“Hikikomori” is a term that describes both the state and the sufferer of acute social withdrawal. First coined by psychiatrist Tamaki Saito in 1998, the term and the condition gained immense popularity in Japan following several newspaper articles and television interviews with Saito. While technically a transliteration of the English term ‘social withdrawal’, shakaiteki hikikomori was soon reintroduced to the English-speaking community as a uniquely Japanese term (and phenomenon) through Canadian journalist Michael Zielenziger’s 2007 book Shutting Out the Sun and the New York Times’ article “Shutting Themselves In”. Since then, the number of scientific investigations and popular editorials has exponentially increased around the world. The topic continues to intrigue individuals from various social science and humanities backgrounds today.
“the immediate image that comes to mind is a young Japanese man, who has isolated himself within a bedroom in his parents’ house for years on end, refusing to speak, interact, or even be seen by anyone”
When one mentions “hikikomori”, the immediate image that comes to mind is a young Japanese man, who has isolated himself within a bedroom in his parents’ house for years on end, refusing to speak, interact, or even be seen by anyone – sometimes including his own family. Meals are brought to the door a few times a day, and garbage and other refuse are left out in return. He might have started off spending his time playing video games or chatting online, but those activities lost their charm long ago. He now simply stares off into space. Hikikomori. The world of perfect isolation.
While the previous description of hikikomori is not necessarily incorrect, it describes only a subsample of individuals. Because of the diversity of traits and characteristics accompanying hikikomori, much effort has been put into defining the term in a way that consolidates the condition that we are examining. Saito originally describes social withdrawal as the disorder and any accompanying psychiatric symptoms as the expression of this disorder. As a part of the psychoanalytic tradition, he considers hikikomori a “problem of adolescence”, particularly related to how adulthood has now been postponed to one’s thirties. According to his belief, the only cure is the “development of social character into maturity.” Despite the psychoanalytic roots, there have also been many attempts to behaviorally define the condition, creating an apparent discrepancy between the proposed etiology and the definition. The best behavioral definition to date was proposed by Teo and Gaw (2010). This definition of hikikomori captures the core constructs associated with the condition in six criteria: (1.) most of the day, nearly every day, is spent at home, (2.) persistent avoidance of social situations, (3.) persistent avoidance of social relationships, (4.) experienced distress or impairment in an individual’s normal routine, (5.) duration at least six months, and (6.) not better explained by another psychiatric disorder such as social phobia, major depressive disorder, schizophrenia, or avoidant personality disorder.
Similar to how there have been some disagreements and inconsistency with the definition, there are many more misconceptions and misinformation surrounding hikikomori. These include, but are not limited to, (1.) the number of hikikomori in Japan, (2.) the existence of hikikomori outside of Japan, and (3.) whether the phenomenon is caused by modern Japanese culture or society. These will be discussed one by one in the following sections.
“One Million Hikikomori”
Saito’s initial estimate numbered the individuals in a state of hikikomori to be about one million. Since then, other media sources, such as Phil Rees’ BBC special “Hikikomori: The Missing Million”, have echoed this figure primarily to highlight the significance of this “emerging epidemic.” However, the estimate of one million has no empirical basis. There have been three studies to date that have attempted to calculate the number of hikikomori in Japan based on sampling statistics. In 2002, Miyake’s team found 14 cases amongst a sample of 1,646 people in Okinawa, extrapolating to about 410,000 cases in the entire country. In 2008, Inui used statistics on labor market participation to estimate that the number of hikikomori is actually less, about 200,000 cases nationally. The best attempt at ascertaining this number, however, can be found in an epidemiological study by Koyama’s team that used state-of-the-art sampling and statistical techniques to estimate that there are 232,000 hikikomori in Japan. This works itself out to be a lifetime prevalence rate of 1.2% for Japanese individuals between the age of 20 and 49. The scientific community considers this to be the most accurate estimate as of 2010.
“Hikikomori is Uniquely Japanese”
When first investigating this phenomenon, Saito (2008) emailed mental health professionals from around the world asking if they have ever seen a case as he described. While the statistics from this survey were not made available, Saito (2013) highlighted the respondents that replied that they had never heard of it[1, 3]. In a more recent systemized replication of this study in 2012, Kato (2012) and his team found that among 124 mental health professionals from eight countries around the world, nearly all of them stated that they have seen or heard of someone in their own country who matches this description. Similarly, there have been hikikomori case studies from several countries outside Japan including, Spain, Oman, the United States, Canada, Italy, the United Kingdom, France, Taiwan, and South Korea. There has even been exploratory research comparing hikikomori cross-nationally on traits such as loneliness and treatment preferences. In my own place of employment, a child assessment and treatment center in Hawaii, we have seen no less than six individuals in the last two years that meet criteria for hikikomori by Teo and Gaw’s definition (excluding criterion 6). Also pertinent to this question, the epidemiological estimates of hikikomori in South Korea are approximately the same population percentage as in Japan (2% or about 100,000 people).
“Despite this strong emerging evidence that the hikikomori phenomena is worldwide, certain investigators and reporters have tried to construe the issue as uniquely Japanese, and in that way pathologized the country and culture.”
Despite this strong emerging evidence that the hikikomori phenomena is worldwide, certain investigators and reporters have tried to construe the issue as uniquely Japanese (see next section), and in that way pathologized the country and culture. Even after Teo and Gaw’s proposal to formally add hikikomori as a “culture-bound” psychiatric disorder, they specifically stated in a later publication that the term “culture-bound”, which denotes only occurring in a certain cultural context, should actually be “culture-influenced.” However, by that definition, every psychiatric disorder from oppositional defiant disorder, to major depressive disorder, to schizophrenia is “culture-bound.” Needless to say, all of this evidence culminates to underscore that while the term “hikikomori” is Japanese, the phenomenon is global.
“Hikikomori Represents a Culture in Crises”
This claim is more difficult to refute because it is so inherently subjective. Some investigators such as Zielenziger (2007) and Sugai (2013), rely on the fictional assertion that hikikomori does not exist outside of Japan, have compared and contrasted cultural characteristics of Japan and other countries to demonstrate the cultural etiology of hikikomori. None too abashed is the subtitle of Zielenziger’s book, which reads “How Japan Created Its Own Lost Generation.” Various cultural and societal factors including (1.) individualism/collectivism, (2.) Japanese education system, and (3.) Japanese family system/functioning have been attributed to the “rise of hikikomori.” For the following discussion it is first important to recognize two things: Japan, as a society and culture, produces far more non-hikikomori than hikikomori; and that factors that may predict someone becoming hikikomori within Japan, may not be the best explanation on why someone would become hikikomori in Japan as oppose to another country (i.e., within-group vs. between-group predictions). The impact of collectivism and educational systems are outside the scope of this article, and instead of commenting on them directly, I would simply advise investigators to recognize that this type of causal evidence is very difficult to obtain, and that this type of conclusion should be tentative at best when other more parsimonious explanations have been ruled out.
In regards to Japanese families, there have been many assertions that fundamental flaws in family functioning represent a key reason for hikikomori, whether this be parenting style, mother-child attachment or family functioning in general. The evidence for this is that hikikomori and their families frequently report these concerns, but while these two issues may certainly be related, there has been no evidence to date to infer that one causes the other. Furthermore, while some investigators purport that contemporary Japanese families do not meaningfully communicate with each other, it is unclear how “meaningfully” is conceptualized and whether this is unique to Japanese families with or without hikikomori – let alone compared to contemporary families in other countries. In an investigation of family functioning among families of autistic, hikikomori, and healthy children, Koshiba (2007) and her team found that family functioning was lower amongst the hikikomori and autism families than the control group. However, just as family functioning did not “cause” the predominately biological disorder of autism, it is unclear how it influences hikikomori. In another large scale investigation led by Umeda and the World Mental Health Survey Group (Umeda & Kawakami, 2012), parenting style was not related to hikikomori, but psychiatric illness amongst one of the parents was. It is not clear, however, whether the latter relationship is because of a biological predisposition or environmental factors (or both). Furthermore, the relationship between parents’ and children’s psychiatric concerns is a fairly robust finding globally (Goodman, 2011), and does not necessarily denote that “Japan is in crises”.
Diagnostic Labels as Descriptive and Predictive
Now that we have discussed what hikikomori is not, what is it? Just a buzzword? A media hype? While we have certainly challenged some of the common notions and misinformation that has been disseminated about hikikomori, the question still stands: how can we best account for and describe the various characteristics, behaviors, and symptomology experienced by these people who are suffering so deeply? In the end, it isn’t about the label “hikikomori” or otherwise, but it is finding the best way to conceptualize this condition that would have the most clinical utility and lead to the most treatment success. Issues of comorbidity, psychiatric disorders that co-occur with hikikomori, further complicate this. While the working definition of hikikomori specifies that no other psychiatric condition can be present (criterion 6), this describes only a small subset of individuals who presented as hikikomori. Even Saito admits that the majority of his cases meet criteria for another disorder such as social phobia, obsessive-compulsive disorder, schizophrenia, and pervasive developmental disorder. Early estimates indicated that the comorbidity rates between hikikomori and other psychiatric disorders ranged between 54% and 73%. These studies, however, had key methodological flaws and did not assess for developmental disorders or psychotic disorders, both of which have been demonstrated to be highly comorbid (between 20 and 33%) with hikikomori in other studies. The most thorough study to date reliably demonstrated 99.7% comorbidity (all but one case) with other psychiatric disorders amongst their sample of 337 hikikomori from multiple treatment centers assessed by multiple, highly-trained psychiatrists/psychologists.
“Because social withdrawal is a symptom for many psychiatric concerns including anxiety disorders, depressive disorders, psychotic disorders, personality disorders, and pervasive developmental disorders, this means that the entire syndrome of hikikomori (and its heterogeneous presentation) could potentially be explained by already well-established and well-researched psychiatric conditions.”
Because social withdrawal is a symptom for many psychiatric concerns including anxiety disorders, depressive disorders, psychotic disorders, personality disorders, and pervasive developmental disorders, this means that the entire syndrome of hikikomori (and its heterogeneous presentation) could potentially be explained by already well-established and well-researched psychiatric conditions. Furthermore, comorbidity violates criterion 6 of Teo and Gaw’s definition, meaning that in the majority of cases, hikikomori are not technically hikikomori. At this point, it is important to remember that all diagnostic labels are, in a sense, “made up.” They are ideas that professionals have about how different disorders work and what symptoms are associated with them. The purpose of these labels is to (1.) describe the condition and (2.) prescribe the appropriate treatment that would lead to the greatest success. In this way, it is important to anchor these ideas in empirical observation in order to provide validity, explanatory power, and clinical utility for these diagnostic labels. It is apparent that the next step in the hikikomori research includes providing discriminate validity (the ability to empirically differentiate between diagnostic labels) and explanatory power, by answering the following question: “Can hikikomori explain the condition of acute social withdrawal and accompanying symptoms over and above existing psychiatric disorders?” Until then, it is possible to make the argument that the diagnostic term, “hikikomori”, may represent fiction altogether.
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Image | Davi Ozolin