Oregon Health and Science University
Experts on the Japanese phenomena of hikikomori say the condition of extreme social isolation is more widespread than previously recognized and deserves a clear and consistent definition to improve treatment around the world.
In an article published in the February issue of the journal World Psychiatry , experts cite a lack of broad clinical understanding of the condition.
Although hikikomori is typically associated with young adults in Japan, researchers say many of the same criteria for extended social isolation apply to people around the world, including among older adults and stay-at-home parents.
The authors write that a clear and simplified definition will improve recognition and subsequent treatment for people suffering from the condition.
The article highlights four key aspects of the proposed new definition of hikikomori:
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"The medical profession has not traditionally recognized social isolation as a health problem"
Lead author Alan Teo, MD, associate professor of psychiatry at Oregon Health & Science University School of Medicine and researcher and psychiatrist at the Portland VA Healthcare System, said the medical profession has not traditionally recognized Social isolation as a health problem.
"There is a cultural problem within medicine where we don’t pay attention to it and we don’t believe it is in our path," he said. "These are shared problems, whether you’re an 80-year-old Portlander who is a meals-on-wheels recipient living alone or an 18-year-old with hikikomori in Japan."
Ironically, modern tools to improve communication may be having the opposite effect.
"With advances in digital and communications technologies providing alternatives to in-person social interaction, hikikomori may become an increasingly relevant concern," the authors write.
Spending time online can be detrimental when it replaces interacting with people face to face, Teo said. Those person-to-person social relationships are a critical aspect of mental health.
"Your social life is critical to your quality of life, yet in healthcare, we often forget to think about that," Teo said. "A person’s everyday social life is really what gives them meaning and value."
The recommendations published in World Psychiatry represent an outgrowth of previous collaboration between the three authors, including a perspective published in the journal Psychiatry and Clinical Neurosciences in 2019.
In addition to Teo, the other authors included Takahiro A. Kato, M.D., Ph.D., and Shigenobu Kanba, M.D., Ph.D., of Kyushu University in Japan.
Summary
In the late 1990s, a severe and prolonged form of social withdrawal typically observed among adolescents and young people transitioning to adulthood entered the collective national consciousness in Japan. The so-called "hikikomori" has changed in recent years from being seen as a typical Japanese problem to a problem that can have implications for global health. This change has been driven by growing evidence of hikikomori in epidemiological studies, clinical case series, and media reports from around the world .
As attention to hikikomori grows across cultures and countries, so does the importance of establishing a clear and consistent definition of the disorder. About a decade ago, preliminary diagnostic criteria and a semistructured diagnostic interview were developed.
Over the past decade, we and others in this emerging field of research have gained greater experience in the evaluation, treatment, and follow-up of a number of people with hikikomori, as well as their family members, in Japan and beyond. This has led to an evolution in our biopsychosocial understanding of the disorder and a keen awareness of the limitations of its previous definitions. We believe it is time to provide an updated proposal for diagnostic criteria for hikikomori.
| Hikikomori is a form of pathological social withdrawal or social isolation whose essential characteristic is physical isolation at home. The person must meet the following criteria: a) marked social isolation at home; b) duration of continuous social isolation of at least 6 months; c) significant functional impairment or distress associated with social isolation. |
People who only occasionally leave their home (2-3 days/week), who rarely leave their home (1 day/week or less), or who rarely leave a single room can be characterized as mild, moderate, or severe, respectively. .
People who leave home frequently (4 or more days/week), by definition, do not meet the criteria for hikikomori.
The estimated continuous duration of social withdrawal must be taken into account. People with a duration of at least 3 (but not 6) months of social isolation should be classified as pre-hikikomori .
The age of onset is usually during adolescence or early adulthood . However, onset after the third decade of life is not uncommon, and housewives and the elderly who meet the above criteria may also be diagnosed.
Four aspects of this revised definition of hikikomori stand out .
First, the behavior of remaining homebound, the physical aspect of withdrawing and remaining socially isolated, remains the central and defining characteristic of hikikomori. However, the definition adds clarification on what frequency of leaving the home still qualifies as "marked social isolation at home."
Second, the requirement to avoid social situations and relationships has been removed. In our interviews assessing people for hikikomori , they commonly report having few meaningful social relationships and little social interaction, but deny having avoided social interaction. Many doctors often wonder what distinguishes hikikomori from social anxiety disorder, and this lack of avoidance is one of the main differences.
Third, distress or functional impairment should be carefully assessed. While impairment in individual functioning is vital for hikikomori to be a pathological condition, subjective distress may not be present. Our in-depth clinical interviews with people with hikikomori have revealed that many are actually content with their social withdrawal, particularly in the earlier phase of the condition.
Patients often describe a sense of relief at being able to escape the painful realities of life outside the confines of their home. However, as the duration of social withdrawal lengthens, most people with hikikomori begin to endorse distress, such as feelings of loneliness4.
Fourth, we have eliminated other psychiatric disorders as an exclusion criterion for hikikomori. It is clear that this disorder tends to coexist with other conditions. In our opinion, the frequency of co-occurring conditions increases the importance of addressing social withdrawal as a health problem. It is possible that hikikomori (pathological social withdrawal) coincides with a variety of psychiatric disorders as contributors to psychopathology, similar to how catatonia and panic attacks are now listed as specifiers of various mental disorder diagnoses.
With advances in digital and communication technologies providing alternatives to in-person social interaction, hikikomori may become an increasingly relevant concern. We hope that these simplified diagnostic criteria can help standardize the assessment and encourage cross-cultural comparison of hikikomori.
