Abstract
Dear Editor,
Once a syndrome thought to be bound to Japanese Culture, Hikikomori is being increasingly recognized in other parts of the world, with recent case reports from Spain (Ovejero, Caro-Canizares, de, Leon-Martinez, & Baca-Garcia, 2014), Oman (Sakamoto, Martin, Kumano, Kuboki, & Al-Adawi, 2005), Korea (Lee, Koo, Kim, & Lee, 2001) and the United States (Teo, 2013). With this letter, we present the first adolescent case, and only second case of Hikikomori documented in the United States, to raise awareness of Hikikomori as a form of psychopathology that transcends culture.
Mr. H is a 17-year-old Chinese-American male who presented due to increasing social isolation which began with declining grades and rejection from the school sports team. Subsequently, he began isolating in his room, ceased all hobbies, withdrew from friendships and stopped attending school. There was a brief period in which he applied for a job and planned to move to his own apartment but once these plans fell through, he became increasingly reclusive. For the past 6 months, he had been living alone in his parents’ old home, leaving only once every other week to buy groceries with his mother. Reportedly content with his lifestyle, though unable to verbalize his mood or to describe how he spent his days, responding to nearly all questions with ‘I don’t know’, he denied all psychiatric symptoms including depression, anxiety, or psychotic symptoms.
Several features of Mr. H’s presentation are consistent with Hikikomori (as described in the proposed diagnostic criteria by Teo and Gaw (2010)), including severity and length of social withdrawal (>6 months), ego-syntonic nature of withdrawal and lack of preexisting psychiatric diagnoses. Similar to other cases, Mr. H was from an upper middle-class family, had a close relationship with his mother and had isolation that was preceded by apparent failure (Sakamoto et al., 2005). He also exhibited a profound sense of apathy that is frequently characterized by ‘I don’t know’ responses (Ovejero et al., 2014).
While rigorous epidemiologic studies are lacking in countries outside of Japan, this case adds to overwhelming evidence from the literature and popular media to suggest Hikikomori is not bound to Japanese culture. A recent survey of psychiatrists outside of Japan found that patients with Hikikomori were present in all nine countries surveyed (Kato et al., 2012). Moreover, psychiatrists from all over the world, including France, Hawaii and California, have claimed in recent published news reports to have seen numerous cases in their clinical practice (Conti, 2019; Krieg, 2016). In addition, a simple Google search elicits countless online communities, including blogs and chat rooms, on which many people outside of Japan identify as Hikikomori.
While the literature has largely focused on Hikikomori as a culture-bound syndrome, the recent emergence of cases outside of Japan suggests that this may not be accurate, and perhaps, may even be harmful. We argue that while Hikikomori is likely culturally influenced by several perpetuating factors in Japanese culture, continuing to refer to it as a culture-bound syndrome may slow recognition of the syndrome outside of Japan. Providers in other countries may not recognize the constellation of symptoms and may instead use labels such as depression, social anxiety, avoidant personality disorder, psychosis or prolonged social withdrawal/isolation, without an appreciation for the nuances of psychological factors and precipitating triggers. Potential misdiagnoses may not only impede recognition of a syndrome, but may delay appropriate treatment where early intervention in the form of parent-child interventions and psychotherapy is believed to be critical (Kato, Kanba, & Teo, 2018).
Continuing to refer to Hikikomori as a culture-bound syndrome also risks pathologizing the Japanese culture. Several cultural phenomena in Japan have been hypothesized to explain the development of Hikikomori, including Amae (a child’s dependent behavior toward their parents) (Kato et al., 2012), Seken (social judgment from the public) (Ovejero et al., 2014), recent changing attitudes toward work and economic destabilization. While these factors may perpetuate the development of Hikikomori in Japan, they do not readily explain the emergence of cases outside of the country. Other globalized trends in the post-industrialized world, such as increasing individualism and the shift away from physical forms of communication with the rise of the Internet (Uchida & Norasakkunkit, 2016), may more accurately explain the development of Hikikomori outside of Japan and avoid pathologizing Japanese culture.
A corresponding phenomenon in industrialized countries that aids understanding of Hikikomori’s rise outside of Japan is a growing group of young people who are not in education, employment or training, often referred to as NEETs. While NEETs show a similar tendency to deviate from mainstream cultural values, they do not exhibit the same degree of social isolation as patients with Hikikomori (Uchida & Norasakkunkit, 2016). Some have argued that both NEETs and Hikikomori have similar sociocultural underpinnings and may exist on a spectrum of psychopathology from simply not pursuing vocational work to complete social withdrawal (Uchida & Norasakkunkit, 2016). While early descriptions suggest they are distinct diagnoses, NEETs provide a basis to understand how Hikikomori could be a Japanese term for a global trend.
As Hikikomori becomes increasingly recognized in clinical practice outside of Japan, documentation and epidemiologic study are needed to establish a common diagnostic language and to better understand its prevalence. Continuing to refer to Hikikomori as a culture-bound syndrome may further reduce recognition of the disorder, delay treatment for patients and risk pathologizing the Japanese culture.
