The Global Epidemic of Extreme Social Withdrawal

The need for better diagnostic criteria to define hikikomori takes center stage.

Posted Jan 12, 2020

In the late 1990s, just as home computers and internet access were becoming ubiquitous, people in Japan began paying closer attention to a severe form of social withdrawal—marked by the desire to be alone in one's bedroom—that was becoming commonplace among adolescent boys. They called this form of extreme social withdrawal hikikomori.

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Source: Pixabay

If someone in Japan becomes a shut-in and avoids the outside world for more than six consecutive months, the Japanese Health, Labor and Welfare Ministry labels it a case of hikikomori. Within Japanese society, the noun hikikomori is also used in the verb form, hikikomoru (ひきこもる). The root of this verb, which means "to confine oneself indoors," comes from hiku ("to pull back") and komuru ("to seclude oneself").

Hikikomori: A Brief History and Timeline

A decade ago, the 2010 edition of the Oxford Dictionary of English included a definition of hikikomori for the first time: "In Japan, the abnormal avoidance of social contact, typically by adolescent males; a person who avoids social contact. Origin: Japanese, literally 'staying indoors, (social) withdrawal.'"

In 2009, The International Journal of Social Psychiatry published a paper, "A New Form of Social Withdrawal in Japan: A Review of Hikikomori," by Alan Teo, which includes a composite sketch of a hypothetical hikikomori patient ("T.M.") that was a synthesis of several real-life cases:

"T.M. is a 19-year-old Japanese who lives with his middle-class parents in a two-bedroom urban apartment. For the last two years he has hardly ever left his room, spending 23 hours a day behind its closed door. He eats food prepared by his mother who leaves trays outside his bedroom. He sleeps all day, then awakes in the evening to spend his time surfing the internet, chatting on online bulletin boards, reading manga (comic books), and playing video games."

Tamaki Saitō, a Japanese psychologist who specializes in puberty and adolescence, is credited with making hikikomori a household word in his homeland.

In 1998, he published a book, Hikikomori: Adolescence Without End, which became a bestseller in Japan. Saitō estimates that hikikomori was already affecting an epidemic proportion of adolescents and young adults in Japan by the late-20th century.

In 2013, Saitō’s book was translated into English. This sparked widespread debate about the cause, diagnostic criteria, and extent of extreme social withdrawal among adolescents and other age groups in Japan and around the globe.

A recent paper (Kato, Kanbe, and Teo, 2020), published online January 10 in the journal World Psychiatry, proposes a clearer and more consistent international diagnostic criteria for hikikomori, which the authors view as a 21st-century global phenomenon.

Senior author Alan Teo is currently a researcher and associate professor of psychiatry at the Oregon Health & Science University School of Medicine in the U.S. and a psychiatrist in the Veteran Administration’s Portland Health Care System.

"There is a cultural issue within the house of medicine whereby we don't pay attention to [extreme social withdrawal] and don't think it is in our lane to deal with," Teo said in a news release. "Spending time online can be damaging when it substitutes for interacting with people face to face. 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 health care, we often forget to think about that. A person's day-to-day social life is really what brings them meaning and value."

In their most recent (2020) paper, Alan Teo and co-authors Takahiro Kato and Shigenobu Kanba of Kyushu University in Japan propose new, universal diagnostic criteria for hikikomori and a framework for defining pathological social withdrawal in the digital age.

"[Hikikimori] has shifted in recent years from being viewed as a typical Japanese problem to an issue that may have global health implications. This shift has been driven by increasing evidence of hikikomori in epidemiologic studies, clinical case series and media reports from around the world," the authors write. "As attention to hikikomori grows across cultures and countries, so does the importance of establishing a clear and consistent definition of the disorder."

Diagnostic Criteria for Hikikomori by Kato, Kanba, and Teo (2020)

  1. Individuals who occasionally leave their home (2‐3 days/week), rarely leave their home (1 day/week or less), or rarely leave a single room may be characterized as mild, moderate or severe, respectively. Individuals who leave their home frequently (4 or more days/week), by definition, do not meet criteria for hikikomori. Also, the estimated continuous duration of social withdrawal should be noted. Individuals with a duration of at least 3 (but not 6) months of social isolation should be classified as pre‐hikikomori.
  2. The requirement for avoidance of social situations and relationships has been removed. In our interviews assessing individuals for hikikomori, they commonly report having few meaningful social relationships and little social interaction, but deny avoiding social interaction. Many clinicians often wonder about what distinguishes hikikomori from social anxiety disorder, and this lack of avoidance is one of the primary differences.
  3. Stress or functional impairment should be carefully evaluated. Our in‐depth clinical interviews with people with hikikomori have revealed that many actually feel content in their social withdrawal, particularly in the earlier phase of the condition. Patients frequently describe a sense of relief at being able to escape from the painful realities of life outside the boundaries of their home. However, as the duration of social withdrawal gets longer, most people with hikikomori begin endorsing distress, such as feelings of loneliness.
  4. We have removed other psychiatric disorders as an exclusion criterion for hikikomori. In our view, the frequency of co‐occurring [mental health] conditions increases the importance of addressing extreme social withdrawal as a health issue. It is possible that hikikomori (pathological social withdrawal) co‐occurs with a variety of psychiatric disorders.

“With advances in digital and communication technologies that provide alternatives to in‐person social interaction, hikikomori may become an increasingly relevant concern,” the authors conclude. “We hope that these simplified diagnostic criteria may help standardize evaluation and encourage cross‐cultural comparison of hikikomori.”

Facebook image: kan_chana/Shutterstock

References

Takahiro A. Kato, Shigenobu Kanba,  Alan R. Teo. "Defining Pathological Social Withdrawal: Proposed Diagnostic Criteria for Hikikomori." World Psychiatry (First published online: January 10, 2020) DOI: 10.1002/wps.20705

Takahiro A. Kato, Shigenobu Kanba,  Alan R. Teo. "Hikikomori: Multidimensional Understanding, Assessment, and Future International Perspectives." Psychiatry and Clinical Neurosciences (First published: May 31, 2019) DOI: 10.1111/pcn.12895

Alan R. Teo. "A New Form of Social Withdrawal in Japan: a Review of Hikikomori" International Journal of Social Psychiatry (First published: June 30, 2009) DOI: 10.1177%2F0020764008100629