Characteristics of socially withdrawn youth in France: A retrospective study

Abstract

Background:

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 As far as socially withdrawn youth (SWY) are concerned, studies were mostly conducted on patients seeking care.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

Aims:

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

Method:

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

Results:

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

Conclusion:

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

Keywords

Social withdrawal young adult psychiatric outreach team retrospective study

Background

Limitation of social interactions has been studied since the dawn of psychiatry. Bleuler (1911) introduced the concept of autism to define social withdrawal of schizophrenic patients. Gayral used the term of ‘confinement’, which he associated with chronic psychotic disorders such as paranoia and schizophrenia (Gayral, Carrie, & Bonnet, 1953). More recently, various concepts have come forth to designate social withdrawal: ‘Housebound Syndrome’ (Rapp, 1984) or NEET (Not in Education, Employment, or Training) (Uchida & Norasakkunkit, 2015). The Japanese term hikikomori applies to young adults who severely withdraw from social life and stay at home for more than 6 months (Watts, 2002). Primary forms of hikikomori, without distinct psychiatric disorder, can be differentiated from secondary forms, resulting from a psychiatric pathology: schizophrenia, anxiety disorder, mood disorder or personality disorder (Furuhashi et al., 2013). The term hikikomori has spread internationally, but its place in current nosography and its transposition in non-Japanese cultures are still under discussion (Kato et al., 2012; Tajan, 2015; Teo & Gaw, 2010).

The extent of socially withdrawn youth (SWY) phenomenon is difficult to estimate. In Japan, there could be 210,000–700,000 hikikomori (De Luca & Thoret, 2013; Uchida & Norasakkunkit, 2015). In Southeast Asia, studies claim that 1.2%–2.3% of youth are SWY (Li & Wong, 2015). In the rest of the world, epidemiological data are scarce.

Several studies have taken interest in clinical and socio-demographic characteristics of SWY: psychiatric disorders (Funakoshi & Miyamoto, 2015; Furuhashi et al., 2013; Kondo et al., 2013; Malagón-Amor, Córcoles-Martínez, Martín-López, & Pérez-Solà, 2015; Stip, Thibault, Beauchamp-Chatel, & Kisely, 2016), characteristics of the withdrawal (Chan & Lo, 2016a; Funakoshi & Miyamoto, 2015; Guedj-Bourdiau, 2011; Malagón-Amor et al., 2015) or characteristics of hikikomori families (Chan & Lo, 2016b; Funakoshi & Miyamoto, 2015; Li & Wong, 2015). The studies were mainly conducted within subgroups of SWY to which researchers were able to have access. It is thus precarious to claim representativeness for all SWY (Tajan, 2015). Moreover, criteria for a definition of SWY vary: history, age and psychiatric comorbidities (Li & Wong, 2015).

Psymobile is a mobile psychiatric unit in Lyon (Rhône Département, France) which aims at providing better access to mental health care, thanks to its ability to visit patients. Requests for care are made by relatives or social workers, and the majority of Psymobile patients never had any contact with mental health care (Chauliac, Depraz, Pacaut-Troncin, Straub, & Terra, 2015). This leads Psymobile to often get in contact with withdrawn individuals. The objective of our study was to describe the characteristics of socially withdrawn young adults with whom Psymobile was involved, on socio-demographic and clinical levels.

Methods

We carried out a retrospective analysis of the records of patients aged 18–34 years who were referred to Psymobile for withdrawal between April 2012 and December 2015. Patients aged below 18 years were excluded.

Data collected included the following:

Socio-demographic characteristics: gender, age, education level, professional experience and family composition;

Psychiatric history (including during childhood) and substance use;

Withdrawal characteristics: duration, partial or total withdrawal, triggering factors, maintained relationships and related symptoms;

Psychiatric diagnosis given at the end of Psymobile care;

Characteristics of the Psymobile intervention: originator of request for care and outcome of Psymobile care.

We used the Student test and the Fisher exact test to compare patients not included in the study with those included, as well as those who had a prior contact with psychiatric care and those who had not.

The research protocol was approved by an independent ethics committee.

Results

Patients included in the study

Between April 2012 and December 2015, Psymobile followed up 231 patients aged 18–34 years. Of these, 66 were included in the study. The inclusion process is detailed in Figure 1. We excluded nine patients, for whom more than one-third of the complete dataset was missing (i.e. more than 11 missing data over 35 collected).

Figure 1.

Inclusion flowchart.

SWY included in the study were significantly younger than patients not referred for withdrawal (mean age 23.2 years for patients included and 26.5 years for patients not included, p < .0002). The ratio of patients who already had a contact with psychiatric care was also significantly lower for SWY (62% vs 58%, p < .05). The sex ratio and final diagnoses were not significantly different between patients included and not included.

Socio-demographic characteristics of SWY

A vast majority of SWY (80%) were male. Their mean age was 23.2 years (standard deviation (SD): 4.75, median: 22), identical regardless of gender. Among those patients, 42% had had no prior contact with a mental healthcare professional before being referred to our team. Eighty-six percent of patients were one of several siblings, and in more than half of the cases (55%), they were the youngest of the siblings.

Socio-demographic characteristics of the study population are presented in Table 1.

Table 1.

Socio-demographic and clinical characteristics of withdrawn patients.

	N = 66 (%)
Household composition
Lives with both parents	22 (35)
One-parent family, lone mother	18 (29)
One-parent family, lone father	8 (13)
Lives on his own	13 (21)
Others	2 (3)
Missing data	3
Mean number of siblings including patient (SD)	2.56 (1.27)
Only child	8 (14)
2 siblings	26 (44)
3 siblings or more	25 (42)
Missing data	7
Birth order
Eldest	12 (20)
Youngest	28 (47)
Middle	11 (19)
Only child	8 (14)
Missing data	7
Education level
Secondary school	11 (20)
High school	27 (48)
Higher education	18 (32)
Missing data	10
Professional experience
Yes	15 (29)
No	37 (71)
Missing data	14
Psychiatric history
Mood disorder	3 (6)
Neurodevelopmental disorder	8 (15)
Anxiety disorder	6 (11)
Schizophrenia spectrum	5 (9)
Unspecified history	7 (13)
No history	25 (46)
Missing data	12
Substance use
Cannabis	23 (42)
Missing data	11
Alcohol	9 (17)
Missing data	13
Tobacco	9 (18)
Missing data	17

SD: standard deviation.

When comparing patients included in the study who already had a psychiatric history with the ones having no history, we found no significant difference regarding sex ratio, age (mean and SD), final diagnosis or other clinical and socio-economic characteristics (household composition, number of siblings, birth order, substance use, education level, type of retained relationship, outings).

Withdrawal characteristics

At the time the patients were referred to our team, the mean duration of withdrawal was over 2 years (29 months, median: 19, SD: 32). The mean age at the onset of withdrawal was 20.4 years (median: 20, SD: 4.1, 10 missing data). Clinical data on withdrawal are detailed in Table 2.

Table 2.

Clinical characteristics of withdrawal.

	N = 66 (%)
Type of maintained relationships
None	12 (19)
Family	40 (63)
Friends	5 (8)
Family and friends	5 (8)
Family and others (sentimental, school)	2 (3)
Missing data	2
Outings
Alone	21 (38)
Accompanied	19 (35)
None	15 (27)
Missing data	11
Disorders of the sleep–wake schedule
Yes	27 (73)
No	10 (27)
Missing data	29
Poor personal hygiene or carelessness
Yes	14 (33)
No	28 (67)
Missing data	24
Violence
Self-harm	6 (11)
Missing data	11
Act of violence	18 (31)
Missing data	8
Verbal hostility	24 (42)
Missing data	9
Triggering factors
Romantic break-up	9 (14)
Divorcing parents	5 (8)
School failure	6 (9)
Death of relative	4 (6)
Others	4 (6)
Not known	38 (58)

Diagnoses

The main diagnoses were assessed according to World Health Organization (WHO) International Statistical Classification of Diseases, 10th Revision (ICD-10) classification (WHO, 2015). In seven cases, the main diagnosis was a code for ICD-10 ‘Factors influencing health status and contact with health services’ category (Z00–Z99). After reviewing the case with the psychiatrists who had made the diagnoses, we considered these as cases for which no psychiatric disorder existed. There were 14 missing diagnoses which could not be recovered. The main diagnoses are shown in Figure 2.

Figure 2.

Main diagnoses given at the end of Psymobile care.

Psymobile follow-up characteristics

The mean duration between the referral to Psymobile and the end of care with Psymobile was 127 days (SD: 151, median: 75). Other characteristics of Psymobile follow-up are detailed in Table 3.

Table 3.

Psymobile care characteristics for withdrawn patients.

	N = 66 (%)
Originator of request for care
Relatives	47 (71)
Social workers	12 (18)
Healthcare professional	7 (11)
Outcome of Psymobile care
Hospitalization	14 (21)
Voluntary	3 (5)
Involuntary commitment	11 (17)
Ambulatory care	23 (35)
Public outpatient health care	14 (21)
Private psychiatrist	6 (9)
Others	3 (5)
No follow-up care	29 (44)
Withdrawal of request	18 (27)
Patient refusal	9 (14)
Already in care	2 (3)

Discussion

The main contribution of this study is to present the socio-demographic and clinical characteristics of withdrawn young adults who do not seek health care or social help. The data we present may thus be more representative of withdrawal situations within the French general population than those of patients who seek help or are willing to fill in online surveys (Lee, Lee, Choi, & Choi, 2013; Tajan, 2015). Furthermore, most studies focus on the subgroup of hikikomori, the definition of which is usually more restrictive than mere withdrawal.

We observed a large predominance (80%) of males among SWY. This is consistent with data on hikikomori, showing between 63% and 81% of males (Chan & Lo, 2016a, 2016b; Funakoshi & Miyamoto, 2015; Kondo et al., 2013; Lee et al., 2013; Li & Wong, 2015; Malagón-Amor et al., 2015; Teo et al., 2015; Umeda, Kawakami, & World Mental Health Japan Survey Group 2002–2006, 2012). As far as age is concerned, we find that withdrawal is associated with younger age in our sample population. This is even more the case if we take into account the age at the onset of withdrawal. We find a mean age of 20.4 years at onset, very close to the results of Funakoshi and Miyamoto (2015) and Kondo et al. (2013).

Forty-two percent of SWY in our study live in a single-parent family, which is not so far from the ratio of 28% identified by Chan and Lo (2016b) but much higher than within the general population of the Rhône département (6% of the 20- to 34-year old) (Insee – National Institute of Statistics and Economic Studies, 2013). One-fifth (21%) of SWY are living on their own, which exceeds the results of past studies (Malagón-Amor et al., 2015; Teo et al., 2015; Wong et al., 2015) but is similar to the general population of the Rhône département, where 21% of the 30- to 34-year old live alone (Insee – National Institute of Statistics and Economic Studies, 2013).

As for the level of education, 32% of SWY have studied up to university level. Publications show mixed results (24%–78%) (Chan & Lo, 2016a, 2016b; Kondo et al., 2013; Teo et al., 2015; Wong et al., 2015). In France, 45% of the 25- to 35-year old reach post-secondary school level (Insee – National Institute of Statistics and Economic Studies, 2014).

About half of SWY have been diagnosed with a psychiatric disorder before being referred to Psymobile. Most studies on SWY exclude patients with a psychiatric history, in accordance with the Japanese Health Department’s definition of hikikomori (Tajan, 2015). It is thus difficult to find comparative data in other publications.

Forty-two percent of SWY use cannabis, which is much higher than in the general population of the Rhône-Alpes region, where it is estimated that 5% of 20- to 25-year old and 3% of 26- to 34-year old use cannabis regularly (i.e. at least 10 times in the past month) (Marant-Micallef, Dreneau, & Sonko, 2014). We were not able to find corresponding figures in the international literature concerning SWY.

As for the clinical characteristics of withdrawal, we found a mean duration of 29 months, which seems to tally with other published data: 2.1 years for Teo et al. (2015) and 1–4 years for Stip et al. (2016). Three-quarters (73%) of SWY suffer from disorders of the sleep–wake schedule and one-third show signs of poor personal hygiene. Funakoshi and Miyamoto recorded 41.8% of hikikomori suffering from sleeping disorders (Funakoshi & Miyamoto, 2015). We note that only 19% of SWY have given up all social relationships and 74% maintain family ties, corroborating Funakoshi and Miyamoto’s (2015) 63.6%. Only 27% of withdrawn patients never leave home. For Funakoshi and Miyamoto, 22% of withdrawn patients never left home in the last month, and for Chan and Lo, 20% were confined for the last 3 months (Chan & Lo, 2016a; Funakoshi & Miyamoto, 2015). Self-inflicted violence and hetero-aggressive outbursts are rarely recorded in the studies. However, we noticed that our numbers are higher than those of Funakoshi and Miyamoto (2015): 0% self-harm (versus 11% in our study), 1.8% violence at home (vs 31%) and 10.9% authoritative attitude at home (vs 42% verbal hostility).

Thirteen percent of SWY addressed to our team were not given a psychiatric diagnosis, thus approaching the Japanese Health Department’s definition of hikikomori. The most frequent diagnoses were psychotic disorder (for 37% of patients), mood disorder (23%) and personality disorder (15%). This coincides with the data of Malagón-Amor et al. (2015): psychotic disorder 36%, mood disorder 17%, anxiety disorder 20% and personality disorder 15.9%. Yet we note that in the study by Malagón-Amor et al., only 2% of patients were not given a diagnosis.

Our study has several limitations. First, it is a retrospective study, which is exposed to biases in terms of availability and reliability of data. Furthermore, the diagnoses were given after a clinical assessment and were not based on structured questionnaires. In addition, we did not collect data on online activities and technological device use. In our point of view, the clinical meaning of such behaviours is difficult to assess retrospectively, as they can be merely occupational, a pleasurable entertainment or an actual addiction. Some authors consider, however, that there are major similarities between the hikikomori concept and Internet addiction (Stip et al., 2016).

For patients who already had a contact with psychiatric care, our retrospective study gives only little information on the reasons why this care was stopped. It can only be hypothesized that some are common with reasons for treatment non-adherence in schizophrenia and depression, such as comorbidities, insight, patient–professional relationship, low income and experience during hospitalization (Day et al., 2005; Hung, 2014). These factors may be exacerbated by a tendency for social withdrawal, whose causes still have to be further investigated.

Explanatory hypotheses for withdrawal are based on attachment theory or the maturation process and focus on the complications of severance from the family environment (Li & Wong, 2015). In our study, the repartition of diagnoses is not significantly different between SWY and other Psymobile patients of the same age group. It can thus be hypothesized that psychiatric diagnosis is not a prominent factor explaining social withdrawal.

Deepening research on the causes of withdrawal, whether for hikikomori or for SWY, could help developing intervention strategies and offering adequate health care to these patients.

It seems currently that care is more social and community-based in Japan, while more medical-oriented in France (Guedj-Bourdiau, 2011). To our knowledge, little is known about the efficacy of interventions dedicated to SWY. In our study, SWY were younger and had had less contact with psychiatric care than the rest of Psymobile patients of the same age group, all being characterized by the fact that they do not seek psychiatric care. Being able to meet SWY at home, even when they did not explicitly take action to ask for care, may thus be a promising way to reach them.

Conclusion

More than one-quarter of 18- to 34-year-old patients referred to Psymobile between April 2012 and December 2015 were referred for withdrawal at home. It is thus a significant phenomenon which remains understudied, mainly because SWY are often not seeking help.

The withdrawn youth followed by Psymobile are predominantly male in their early 20s, from large families or single-parent ones. They often use cannabis and about a half have a psychiatric history. We were contacted in average after a 2.5-year history of withdrawal, which had started when subjects were 20 years old. Most SWY suffer from disorders of the sleep–wake schedule and retain only few social ties beyond close family. Less than one-third do not venture outside home. Most of the time, we were able to give a psychiatric diagnosis, mainly schizophrenia or mood disorder. Only 13% of patients could not be given a psychiatric diagnosis and thus can be considered as hikikomori, as defined by the Japanese Health Department.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

References

Bleuler

(1911). Dementia praecox oder Gruppe der Schizophrenien [Dementia Praecox, or the Group of Schizophrenias] (1st ed.). Leipzig, Germany: Deuticke.

Chan

G. H.

T. W.

(2016a). The effect of negative experiences on delinquent behavior of youth in a social withdrawal situation. Journal of Adolescence, 50, 69–80.

Chan

G. H.

T. W.

(2016b). Family relationships and the self-esteem of hidden youth: A power dynamics perspective. Journal of Family Issues, 37, 1244–1266.

Chauliac

Depraz

Pacaut-Troncin

Straub

Louis Terra

(2015). Psymobile et le phénomène des hikikomori [Psymobile and the phenomenon of the hikikomori]. Soins Psychiatrie, 36(298), 30–33.

Day

J. C.

Bentall

R. P.

Roberts

Randall

Rogers

Cattell

… Power

(2005). Attitudes toward antipsychotic medication: The impact of clinical variables and relationships with health professionals. Archives of General Psychiatry, 62, 717–724.

De Luca

Thoret

. (2013). Hikikomori à l’adolescence. Syndrome de retrait à domicile chez les adolescents japonais. [Adolescent hikikomori. Home withdrawal syndrome of Japanese adolescents]. EMC – Psychiatrie, 10(4), 1–7.

Funakoshi

Miyamoto

(2015). Significant factors in family difficulties for fathers and mothers who use support services for children with hikikomori. Psychiatry and Clinical Neurosciences, 69(4), 210–219.

Furuhashi

Tsuda

Ogawa

Suzuki

Shimizu

Teruyama

… Castel

P.-H.

(2013). État des lieux, points communs et différences entre des jeunes adultes retirants sociaux en France et au Japon (Hikikomori). [Current situation, common features and differences between social withdrawn young adults in France and Japan]. L’Évolution Psychiatrique, 78(2), 249–266.

Gayral

Carrie

Bonnet

(1953). La claustration. [Confinement] Annales Médico-psychologiques, revue psychiatrique, 1, 469–496.

10.

Guedj-Bourdiau

M.-J.

(2011). Claustration à domicile de l’adolescent. Hikikomori. [Home confinement of the adolescent. Hikikomori] Annales Médico-psychologiques, revue psychiatrique, 169(10), 668–673.

11.

Hung

C.-I.

(2014). Factors predicting adherence to antidepressant treatment. Current Opinion in Psychiatry, 27, 344–349.

12.

Insee – National Institute of Statistics and Economic Studies. (2013). Rhône Département database [‘Database for the Rhône Département]. Retrieved from http://www.insee.fr/fr/bases-de-donnees/

13.

Insee – National Institute of Statistics and Economic Studies. (2014). National database. Retrieved from http://www.insee.fr/fr/bases-de-donnees/

14.

Kato

T. A.

Tateno

Shinfuku

Fujisawa

Teo

A. R.

Sartorius

… Kanba

(2012). Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary international investigation. Social Psychiatry and Psychiatric Epidemiology, 47, 1061–1075.

15.

Kondo

Sakai

Kuroda

Kiyota

Kitabata

Kurosawa

(2013). General condition of hikikomori (prolonged social withdrawal) in Japan: Psychiatric diagnosis and outcome in mental health welfare centres. International Journal of Social Psychiatry, 59, 79–86.

16.

Lee

Y. S.

Lee

J. Y.

Choi

T. Y.

Choi

J. T.

(2013). Home visitation program for detecting, evaluating and treating socially withdrawn youth in Korea. Psychiatry and Clinical Neurosciences, 67, 193–202.

17.

T. M.

Wong

P. W.

(2015). Youth social withdrawal behavior (hikikomori): A systematic review of qualitative and quantitative studies. The Australian and New Zealand Journal of Psychiatry, 49, 595–609.

18.

Malagón-Amor

Á.

Córcoles-Martínez

Martín-López

L. M.

Pérez-Solà

. (2015). Hikikomori in Spain: A descriptive study. International Journal of Social Psychiatry, 61, 475–483.

19.

Marant-Micallef

Dreneau

Sonko

(2014). Baromètre Santé 2010: Données régionales Rhône-Alpes. [2010 Health Barometer: Data of the Rhône-Alpes Region]. Retrieved from http://www.ors-rhone-alpes.org/pdf/Barometre2010.pdf

20.

Rapp

M. S.

(1984). Differential diagnosis and treatment of the ‘housebound syndrome’. Canadian Medical Association Journal, 131, 1041–1044.

21.

Stip

Thibault

Beauchamp-Chatel

Kisely

(2016). Internet addiction, hikikomori syndrome, and the prodromal phase of psychosis. Frontiers in Psychiatry, 7, 6.

22.

Tajan

(2015). Social withdrawal and psychiatry: A comprehensive review of Hikikomori. Neuropsychiatrie de l’Enfance et de l’Adolescence, 63(5), 324–331.

23.

Teo

A. R.

Fetters

M. D.

Stufflebam

Tateno

Balhara

Choi

T. Y.

… Kato

T. A.

(2015). Identification of the hikikomori syndrome of social withdrawal: Psychosocial features and treatment preferences in four countries. The International Journal of Social Psychiatry, 61, 64–72.

24.

Teo

A. R.

Gaw

A. C.

(2010). Hikikomori, a Japanese culture-bound syndrome of social withdrawal?: A proposal for DSM-5. The Journal of Nervous and Mental Disease, 198, 444–449.

25.

Uchida

Norasakkunkit

(2015). The NEET and Hikikomori spectrum: Assessing the risks and consequences of becoming culturally marginalized. Frontiers in Psychology, 6. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540084/

26.

Umeda

Kawakami

World Mental Health Japan Survey Group 2002–2006. (2012). Association of childhood family environments with the risk of social withdrawal (‘hikikomori’) in the community population in Japan. Psychiatry and Clinical Neurosciences, 66, 121–129.

27.

Watts

(2002). Public health experts concerned about ‘hikikomori’. The Lancet, 359, 1131.

28.

Wong

P. W. C.

T. M. H.

Chan

Law

Y. W.

Chau

Cheng

… Yip

P. S.

(2015). The prevalence and correlates of severe social withdrawal (hikikomori) in Hong Kong: A cross-sectional telephone-based survey study. The International Journal of Social Psychiatry, 61, 330–342.

29.

World Health Organization. (2015). International statistical classification of diseases and related health problems. Geneva, Switzerland: Author.