A 39-Year-Old “Adultolescent”: Understanding Social Withdrawal in Japan

Discussion

Although extreme social isolation has deep cultural roots in Japan, academic writing in Japanese psychiatry on social withdrawal only dates to the 1970s, and the term hikikomori only emerged into prominence in the 1990s (1). In the language of cultural concepts in DSM-5, hikikomori is both an idiom of distress and cultural syndrome. As an idiom of distress, it is a household term in Japan, has entered the English lexicon, and—thanks to media attention—is used around the globe by people who self-identify as being hikikomori (2). As a syndrome, we have operationalized hikikomori in our work as spending most of the day and nearly every day at home and avoidance of social situations and relationships, with significant associated distress or impairment, for a duration of at least 6 months (3). The lifetime prevalence of hikikomori among young adults is approximately 1.2% in Japan (4). Onset is typically during adolescence or early adulthood, and, on average, 4 years pass before a case presents clinically (5).

Idiopathic hikikomori exists (6). However, as with Mr. T, psychiatric comorbidity is more common, including avoidant personality disorder, major depressive disorder, and social anxiety disorder. In the United States, Mr. T’s presentation with guarded and at times agitated behavior around others may have led to a diagnosis of schizophrenia. Family dynamics gone awry are a key feature of Mr. T’s case, evidenced by overdependence between mother and son and a largely absent father. Hikikomori has tremendous societal and economic implications because the affected often rely on others (usually their parents) for food, shelter, and clothing well into adulthood—hence our characterization of Mr. T as an “adultolescent” of sorts. A recent conceptual framework developed from a systematic review similarly identified maladaptive parenting and family dysfunction as critical factors in the development of hikikomori (7).

Mr. T has had a partial treatment response, largely through psychotherapy, which is the preferred approach in Japan (8). Observational studies suggest that lackluster treatment response is typical, and, to date, only one robust intervention study exists in the literature (7). Despite the lack of evidence-based treatment, public health and clinical resources for hikikomori are widespread in Japan. Since 2000, Japan has required nationwide hikikomori support centers, which often provide telephone consultation to struggling families and in-person psychiatric, counseling, and vocational resources. Expanding and rigorously evaluating public health strategies are key to improving the prognosis for hikikomori. We are also investigating whether shortening the minimum duration of withdrawal to 3 months might help with earlier detection.

Research on hikikomori is still in its infancy, leaving many more questions than answers about its precise etiology, distinction from other conditions, efficacy of treatments, and prognosis. Yet already more articles are indexed in PubMed on hikikomori than on taijin kyofusho, despite the latter having been described more than half a century earlier. The notion of a syndrome of social withdrawal appears to resonate strongly in our time and across many cultures, possibly promoted by internationalization of Japan’s amae culture (8, 9). May this fascination spur much-needed work to dig deeper into understanding and treating hikikomori.

“Mr. T” is a 39-year-old unemployed man living with his parents. For the past 19 years, he has spent the vast majority of his time restricted to his room. He has never worked and describes his attitude toward life as “taking it easy.” Video games and online shopping help him pass the time. At one point several years ago, his online shopping habits caused the equivalent of tens of thousands of dollars of debt. He views his parents’ home as a complimentary hotel of sorts, with his parents tending to his basic needs. Mr. T’s mother, a homemaker, prepares meals for him daily. Financially, he has supported his lifestyle with ongoing funds from his wealthy grandfather and, more recently, his father’s retirement pension.

When asked why he rarely leaves his home, his primary explanation is that he does not want to be seen by others, particularly in light of his lack of accomplishments. Although the frequency with which he leaves home has fluctuated over the years, in general he leaves just once a month when he has an outpatient clinic appointment. He reports having a reversed sleep-wake cycle, and typically he is awake during the daytime only on clinic days.

His mother’s prenatal course was uneventful and she recalled no developmental problems during Mr. T’s childhood. Mr. T was temperamentally shy as a child, though, and avoided participating in activities that would draw attention to him. Growing up, he had a few friends, but his interactions with friends dwindled in high school as he became more concerned about being seen in public. He consistently obtained average grades throughout compulsory school, and after high school he went on to complete a vocational training program and obtain a certificate as a health technician. However, he lacked the motivation to obtain a job, and it was during this period that he began withdrawing into his room.

One year into his social withdrawal, at age 21, Mr. T’s mother brought him to a community psychiatrist specializing in psychosomatic medicine. His chief complaint was pain from craning his neck when in public. Examination revealed no organic abnormalities, and he underwent regular treatment with counseling and pharmacotherapy. This continued for 3 years until he transferred care to another psychiatrist, at his mother’s request, due to lack of improvement. This psychiatrist suspected a prodromal state of psychosis and began pharmacotherapy with an atypical antipsychotic. Despite three adequate medication trials, no improvement occurred. At age 28, Mr. T’s sister’s health declined, and their mother began focusing her energies on her care, which led to Mr. T suddenly becoming physically aggressive toward his mother. At that point, Mr. T was involuntarily hospitalized at a university hospital. On examination, Mr. T was agitated but lacked hallucinations or delusions. Brain MRI and EEG were unremarkable. He was started on haloperidol and valproic acid to target his agitation and irritability; he participated little in ward activities or group therapy. However, after 4 months he was discharged with a diagnosis of taijin kyofusho (an interpersonal fear of offending others) and suspicion for a pervasive developmental disorder (his symptoms were subthreshold for diagnosis).

After discharge, he began seeing a new psychiatrist who suspected hikikomori, a form of profound and prolonged social withdrawal, and began family therapy to target underlying family dynamic problems. The patient and his mother attended biweekly visits at the university’s outpatient clinic. Through these visits, Mr. T was finally able to express his feeling of amae—a desire for dependence on and receiving care from his mother—which had further triggered jealousy and anger when his sister began receiving additional care from his mother. Behavioral therapy with exposure and response prevention was added, and Mr. T’s fear of being seen gradually reduced to the point where he began occasionally going out on shopping errands. When his father retired, he too began participating in family therapy sessions. Overall, family functioning improved, and incidents of reckless spending on shopping resolved. The patient also gained insight into the immaturity of his pattern of avoidance. With recognition of his parents’ rapid aging and his need to take on more adult responsibilities, Mr. T is currently grappling in therapy with how he will care for himself after his parents die.