Although extreme social isolation has deep cultural roots in Japan, academic writing in Japanese psychiatry on social withdrawal only dates to the 1970s, and the term hikikomori only emerged into prominence in the 1990s (1). In the language of cultural concepts in DSM-5, hikikomori is both an idiom of distress and cultural syndrome. As an idiom of distress, it is a household term in Japan, has entered the English lexicon, and—thanks to media attention—is used around the globe by people who self-identify as being hikikomori (2). As a syndrome, we have operationalized hikikomori in our work as spending most of the day and nearly every day at home and avoidance of social situations and relationships, with significant associated distress or impairment, for a duration of at least 6 months (3). The lifetime prevalence of hikikomori among young adults is approximately 1.2% in Japan (4). Onset is typically during adolescence or early adulthood, and, on average, 4 years pass before a case presents clinically (5).
Idiopathic hikikomori exists (6). However, as with Mr. T, psychiatric comorbidity is more common, including avoidant personality disorder, major depressive disorder, and social anxiety disorder. In the United States, Mr. T’s presentation with guarded and at times agitated behavior around others may have led to a diagnosis of schizophrenia. Family dynamics gone awry are a key feature of Mr. T’s case, evidenced by overdependence between mother and son and a largely absent father. Hikikomori has tremendous societal and economic implications because the affected often rely on others (usually their parents) for food, shelter, and clothing well into adulthood—hence our characterization of Mr. T as an “adultolescent” of sorts. A recent conceptual framework developed from a systematic review similarly identified maladaptive parenting and family dysfunction as critical factors in the development of hikikomori (7).
Mr. T has had a partial treatment response, largely through psychotherapy, which is the preferred approach in Japan (8). Observational studies suggest that lackluster treatment response is typical, and, to date, only one robust intervention study exists in the literature (7). Despite the lack of evidence-based treatment, public health and clinical resources for hikikomori are widespread in Japan. Since 2000, Japan has required nationwide hikikomori support centers, which often provide telephone consultation to struggling families and in-person psychiatric, counseling, and vocational resources. Expanding and rigorously evaluating public health strategies are key to improving the prognosis for hikikomori. We are also investigating whether shortening the minimum duration of withdrawal to 3 months might help with earlier detection.
Research on hikikomori is still in its infancy, leaving many more questions than answers about its precise etiology, distinction from other conditions, efficacy of treatments, and prognosis. Yet already more articles are indexed in PubMed on hikikomori than on taijin kyofusho, despite the latter having been described more than half a century earlier. The notion of a syndrome of social withdrawal appears to resonate strongly in our time and across many cultures, possibly promoted by internationalization of Japan’s amae culture (8, 9). May this fascination spur much-needed work to dig deeper into understanding and treating hikikomori.
References
1.
Teo AR: A new form of social withdrawal in Japan: a review of hikikomori. Int J Soc Psychiatry 2010; 56:178–185
Teo AR, Fetters MD, Stufflebam K, et al: Identification of the hikikomori syndrome of social withdrawal: psychosocial features and treatment preferences in four countries. Int J Soc Psychiatry 2015; 61:64–72
Koyama A, Miyake Y, Kawakami N, et al: Lifetime prevalence, psychiatric comorbidity, and demographic correlates of “hikikomori” in a community population in Japan. Psychiatry Res 2010; 176:69–74
Kondo N, Sakai M, Kuroda Y, et al: General condition of hikikomori (prolonged social withdrawal) in Japan: psychiatric diagnosis and outcome in mental health welfare centres. Int J Soc Psychiatry 2013; 59:79–86
Teo AR, Stufflebam K, Saha S, et al: Psychopathology associated with social withdrawal: idiopathic and comorbid presentations. Psychiatry Res 2015; 228:182–183
Li TM, Wong PW: Youth social withdrawal behavior (hikikomori): a systematic review of qualitative and quantitative studies. Aust N Z J Psychiatry 2015; 49:595–609
Kato TA, Tateno M, Shinfuku N, et al: Does the “hikikomori” syndrome of social withdrawal exist outside Japan? A preliminary international investigation. Soc Psychiatry Psychiatr Epidemiol 2012; 47:1061–1075
From the Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; the Brain Research Unit, Innovation Center for Medical Redox Navigation, Kyushu University, Fukuoka; the VA Portland Health Care System, Portland, Oreg.; and the Department of Psychiatry, Oregon Health and Science University, Portland.
From the Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; the Brain Research Unit, Innovation Center for Medical Redox Navigation, Kyushu University, Fukuoka; the VA Portland Health Care System, Portland, Oreg.; and the Department of Psychiatry, Oregon Health and Science University, Portland.
From the Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; the Brain Research Unit, Innovation Center for Medical Redox Navigation, Kyushu University, Fukuoka; the VA Portland Health Care System, Portland, Oreg.; and the Department of Psychiatry, Oregon Health and Science University, Portland.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
Japan Society for the Promotion of Science10.13039/501100001691: 26713039, 15K15431, Bilateral Joint Research Project between USA-Japan
Japan Agency for Medical Research and Development: H27 - Seishin-Syogai Taisaku-Jigyo
Supported in part by a grant to Dr. Kato from the Japan Society for the Promotion of Science (JSPS) Grants-in-Aid for Scientific Research (KAKENHI grants 26713039 and 15K15431) and the JSPS Bilateral Joint Research Project between the United States and Japan. Dr. Kanba is supported by the Japan Agency for Medical Research and Development and the Japanese Ministry of Health, Labor, and Welfare (H27 - Seishin-Syogai Taisaku-Jigyo). Dr. Teo is supported by the U.S. Department of Veterans Affairs.
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