Clarifying Deeper Psychological Characteristics of Hikikomori Using the Rorschach Comprehensive System: A Pilot Case-Control Study

Shifting the paradigm of social withdrawal: a new era of coexisting pathological and non-pathological hikikomori

PURPOSE OF REVIEW

Social withdrawal syndrome, known as "hikikomori," has been highlighted since the late 1990 s in Japan. Hikikomori is more common in urban areas, and often comorbid with mental disorders, and now spreading throughout the world. In the post-COVID-19 era, not outing is no longer considered pathological in itself as the "new normal," and a novel concept of hikikomori is needed. This review summarizes the concept of hikikomori, and presents the latest methods for identification of hikikomori.

RECENT FINDINGS

The novel definition can distinguish between pathological and non-pathological hikikomori using the scale of "Hikikomori Diagnostic Evaluation (HiDE)," which has been developed in the hikikomori research lab at Kyushu University. An online survey among non-working adults has revealed that persons who have become pathological hikikomori for less than three months showed a particularly strong tendency toward gaming disorder and depression.

SUMMARY

Now, physical isolation itself is not pathological, but when dysfunction and distress are present, rapid mental health support should be provided. In the novel urban society, the establishment of a checkup system to assess whether persons who stay home are happy or suffering is important for prevention against mental disorders triggered by social isolation.

Relationship Between Social Withdrawal (Hikikomori), Personality, and Coping in an Adult Population

OBJECTIVE

The aim of this study was to investigate the relationships between personality dimensions, coping strategies, and Hikikomori while controlling for the presence of depression and anxiety.

METHODS

Two groups, recruited on social networks, were compared: the control group (n=101, mean age±standard deviation [SD]= 36.2±12.8 years) and the Hikikomori group (n=28, mean age±SD=30.1±9.1 years). Participants of both groups completed the Big Five Inventory, the Brief Coping Orientation to Problems Experienced, and the Hospital Anxiety and Depression Scale.

RESULTS

The Hikikomori group had higher depression, anxiety, neuroticism, and dysfunctional coping dimension (self-blame and behavioral disengagement) scores than the control group. Being alone and depression were positively associated with Hikikomori while extraversion and instrumental support were negatively associated with Hikikomori.

CONCLUSION

These findings contribute to a better understanding of the psychological functioning of Hikikomori as well as to treatment elaboration and confirm that some psychological characteristics are transcultural.

Who are hikikomori? Demographic and clinical features of hikikomori (prolonged social withdrawal): A systematic review

OBJECTIVE

This review, which was registered with PROSPERO (CRD42021237988), aimed to systematically extract common elements in the hikikomori definition or criteria applied by researchers and examine cultural differences and chronological changes in the demographic characteristics of hikikomori individuals such as age, gender and hikikomori duration.

METHOD

For inclusion in the review, the hikikomori criteria, age and gender of the hikikomori individuals had to be specified, and the article had to be peer-reviewed and written in Japanese or English, focusing on hikikomori individuals or their families. Case studies, reviews and qualitative studies were excluded.

RESULTS

The total sample size for the 52 studies included in the review was 4744. Over 80% of the studies included the elements 'not working or attending school', 'not socializing outside one's home' and 'duration of hikikomori' in their hikikomori criteria, and many studies included the element 'staying at home on most days except solitary outings'. A cross-temporal meta-analysis showed the possibility that the age of hikikomori individuals increased chronologically (β = 0.44, B = 0.50, 95% confidence interval = [0.16, 0.84]). Comparisons weighted by sample size between Japan and other countries showed the possibility that the age of hikikomori individuals was higher (d = 0.32), the percentage of males was lower (d = 0.91) and the hikikomori duration was shorter (d = 2.06) in studies conducted in countries other than Japan. However, many of the included studies had a high risk of selection bias, and this bias may have influenced the results obtained. Thus, the results of this study may represent the researcher's perception of hikikomori rather than accurately representing the actual condition of hikikomori.

CONCLUSION

Researchers should specifically identify similarities and differences in the clinical picture of hikikomori and compare the studies to organize the findings derived from studies focusing on hikikomori.

Home visiting support for people with hikikomori (social withdrawal) provided by experienced and effective workers

OBJECTIVES

Hikikomori - an almost complete withdrawal from social interaction first seen in Japan - is becoming an emerging psychological syndrome worldwide. The mental health community in Japan has focused on hikikomori since the 1990s. Hikikomori was initially considered a culture-bound trait, unique to Japan; however, it has become an international concern, and cases have been reported even outside of Japan. While home visiting support for people with hikikomori has gained popularity, an effective solution remains elusive. This paper describes the process involved in effective home visiting support provided by experienced workers to help people with hikikomori.

METHOD

Semi-structured interviews were conducted with 21 home-visiting support workers in Japan. Collected data were analysed using a constant comparative method based on Grounded Theory.

RESULTS

'Supporting them in finding their own way to participate in society' was identified as the core category. This core category was substantiated by following three interrelated stages: preparing the involved surroundings for reaching out to a person, maintaining constant communication and expanding the range of activities and relationships. The process encouraged people with hikikomori to enhance their social connections and improved their motivation for social participation. People with hikikomori experiencing despair and isolation began to find pleasure in social participation through the three stages of support provided by home-visiting workers.

CONCLUSION

Our study suggests that Home visiting support for people with hikikomori can be enhanced by these three interrelated methods which can help individuals integrate into society and connect with others.

The scope and nature of prolonged social withdrawal in Israel: An initial quantitative and qualitative investigation

OBJECTIVE

Over the past few decades, prolonged social withdrawal (PSW) among young people has been recognized in several countries. Most research has been quantitative and focused on the characteristics of PSW individuals and their families. Little attention has been given to the valuable perspective of professionals providing service to this population. The purpose of the present study is to identify the characteristics of PSW in Israel, where this phenomenon has not been researched yet. For this initial investigation, the study will utilize a combination of quantitative self-report data from parents of PSW individuals, as well as qualitative data gathered from interviews with mental health professionals who work with this population.

METHODS

Quantitative data were derived from records of referrals by parents of 121 PSW individuals, and later categorized into apparent characteristics of PSW. Qualitative data was collected through semi-structured interviews conducted with 19 professionals experienced in treating PSW, and later analyzed in a thematic analysis process.

RESULTS

Findings from the quantitative data revealed a majority of males (70%) with an average age of 24.2, with previously diagnosed psychiatric conditions (64%). Findings from the qualitative data exposed frequently reported characteristics of PSW individuals and their families, out of which five themes emerged: Family Dynamics, Psychological Characteristics, Typical Behaviors, Past Difficulties, and Present Challenges.

CONCLUSION

This study is the first to identify and report characteristics of PSW in Israel, which are consistent with previous research reported in other countries. The study is highlighting familial characteristics as well as individual ones, while also considering the broader socio-cultural context. These findings draw attention to the importance of notifying the general public, clinicians, researchers, and policymakers in Israel and beyond to the concerning problem of PSW, while contributing to the efforts to develop a map of this barely explored territory.

The relationship between Hikikomori risk factors and social withdrawal tendencies among emerging adults-An exploratory study of Hikikomori in Singapore

INTRODUCTION

Once a localized Japanese phenomenon, Hikikomori-type social withdrawal has since been observed globally in increasing numbers. However, there is a lack of research about Hikikomori in Singapore. Consequently, local variations of Hikikomori may differ from past research in Japan. Drawing on associations found in international and Japanese Hikikomori research, we explored some variables relevant and generalizable to the Singaporean context. Specifically, we examined the relationships between (1) Hikikomori risk factors, (2) social withdrawal tendencies, (3) depression and anxiety, (4) connections with family and friends, and (5) employment status.

METHODS

In a cross-sectional survey study (N = 416; M _age = 24.90, SD _age = 4.79; females = 236, males = 177, undisclosed = 3), participants were provided a Qualtrics link and asked to complete a questionnaire comprising the NHR scale, LSNS-6, DASS-21, ERQ, and HQ-25.

RESULTS

We found that (a) Hikikomori risk factors positively correlated with social withdrawal tendencies and depression and anxiety but negatively correlated with support from family and friends, (b) high Hikikomori risk factors predicted high social withdrawal tendencies, (c) support from friends (one of the psychosocial factors) predicted social withdrawal tendencies together with the Hikikomori risk factors, and (d) social withdrawal tendencies moderated the relationship between Hikikomori risk factors and depression among the emerging adults in Singapore.

CONCLUSION

The current research findings serve as a basis for future Hikikomori research in Singapore.

Neurodevelopmental Disorder Traits in Taijin-Kyofu-sho and Social Anxiety Disorder: A Cross-Sectional Study among University Students

Taijin-Kyofu-sho is an East Asian culture-bound anxiety disorder with similarities to social anxiety disorder. However, few studies have examined these two disorders from the perspective of neurodevelopmental disorders. This study is aimed at examining the association of Taijin-Kyofu-sho and social anxiety disorder with the attention-deficit/hyperactivity disorder (ADHD) trait and autism spectrum disorder (ASD) trait. The Liebowitz Social Anxiety, Taijin-Kyofu-sho, and Adult Attention-Deficit/Hyperactivity Disorder Self-Report scales and the 16-item Autism-Spectrum Quotient were administered to 818 university students. Participants were divided into four groups: control (neither Taijin-Kyofu-sho nor social anxiety disorder), pure Taijin-Kyofu-sho (Taijin-Kyofu-sho alone), pure social anxiety disorder (social anxiety disorder alone), and mixed Taijin-Kyofu-sho-social anxiety disorder (both Taijin-Kyofu-sho and social anxiety disorder). We used logistic regression analysis to examine whether the ADHD trait and ASD trait were associated with Taijin-Kyofu-sho and social anxiety disorder. ASD trait was significantly associated with pure Taijin-Kyofu-sho (p = 0.006, odds ratio: 3.99). Female sex and ADHD trait were significantly associated with pure social anxiety disorder (sex: p = 0.013, odds ratio: 2.61; ADHD trait: p = 0.012, odds ratio: 2.46). Female sex, ADHD trait, and ASD trait were significantly associated with mixed Taijin-Kyofu-sho-social anxiety disorder (sex: p = 0.043, odds ratio: 2.16; ADHD trait: p = 0.003, odds ratio: 2.75; ASD trait: p < 0.001, odds ratio: 16.93). Neurodevelopmental disorder traits differed between individuals with Taijin-Kyofu-sho and those with social anxiety disorder. Overall, our study reveals that Japanese individuals with the ADHD or ASD traits are at a heightened risk of developing Taijin-Kyofu-sho or social anxiety disorder.

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.

Autism spectrum conditions in hikikomori: A pilot case-control study

AIM

Hikikomori, a form of pathological social withdrawal, has been suggested to have comorbidity with autism spectrum disorder (ASD). This study aimed to clarify how characteristics of hikikomori are associated with ASD, including undiagnosed autism spectrum conditions (ASC), in clinical settings.

METHODS

A total of 416 clinical patients were recruited through the Mood Disorder/Hikikomori Clinic at Kyushu University Hospital. A total of 103 hikikomori cases and 221 clinical controls without hikikomori conditions were extracted using a semi-structured interview, and completed a series of self-rated scales, including the Japanese version of the Autism-Spectrum Quotient (AQ-J).

RESULTS

Compared to non-hikikomori controls, hikikomori cases were more likely to have higher autistic tendency based on the AQ-J. The cases showed more severe subjective depressive symptoms based on the self-rated Beck Depression Inventory II, whereas no significant difference was found on interview-based severity evaluation using the Hamilton Depression Rating Scale. Comparison within hikikomori cases based on the AQ-J cut-off score revealed that hikikomori cases with high ASC were significantly more likely to have higher traits of modern-type depression, smaller social networks, and less social support.

CONCLUSION

The present data suggest that hikikomori sufferers are more likely to have autistic tendency, and that hikikomori sufferers with high ASC may have much more difficulty in social communication and social interaction. In addition, those with high ASC may also have lower self-esteem and higher complaint tendencies as aspects of modern-type depression traits, which may relate to the occurrence of hikikomori. Thus, evaluating autistic tendencies is important for appropriate interventions in hikikomori. Further investigations should be conducted to validate our pilot findings using structured diagnostic systems of ASD.

Social withdrawal in major depressive disorder: a case-control study of hikikomori in japan

BACKGROUND

Social withdrawal is a feature of a number of psychiatric disorders including major depressive disorder (MDD), yet research examining social withdrawal as a feature of MDD is rare.

METHODS

This was a retrospective case-control study. Participants (N = 67) were recruited through an outpatient clinic at an academic medical center in Japan. Major depressive disorder (MDD) and social withdrawal were established with the Structured Clinical Interview for DSM-IV Axis I Disorders and a semi-structured psychiatric interview, respectively. Participants also completed self-report measures.

RESULTS

We classified 24 participants as cases (MDD with social withdrawal) and 43 participants as controls (MDD without social withdrawal). Cases, on average, were more likely to have lower education level, prior episodes of depression, and higher suicidal ideation at baseline than controls. In unadjusted regression models, cases had significantly less social connection, less reward dependence, less self-directedness, and higher scores on scales of modern-type depression and hikikomori. In adjusted regression models, associations between social withdrawal and hikikomori (p<0.01) and reward dependence (p = 0.03) remained significant.

LIMITATIONS

The sample was limited in size and drawn from a single site.

CONCLUSIONS

In patients with MDD, social withdrawal may have subtle associations with clinical symptoms, social connection, and personality traits. Developing a better understanding of social withdrawal's phenotype in depression requires more in-depth examination.

Internet society, internet addiction, and pathological social withdrawal: the chicken and egg dilemma for internet addiction and hikikomori

PURPOSE OF REVIEW

Internet society has made our daily life more convenient, while its negative consequences especially internet, smartphone, and gaming addiction are emerging. At the same time, the phenomenon of pathological social withdrawal called 'hikikomori' has been increasingly highlighted as a problematic behavior in Japan. Now hikikomori is becoming a global mental health issue. The interaction between internet society, internet addiction, and hikikomori has not been well clarified.

RECENT FINDINGS

A case vignette survey among psychiatrists suggested that hikikomori cases could be comorbid with internet addiction. In reality, hikikomori cases with internet addiction have been reported internationally. A recent survey among college/university students in Japan has indicated positive interactions between internet addiction, smartphone addiction, gaming internet disorder, and hikikomori-tendencies.

SUMMARY

The cause of hikikomori has not been well understood, and the emergence of internet may be one of the important contributing factors for the occurrence of hikikomori. Whether pathological social withdrawal creates internet addiction, or internet overuse creates hikikomori remains unclear. Both possibilities exist, and we herein propose the conceptual model of these hypothetical interactions. Clarifying the mechanisms of both conditions will help to solve these crucial issues for contemporary urban societies.

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.