Hikikomori and the COVID-19 pandemic: not leaving behind the socially withdrawn

The coronavirus disease 2019 (COVID-19) pandemic, which started in China in December 2019 and rapidly spread worldwide, has required most world leaders to take measures to contain and control the spread of the virus, including social distancing and mass quarantine.¹ However, these interventions are likely to produce a considerable burden on the mental health of affected populations.² In the past few months, teams of investigators have been joining efforts to arrive at a more comprehensive understanding of the mental health consequences of the COVID-19 outbreak. Nevertheless, it would be important to add discussion about the potential impact that such measures may have on the prevalence of a relatively new psychiatric disorder called hikikomori or “pathological social withdrawal.”

Hikikomori was initially reported in Japan in the 1990s and is described as a condition of prolonged and severe social withdrawal lasting for at least six months, apparently not better explained by co-occurring severe psychiatric disorders.³,⁴ In most cases, the affected individual, usually a young male, remains isolated in his own house, or in his own room in more severe cases.⁴ Although it was initially considered a Japanese cultural syndrome, over the years it has been reported in a variety of countries around the world, gaining the status of a public health problem in Asia, with prevalence estimates in community populations varying from 0.87 to 2.3%.³-⁵ Although it is not possible to make inferences about causality in hikikomori cases, it seems that technology and the Internet are associated with this diagnosis.⁴,⁶ Additionally, comorbid psychiatric conditions have been reported in many hikikomori cases, and these patients may be at increased suicide risk.⁴,⁶ Family interventions, comorbidity treatment, online interventions, physical activity, multiple psychotherapeutic approaches, social skills training, etc., have been indicated as potentially useful strategies for hikikomori cases.³,⁷-¹¹ Nevertheless, the evidence to support these treatment approaches is weak, mainly due to a lack of studies on the topic.³,⁶

In 2020, updated diagnostic criteria⁴ were proposed for hikikomori, with the inclusion of a severity classification based on the weekly frequency the individual leaves his home or room. Physical isolation at home is regarded as the central characteristic of the syndrome, which can be diagnosed only when all the following criteria are met: “a) marked social isolation in one's home; b) duration of continuous social isolation of at least 6 months; c) significant functional impairment or distress associated with the social isolation.” Per definition, only individuals who leave home 3 or less days/week, for a prolonged period of time as stated above, can be defined as hikikomori.⁴ Even though loneliness is not one of the mandatory diagnostic criteria of the syndrome, it is a characteristic that becomes more pronounced with increasing continuous social withdrawal.⁴,¹⁰

The prevalence of hikikomori in Brazil is unknown due to a lack of empirical research on the phenomenon; however, the syndrome has been reported three times in Brazilian patients.⁹,¹²,¹³ Recently, our group described the complete treatment program for one of these cases. The patient reported substantial clinical improvement after a multimodal intervention strategy, including pharmacological treatment of comorbidities, family psychoeducation, and the use of different psychotherapy techniques.⁹

Considering this scenario, we hypothesized that strict confinement measures may have relevant negative consequences on hikikomori cases, and the syndrome is likely to grow in prevalence. Young people, not only those with pathological social withdrawal, may increase the time spent gaming or on the Internet, factors potentially associated with the syndrome.⁴,⁶ In Italy, for instance, empirical data described an increase in the use of digital media near bedtime during the lockdown.¹⁴ Another important point of discussion is the expected increase of new technology-dependent habits during the COVID-19 pandemic that may persist in the aftermath of the pandemic, such as online shopping, food delivery, online education courses, exclusively online social interaction, and online medical and psychological appointments. Such life habits may be associated with hikikomori cases and could further increase their prevalence in the near future.⁶,⁸ The rise in prevalence of psychiatric symptoms and disorders also may result in more hikikomori cases. Studies from China highlighted a substantial increase in anxiety and depression¹⁵ during the COVID-19 outbreak, with a depression prevalence of 43.7% among Chinese adolescents.¹⁶

It is also necessary to assess how painful and emotionally distressing quarantine and social distancing measures are for hikikomori cases in comparison to other populations. Although it could be that populations that were socially withdrawn prior to the pandemic may not suffer as much, empirical data from Spain indicated loneliness as the strongest predictor of depression, PTSD and anxiety during the COVID-19 outbreak.¹⁷

Despite the lack of empirical data, families and health professionals should be vigilant about the potential increased risk of hikikomori among young people during and after the COVID-19 pandemic. Exercising at home, maintaining a healthy diet, and limiting screen time are all lifestyle behaviours that have been recommended during this pandemic¹⁸ and are likely to promote better mental health outcomes. They may also have a positive impact on individuals at risk for hikikomori. In addition, once the pandemic is over, parents could focus on fostering outdoor activities and face-to-face interaction.

Social isolation has been growing in prevalence over the past decades, which has led some authors to say that we have been facing a silent and rising epidemic, potentially associated with other serious contemporary epidemics such as suicide and opioid use, called the “modern behavioral epidemic of loneliness.”¹⁹Hikikomori, likewise, could be considered a rising and silent epidemic during and in the aftermath of the COVID-19 pandemic, since physical and social isolation is likely to increase. Therefore, it is essential not to further isolate this population in terms of clinical and scientific efforts.

References

• ¹
  Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med. 2020;27:taaa020.
• ²
  Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912-20.
• ³
  Li TM, Wong PW. Youth social withdrawal behavior (Hikikomori): a systematic review of qualitative and quantitative studies. Aust N Z J Psychiatry. 2015;49:595-609.
• ⁴
  Kato TA, Kanba S, Teo AR. Defining pathological social withdrawal: proposed diagnostic criteria for hikikomori. World Psychiatry. 2020;19:116-7.
• ⁵
  Pozza A, Coluccia A, Kato T, Gaetani M, Ferretti F. The ‘Hikikomori’ syndrome: worldwide prevalence and co-occurring major psychiatric disorders: a systematic review and meta-analysis protocol. BMJ Open. 2019;9:e025213.
• ⁶
  Kato TA, Shinfuku N, Tateno M. Internet society, internet addiction, and pathological social withdrawal: the chicken and egg dilemma for internet addiction and Hikikomori. Curr Opin Psychiatry. 2020;33:264-70.
• ⁷
  Kubo H, Urata H, Sakai M, Nonaka S, Saito K, Tateno M, et al. Development of 5-day Hikikomori intervention program for family members: a single-arm pilot trial. Heliyon. 2020;6:e03011.
• ⁸
  Wong JC, Wan MJ, Kroneman L, Kato TA, Lo TW, Wong PW, et al. Hikikomori phenomenon in East Asia: regional perspectives, challenges, and opportunities for social health agencies. Front Psychiatry. 2019;10:512.
• ⁹
  Roza TH, Spritzer DT, Lovato LM, Passos IC. Multimodal treatment for a Brazilian case of Hikikomori. Braz J Psychiatry. 2020 May 11;S1516-44462020005012203. doi: http://10.1590/1516-4446-2020-0804 Online ahead of print.
  » http://10.1590/1516-4446-2020-0804
• ¹⁰
  Kato TA, Kanba S, Teo AR. Hikikomori: multidimensional understanding, assessment, and future international perspectives. Psychiatry Clin Neurosci. 2019;73:427-40.
• ¹¹
  Nishida M, Kikuchi S, Fukuda K, Kato S. Jogging therapy for Hikikomori social withdrawal and increased cerebral hemodynamics: a case report. Clin Pract Epidemiol Ment Health. 2016;12:38-42.
• ¹²
  Gondim FA, Aragão AP, Holanda Filha JG, Messias EL. Hikikomori in Brazil: 29 years of voluntary social withdrawal. Asian J Psychiatr. 2017;30:163-4.
• ¹³
  Prioste CD, de Siqueira RC. Fetichismo virtual na vida de um Hikikomori brasileiro: um estudo de caso. DOXA: Rev Bras Psicol Educ. 2019;21:4-16.
• ¹⁴
  Cellini N, Canale N, Mioni G, Costa S. Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy. J Sleep Res. 2020 May 15;e13074. doi: http://10.1111/jsr.13074 Online ahead of print.
  » http://10.1111/jsr.13074
• ¹⁵
  Li J, Yang Z, Qiu H, Wang Y, Jian L, Ji J, et al. Anxiety and depression among general population in China at the peak of the COVID-19 epidemic. World Psychiatry. 2020;19:249-50.
• ¹⁶
  Zhou SJ, Zhang LG, Wang LL, Guo ZC, Wang JQ, Chen JC, et al. Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19. Eur Child Adolesc Psychiatry. 2020;29:749-58.
• ¹⁷
  González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun. 2020;87:172-6.
• ¹⁸
  Balanzá-Martínez V, Atienza-Carbonell B, Kapczinski F, De Boni RB. Lifestyle behaviours during the COVID-19, time to connect. Acta Psychiatr Scand. 2020;141:399-400.
• ¹⁹
  Jeste DV, Lee EE, Cacioppo S. Battling the modern behavioral epidemic of loneliness: suggestions for research and interventions. JAMA Psychiatry. 2020 Mar 4. doi: http://10.1001/jamapsychiatry.2020.0027 Online ahead of print.
  » http://10.1001/jamapsychiatry.2020.0027

Publication Dates

• Publication in this collection
  21 Aug 2020
• Date of issue
  Jan-Feb 2021

History

• Received
  19 May 2020
• Accepted
  9 July 2020