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Hajek A, Teo AR, Zwar L, König H. Validation of the German version of the 25-item hikikomori questionnaire 25. Int J Methods Psychiatr Res 2024; 33:e2027. [PMID: 38899465 PMCID: PMC11187541 DOI: 10.1002/mpr.2027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/19/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES The 25-item Hikikomori Questionnaire (HQ-25) is an instrument developed to measure a condition characterized by extreme social withdrawal that was first described in Japan. This study aimed to translate the HQ-25 into German and validate the German version (HQ-25-G). METHODS Translation was conducted according to established guidelines. Validation was based on data from a quota sample of individuals living in Germany, ranging from 18 to 74 years old (representing the distribution of age, sex and federal state, n = 5000). Data collection occurred during August and September 2023. We tested reliability, construct validity and concurrent validity. Moreover, HQ-25 scores for key sociodemographic group were reported. RESULTS Internal reliability for the HQ-25-G was excellent (Cronbach's alpha = 0.93). We confirmed the original three-factor model. Moreover, higher hikikomori levels were significantly associated with more depressive symptoms (r = 0.50), more anxiety symptoms (r = 0.45), higher loneliness levels (r = 0.56), higher levels of objective social isolation (r = -0.47), higher levels of perceived social isolation (r = 0.59) and a higher preference for solitude (r = 0.45). CONCLUSIONS In a large population-based sample (including younger adults, middle-aged adults and older adults), the HQ-25-G version proves to be a psychometrically robust instrument, which is useful for further exploring the phenomenon of hikikomori within the German-speaking population.
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Affiliation(s)
- André Hajek
- Department of Health Economics and Health Services ResearchUniversity Medical Center Hamburg‐EppendorfHamburg Center for Health EconomicsHamburgGermany
| | - Alan R. Teo
- Health Services Research and Development Center to Improve Veteran Involvement in CareVA Portland Health Care SystemPortlandOregonUSA
- Department of PsychiatryOregon Health and Science UniversityPortlandOregonUSA
| | - Larissa Zwar
- Department of Health Economics and Health Services ResearchUniversity Medical Center Hamburg‐EppendorfHamburg Center for Health EconomicsHamburgGermany
| | - Hans‐Helmut König
- Department of Health Economics and Health Services ResearchUniversity Medical Center Hamburg‐EppendorfHamburg Center for Health EconomicsHamburgGermany
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Orsolini L, Longo G, Bellagamba S, Kato TA, Volpe U. Predominant affective temperaments in depressive patients with severe social withdrawal. Ann Gen Psychiatry 2024; 23:12. [PMID: 38504352 PMCID: PMC10949599 DOI: 10.1186/s12991-024-00496-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/02/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Hikikomori (HK) is characterized by self-isolation and social refusal, being more likely also associated with affective disorders, including depression. This case-control study primarily aimed at identifying (if any) predominant affective temperaments are associated with HK in depressed versus not-depressed individuals. Secondary objectives comprise assessing which other psychopathological dimensions (e.g., boredom, anxiety) are associated with the HK specifier in depressed individuals. METHODS From the larger SWATCH study, 687 Italian young people were screened for depression, as measured by 9 items-Patient Health Questionnaire (PHQ-9) and HK-like social withdrawal, through the Hikikomori Questionnaire-25 (HQ-25). All subjects were administered a brief-Temperament Evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-M), the 7 items-Generalized Anxiety Disorder (GAD-7) and the Multidimensional State Boredom Scale (MSBS). RESULTS Males reported significantly higher scores at HQ-25 total score than females (p = 0.026). In the total sample, HK social withdrawal is positively predicted by MSBS low arousal, disengagement, depressive levels, depressive and irritable affective temperaments, while negatively by anxiety (F(6, 680) = 82.336, p < 0.001, R2 = 0.421). By selecting only depressed sample, HQ-25 is positively predicted by MSBS total score, low arousal and depressive affective temperament, while negatively by MSBS high arousal (F(4, 383) = 48.544, p < 0.001, R2 = 0.336). The logistic regression model found that the likelihood of developing depression with the HK specifier is significantly predicted by depressive and cyclothymic affective temperaments. CONCLUSIONS These preliminary findings could help in clinically characterizing the relationship between specific affective temperamental profiles among individuals with depression with/without HK specifier, in order to provide a more tailored and personalized therapeutic approach. Our Italian study should be extensively replicated in larger, longitudinal and multicentric pan-European studies, by specifically assessing the impact of these findings on depression clinical course, prognosis and treatment outcomes.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy.
| | - Giulio Longo
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - Silvia Bellagamba
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
| | - Takahiro A Kato
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Via Conca 71, 60126, Ancona, Italy
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Miou M, Fujimoto H, Yotsumoto K, Hirota M, Nishigaki S, Hashimoto T. Exploring Psychiatric Home-Visit Nursing Practices for Patients with Schizophrenia and Hikikomori with a Thematic Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:181. [PMID: 38397672 PMCID: PMC10887901 DOI: 10.3390/ijerph21020181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
The phenomenon of some patients with schizophrenia withdrawing and becoming hikikomori needs to be resolved. In some countries, outreach methods are being employed. In Japan, psychiatric home-visit nursing for patients with schizophrenia and hikikomori is being implemented. However, it is not based on sufficient evidence and relies on the experience and intuition of individual nurses. This study explored the underlying themes in the nursing practices of psychiatric home-visit nurses via semi-structured interviews with 10 nurses and a thematic analysis. Nine key themes emerged. Four themes-(i) understanding the patient's world, (ii) supporting the patients as they are, (iii) providing a sense of relief, and (iv) having equal relationships-highlighted the nurses' commitment to respecting patients' individuality while building and sustaining relationships. Two themes-(v) exploring the right timing and (vi) waiting for the appropriate timing-illustrated the nurses' anticipation of proactive patient engagement. Finally, three themes-(vii) working together on things, (viii) continuing care for expanding the patient's world, and (ix) nursing care for the patient's future-underscored the nurses' gradual and methodical approach to working alongside patients. Nursing practices based on these nine themes cultivated meaningful relationships and secured a sense of relief for the patients. Additionally, they awaited patients' proactive engagement and delivered timely support to facilitate positive daily life changes. These findings contribute to the establishment of evidence-based nursing practices for patients with schizophrenia and hikikomori.
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Affiliation(s)
- Maki Miou
- Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe 6540142, Japan; (K.Y.); (M.H.); (T.H.)
- Faculty of Nursing, Osaka Shin-Ai Gakuin University, 6-2-28 Tsurumi, Tsurumi-ku, Osaka 5380053, Japan
| | - Hirokazu Fujimoto
- Faculty of Nursing, Hyogo Medical University, 1-3-6 Minatojima, Chuo-ku, Kobe 6508530, Japan
| | - Kayano Yotsumoto
- Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe 6540142, Japan; (K.Y.); (M.H.); (T.H.)
| | - Misato Hirota
- Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe 6540142, Japan; (K.Y.); (M.H.); (T.H.)
| | - Satoshi Nishigaki
- School of Nursing, Takarazuka University, 1-13-16 Shibata, Kita-ku, Osaka 5300012, Japan;
| | - Takeshi Hashimoto
- Graduate School of Health Sciences, Kobe University, 7-10-2 Tomogaoka, Suma-ku, Kobe 6540142, Japan; (K.Y.); (M.H.); (T.H.)
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Al-Sibani N, Chan MF, Al-Huseini S, Al Kharusi N, Guillemin GJ, Al-Abri M, Ganesh A, Al Hasani Y, Al-Adawi S. 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. PLoS One 2023; 18:e0279612. [PMID: 37549148 PMCID: PMC10406187 DOI: 10.1371/journal.pone.0279612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 07/22/2023] [Indexed: 08/09/2023] Open
Abstract
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.
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Affiliation(s)
- Nasser Al-Sibani
- Department of Behavioural Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Al-Khoudh, Muscat, Oman
| | - Moon Fai Chan
- Department of Family Medicine and Public Health, College of Medicine & Health Sciences, Sultan Qaboos University, Al-Khoudh, Muscat, Oman
| | - Salim Al-Huseini
- Department of Psychiatry, Al Masarrah Hospital, Ministry of Health, Muscat, Oman
| | - Nutaila Al Kharusi
- Department of Behavioural Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Al-Khoudh, Muscat, Oman
| | - Gilles J Guillemin
- Neuroinflammation Group, Macquarie Medical School, Macquarie University, Sydney, New South Wales, Australia
| | - Mohammed Al-Abri
- Clinical Physiology, Sultan Qaboos University, Al-Khoudh, Muscat, Oman
| | - Aishwarya Ganesh
- Department of Behavioural Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Al-Khoudh, Muscat, Oman
| | - Yousuf Al Hasani
- Organizational Development & Education, Curative Services, Directorate General of Medical Services, Muscat, Oman
| | - Samir Al-Adawi
- Department of Behavioural Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Al-Khoudh, Muscat, Oman
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Muris P, Ollendick TH. Contemporary Hermits: A Developmental Psychopathology Account of Extreme Social Withdrawal (Hikikomori) in Young People. Clin Child Fam Psychol Rev 2023; 26:459-481. [PMID: 36653555 PMCID: PMC9848719 DOI: 10.1007/s10567-023-00425-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/19/2023]
Abstract
Although it is widely accepted that human beings have an ingrained 'need to belong,' there seem to be a substantial subset of young people who seclude themselves for most of the time at home and no longer engage in education or work, ultimately withdrawing from participation in society. In Japan, this phenomenon has been labeled as 'hikikomori,' but given its global presence it may be preferable to use the term 'extreme social withdrawal' (ESW). In this qualitative review, we provide a description and definition of ESW, provide figures on its prevalence, and discuss a number of associated concepts, including loneliness and "aloneliness," school absenteeism and dropout, the 'new' developmental stage of adultolescence, and the labor force categories of freeter ('freelance arbeiter') and NEET (a young person not in employment, education, or training). The core of the paper is focused on the origins of ESW in young people and provides a narrative overview of relevant etiological factors, such as aberrant brain processes, unfavorable temperament, psychiatric conditions, adverse family processes including detrimental parenting, negative peer experiences, societal pressures, and excessive internet and digital media use, which are all placed within a comprehensive developmental psychopathology framework. We will close with a discussion of possible interventions for young people with ESW and formulate a guideline that describes (the temporal order of) various components that need to be included in such a treatment.
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Affiliation(s)
- Peter Muris
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Thomas H Ollendick
- Department of Psychology, Child Study Center, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
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Neoh MJY, Carollo A, Lim M, Esposito G. Hikikomori: A Scientometric Review of 20 Years of Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095657. [PMID: 37174175 PMCID: PMC10177810 DOI: 10.3390/ijerph20095657] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Michelle Jin Yee Neoh
- Psychology Program, School of Social Sciences, Nanyang Technological University, Singapore 639818, Singapore
| | - Alessandro Carollo
- Department of Psychology and Cognitive Science, University of Trento, 38068 Rovereto, Italy
| | - Mengyu Lim
- Psychology Program, School of Social Sciences, Nanyang Technological University, Singapore 639818, Singapore
| | - Gianluca Esposito
- Department of Psychology and Cognitive Science, University of Trento, 38068 Rovereto, Italy
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Amendola S, Presaghi F, Teo AR, Cerutti R. Psychometric Properties of the Italian Version of the 25-Item Hikikomori Questionnaire. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192013552. [PMID: 36294128 PMCID: PMC9603413 DOI: 10.3390/ijerph192013552] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 05/27/2023]
Abstract
A serious form of social withdrawal, initially described within Japan as hikikomori, has received increasing attention from the international scientific community during the last decade. The 25-item Hikikomori Questionnaire (HQ-25) was initially developed and validated in Japan. To date, data on its psychometric properties in other populations where cases of hikikomori have been described are still scarce. Thus, the aims of this study were to (1) translate, adapt, and validate the Italian version of the HQ-25 analyzing its psychometric properties; and (2) verify the association between hikikomori and personality functioning, social support, and problematic Internet use. A sample of 372 Italian adults aged 18 to 50 years completed the HQ-25 and measures of psychoticism, personality dysfunction, social support, and problematic Internet use were employed to test the convergent validity of the HQ-25. The data showed a satisfactory fit for a three-factor model, significantly better than a one-factor model. The three factors (socialization, isolation, and emotional support, as in the original study on the HQ-25) correlated positively with psychoticism, personality dysfunction, and problematic Internet use, and correlated negatively with social support. A lifetime history of hikikomori was present in 1.1% of the sample (n = 4). This is the first study to use the Italian validated version of the HQ-25 with an adult population. The findings from this study provide evidence of the satisfactory psychometric properties of the Italian version of the HQ-25 and support further investigation of the HQ-25 as an instrument to help screen for and investigate the presence of hikikomori.
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Affiliation(s)
- Simone Amendola
- Department of Dynamic and Clinical Psychology and Health Studies, Sapienza University of Rome, 00185 Rome, Italy
| | - Fabio Presaghi
- Department of Psychology of Development and Socialization Processes, Sapienza University of Rome, 00185 Rome, Italy
| | - Alan R. Teo
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR 97239, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR 97239, USA
| | - Rita Cerutti
- Department of Dynamic and Clinical Psychology and Health Studies, Sapienza University of Rome, 00185 Rome, Italy
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Orsolini L, Bellagamba S, Volpe U, Kato TA. Hikikomori and modern-type depression in Italy: A new phenotypical trans-cultural characterization? Int J Soc Psychiatry 2022; 68:1010-1017. [PMID: 35723190 DOI: 10.1177/00207640221099408] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Hikikomori is a Japanese term etymologically derived from 'hiku' (i.e. 'to pull back') and 'komoru' (i.e. 'seclude oneself'), which identifies those subjects who deliberately withdraw themselves by social life, remaining confined into their own home/room. The phenomenon is widely diffused in Japan, even though it is currently spread outside the Japanese culture. However, a universally shared and cross-cultural adaptation of Hikikomori definition, phenomenological and psychopathological characterization is still missing. METHODOLOGY An expert-guided opinion paper was here provided to clinical characterize the Hikikomori-like social withdrawal in the Italian context, by considering the transformation from a family-based society to a 'fluid' digital-structured culture, also discussing the concept of modern-type depression. This was provided deepening the principal current studies available in literature and giving an interpretation based on clinical experience in the Italian society. The work was supervised through a consensus by the most international expert of Japanese Hikikomori syndrome. RESULTS Current individual, family and social trajectories may potentially act as a mediator in favouring the occurrence of Hikikomori-like social withdrawal also in western countries, including Italy. Despite the differences between Japanese and Italian society and culture, the recent shaping of family structure and intra-familial dynamics, typical of the current post-modern society, may potentially influence the emergence of psychopathologies not typical of Italian culture. Unemployment and 'Not in Employment Education or Training' (NEET) conditions may represent another potential risk factor for economical/social marginalization of youngsters, together with the recent dramatic emergence of web-based psychopathologies. CONCLUSION A diagnostic culturally-adapted flow-chart is proposed for clinical characterizing Hikikomori in Italian context, which may help in proposing preventive strategies, ensuring early identification and prompt therapeutic interventions, particularly among youngsters.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Silvia Bellagamba
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Takahiro A Kato
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Kubo H, Katsuki R, Horie K, Yamakawa I, Tateno M, Shinfuku N, Sartorius N, Sakamoto S, Kato TA. Risk factors of hikikomori among office workers during the COVID-19 pandemic: A prospective online survey. CURRENT PSYCHOLOGY 2022; 42:1-19. [PMID: 35919757 PMCID: PMC9334542 DOI: 10.1007/s12144-022-03446-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2022] [Indexed: 12/01/2022]
Abstract
The global pandemic of COVID-19 has forced people to restrict their outings. In Japan, self-restraint behavior (SRB) has been requested by the government, and some of those decreasing their outings may shift to pathological social withdrawal; hikikomori. The purpose of this study was to examine the risk factors of hikikomori conducting an online prospective survey. An online survey was conducted in June 2020 and December 2020; (1) SRB-related indicators (degree of SRB, motivation for SRB, stigma and self-stigma toward COVID-19, anxiety and depressive feelings toward COVID-19) and (2) general mental health (hikikomori tendency, depressive symptoms, modern type depression (MTD) tendency, internet addiction) were collected. A cross-lagged effects model was performed to examine the association between these variables. Lack of emotional support and lack of socialization in June 2020 increased isolation in December 2020. Besides, MTD and hikikomori interacted with each other. Interestingly, although hikikomori tendency increased depressive tendencies, SRB itself did not have a significant path on any mental health-related variables. Poor interpersonal relationships, rather than SRB per se, are suggested to be a risk factor for increased isolation among office workers in the COVID-19 pandemic. Appropriate early interventions such as interpersonal or emotional support may prevent the transition to pathological hikikomori. The association between MTD and hikikomori seems to reveal the interesting possibility that MTD is a gateway to increased risk of hikikomori, and that hikikomori is a gateway to MTD as well. Future research is required to elucidate the relationship between hikikomori and MTD.
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Affiliation(s)
- Hiroaki Kubo
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Ryoko Katsuki
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Kazumasa Horie
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Itsuki Yamakawa
- Department of Health and Human Services, Faculty of Medical and Welfare, Tohoku Bunka Gakuen University, Miyagi, Japan
- Department of Psychology, College of Humanities and Sciences, Nihon University, Tokyo, Japan
| | - Masaru Tateno
- Tokiwa Child Development Center, Tokiwa Hospital, Sapporo, Japan
- Department of Neuropsychiatry, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Naotaka Shinfuku
- School of Human Sciences, Seinan Gakuin University, Fukuoka, Japan
| | - Norman Sartorius
- Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
| | - Shinji Sakamoto
- Department of Psychology, College of Humanities and Sciences, Nihon University, Tokyo, Japan
| | - Takahiro A. Kato
- Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-Ku, Fukuoka, 812-8582 Japan
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Hamasaki Y, Pionnié-Dax N, Dorard G, Tajan N, Hikida T. Preliminary study of the social withdrawal (hikikomori) spectrum in French adolescents: focusing on the differences in pathology and related factors compared with Japanese adolescents. BMC Psychiatry 2022; 22:477. [PMID: 35842596 PMCID: PMC9287690 DOI: 10.1186/s12888-022-04116-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Social withdrawal (hikikomori) has become an internationally recognized phenomenon, but its pathology and related factors are not yet fully known. We previously conducted a statistical case-control study on adolescent patients with hikikomori in Japan, which revealed the non-specificity of pathology in patients with hikikomori. Further, environmental factors, such as the lack of communication between parents and Internet overuse, were found to be significant predictors of hikikomori severity. Here, we aimed to conduct a similar preliminary case-control study in France and to compare the results with those from the study conducted in Japan. METHODS Parents of middle school students who underwent psychiatric outpatient treatment for hikikomori (n = 10) and control group parents (n = 115) completed the Child Behavior Checklist to evaluate their child's psychopathological characteristics and the Parental Assessment of Environment and Hikikomori Severity Scales, as in our previous study in Japan. We compared the descriptive statistics and intergroup differences in France with those from the previous study conducted in Japan. In the multiple regression analysis to find predictors of hikikomori severity in French and also Japanese subjects, the same dependent and independent variables were chosen for the present study (both differed from the previous study). These were used in order to make accurate intercountry comparisons. RESULTS The comparisons revealed no differences in the pathology of hikikomori between Japan and France. Specifically, both studies found similarly increased scores for all symptom scales, with no specific bias. However, the statistical predictors of hikikomori severity in France (lack of communication between parents and child and lack of communication with the community) differed from those in Japan (lack of communication between parents). CONCLUSION Hikikomori in Japan and France could be considered essentially the same phenomenon; moreover, our findings demonstrated the universal non-specificity and unbiasedness of the hikikomori pathology. This suggests that hikikomori is not a single clinical category with a specific psychopathology; instead, it is a common phenotype with various underlying pathologies. However, different strategies may be required in each country to prevent the onset and progression of hikikomori.
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Affiliation(s)
- Yukiko Hamasaki
- Faculty of Contemporary Society, Kyoto Women's University, 35, Kitahiyoshi-cho, Imakumano, Higashiyama-ku, Kyoto, 605-8501, Japan. .,Shigasato Hospital, 1 Chome-18-41 Shigasato, Otsu, Shiga, 520-0006, Japan.
| | - Nancy Pionnié-Dax
- Child and Adolescent Psychiatry Department, EPS ERASME, Antony, France
| | - Géraldine Dorard
- Child and Adolescent Psychiatry Department, EPS ERASME, Antony, France ,grid.508487.60000 0004 7885 7602Université Paris Cité, LPPS, F-92100 Boulogne-Billancourt, France
| | - Nicolas Tajan
- grid.258799.80000 0004 0372 2033Psychopathology and Psychoanalysis Laboratory, Graduate School of Human and Environmental Studies, Kyoto University, Kyoto, Japan
| | - Takatoshi Hikida
- grid.136593.b0000 0004 0373 3971Laboratory for Advanced Brain Functions, Institute for Protein Research, Osaka University, Osaka, Japan
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Lee JI, Parhar IS, Soga T. Hikikomori: Social withdrawal a risk factor for depression. Psychiatry Clin Neurosci 2022; 76:343-344. [PMID: 35338539 DOI: 10.1111/pcn.13354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/05/2022] [Accepted: 03/06/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jo Ie Lee
- Brain Research Institute Monash Sunway, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Ishwar S Parhar
- Brain Research Institute Monash Sunway, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Tomoko Soga
- Brain Research Institute Monash Sunway, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
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12
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Dong B, Li D, Baker GB. Hikikomori: A Society-Bound Syndrome of Severe Social Withdrawal. PSYCHIAT CLIN PSYCH 2022; 32:167-173. [PMID: 38764869 PMCID: PMC11099621 DOI: 10.5152/pcp.2022.22429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/12/2022] [Indexed: 05/21/2024] Open
Abstract
Background Hikikomori, a severe and often prolonged social withdrawal observed primarily in young people, was first described in Japan, but cases have now been reported in many other countries. Methods A review paper on hikikomori has been prepared following the literature searches in 3 databases. Search terms related to hikikomori included epidemiology, globalization, diagnosis, treatment, comorbidity, and COVID-19. Conclusions Hikikomori was first reported in Japan and has been described in detail by researchers there, but there are now reports in many countries of hikikomori-like cases. It occurs primarily in young people, often men in their late teens and early twenties who isolate themselves, sometimes confining themselves to their homes for months or even years. It has been proposed that hikikomori has increased in recent years in part because of advances in information technology that result in decreased socialization. Hikikomori was originally considered a non-psychotic phenomenon, but comorbidity with psychiatric disorders is often present and should be considered during diagnosis. Considerable efforts have been made in recent years to establish reliable, widely applicable guidelines for the diagnosis and treatment of hikikomori. There is very little information with regard to neurobiology, although involvement of the immune system, oxidative stress, and the social brain network has been proposed. It is widely agreed that hikikomori must be treated in a multi-dimensional fashion, with family support very important. Lessons learned from these treatment approaches are relevant to the potential increased risk of social withdrawal arising from COVID-19 pandemic lockdowns.
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Affiliation(s)
- Bin Dong
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
| | - Daniel Li
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | - Glen B. Baker
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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13
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Funakoshi A, Saito M, Yong R, Suzuki M. Home visiting support for people with hikikomori (social withdrawal) provided by experienced and effective workers. Int J Soc Psychiatry 2022; 68:836-843. [PMID: 33832328 DOI: 10.1177/00207640211009266] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Akiko Funakoshi
- Department of Nursing, Kobe City College of Nursing, Hyogo, Japan
| | - Masako Saito
- Department of Nursing, Nagaoka Sutoku University, Niigata, Japan
| | - Roseline Yong
- Graduate School of Medicine, Akita University, Japan
| | - Midori Suzuki
- Non-Profit Organization Orange Association, Nagoya, Japan
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14
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Nonaka S, Sakai M. Measuring the Quality of Life for Individuals With Prolonged Social Withdrawal (Hikikomori). Psychiatry Investig 2022; 19:341-347. [PMID: 35505459 PMCID: PMC9136523 DOI: 10.30773/pi.2021.0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/21/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aimed to develop a quality of life scale for hikikomori (QOL-H), measuring the subjective quality of life (QOL) of individuals with hikikomori, and confirming its reliability and validity. METHODS The characteristics of the scale were examined using item response theory. Data were collected from 99 people with hikikomori, 100 people who had experienced hikikomori in the past, and 198 people who had not experienced hikikomori, to develop the scale, examine its reliability, validity, and characteristics. For convergent validity, the correlation coefficients between QOL-H and social interaction behaviors, hikikomori characteristics, depressive symptoms, subjective happiness, and difficulty in social participation were calculated. RESULTS Good internal consistency, test-retest reliability, and convergent validity were confirmed for the QOL-H. Furthermore, significant differences in scores among all groups confirmed adequate criterion-related validity. Total information function indicated a high measurement accuracy when QOL was average or slightly high. CONCLUSION This study suggests that QOL-H can be an appropriate measure of QOL for individuals with hikikomori.
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Affiliation(s)
- Shunsuke Nonaka
- School of Child Psychology, Tokyo Future University, Tokyo, Japan
| | - Motohiro Sakai
- Faculty of Education, University of Miyazaki, Miyazaki, Japan
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15
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Muzi S, Rogier G, Pace CS. Peer Power! Secure Peer Attachment Mediates the Effect of Parental Attachment on Depressive Withdrawal of Teenagers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:4068. [PMID: 35409754 PMCID: PMC8998754 DOI: 10.3390/ijerph19074068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/25/2022] [Accepted: 03/27/2022] [Indexed: 11/16/2022]
Abstract
Adolescents' depressive social withdrawal is a relevant concern for mental health professionals, and it is widespread among community teenagers in form of subclinical symptoms. Different studies suggest that insecure attachment representations increase the adolescents' likelihood to show symptoms of withdrawal (e.g., loneliness). This study explored the effect of the general attachment internal working model (IWM) and the independent and cumulative effects of the specific attachment representations of parents-in terms of secure base/safe haven-and peers on adolescents' withdrawal. Additionally, the mediation of peer attachment on the effect of parental attachment on symptoms was explored. All analyses were conducted controlling for the difference between teenagers living with parents together or divorced/separated, as children of divorcees are considered more exposed to stressors. Ninety-one adolescents aged 12-17 years old were assessed online during the COVID pandemic period, employing the Youth Self-Report to assess withdrawal and the Friends and Family Interview to assess attachment-general IWM and attachment-specific representations. Results show no influence of parents together/separated or of the general IWM on withdrawal, but higher parent secure base/safe haven and peer attachment cumulatively predicted 10-21% less withdrawal. Moreover, more positive peer attachment mediated 61% of the effect of the parental secure attachment on withdrawal, revealing an indirect effect of parental attachment on withdrawal through peer attachment. In conclusion, both parents and peers are influential on adolescent mental health, and fostering positive peer relationships can buffer the effect of dysfunctional family relationships on teenagers' withdrawal.
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Affiliation(s)
| | | | - Cecilia Serena Pace
- Department of Educational Sciences, University of Genoa, 16129 Genoa, Italy; (S.M.); (G.R.)
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16
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Gavin J, Brosnan M. The Relationship Between Hikikomori Risk and Internet Use During COVID-19 Restrictions. CYBERPSYCHOLOGY, BEHAVIOR AND SOCIAL NETWORKING 2022; 25:189-193. [PMID: 35021891 DOI: 10.1089/cyber.2021.0171] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study explores the phenomenon of hikikomori, or extreme social isolation, which for the past 20 years has been associated with a range of negative outcomes, including psychological, financial, and social. As hikikomori is associated with marked social withdrawal in one's home and increased Internet use, it has been suggested that the social and technological changes brought about by COVID-19 restrictions may exacerbate the risk of hikikomori in young adults. This study, therefore, sought to identify the relationship between hikikomori risk and changes in Internet use for young people aged 16-24 years during COVID-19 restrictions. An international sample of 826 participants completed an online survey consisting of questions about demographics, experience of lockdown restrictions in the previous 12 months, changes to Internet use in the previous 12 months and a hikikomori risk scale. Higher hikikomori risk was associated with being male, greater time spent in lockdown, and leaving the house less frequently. An increase in Internet use during lockdown was associated with reduced risk of hikikomori. Findings are discussed in relation to gender differences in the type of Internet use engaged in by males and females. It is concluded that online social interaction may be a means of mitigating hikikomori risk in post-COVID-19 societies.
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Affiliation(s)
- Jeff Gavin
- Department of Psychology and Department of Psychology, University of Bath, Bath, United Kingdom
| | - Mark Brosnan
- Centre for Applied Autism Research, Department of Psychology, University of Bath, Bath, United Kingdom
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17
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Nonaka S, Shimada H, Sakai M. Individuals with hikikomori and their families’ cognitive behavioral factors: A prospective study. CURRENT PSYCHOLOGY 2022. [DOI: 10.1007/s12144-022-02772-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Martinotti G, Vannini C, Di Natale C, Sociali A, Stigliano G, Santacroce R, di Giannantonio M. Hikikomori: psychopathology and differential diagnosis of a condition with epidemic diffusion. Int J Psychiatry Clin Pract 2021; 25:187-194. [PMID: 32985914 DOI: 10.1080/13651501.2020.1820524] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Hikikomori, from the Japanese words 'hiku' (to pull) and 'komoru' (to withdraw), is a clinical condition in which a subject locks himself/herself into his/her own house for more than 6 months. This condition is becoming relevant in Japan and other Asian countries, with new cases emerging in Europe and a steep increase in its incidence. METHODS In this article, the various psychopathological and diagnostic hypothesis and the different criteria proposed by the various authors have been analysed and compared, paying attention also to the new studies conducted in Europe and to therapeutic perspectives that are opening up for its treatment. RESULTS Numerous hypothesis have been put forward for the genesis of hikikomori, in particular, the hypothesis of a behaviour seen as a dysfuncion of the family system or as a result of our current modern society. Furthermore, this behaviour has been compared to other conditions such as internet addiction and a specific form of depression called Modern Type Depression (MTD). CONCLUSIONS Hikikomori could represent the clinical answer to a social evolution, similarly to other phenomena such as binge behaviours and use of psychoactive substances. Further studies are needed to clarify diffusion, diagnosticassessment and differential diagnosis.Key pointsHikikomori is now considered a contemporary society-bound syndrome linked to modern society changes.Hikikomori might be a coping strategy to avoid relationships, social judgement and possible failures.Hikikomori might represent an extreme suffering that needs to be identified early: it is linked to severe form of modern type depression and it is a risk factor for suicidal behaviours.It is important to inform and sensitise communities about hikikomori to assure early interventions.More clinical studies are needed to define a unitary and specific model of hikikomori and to structure focussed interventions.
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Affiliation(s)
- Giovanni Martinotti
- Department of Psychiatry, "Gabriele d'Annunzio" University of Chieti, Pescara, Italy.,Department of Pharmacy, Pharmacology, Clinical Science, University of Hertfordshire, Herts, UK
| | - Chiara Vannini
- Department of Psychiatry, "Gabriele d'Annunzio" University of Chieti, Pescara, Italy
| | - Chiara Di Natale
- Department of Psychiatry, "Gabriele d'Annunzio" University of Chieti, Pescara, Italy
| | - Antonella Sociali
- Department of Psychiatry, "Gabriele d'Annunzio" University of Chieti, Pescara, Italy
| | - Gianfranco Stigliano
- Department of Psychiatry, "Gabriele d'Annunzio" University of Chieti, Pescara, Italy
| | - Rita Santacroce
- Department of Psychiatry, "Gabriele d'Annunzio" University of Chieti, Pescara, Italy
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Italia M, Forastieri C, Longaretti A, Battaglioli E, Rusconi F. Rationale, Relevance, and Limits of Stress-Induced Psychopathology in Rodents as Models for Psychiatry Research: An Introductory Overview. Int J Mol Sci 2020; 21:E7455. [PMID: 33050350 PMCID: PMC7589795 DOI: 10.3390/ijms21207455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/18/2022] Open
Abstract
Emotional and cognitive information processing represent higher-order brain functions. They require coordinated interaction of specialized brain areas via a complex spatial and temporal equilibrium among neuronal cell-autonomous, circuitry, and network mechanisms. The delicate balance can be corrupted by stressful experiences, increasing the risk of developing psychopathologies in vulnerable individuals. Neuropsychiatric disorders affect twenty percent of the western world population, but therapies are still not effective for some patients. Elusive knowledge of molecular pathomechanisms and scarcity of objective biomarkers in humans present complex challenges, while the adoption of rodent models helps to improve our understanding of disease correlate and aids the search for novel pharmacological targets. Stress administration represents a strategy to induce, trace, and modify molecular and behavioral endophenotypes of mood disorders in animals. However, a mouse or rat model will only display one or a few endophenotypes of a specific human psychopathology, which cannot be in any case recapitulated as a whole. To override this issue, shared criteria have been adopted to deconstruct neuropsychiatric disorders, i.e., depression, into specific behavioral aspects, and inherent neurobiological substrates, also recognizable in lower mammals. In this work, we provide a rationale for rodent models of stress administration. In particular, comparing each rodent model with a real-life human traumatic experience, we intend to suggest an introductive guide to better comprehend and interpret these paradigms.
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Ferrara P, Franceschini G, Corsello G, Mestrovic J, Giardino I, Sacco M, Vural M, Pettoello-Mantovani M, Pop TL. The Hikikomori Phenomenon of Social Withdrawal: An Emerging Condition Involving Youth's Mental Health and Social Participation. J Pediatr 2020; 225:286-288. [PMID: 32622672 DOI: 10.1016/j.jpeds.2020.06.089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Pietro Ferrara
- European Paediatric Association/Union of National European Paediatric Societies and Associations (EPA/UNEPSA), Berlin, Germany; Italian Society of Pediatrics, Rome, Italy
| | | | - Giovanni Corsello
- European Paediatric Association/Union of National European Paediatric Societies and Associations (EPA/UNEPSA), Berlin, Germany; Italian Society of Pediatrics, Rome, Italy
| | - Julije Mestrovic
- European Paediatric Association/Union of National European Paediatric Societies and Associations (EPA/UNEPSA), Berlin, Germany; Medical School of Split, University Hospital of Split, Split, Croatia
| | - Ida Giardino
- Department of Biomedical Sciences, University of Foggia, Foggia, Italy
| | - Michele Sacco
- Department of Pediatrics, Scientific Institute "Casa Sollievo della Sofferenza", Foggia, Italy
| | - Mehmet Vural
- European Paediatric Association/Union of National European Paediatric Societies and Associations (EPA/UNEPSA), Berlin, Germany; University of Istanbul, Istanbul University Cerrahpaşa, Medical Faculty, Istanbul, Turkey
| | - Massimo Pettoello-Mantovani
- European Paediatric Association/Union of National European Paediatric Societies and Associations (EPA/UNEPSA), Berlin, Germany; University of Foggia, Department of Pediatrics, Scientific Institute "Casa Sollievo della Sofferenza", Foggia, Italy.
| | - Tudor Lucian Pop
- European Paediatric Association/Union of National European Paediatric Societies and Associations (EPA/UNEPSA), Berlin, Germany; 2nd Pediatric Clinic, Mother and Child Department, University of Medicine and Pharmacy Iuliu Haţieganu Cluj-Napoca, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
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