Social withdrawal and psychiatry: A comprehensive review of Hikikomori

Exploring Hikikomori-like idiom of distress a year into the SARS-CoV-2 pandemic in Oman: Factorial validity of the 25-item Hikikomori Questionnaire, prevalence and associated factors

BACKGROUND

Existing literature that examines the Hikikomori-like idiom of distress (HLID) initially labelled this phenomenon as a culture-bound syndrome. However, the increasing number of reports from other parts of the world suggest that HLID could instead be a culture-reactive idiom of distress, originating from biopsychosocial disequilibrium and cultural upheaval. The impact of imposed social withdrawal due to the Coronavirus 2 severe acute respiratory syndrome (SARS-CoV-2) pandemic on the growing prevalence of HLID has not yet been adequately explored. Aims: The first objective is to examine the factorial validity of the 25-item Hikikomori Questionnaire (HQ-25) in Oman. Second, we aimed to investigate the prevalence of HLID following the lifting of SARS-COV-2 restrictions in the Arabian Gulf country of Oman. The third related objective is to examine factors associated with the variation of HLID.

METHODS

This cross-sectional online survey was widely distributed across the diverse socio-demographic population residing in Oman. After the validation of the questionnaire and the factorial validity, the Arabic version of HQ-25 was used to explore the prevalence and factors associated with HLID.

RESULTS

A total of 1529 participants were included in the study (response rate = 76.5%), of whom 44% (n = 673) expressed HLID. We randomly split it into half, one for exploratory factor analysis (EFA) (n = 764) and the other half for confirmatory factor analysis (CFA) (n = 765). From the EFA results, a three-factor model was found for the Omani version of HQ-25, which represented 52.87% of the variance with good internal reliability (Overall Cronbach's: 0.92; Socialisation: 0.92; Isolation: 0.84; Emotional support: 0.73). The CFA results report acceptable goodness-of-fit indices (χ2/df = 17.92, p < .001; CFI = 0.90; TLI = 0.95; RMSEA = 0.04, 95% CI 0.02-0.07; SRMR = 0.05) of the three-factor model of the collected samples. All 1529 data were used in the respondents. The results of the logistic regression showed that married marital status (OR = 1.51, 95% CI: 1.12-2.03, p = 0.007), older age (OR = 0.97, 95% CI: 0.95-0.99, p = 0.008), living in an urban area (OR = 0.71, 95% CI: 0.56-0.91, p = 0.006), unemployed occupational status (OR = 1.72, 95% CI: 1.30-2.88, p < .001), screen time (7+ hours vs. <4 hours: OR = 4.50, 95% CI: 3.16-6.41, p < .001; 4-7 hours vs. <4 hours: OR = 2.10, 95% CI: 1.61-2.70, p < .001), history of mental illness (OR = 3.70, 95% CI: 2.29-5.91, p < .001), and adverse childhood experiences (OR = 2.60, 95% CI: 2.03-3.20, p < .001) were significant risk factors for HLID.

CONCLUSION

The factorial validity of the HQ-25 performed in this study appears to mirror the previously reported 3-factor structures. Some of the associated factors appear to support and, conversely, dissent from the findings of previous studies. These are discussed in terms of the attributions of the SARS-COV-2 pandemic, demographic trends in Oman, and sociocultural factors specific to the region of interest.

Hikikomori: A Scientometric Review of 20 Years of Research

The Japanese term hikikomori was first used to describe prolonged social withdrawal in the 1990s. Since then, research across the world have reported similar prolonged social withdrawal in many countries outside Japan. This study systematically analyses the evolution of literature on hikikomori in the past 20 years to gain a better understanding of the development of the knowledge base on hikikomori since it garnered attention in Japan. Findings from the scientometric review indicate many perspectives on the etiology of hikikomori including cultural, attachment, family systems and sociological approaches. However, similarities with modern type depression, a novel psychiatric syndrome, have been proposed and there are signs of a recent paradigm shift of hikikomori as a society-bound syndrome rather than a cultural-bound syndrome unique to Japan. As research into hikikomori continues to grow, results from the review also highlight the need for a more universally shared definition of hikikomori in order to better consolidate cross-cultural research for meaningful and valid cross-cultural comparisons which can help to promote evidence-based therapeutic interventions for hikikomori.

Hikikomori Risk Inventory (HRI-24): A new instrument for evaluating Hikikomori in both Eastern and Western countries

BACKGROUND

Hikikomori, a clinical condition widely studied in Japan, is receiving increasing attention in Western Countries.

AIMS

This study aimed to create a new instrument for evaluating the risk of Hikikomori in both Eastern and Western countries.

METHODS

Through two studies on Italian adolescents, youths, and adults (n = 1,285) and a study on Japanese youths and adults (n = 392), we analyzed the psychometric properties of the Hikikomori Risk Inventory (HRI-24).

RESULTS

We found support, in both the Italian and Japanese samples, for the good and stable factor structure of the scale (CFI = 0.94, RMSEA = 0.057 for both the adult samples), as well as for its convergent and divergent validity.

CONCLUSIONS

The HRI-24 might be used in future studies in both Western and Eastern countries to shed light on the features of this clinical disorder in different cultures. This will allow the development of culture-sensitive preventive and clinical interventions.

Is Mental Illness like Any Other Medical Illness? Causal Attributions, Supportive Communication and the Social Withdrawal Inclination of People with Chronic Mental Illnesses in China

The saying "mental illness is like any other illness" has increasingly become pervasive in promoting mental health literacy among the public in China. This discourse is based on the fact that mental illness is attributed to primarily biogenetic causes. This study comprises an investigation of the impact of causal attributions of mental illness on the social withdrawal inclination of people with chronic mental illnesses (PCMIs) in China. Drawing on attribution theory and a sample of PCMIs, the current authors further question the effectiveness of biogenetic discourse to combat social stigma and to integrate PCMIs into society. In addition, in response to the proliferation of discussion on the digital inclusion of those with mental disabilities, this study constructs a structural model in which the varied effects of supportive communication are used as bridging factors, including face-to-face, telephonic and social media communication. The results indicate a stronger social withdrawal inclination when the PCMIs attributed their illnesses to biogenetic causes. In addition, biogenetic attribution was also found to potentially hinder the PCMIs from using the telephone and social media to seek supportive communication, while psychosocial attribution was found to have potential to combat PCMIs' social withdrawal inclination. In this vein, this study calls for further investigation on the conditional factors upon which digital inclusion might work for PCMIs in China.

Understanding the experiences of hikikomori through the lens of the CHIME framework: connectedness, hope and optimism, identity, meaning in life, and empowerment; systematic review

BACKGROUND

Hikikomori is a phenomenon describing people who exhibit behaviors of self-secluding themselves at home for long durations of time and usually only having face-to-face social interactions with none other than family. Existing interventions for hikikomori are inconclusive and the majority are absent in using a theoretical framework to guide its components. Therefore, applicability of the psychosocial recovery framework of Connectedness, Hope and Optimism, Identity, Meaning in Life, and Empowerment (CHIME) towards hikikomori care was reviewed.

METHOD

Five databases were searched in April 2020 with the search formula from a published systematic review on hikikomori combined with search terms specific to domains of the CHIME framework. Articles included in the review were of the English language, of all publication years, peer-reviewed, quantitative or qualitative research studies and case studies, included study designs that were observational or interventional in nature, and involved populations of socially withdrawn youth.

RESULTS

CHIME's comprehensive structure and organized approach could guide researchers or service providers in determining areas needing assessments, measurement, and areas of focus. It is suggested that the CHIME framework is applicable after modifying a specific dimension-'meaning of mental illness experiences' into 'meaning of the hikikomori experience'. Thematic overlap occurred between the domains of connectedness, identity, and meaning. Yet, additional dimensions or domains such as trust building, non-linearity, and spatiality can be included for addressing specific limitations in this application, which would help towards catering services to help hikikomori in recovery or in increasing quality-of-life of those individuals' while entrapped in this withdrawn lifestyle.

CONCLUSION

CHIME framework could be applicable towards hikikomori care after applying the suggested modifications. Additionally, many knowledge gaps were found in literature during this review that warrants further investigation to improve hikikomori care.

Suicide Motives and Protective Factors - Contributions from a Hikikomori Discussion Board

The study describes reasons why hikikomoris or socially withdrawn people consider committing suicide, and factors that prevent them from committing the act.2,644 anonymous messages were collected in May 2020 from a Finnish hikikomori discussion forum and analyzed using netnography and inductive content analysis.Suicides motives involved experiences of failure, loneliness and worthlessness, often combined with mental health problems and triggered by loss of employment or significant relationship. Lack of courage was a common reason for not committing suicide. The role of family in preventing suicide is significant, along with support from professionals. Family and individualized interventions are discussed briefly.

The 'Hikikomori' syndrome: worldwide prevalence and co-occurring major psychiatric disorders: a systematic review and meta-analysis protocol

INTRODUCTION

The 'Hikikomori' syndrome (HS) consists of prolonged and severe social withdrawal. It has been studied first in Japan and recently has increasingly drawn the attention of researchers and clinicians all over the world. It is unclear whether it exists in other cultural contexts than Asia. The existing systematic reviews did not provide a quantitative synthesis on its prevalence. In addition, a summary of the co-occurring rates of psychiatric disorders is lacking. To provide a more comprehensive understanding of the clinical picture, it seems important to investigate which psychiatric disorders listed in the classification systems are most frequently associated with this psychological condition affecting young people. This paper describes a systematic review and meta-analysis protocol summarising worldwide prevalence of the HS in general population and clinical samples with psychiatric disorders. The review will also assess the co-occurrence between HS and each psychiatric disorder defined by any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) in any clinical samples with psychiatric disorders.

METHODS AND ANALYSIS

A systematic review will be conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies will be included if they use youth aged 12-35 years, recruited from general population or population with psychiatric disorders, if they use international criteria to diagnose HS. No restriction about design or language will be applied. The search will be conducted during the first week of November 2019 by two independent reviewers through the databases Scopus, PubMed, PsycINFO, Web of Science, by examining study references, by looking for conference proceedings/dissertations/theses, by contacting study corresponding authors. Random-effect meta-analysis will be performed by computing effect sizes as logit event rates. Study quality will be assessed through the Newcastle-Ottawa Scale.

ETHICS AND DISSEMINATION

The current review does not require ethics approval. The results will be disseminated through conference presentations and publications in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD 42018098747.

Epidemic of Loneliness in a Digital Society: Hikikomori as a Cultural and Psychological Phenomenon

The article discusses the problem of desocialization, namely, loneliness at a young age in relation to the hikikomori phenomenon. Hikikomori are young people who have not left their parental home for at least 6 months, have no friends, refuse to study and work and are not in contact with their closest relatives. This kind of loneliness manifests most vividly in Japan. A number of Japanese psychiatrists believe that hikikomori suffer from a previously non-diagnosed mental disease specific to the Japanese culture. The peculiarities of socialization processes characteristic of the Japanese society are considered. We analyze the specifics of hikikomori’s application of digital technologies, namely, their use of the Net for communication and information exchange. While hikikomori shy away from traditional socializing, they accept digital socializing and socialize more than their peers did before the digital era. Conclusion: mental health professionals are going to come across more young people identifying themselves as hikikomori and adopting their lifestyle if only in some ways.

Hikikomori Phenomenon in East Asia: Regional Perspectives, Challenges, and Opportunities for Social Health Agencies

Hikikomori, which originated in Japan, refers to the condition where youths withdraw into the home and do not participate in society for an extended period of time. Recent updates on hikikomori presentation within the region were exchanged at a Hikikomori Round Table and Regional Symposium (HRTRS) discussion late 2017, leading to this perspective paper. Hikikomori presents as an overall homogeneous construct, while diversity in clinical presentation exists across East Asian countries. We examined the various presentations, risk factors, theoretical frameworks, and classification issues about hikikomori. In particular, specific risk factors have emerged to some degree across the region, while some are more locale specific. We propose that hikikomori youths have differential onset and developmental patterns, potentially resulting in heterogeneous presentation. We briefly summarized existing interventions in the East Asian region. Intervention strategies need to be tailored to different subtypes. A multicomponent approach would address complexity, multifactorial onset, and development of the condition. The HRTRS presented to participating countries the opportunity to collectively work toward a more universal definition of the hikikomori condition and explored innovative ways to shape existing service structures. Opportunities for participating countries described pertain to early detection of cases, adoption of assessment tools, and improved intervention services.

Hikikomori: revisão sobre um grave fenômeno de isolamento social

RESUMO Objetivos Expandir os conhecimentos sobre o fenômeno de isolamento social prolongado, voluntário e grave denominado hikikomori e facilitar a identificação e o acompanhamento terapêutico desses indivíduos. Métodos Foi realizada uma revisão da literatura de 2000 a 2017, sendo utilizadas várias bases de dados como instrumentos de busca usando as palavras-chave: “hikikomori”, “youth social withdrawal” e “isolamento social prolongado”. Resultados O hikikomori foi descrito inicialmente no Japão, sendo considerado uma síndrome ligada à cultura nipônica. Porém, nos últimos anos foi descrito em diversos países, inclusive no ocidente. Afeta principalmente adolescentes e adultos jovens do sexo masculino, os quais vivem espontaneamente reclusos em seus quartos por pelo menos seis meses. São pessoas solitárias, tímidas, com um suporte social deficiente e que, frequentemente, tiveram alguma experiência traumática na infância. A maioria dos indivíduos apresenta algum transtorno psiquiátrico associado. O fenômeno acarreta terríveis prejuízos para o indivíduo, familiares e para a sociedade como um todo. Conclusão O hikikomori é subdiagnosticado e subtratado fora do Japão, pelo desconhecimento dos profissionais da saúde e pela recusa dos portadores em buscar ajuda. O fenômeno ainda não foi incluído numa categoria de diagnóstico psiquiátrico, o que dificulta a padronização e a realização de pesquisas ao redor do mundo.

A preliminary cross-cultural study of Hikikomori and Internet Gaming Disorder: The moderating effects of game-playing time and living with parents

Background

Internet Gaming Disorder (IGD) and Hikikomori (an extreme form of social real-life withdrawal, where individuals isolate themselves from society) have both been suggested as mental disorders that require further clinical research, particularly among young adult populations.

Objective

To add to the extant literature, the present study used a cross-cultural, cross-sectional design to investigate the association between Hikikomori and IGD, and the potential moderating effects of reported game-playing time and living with parents.

Method

Two online samples of 153 Australian and 457 U.S.-North American young adult players of Massively Multiplayer Online (MMO) games were collected. The nine-item Internet Gaming Disorder Scale-Short Form (IGDS-SF9), and the Hikikomori Social Withdrawal Scale were administered to dimensionally assess IGD and Hikikomori, respectively.

Results

Linear regression analyses confirmed that Hikikomori symptoms are associated with IGD. Additionally, moderation analyses indicated that the association was exacerbated by longer game playing time across both populations. Gamers living with their parents was a significant moderator of the relationship for the Australian sample.

Conclusions

Extreme real-life social withdrawal and IGD are related, and this association is exacerbated for those who spend more time playing MMOs per day, and, for Australian participants, living with their parents.

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Internet Gaming Disorder (IGD) and Hikikomori are two relatively new disorders.

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Hikikomori symptoms are associated with higher IGD scores.

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Longer periods of gaming exacerbated the Hikikomori-IGD association.

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Living with parents exacerbated IGD among Australian gamers.

Hikikomori: debating a XXI century phenomenon from a clinical point of view

The term hikikomori describes a specific form of social withdrawal that can be observed in children, adolescents, and young adults. Epidemiological research studies have shown that this condition is comorbid with a psychopathological disorder only in 50% of all cases. Many young people in a state of withdrawal do not show symptoms ascribable to already known diagnostic parameters. The authors, psychologist, and psychiatrist at the UFSMIA (Functional Mental Health Unit for Children and Adolescents) in Arezzo, illustrate the current debate on the hikikomori phenomenon from a number of viewpoints: psychiatric, sociological, anthropological, and psychological. On the basis of a clinical case discussed at length in this paper, the authors define their viewpoints and the strategies initiated at the Mental Health Unit in the presence of a patient displaying a state of acute social withdrawal. The multiple actions taken by the UFSMIA are combined according to the concept of modularity. Clinical experiences collected allow the definition of therapeutic protocols useful for the treatment of hikikomori adolescents. The overall objective is to promote the autonomy of the adolescent, as well as the reinforcement of his/her identity and personal resources, as well as the non-traumatic re-entry into the social context.

Characteristics of socially withdrawn youth in France: A retrospective study

BACKGROUND

Poor social interactions have been recognized as a symptom since the beginnings of psychiatry. As far as socially withdrawn youth (SWY) are concerned, studies were mostly conducted on patients seeking care. Our psychiatric outreach team called Psymobile was able to reach SWY patients who were not seeking mental health care.

AIMS

To identify the clinical and socio-demographic characteristics of SWY patients referred to our Psymobile unit.

METHOD

We carried out a retrospective study on the records of patients aged 18-34 years, who were referred to Psymobile for 'withdrawal', between April 2012 and December 2015.

RESULTS

In total, 66 patients were included in the study. SWY are predominantly male (80%) from large families or single-parent ones. About 42% had no prior contact with a mental health professional before being referred to Psymobile. The mean duration of withdrawal is 29 months. In all, 42% of SWY use cannabis and 73% present disorders of the sleep-wake schedule. About 71% maintain relations with their families and 73% go out occasionally. They are mostly diagnosed with schizophrenia (37%) or mood disorders (23%).

CONCLUSION

Over one-third of Psymobile patients aged 18-34 years were referred on grounds of social withdrawal. Our data may illustrate more accurately the situation of youth social withdrawal amid the general population than data from help-seeking patients or online questionnaires.

Comparing Social Anxiety Between Asian Americans and European Americans: An Examination of Measurement Invariance

There have been over 30 studies and two meta-analyses comparing social anxiety between Asian Americans and European Americans. However, few have investigated the invariance of social anxiety measures that would make these comparisons appropriate. In the current study, we systematically examined psychometric properties and configural, metric, and scalar invariance of five social anxiety measures and four short forms that have been used more than once to compare Asian Americans ( n = 232) and European Americans ( n = 193). We found that four (i.e., SPS-6, SIAS-6, SPS, and SPAI-18) of the nine scales were scalar invariant, three scales (i.e., SIAS, SPAI, and B-FNES) only achieved configural invariance, and two scales (i.e., FNES and SADS) failed to achieve configural invariance. Latent mean comparisons based on the scalar invariant measures revealed higher social anxiety scores for Asian Americans than European Americans. The findings are discussed with regard to the issues and challenges when comparing social anxiety among different cultural and ethnic groups.

Internet Addiction, Hikikomori Syndrome, and the Prodromal Phase of Psychosis

Computers, video games, and technological devices are part of young people's everyday lives. Hikikomori is a Japanese word describing a condition that mainly affects adolescents or young adults who live isolated from the world, cloistered within their parents' homes, locked in their bedrooms for days, months, or even years on end, and refusing to communicate even with their family. These patients use the Internet profusely, and only venture out to deal with their most imperative bodily needs. Although first described in Japan, cases have been described from around the world. This is the first published report from Canada. The disorder shares characteristics with prodromal psychosis, negative symptoms of schizophrenia, or Internet addiction, which are common differential or comorbid diagnoses. However, certain cases are not accompanied by a mental disorder. Psychotherapy is the treatment of choice although many cases are reluctant to present. The exact place of hikikomori in psychiatric nosology has yet to be determined. We searched Medline up to 12th May, 2015 supplemented by a hand search of the bibliographies of all retrieved articles. We used the following search terms: Hikikomori OR (prolonged AND social AND withdrawal). We found 97 potential papers. Of these 42 were in Japanese, and 1 in Korean. However, many of these were cited by subsequent English language papers that were included in the review. Following scrutiny of the titles and abstracts, 29 were judged to be relevant. Further research is needed to distinguish between primary and secondary hikikomori and establish whether this is a new diagnostic entity, or particular cultural or societal manifestations of established diagnoses.