the state of psychosomatic medicine in japan (prof chiharu kubo)

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    The State of Psychosomatic

    Medicine in Japan

    Chiharu Kubo

    Director, Kyushu University HospitalPresident: Japanese, Asian Societies of

    Psychosomatic Medicine

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    Kyushu University

    HospitalFukuoka

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    The State of Psychosomatic

    Medicine in Japan1. What is Psychosomatic Medicine?

    2. The development of Japanese PsychosomaticMedicine

    3. The Research of Psychosomatic Medicine

    4. World Congress on Psychosomatic Medicine

    5. Asian College of Psychosomatic Medicine

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    1. What is Psychosomatic

    Medicine?Psychosomatic medicine can bedefined as a holistic medicine

    which considers not only physical,but also psychological ,social andexistential aspects of illness and

    which offers a more general andintegrated approach to medicine.

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    Definition of Psychosomatic

    DisordersPathophysiological state of somatic

    disorders that have been closely affected

    by psychosocial factors in their onset anddevelopment, and in which organic and/

    or dysfunctional lesions are found, Rule

    out psychiatric disorder, anxiety disorderor depression accompanied by mainly

    somatic symptoms

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    StressPsychological factors affecting medical conditions

    Physicaldysfunction

    Psychosomaticdiseases

    Acting out

    Absent from school andAnti-social behavior

    Psychologicaldysfunction

    Anxiety disorders,Depression, etc.

    Healthy ventilation

    Hobby, Sport, etc.

    Alexithymia

    Overadaptation

    Disease-pronepersonality

    DSM-V Axis-I

    DSM-V Axis-III

    DSM-V Axis-I

    DSM-V Axis-II

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    Psychosomatic treatment

    1. Physical therapy in internal medicineand other clinical fields

    2. Pharmacotherapy (psychotropic drugs,Chinese herbs)

    3. Life guidance

    4. Social casework5. Psychotherapy

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    Psychotherapy

    Counseling, Behavioral (cognitive) therapy,Autogenic training, Muscle relaxation,Hypnosis, Psychoanalytic therapy,Transactional analysis, Gestalt therapy,Biofeedback therapy, Cognitive therapy,Family therapy, Occupational therapy, Playtherapy, Music therapy, Group therapy

    Oriental psychotherapy :

    Herbal Medicine(Kampo therapy), Acupuncturemoxibustion therapy, Qi-gong therapy, Fastingtherapy, Morita therapy, Naikan therapy, Yogatherapy,

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    2. The Development of Japanese

    Psychosomatic Medicine(1)

    1959 It was established in Kyushu University as The Japanese

    Society of Psychosomatic Medicine.

    1961 The magazine " Psychosomatic Medicine " was published.

    The Faculty of Medicine of Kyushu University attached

    Psychosomatic Medicine Research Institute was established.1963 The Department of Psychosomatic medicine, Faculty of

    Medicine of Kyushu University was established

    1975 The name The Japanese Society of Psychosomatic Medicine

    was changed.

    1976 The name of the magazine Psychosomatic Medicine waschanged.

    1979 Joined The Japan Medical Association.

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    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 ofpsychosomatic 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.

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    Member of Psychosomatic

    Medicine in JapanIn 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.

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    Prof. Yujiro Ikemi

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    The Establishment of Psychosomatic MedicineDepartments at Universities in Japan 1961 Kyushu University

    1972 Tokyo University

    1974 Tohoku University

    1979 Nihon University 1980 Toho University

    1993 Kansai Medical University

    1994 Kagoshima University

    1999 Kinki University

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

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    Sub-association of

    Psychosomatic MedicineWe have fiveassociated 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.

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    Psychosomatic Medicine

    Department and JournalThere are eightuniversities with psychosomatic

    medicine departments.

    There are two journals of psychosomatic medicine.

    1. Shinshinigaku (Japanese language)

    2. Biopsychosocial Medicine (English): Impact Factor 1

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    Psychosomatic Education in JapanMost medical schools include psychosomatic

    medicine as part of their basic educational

    program for doctors, and continuing education isprovided by the many medical societies that focus

    on such areas as allergy, pain disorder, eating

    disorders, irritable bowel syndrome, psycho-

    oncology, depression, et al. Our doctors arelicensed by the Ministry of Health and can receive

    board certification by the Japanese Society of

    Psychosomatic Medicine.

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    Psychosomatic care in Japan

    Psychosomatic care for Japanese patients

    with mental health problems has progressed

    dramatically over the past few decades. Thehealth ministry has included most

    psychosomatic diseases for coverage under

    the national health insurance system, andmost hospitals have sections that deal

    specifically with psychosomatic diseases.

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    3. The Research of

    Psychosomatic Medicine

    Cutting edge basic researchis being done

    in areas such as psycho-neuro-endocrine-

    immunology 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.

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    The Relationship of Host and Environment

    Internal environment

    Cardiovascular disease

    Myocardial infarctionPeriarteritisHypertensionAtherosclerosis

    Endocrine diseaseDiabetesObesity

    Immunological disorder

    AutoimmunityCancerInfection

    Peripheral endocrine

    Physiological

    aging

    External environmentNutrition, Exercise,Sleep, Stress,

    Temperature, RadiationCarcinogen, Bacteria, Virus

    Genetic Programmolecular, cellular,organ

    Pathological aging

    Neurological diseaseCerebral infarctionAlzheimer disease

    Respiratory diseasePulmonary fibrosisPulmonary emphysema

    Hypothalamus, Pituitary,

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    The Current Status ofPsychoneuroimmunology

    : Basic Research Using Animal Stress

    Models

    1. Stress and cardiovascular diseases2. Stressand Autoimmune diseases

    3. Stress andAllergic diseases

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    Takatoshi Hizume, KeikoMorikawa,

    Aya Takaki, Kohtaro Abe, Kenji

    Sunagawa, Mutsuki Amano, KozoKaibuchi,

    Chiharu Kuboand HiroakiShimokawa

    Sustained Elevation of Serum Cortisol

    Level Causes Sensitization of Coronary

    Vasoconstricting Responses in Pigs InVivo: A Possible Link Between Stressand Coronary Vasospasm

    B k d

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    Background1. Vasospastic angina pectoris is known to be induced

    by various mental stress.

    (Jiang W et al. JAMA.1996;275:1651-1656. )

    2. Cortisol secreted by the activated hypothalamo-pituitary-adrenal axis, may play a key role in mental

    stress.(McEwen BS. Biol Psych iatry .2003;54:200207.)

    3. Rho-kinase, an effector of the small GTP-bindingprotein Rho, plays an important role in vascularsmooth muscle contraction. (Kandabashi T.Circulat ion.2000;101:1319-1323. )

    Serotonin Induced Diffuse Coronary

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    Before 5-HT

    IC

    After 5-HT IC

    Control

    group

    Serotonin-Induced Diffuse CoronaryHyperconstriction in the Cortisol Group

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

    Cortisolgroup

    A t I hibit Eff t f Rh ki

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    Acute Inhibitory Effect of Rho-kinaseinhibitor on Serotonin-Induced

    Hyperconstriction in the Cortisol Group

    Hydroxyfasudil+ 5-HT IC

    5-HT IC

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

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    1. Sustained elevation of serum cortisol levelscaused sensitization of serotonin-inducedcoronary hyperconstriction both in vivo and invitro.

    2. Serotonin-induced hyperconstriction ofcoronary arteries under sustained elevation of

    serum level of cortisol was inhibited byhydroxyfasudil, a specific Rho-kinase inhibitor,both in vivo and in vitro.

    Summary

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    Basic Research

    1. Stress and cardiovascular diseases2. Stressand Autoimmune diseases

    3. Stress andAllergic diseases

    4. Stress and liver diseases

    5. Stress and respiratory diseases

    6. Stress and gastrointestinal diseases

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    MRL/lprmouse (Lupus autoimmune animal

    model)

    Lymphadenopathy

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    Social isolation stress

    Control group

    (5 mice/cage)

    Isolation stress group

    (1 mouse/cage)

    Cardboard walls

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    Material & Methods

    Isolation stress5w

    Body weight / 2wSerum corticosteroneUrinary protein/ 4wSurvival rateSerum dsDNA IgG/ 5w

    Control(5 mice/cage)

    Isolation stress(1 mouse/cage)

    Cytokine production of invitroanti-CD3 Ab-stimulated

    splenic cells (IFN-g, IL-4, IL-

    20w

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    Bodyweight(g)

    5 9 13 17

    21

    25 29

    (wks

    )

    20

    30

    40

    50

    60

    ***

    ***

    ***

    *** ******

    Control(n=15)Stress

    (n=15)

    The effect of isolation stress on the body

    weight

    (***p< 0.001)

    The effect of isolation stress on the serum corticosterone

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    5 14 19 (wks)

    Serum

    corticosterone(ng/ml)

    Control(n=8)Stress

    (n=8)

    950

    60

    70

    80

    90

    100

    110

    120

    ## ##

    ######

    ###

    *

    The effect of isolation stress on the serum corticosterone

    levels

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

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    Control

    (n=12)Stress(n=12)

    Survival(

    %)

    0

    20

    40

    60

    80

    100

    5 15 25 35 45 (wks

    The effect of isolation stress on the

    survival

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    0

    100200

    300

    400

    500

    600

    700

    0

    50100

    150

    200

    250

    300

    350

    IFN-g(ng/ml)

    IL-4 (pg/ml) IL-10(pg/ml)**

    0

    100

    200

    300

    400* **

    n.d.n.d.

    aCD3(-

    )

    aCD3(+

    )

    aCD3(-

    )

    aCD3(+

    )

    aCD3(-

    )

    aCD3(+

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

    Control

    (n=8)Stress(n=8)

    The cytokine production of in vitroanti-CD3 Ab-stimulated splenic

    cells

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    Conclusion (Stress &Autoimmune disease

    Social isolation stress was shown toexacerbate the autoimmune disease of

    MRL/lprmice.

    1.

    This stress also promoted a Th1/Th2 balanceshift toward Th1 predominance and inhibited

    the blood corticosterone response to chronic

    inflammation, both of which may be associatedwith stress-induced exacerbation of

    autoimmune disease.

    2.

    (Chida Y, Sudo N, Kubo C. J Neuroimmunol 158: 138-144, 2005)

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    The Current Status ofPsychoneuroimmunology

    : Basic Research Using Animal StressModels

    1. Stress and cardiovascular diseases2. Stressand Autoimmune diseases

    3. Stress andAllergic diseases

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    Psychological stressin childhood &Asthmainadults

    Balb/c mice

    Control (CON)

    Communication box-induced stress (CS)

    Stress 1hr

    timesW

    3W 8W 10W 11W

    OVA 10mg +Alum 2mg

    i.p.

    2% OVA nebulizer30min/day 3days

    Airway inflammation

    Total number of MNCs inBAL

    Subpopulation of MNCs

    in BAL

    (Wright-Giemsa)

    24h

    (MNCs: mononuclear cells, BAL: bronchoalveolar lavage)

    Result 2Subpopulation of MNCs in BAL

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    Result 2Subpopulation of MNCs in BAL

    0

    10

    20

    30

    40

    50

    60

    Celln

    umb

    er

    (

    103)

    *

    Eosinophil Neutrophil LymphcyteMonocyte

    CON

    CS

    * P < 0.05

    Eff t f RU 486( t id t t i t) B h l

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

    CON+RU (n=11)

    FS+RU (n=9)

    CS+RU (n=8)

    Eosinophil Neutrophil LymphcyteMonocyte

    * P < 0.05

    *

    *

    0

    50

    100

    150

    200

    CON+RU

    FS+RU

    CS+RU

    0

    10

    20

    30

    40

    50

    60

    70

    80

    Celln

    umber

    (1

    03)

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    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 mediatessuch stress-induced exacerbation of asthma.

    The Relationship between Stress and Neuro-Endocrin-

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    Generalsensation

    (Skin, Muscle)

    Specialsensation

    (Vision, Audition,Smell)

    Sense ofequilibrium

    Thalamus

    Hypothalamus

    Pituitarygland

    Autonomic nervous

    system

    Immunesystem

    Internal organs

    Endocrine

    system

    OVLT

    Stress

    Central nervoussystem

    Cerebralcortex

    Association areas(Cognition)

    Limbic system(Emotion)

    Hormone

    Cytokine

    Metabolicmaterial

    The Relationship between Stress and Neuro Endocrin

    Immune systems

    4. World Congress of Psychosomatic Medicine

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    g yyear Place (Country)

    The 1st 1971 Guadalajara Mexico

    The 2nd 1973 Amsterdam Netherlands

    The 3rd 1975 Rome Italy

    The 4th 1977 Kyoto Japan

    The 5th 1979 Jerusalem Israel

    The 6th 1981 Montreal Canada

    The 7th 1983 Hamburg Germany

    The 8th 1985 Chicago USA

    The 9th 1987 Sydney Australia

    The 10

    th

    1989 Madrid SpainThe 11th 1991 cancelled

    The 12th 1993 Bern Swiss

    The 13th 1995 Jerusalem Israel

    The 14th 1997 Cairns Australia

    The 15th 1999 Athens Greece

    The 16th 2001 Gothenburg Sweden

    The 17th 2003 Hawaii USA

    The 18th 2005 Kobe Japan

    The 19th 2007 Quebec (Canada)

    The 20th 2009 Torino (Italy)

    The 21st 2011 Seoul(Korea)

    The 22nd 2013 Lisbon(Portugal)

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    5 A i C ll f P h ti M di i

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    5.Asian College of Psychosomatic Medicine

    Yujiro Ikemi

    Singh A.N.

    Mahadevan M.

    Jinichi Suzuki

    Hsien Rin

    Chiharu Kubo

    Liu ZengyuanByung Il Min

    Sueharu Tsutsui

    Ming-Been Lee

    Hiroshi Ishizu

    Lorreine Denerstein

    Bong Yul Huh/Kyung Bong Koh

    Zhao Zhifu

    Lkhagvasuren Tserenkhuu

    Rudi

    The 1st 1984

    The 2nd 1986

    The 3rd 1988

    The 4th 1990

    The 5th 1992

    The 6th 1994

    The 7th 1996The 8th 1998

    The 9th 2000

    The10th 2002

    The11th 2004

    The12th 2006

    The13th 2008

    The14th 2010

    The15th 2012

    The16th 2014

    TokyoJapan

    New DelhiIndia

    Kuala LumpurMalaysia

    SendaiJapan

    TaipeiTaiwan

    FukuokaJapan

    DalianChinaSeoulKorea

    TokyoJapan

    TaipeiTaiwan

    Okinawa (Japan)

    Melbourne(Australia)

    SeoulKorea

    Beijing China

    Ulaanbaatar

    Jakarta

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    Perspective of PsychosomaticMedicineIncrease in psychosomatic diseases

    Stress management

    Preventive medicine

    Health promotion

    Integration of eastern and western medicine