Multimodal treatment for a Brazilian case of hikikomori

Hikikomori is defined as a condition of severe and prolonged social withdrawal apparently not explained by other severe psychiatric disorders, lasting for at least 6 months, in which the individual – usually a young adult – remains a recluse in his own house.¹-³ Initially described in Japan in the late 1990s as a cultural syndrome, hikikomori has been recently recognized as a prevalent pathological phenomenon worldwide, with reports from several countries.⁴-⁶

We report the case of a 35-year-old man who was referred to outpatient psychiatric treatment during his second hikikomori episode, which started soon after he left university. During the preceding 14 months, he reported barely leaving his apartment, having no friends nor romantic relationships, neglecting hygiene and self-care, spending 14 hours/day playing computer games and an additional 3-5 hours/day watching gameplay videos on internet websites. He complained of depressive symptoms of moderate to severe intensity (Hamilton Depression Rating Scale [HAM-D] = 26) for the last 3 months, precipitated by a switch in antidepressant from sertraline 200 mg/day to desvenlafaxine 100 mg/day, which was part of a treatment trial aiming to increase his energy levels. During the first 11 months of this second hikikomori episode, he did not complain about depression symptoms, using a combination of OROS methylphenidate 54 mg/day (started in 2011 as treatment for hypersomnolence) and sertraline 200 mg/day (started in 2009 for recurrent depressive disorder).

He described a normal neuro-developmental, social, and educational history, having friends, good grades at school, and even a girlfriend. His psychiatric history (as reported by himself and his mother) was negative until age 19, when he developed hypersomnolence and mild depressive symptoms. At that time, he was enrolled in university, and despite both problems, he maintained good social involvement and participated in many activities.

Around age 26, after breaking up a romantic relationship, he entered the most pronounced period of social withdrawal to date, which corresponded to the first episode of hikikomori. During that episode, he developed significant social and functional impairment, which included giving up gym, not attending classes, losing contact with friends, spending most of the time at home (mainly in his bedroom) playing computer games for around 15 hours/day, and watching gameplays on internet websites for another 3 to 4 hours/day. This behavior persisted for at least 6 years, during which time he experienced only mild depressive symptoms and occasional sleep problems. After this time, he reported spontaneous improvement of social interactions, which lasted approximately 8 months, when he was actively engaged in routine university activities required for graduation. He took 12 years to complete his undergraduate degree, and has never been gainfully employed. A thorough psychiatric evaluation, which included his mother’s report, was not consistent with autism, psychotic symptoms, bipolar disorder, social anxiety disorder, or schizoid personality disorder.

After clinical evaluation, we decided to switch desvenlafaxine to sertraline up to a dose of 200 mg/day. After 4 weeks, he achieved remission of the depressive episode (HAM-D = 6), but remained socially withdrawn. Cognitive-behavioral therapy (CBT) sessions were initiated, focusing on behavioral activation routines and planning of outdoor social activities. Family interventions focused on psychoeducation were delivered to the patient’s mother. Moreover, motivational interviewing techniques were constantly applied during most sessions. After 4 months of this weekly multimodal treatment, he presented marked clinical improvement, being more involved in social activities with his family and friends; his gaming behavior diminished substantially, to around 1 hour/day; he started his first-ever (though part-time) job, as a driver (after 17 years without driving); and began looking for jobs in his field of expertise and seeking romantic relationships.

After this considerable clinical improvement, he continued to attend weekly psychotherapy sessions for 2 additional months, with a focus on relapse prevention. Subsequently, upon completion of 6 months of follow-up, he was discharged from outpatient care.

In a telephone follow-up evaluation 4 months after outpatient discharge, he remained in remission from his depressive episode (HAM-D = 5), did not report any sleep problems, and only spent 1 hour/day playing computer games. He reported driving at least twice a week (even though he was no longer working as a driver), being more socially active with his family, and still seeking romantic relationships and jobs in his field.

This is the third case of hikikomori described in Brazil, with the first reporting spontaneous recovery after 29 years of social withdrawal,⁷ and the second presenting partial clinical improvement after 9 months of weekly psychoanalytical psychotherapy.⁸ Nevertheless, this is the first Brazilian case of recurrent hikikomori, and the first in which a multimodal treatment approach was applied.

Recently, a group of researchers proposed updated diagnostic criteria for hikikomori and a severity classification based on the weekly frequency with which the patient leaves his room or home.⁹ According to their definition, the central feature of hikikomori is physical isolation in the individual’s home, and the condition can be diagnosed when the following three 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.”⁹ According to these criteria, individuals leaving home 4 or more days/week, are not defined as hikikomori; additionally, the presence of other psychiatric disorders no longer excludes this diagnosis.⁹ The patient described in this report meets all three criteria, and could be further classified as “moderate hikikomori” before the treatment of his second episode, according to this new diagnostic proposition.

Potential treatments for hikikomori already described in scientific literature consist of family interventions, different psychotherapeutic approaches, social-skills training, group activities, support groups, planning of activities (on a flexible schedule) in order to take the affected individual out of the home, and physical activity, among others; however, the quality of the evidence for treatment strategies is low.¹-³,¹⁰-¹² The role of pharmacological treatment – mainly antidepressants – in hikikomori is still uncertain. Better response rates are achieved in the treatment of comorbidities than in treatment of hikikomori itself¹⁰-¹²; the reported case herein follows this pattern.

This brief clinical report illustrates once more the occurrence of hikikomori in Brazil, and is the first to describe multimodal treatment of a Brazilian patient. Our approach, combining family psychoeducation, different psychotherapeutic approaches, and pharmacotherapy for comorbidities, may be a promising strategy for patients presenting with this syndrome.

References

• ¹
  Teo AR. A new form of social withdrawal in Japan: a review of Hikikomori. Int J Soc Psychiatry. 2010;56:178-85.
• ²
  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.
• ³
  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.
• ⁴
  Kato TA, Shinfuku N, Sartorius N, Kanba S. Are Japan’s hikikomori and depression in young people spreading abroad? Lancet. 2011;378:1070.
• ⁵
  Kato TA, Tateno M, Shinfuku N, Fujisawa D, Teo AR, Sartorius N, et al. Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary international investigation. Soc Psychiatry Psychiatr Epidemiol. 2012;47:1061-75.
• ⁶
  Kato TA, Kanba S, Teo AR. Hikikomori: experience in Japan and international relevance. World Psychiatry. 2018;17:105-6.
• ⁷
  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.
• ⁸
  Prioste CD, de Siqueira RC. Fetichismo virtual na vida de um Hikikomori brasileiro: um estudo de caso. Rev Bras Psicol Educ. 2019;21:4-16.
• ⁹
  Kato TA, Kanba S, Teo AR. Defining pathological social withdrawal: proposed diagnostic criteria for hikikomori. World Psychiatry. 2020;19:116-7.
• ¹⁰
  Nagata T, Yamada H, Teo AR, Yoshimura C, Nakajima T, van Vliet I. Comorbid social withdrawal (hikikomori) in outpatients with social anxiety disorder: clinical characteristics and treatment response in a case series. Int J Soc Psychiatry. 2013;59:73-8.
• 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
  Komori T, Makinodan M, Kishimoto T. Social status and modern-type depression: a review. Brain Behav. 2019;9:e01464.

Publication Dates

• Publication in this collection
  11 May 2020
• Date of issue
  Jul-Aug 2020

History

• Received
  27 Nov 2019
• Accepted
  23 Jan 2020