huh/Kyung Bong Koh

Zhao Zhifu Lkhagvasuren Tserenkhuu Rudi

Symposium of The 6th ACPM in Fukuoka Japan (1994)

7th Asian College of Psychosomatic Medicine (Dailian,1996)

Perspective of Psychosomatic Medicine

Increase in psychosomatic diseases Stress management

Preventive medicine
Health promotion

Integration of eastern and western medicine