A 39-Year-Old “Adultolescent”: Understanding Social Withdrawal in Japan

“Mr. T” is a 39-year-old unemployed man living with his parents. For the past 19 years, he has spent the vast majority of his time restricted to his room. He has never worked and describes his attitude toward life as “taking it easy.” Video games and online shopping help him pass the time. At one point several years ago, his online shopping habits caused the equivalent of tens of thousands of dollars of debt. He views his parents’ home as a complimentary hotel of sorts, with his parents tending to his basic needs. Mr. T’s mother, a homemaker, prepares meals for him daily. Financially, he has supported his lifestyle with ongoing funds from his wealthy grandfather and, more recently, his father’s retirement pension.

When asked why he rarely leaves his home, his primary explanation is that he does not want to be seen by others, particularly in light of his lack of accomplishments. Although the frequency with which he leaves home has fluctuated over the years, in general he leaves just once a month when he has an outpatient clinic appointment. He reports having a reversed sleep-wake cycle, and typically he is awake during the daytime only on clinic days.

His mother’s prenatal course was uneventful and she recalled no developmental problems during Mr. T’s childhood. Mr. T was temperamentally shy as a child, though, and avoided participating in activities that would draw attention to him. Growing up, he had a few friends, but his interactions with friends dwindled in high school as he became more concerned about being seen in public. He consistently obtained average grades throughout compulsory school, and after high school he went on to complete a vocational training program and obtain a certificate as a health technician. However, he lacked the motivation to obtain a job, and it was during this period that he began withdrawing into his room.

One year into his social withdrawal, at age 21, Mr. T’s mother brought him to a community psychiatrist specializing in psychosomatic medicine. His chief complaint was pain from craning his neck when in public. Examination revealed no organic abnormalities, and he underwent regular treatment with counseling and pharmacotherapy. This continued for 3 years until he transferred care to another psychiatrist, at his mother’s request, due to lack of improvement. This psychiatrist suspected a prodromal state of psychosis and began pharmacotherapy with an atypical antipsychotic. Despite three adequate medication trials, no improvement occurred. At age 28, Mr. T’s sister’s health declined, and their mother began focusing her energies on her care, which led to Mr. T suddenly becoming physically aggressive toward his mother. At that point, Mr. T was involuntarily hospitalized at a university hospital. On examination, Mr. T was agitated but lacked hallucinations or delusions. Brain MRI and EEG were unremarkable. He was started on haloperidol and valproic acid to target his agitation and irritability; he participated little in ward activities or group therapy. However, after 4 months he was discharged with a diagnosis of taijin kyofusho (an interpersonal fear of offending others) and suspicion for a pervasive developmental disorder (his symptoms were subthreshold for diagnosis).

After discharge, he began seeing a new psychiatrist who suspected hikikomori, a form of profound and prolonged social withdrawal, and began family therapy to target underlying family dynamic problems. The patient and his mother attended biweekly visits at the university’s outpatient clinic. Through these visits, Mr. T was finally able to express his feeling of amae—a desire for dependence on and receiving care from his mother—which had further triggered jealousy and anger when his sister began receiving additional care from his mother. Behavioral therapy with exposure and response prevention was added, and Mr. T’s fear of being seen gradually reduced to the point where he began occasionally going out on shopping errands. When his father retired, he too began participating in family therapy sessions. Overall, family functioning improved, and incidents of reckless spending on shopping resolved. The patient also gained insight into the immaturity of his pattern of avoidance. With recognition of his parents’ rapid aging and his need to take on more adult responsibilities, Mr. T is currently grappling in therapy with how he will care for himself after his parents die.