Alexithymia refers to difficulty in identifying and expressing one’s emotions, and it is related to disturbed emotional regulation. It was originally proposed as a personality trait that plays a central role in psychosomatic diseases. This review of neuroimaging studies on alexithymia suggests that alexithymia is associated with reduced neural responses to emotional stimuli from the external environment, as well as with reduced activity during imagery, in the limbic and paralimbic areas (i.e., amygdala, insula, anterior/posterior cingulate cortex). In contrast, alexithymia is also known to be associated with enhanced neural activity in somatosensory and sensorimotor regions, including the insula. Moreover, neural activity in the medial, prefrontal, and insula cortex was lowered when people with alexithymia were involved in social tasks. Because most neuroimaging studies have been based on sampling by self-reported questionnaires, the contrasted features of neural activities in response to internal and external emotional stimuli need to be elucidated. The social and emotional responses of people with alexithymia are discussed and recommendations for future research are presented.
Alexithymia; fMRI; PET; Neuroimaging study; Interoception; Psychosomatic medicine; Emotional awareness
Alexithymia is a personality trait characterized by difficulties in identifying and describing feelings and is associated with psychiatric and psychosomatic disorders. The mechanisms underlying the link between emotional dysregulation and psychosomatic disorders are unclear. Recent progress in neuroimaging has provided important information regarding emotional experience in alexithymia. We have conducted three brain imaging studies on alexithymia, which we describe herein. This article considers the role of emotion in the development of physical symptoms and discusses a possible pathway that we have identified in our neuroimaging studies linking alexithymia with psychosomatic disorders. In terms of socio-affective processing, alexithymics demonstrate lower reactivity in brain regions associated with emotion. Many studies have reported reduced activation in limbic areas (e.g., cingulate cortex, anterior insula, amygdala) and the prefrontal cortex when alexithymics attempt to feel other people’s feelings or retrieve their own emotional episodes, compared to nonalexithymics. With respect to primitive emotional reactions such as the response to pain, alexithymics show amplified activity in areas considered to be involved in physical sensation. In addition to greater hormonal arousal responses in alexithymics during visceral pain, increased activity has been reported in the insula, anterior cingulate cortex, and midbrain. Moreover, in complex social situations, alexithymics may not be able to use feelings to guide their behavior appropriately. The Iowa gambling task (IGT) was developed to assess decision-making processes based on emotion-guided evaluation. When alexithymics perform the IGT, they fail to learn an advantageous decision-making strategy and show reduced activity in the medial prefrontal cortex, a key area for successful performance of the IGT, and increased activity in the caudate, a region associated with impulsive choice. The neural machinery in alexithymia is therefore activated more on the physiologic, motor-expressive level and less in the cognitive-experiential domains of the emotional response system. Affects may play an important role in alleviating intrinsic physiologic reactions and adapting to the environment. Deficient development of emotional neural structures may lead to hypersensitivity to bodily sensations and unhealthy behaviors, a possible mechanism linking alexithymia to psychosomatic disorders.
Affect; Alexithymia; Emotional dysregulation; Neuroimaging; Psychosomatic disorders
The number of articles on alexithymia has been steadily increasing since the word “alexithymia” was coined in the 1970s to denote a common characteristic that is observed among classic psychosomatic patients in whom therapy was unsuccessful. Alexithymia, a disorder of affect regulation, has been suggested to be broadly associated with various mental and physical health problems. However, most available evidence is based on anecdotal reports or cross-sectional observations. To clarify the predictive value of alexithymia for health problems, a systematic review of prospective studies was conducted. A search of the PubMed database identified 1,507 articles on “alexithymia” that were published by July 31, 2011. Among them, only 7 studies examined the developmental risks of alexithymia for health problems among nonclinical populations and 38 studies examined the prognostic value of alexithymia among clinical populations. Approximately half of the studies reported statistically significant adverse effects, while 5 studies demonstrated favorable effects of alexithymia on health outcomes; four of them were associated with surgical interventions and two involved cancer patients. The studies that showed insignificant results tended to have a small sample size. In conclusion, epidemiological evidence regarding alexithymia as a prognostic risk factor for health problems remains un-established. Even though alexithymia is considered to be an unfavorable characteristic for disease control and health promotion overall, some beneficial aspects are suggested. More prospective studies with sufficient sample sizes and follow-up period, especially those involving life course analyses, are needed to confirm the contribution of alexithymia to health problems.
Systematic review; Prospective study; Epidemiology
The healing power of nature, vis medicatrix naturae, has traditionally been defined as an internal healing response designed to restore health. Almost a century ago, famed biologist Sir John Arthur Thomson provided an additional interpretation of the word nature within the context of vis medicatrix, defining it instead as the natural, non-built external environment. He maintained that the healing power of nature is also that associated with mindful contact with the animate and inanimate natural portions of the outdoor environment. A century on, excessive screen-based media consumption, so-called screen time, may be a driving force in masking awareness of the potential benefits of nature. With global environmental concerns, rapid urban expansion, and mental health disorders at crisis levels, diminished nature contact may not be without consequence to the health of the individual and the planet itself. In the context of emerging research, we will re-examine Sir J. Arthur Thomson's contention that the healing power of the nature-based environment - green space, forests and parks in particular - extends into the realm of mental health and vitality.
Self-esteem is the "feeling of self-appreciation" and is an indispensable emotion for people to adapt to society and live their lives. For children, in particular, the environment in which they are raised contributes profoundly to the development of their self-esteem, which in turn helps them to adapt better to society. Various psychologists have provided definitions of self-esteem, and examined methods of objectively evaluating self-esteem. Questionnaire-style assessment methods for adult include Rosenberg Self-Esteem Scale and Janis-Field Feeling of Inadequacy Scale, and these for children include Coopersmith Self-Esteem Inventory, Pope's 5-Scale Test of Self-Esteem for children, and Kid- KINDL®. Other methods include Ziller Social Self-Esteem Scale and Implicit Association Test. The development of children's self-esteem is heavily influenced by their environment, that is, their homes, neighborhoods, and schools. Children with damaged self-esteem are at risk of developing psychological and social problems, which hinders recovery from low self-esteem. Thus, to recover low self-esteem, it is important for children to accumulate a series of successful experiences to create a positive concept of self. Evaluating children's self-esteem can be an effective method for understanding their past and present circumstances, and useful to treat for children with psychosomatic disorders.
Self-esteem; Psychosomatic disorder; Pope's 5-Scale Test of Self-Esteem for Children; Quality of life; Mental health
Psychosomatic and developmental behavioral medicine in pediatrics has been the subject of significant recent attention, with infants, school-age children, and adolescents frequently presenting with psychosomatic, behavioral, and psychiatric symptoms. These may be a consequence of insecurity of attachment, reduced self-confidence, and peer -relationship conflicts during their developmental stages. Developmental cognitive neuroscience has revealed significant associations between specific brain lesions and particular cognitive dysfunctions. Thus, identifying the biological deficits underlying such cognitive dysfunction may provide new insights into therapeutic prospects for the management of those symptoms in children. Recent advances in noninvasive neuroimaging techniques, and especially functional near-infrared spectroscopy (NIRS), have contributed significant findings to the field of developmental cognitive neuroscience in pediatrics. We present here a comprehensive review of functional NIRS studies of children who have developed normally and of children with psychosomatic and behavioral disorders.
Development; Children; Cognitive neuroscience; Near-infrared spectroscopy
In Japan there are a number of children and adolescents with emotion-related disorders including psychosomatic diseases (orthostatic dysregulation, anorexia nervosa, recurrent pains), behavior problems and school absenteeism. According to our previous report, the Japanese children had significantly higher score of physical symptoms and psychiatric complaints than did the Swedish children, and these were more strongly influenced by school-related stress than by home-related stress. To enforce countermeasures for psychosomatic problems in children, the Japanese Society of Psychosomatic Pediatrics (established in 1982) have started several new projects including multi-center psychosomatic researches and society-based activities. In this article, we present an outline of our study on mental health in Japanese children in comparison with Swedish children. Countermeasures including clinical guidelines for child psychosomatic diseases are reviewed and discussed.
Psychosomatic disease; Orthostatic dysregulation; Anorexia nervosa; School absenteeism; Migraine
Not only has accidental injury been shown to account for a significant health burden on all populations, regardless of age, sex and geographic region, but patients with accidental injury frequently present with the psychiatric condition of posttraumatic stress disorder (PTSD). Prevention of accident-related PTSD thus represents a potentially important goal. Physicians in the field of psychosomatic medicine and critical care medicine have the opportunity to see injured patients in the immediate aftermath of an accident. This article first briefly reviews the prevalence and associated factors of accident-related PTSD, then focuses on a conceptual model of fear memory and proposes a new, rationally hypothesized translational preventive intervention for PTSD through promoting hippocampal neurogenesis by omega-3 fatty acid supplementation. The results of an open-label pilot trial of injured patients admitted to the intensive care unit suggest that omega-3 fatty acid supplementation immediately after accidental injury can reduce subsequent PTSD symptoms.
With the globalization of occupational health psychology, more and more researchers are interested in applying employee well-being like work engagement (i.e., a positive, fulfilling, work-related state of mind that is characterized by vigor, dedication, and absorption) to diverse populations. Accurate measurement contributes to our further understanding and to the generalizability of the concept of work engagement across different cultures. The present study investigated the measurement accuracy of the Japanese and the original Dutch versions of the Utrecht Work Engagement Scale (9-item version, UWES-9) and the comparability of this scale between both countries. Item Response Theory (IRT) was applied to the data from Japan (N = 2,339) and the Netherlands (N = 13,406). Reliability of the scale was evaluated at various levels of the latent trait (i.e., work engagement) based the test information function (TIF) and the standard error of measurement (SEM). The Japanese version had difficulty in differentiating respondents with extremely low work engagement, whereas the original Dutch version had difficulty in differentiating respondents with high work engagement. The measurement accuracy of both versions was not similar. Suppression of positive affect among Japanese people and self-enhancement (the general sensitivity to positive self-relevant information) among Dutch people may have caused decreased measurement accuracy. Hence, we should be cautious when interpreting low engagement scores among Japanese as well as high engagement scores among western employees.
In Japan, attention has increasingly focused on ensuring the quality of care, particularly in the area of cancer care. The 2006 Basic Cancer Control Act reinforced efforts to ensure the quality of cancer care in a number of sectors, including the role of government in ensuring quality. We initiated a government-funded research project to develop quality indicators to measure the quality of care for five major cancers (breast, lung, stomach, colorectal, and liver cancer) in Japan, and palliative care for cancers in general. While we successfully developed a total of 206 quality indicators, a number of issues have been raised regarding the concepts and methodologies used to measure quality. Examples include the choice between measuring the process of care versus the outcome of care; the degree to which the process-outcome link should be confirmed in real-world measurement; handling of exceptional cases; interpretation of measurement results between quality of care versus quality of documentation; creation of summary scores; and the optimal number of quality indicators for measurement considering the trade-off between the measurement validity versus resource limitations. These and other issues must be carefully considered when attempting to measure quality of care, and although many appear to have no correct answer, continuation of the project requires that a decision nevertheless be made. Future activities in this project, which is still ongoing, should focus on the further exploration of these problems.
Health communication consists of interpersonal or mass communication activities focused on improving the health of individuals and populations. Skills in understanding and applying information about health issues are critical to this process and may have a substantial impact on health behaviors and health outcomes. These skills have recently been conceptualized in terms of health literacy (HL). This article introduces current concepts and measurements of HL, and discusses the role of HL in health communication, as well as future research directions in this domain. Studies of HL have increased dramatically during the past few years, but a gap between the conceptual definition of HL and its application remains. None of the existing instruments appears to completely measure the concept of HL. In particular, studies on communication/interaction and HL remain limited. Furthermore, HL should be considered not only in terms of the characteristics of individuals, but also in terms of the interactional processes between individuals and their health and social environments. Improved HL may enhance the ability and motivation of individuals to find solutions to both personal and public health problems, and these skills could be used to address various health problems throughout life. The process underpinning HL involves empowerment, one of the major goals of health communication.
Suicide is among the most tragic outcomes of all mental disorders, and the prevalence of suicide has risen dramatically during the last decade, particularly among workers. This paper reviews and proposes strategies to avert suicide and depression with regard to the mind body medicine equation hypothesis, metrics analysis of mental health problems from a public health and clinical medicine view.
In occupational fields, the mind body medicine hypothesis has to deal with working environment, working condition, and workers' health. These three factors chosen in this paper were based on the concept of risk control, called San-kanri, which has traditionally been used in Japanese companies, and the causation concepts of host, agent, and environment. Working environment and working condition were given special focus with regard to tackling suicide problems. Matrix analysis was conducted by dividing the problem of working conditions into nine cells: three prevention levels (primary, secondary, and tertiary) were proposed for each of the three factors of the mind body medicine hypothesis (working environment, working condition, and workers' health). After using these main strategies (mind body medicine analysis and matrix analysis) to tackle suicide problems, the paper talks about the versatility of case-method teaching, "Hiyari-Hat activity," routine inspections by professionals, risk assessment analysis, and mandatory health check-up focusing on sleep and depression. In the risk assessment analysis, an exact assessment model was suggested using a formula based on multiplication of the following three factors: (1) severity, (2) frequency, and (3) possibility.
Mental health problems, including suicide, are rather tricky to deal with because they involve evaluation of individual cases. The mind body medicine hypothesis and matrix analysis would be appropriate tactics for suicide prevention because they would help the evaluation of this issue as a tangible problem.
This article introduces key concepts of work-related stress relevant to the clinical and research fields of psychosomatic medicine. Stress is a term used to describe the body's physiological and/or psychological reaction to circumstances that require behavioral adjustment. According to the Japanese National Survey of Health, the most frequent stressors are work-related problems, followed by health-related and then financial problems. Conceptually, work-related stress includes a variety of conditions, such as overwork, unemployment or job insecurity, and lack of work-family balance. Job stress has been linked to a range of adverse physical and mental health outcomes, such as cardiovascular disease, insomnia, depression, and anxiety. Stressful working conditions can also impact employee well-being indirectly by directly contributing to negative health behaviors or by limiting an individual's ability to make positive changes to lifestyle behaviors, such as smoking and sedentary behavior. Over the past two decades, two major job stress models have dominated the occupational health literature: the job demand-control-support model and the effort-reward imbalance model. In both models, standardized questionnaires have been developed and frequently used to assess job stress. Unemployment has also been reported to be associated with increased mortality and morbidity, such as by cardiovascular disease, stroke, and suicide. During the past two decades, a trend toward more flexible labor markets has emerged in the private and public sectors of developed countries, and temporary employment arrangements have increased. Temporary workers often complain that they are more productive but receive less compensation than permanent workers. A significant body of research reveals that temporary workers have reported chronic work-related stress for years. The Japanese government has urged all employers to implement four approaches to comprehensive mind/body health care for stress management in the workplace: focusing on individuals, utilizing supervisory lines, enlisting company health care staff, and referring to medical resources outside the company. Good communications between occupational health practitioners and physicians in charge in hospitals/clinics help employees with psychosomatic distress to return to work, and it is critical for psychosomatic practitioners and researchers to understand the basic ideas of work-related stress from the viewpoint of occupational health.
Recent progress in neuroscience revealed diverse regions of the CNS which moderate autonomic and affective responses. The ventro-medial prefrontal cortex (vmPFC) plays a key role in these regulations. There is evidence that vmPFC activity is associated with cardiovascular changes during a motor task that are mediated by parasympathetic activity. Moreover, vmPFC activity makes important contributions to regulations of affective and stressful situations.
This review selectively summarizes literature in which vmPFC activation was studied in healthy subjects as well as in patients with affective disorders. The reviewed literature suggests that vmPFC activity plays a pivotal role in biopsychosocial processes of disease. Activity in the vmPFC might link affective disorders, stressful environmental conditions, and immune function.
Many physical diseases have been reported to be associated with psychosocial factors. In these diseases, assessment relies mainly on subjective symptoms in natural settings. Therefore, it is important to assess symptoms and/or relationships between psychosocial factors and symptoms in natural settings. Symptoms are usually assessed by self-report when patients visit their doctors. However, self-report by recall has an intrinsic problem; "recall bias". Recently, ecological momentary assessment (EMA) has been proposed as a reliable method to assess and record events and subjective symptoms as well as physiological and behavioral variables in natural settings. Although EMA is a useful method to assess stress-related diseases, it has not been fully acknowledged, especially by clinicians. Therefore, the present brief review introduces the application and future direction of EMA for the assessment and intervention for stress-related diseases.
The literature measuring effects of antidepressant and electroconvulsive therapy (ECT) for major depression on heart rate variability (HRV) in medically well individuals was reviewed.
Fourteen studies evaluating HRV were included. Twenty three pre-post or within group comparisons were available. Treatment impact on measures of HRV was pooled over studies. We examined different classes of antidepressants, and for short and long electrocardiogram (ECG) recordings separately.
Tricyclic antidepressants (TCAs) were associated with declines in most measures of HRV and significant increase in heart rate (HR) in studies with short recording intervals. No significant changes were found for longer recording times.
Treatment effects with selective serotonin reuptake inhibitors (SSRIs) were more variable. Short-recording studies revealed a significant decrease in HR and an increase in one HRV measure. In two 24-hour recording studies no significant changes were observed. No relationship between ECT and HRV has been established in the literature. The effects of other drugs are reported.
Few studies measure the effects of treatment of depression on HRV. Existing studies have generally used very small samples, employing a variety of measurements and methodologies.
We confirm that TCAs are associated with a large decrease in HRV and increase HR. However, data for SSRIs is not clear. Although the effect of SSRIs on HRV is weaker than for TCAs, evidence shows that SSRIs are associated with a small decrease in HR, and an increase in one measure of HRV. The use of TCAs in depression leads to changes in HRV that are associated with increased risk of mortality.
The purpose of this paper is to provide primary care physicians and medical specialists with an experiential psychosomatic framework for understanding patients with body distress symptoms. The framework relies on somatic awareness, a normal part of consciousness, to resolve the dualism inherent in conventional multidisciplinary approaches. Somatic awareness represents a guiding healing heuristic which acknowledges the validity of the patient's physical symptoms and uses body sensations to identify the psychological, physiological, and social factors needed for symptom self-regulation. The experiential approach is based on psychobiologic concepts which include bodily distress disorder, central sensitization, dysfunctional breathing, and contextual nature of mood.
Empathy is a concept central to psychiatry, psychotherapy and clinical psychology. The construct of empathy involves not only the affective experience of the other person's actual or inferred emotional state but also some minimal recognition and understanding of another's emotional state. It is proposed, in the light of multiple levels of analysis including social psychology, cognitive neuroscience and clinical neuropsychology, a model of empathy that involves both bottom-up and top-down information processing underpinned by parallel and distributed computational mechanisms. The predictive validity of this model is explored with reference to clinical conditions. As many psychiatric conditions are associated with deficits or even lack of empathy, we discuss a limited number of these disorders including psychopathy/antisocial personality disorders, borderline and narcissistic personality disorders, autistic spectrum disorders, and alexithymia. We argue that future clinical investigations of empathy disorders can only be informative if behavioral, dispositional and biological factors are combined.
Many patients with somatoform disorders are frequently encountered in psychosomatic clinics as well as in primary care clinics. To assess such patients objectively, the concept of somatosensory amplification may be useful. Somatosensory amplification refers to the tendency to experience a somatic sensation as intense, noxious, and disturbing. It may have a role in a variety of medical conditions characterized by somatic symptoms that are disproportionate to demonstrable organ pathology. It may also explain some of the variability in somatic symptomatology found among different patients with the same serious medical disorder. It has been assessed with a self-report questionnaire, the Somatosensory Amplification Scale. This instrument was developed in a clinical setting in the U.S., and the reliability and validity of the Japanese and Turkish versions have been confirmed as well.
Many studies have attempted to clarify the specific role of somatosensory amplification as a pathogenic mechanism in somatization. It has been reported that somatosensory amplification does not correlate with heightened sensitivity to bodily sensations and that emotional reactivity exerts its influence on somatization via a negatively biased reporting style. According to our recent electroencephalographic study, somatosensory amplification appears to reflect some aspects of long-latency cognitive processing rather than short-latency interoceptive sensitivity.
The concept of somatosensory amplification can be useful as an indicator of somatization in the therapy of a broad range of disorders, from impaired self-awareness to various psychiatric disorders. It also provides useful information for choosing appropriate pharmacological or psychological therapy. While somatosensory amplification has a role in the presentation of somatic symptoms, it is closely associated with other factors, namely, anxiety, depression, and alexithymia that may also influence the same. The specific role of somatosensory amplification with regard to both neurological and psychological function should be clarified in future studies. In this paper, we will explain the concept of amplification and describe its role in psychosomatic illness.
Psychogenic fever is one of the most common psychosomatic diseases. Patients with psychogenic fever have acute or persistent body temperature above normal range in psychologically stressful situations. In spite of numerous case reports on psychogenic fever, there are few epidemiological studies. Therefore, our goal was to investigate the age distribution and gender differences of psychogenic fever in Japan.
To achieve this goal, we searched Medline and Ichushi WEB, a Japanese medical database, and added other publications that were not included in these databases. Thus, we reviewed 195 Japanese cases of psychogenic fever published in 62 papers.
Psychogenic fever patients ranged from 3 to 56 years old, with the highest number of cases occurring in 13 year-olds in both sexes. The male: female ratio of 1: 1.19 suggested a slight predominance of female cases. Psychogenic fever accounted for 18% of fever cases of unknown origin in children and 2–6% of the psychosomatic diseases of pediatric patients. Patients with psychogenic fever were not only found in pediatrics departments, but also in psychosomatic medicine, psychiatry, internal medicine, anesthesiology, dentistry, and obstetrics/gynecology departments.
The age of psychogenic fever patients ranged from 3 to 56 years old and the male: female ratio was 1:1.19. Psychogenic fever is seen especially in adolescence in Japan.
Prostate cancer (PCA) is the most common malignancy and a major cause of death in men but, importantly, a substantial proportion will live for several years following diagnosis. However, they face the prospect of experiencing symptoms, side-effects of treatment and diminished quality of life. The patient's psychological adjustment is particularly complex, given the potential trajectory of the disease, from the point of diagnosis, with its immediate impact, to the phase of palliative care, with its attendant issue of facing mortality. Since a comprehensive review of the literature on psychological adjustment of men with PCA has not yet been done, we have documented relevant research, integrated findings and drawn conclusions, where possible, in order to map out clinical and research implications.
We searched 5 databases for the period 1994 – July 2006, during which most of the work in the field has been done.
We found few studies of substance among the 60 we examined to draw conclusions about psychological adjustment to prostate cancer and its treatment. This is in marked contrast to the picture in breast cancer. While some patterns have emerged, many gaps remain to be filled.
Aspects of methodology need attention, particularly longitudinal, prospective designs, incorporation of control groups and the use of valid and reliable measures. There is scope for qualitative studies as a complement to quantitative research.