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Monday, 5 May 2014

Magnifying detailed core differences in symptomatic display of hikikomori from a cross cultural perspective.

NOT FINISHED: disclaimer, references not yet added...biblio not yet done. 1st draft.

In answer to areas of doubt that surface in the ongoing claim that ‘hikikomori’ is a culture bound
syndrome, this paper looks very briefly but closely at five important differences in the symptomatic
manifestations that are different in social withdrawal in both Japan and other countries; and in doing so draws from the limited documented research available on differences of not only symptom but also
societal attitude and treatment approach.

In this paper I would like to define and further address five of the key points that arose from question
and answer session at the international IAFOR Psychiatry and Behavioral Science Conference in Osaka this March.  I presented the opinion that hikikomori is a Japanese culture bound symptom and
disorder at the conference and had the fortune to speak with many clinical psychiatrists from New
Zealand, Australia, Taiwan, India, UK, Korea,  and USA  afterwards regarding the claim.  In doing so I narrowed down the five areas that I believe are  key in identifying hikikomori as a specifically culture bound  phenomena, in other words a Japanese specific psychiatric symptom.
1.      The confusion and definitive boundary definition lines of hikikomori and agoraphobia or acute social withdrawal which are synonymously used as other definitive descriptions of hikikomori in the US and UK.

2.       The fact that 80% of hikikomori sufferers  in Japan only, are male.
3.       The specific connection that Japanese hikikomori has with prior school truancy V the very low percentage of this being a trigger factor in other countries.
4.       The extreme length/duration of hikikomori withdrawal in Japan V other countries.
5.       The absence of key symptoms such as panic and lack of social stigma that are present in social withdrawal and agoraphobia as defined in Western Psychiatry but not in hikikomori.

Key difference #1.

William Foreman from Michigan in USA( 2012:3 ) writes:

Hikikomori overlaps with several Western mental health diagnoses including pervasive developmental disorders, avoidant personality disorder, PTSD and other anxiety disorders. I will outline some of the comparisons to agoraphobia and social phobia.
Hikikomori is similar in many respects to severe agoraphobia. While many people with agoraphobia are afraid only of specific clusters of activity such as driving or attending crowded events, others are afraid to leave home at all. Hikikomori is defined as a state of complete social withdrawal that lasts at least three months in Korea or six months in Japan. In both disorders, sufferers typically do not communicate with anyone outside the home.
A major difference between hikikomori and agoraphobia is the age of onset. Hikikomori is strictly a disorder of young adults. Those who were in the first group to be diagnosed are, as of 2013, not yet 40 years old. To be initially diagnosed, the sufferer must be no older than 30

This is just one of many clinical psychiatrist’s observations that specific differences exist in the  
actual semantic clarity of definitive status between hikikomori and similar psychiatric symptoms
elsewhere. Foreman writes “overlaps with” and I believe this is an accurate claim that clarifies
the uniquely cultural bound nature of hikikomori. There are too many other examples to list here
but time and again in published definitions found in psychiatric journals¹both social withdrawal
and agoraphobia are defined with elements or key components missing when compared with the
Japanese definition of hikikomori²

While some of the non Japanese psychiatrists I have spoken with and mailed with, have claimed to have seen patients who are suffering from ‘hikikomori’, their interpretation of the term does not include some of the components I believe to be Japanese specific and therefore, like the name itself
include;  the extreme reluctance of families to take part in behavioral therapy at initial onset-
where it is proven to be most effective; the pressure on first borns and often male children to follow one educational path toward job fulfilment; the prevalence of truancy preceding hikikomori, the history of Japanese mind set “retreat/ignore” as a defense position; the unique social stigma magnified by proximity of neighbors in a small land space and many others.

Many psychiatrists from other countries that I spoke with claimed that the treatment of what they felt
was hikikomori or its equivalent,  necessitated a strong approach by bringing the young adult out of his room with force and into family group therapy urgently; interestingly the ways felt appropriate to broach treatment and healing of hikikomori symptoms also vary from country to country according to educational and child raising norms- meaning the ways felt appropriate to treat hikikomori are also culturally specific; in itself an indication that there is little reason not to assume that the  specific definition and manifestation of hikikomori is also culturally specific.

Key Difference #2
Dr. Saito Tamaki, who coined the term hikikomori back in 1998, and with whom I had the great pleasure of meeting in his Funabashi clinic in March 2014, claims in his book  (   ) that hikikomori is culture bound due to the epic number (over one million) who have chosen to stay in their rooms in an act of seeming defiance against cultural expectations that do not exist in the exact same way in other countries. This was an area I felt to be one connected to the history and language and social etiquette that is linked to the unique culture of Japanese people. In a culture that is so very different from Western culture, how can we expect psychological disorders to be the same when………………………………………….()
Moreover, research that Dr. Saito conducted with patients estimated 80% of hikikomori are male and
Of those 80%.................are first born male. As explained in detail in my last paper in a male dominated value index country (Hofstede :   ) this fact alone could be enough to label hikikomori as Japanese culture bound given the pressure for Japanese males to get work and stay in that same work and the devotion above all to the company versus family. Conversely, Western society has the similar symptoms of  “social withdrawal” standing at equal part male versus female and “agoraphobia” being statistically mainly female.

Quoting Foreman again (ibid):
Identified in 1998, it appears to be culturally linked to changing labor market realities in Asia. Under the traditional system, middle and upper-class youths follow a highly structured path from adolescence to adulthood. They are expected to rigorously apply themselves in high school and college, and then immediately take a professional job. The job market has traditionally been secure, and the first employer out of college is expected to be the company that the young adult will remain with until retirement.
Increased globalization and changing labor markets have made this ideal unattainable for many youth. Many adolescents follow the expected path through college only to discover that they are unable to find a job, or can only find one for which they are vastly overqualified. For some young people, the realization that they did everything right but cannot reap the benefits leads them to shut down. Hikikomori overlaps with several Western mental health diagnoses including pervasive developmental disorders, avoidant personality disorder, PTSD and other anxiety disorders..

Key Difference #3.

In the following diagram, it can be seen the main reasons for “dropping out” of college in the US.
The validity of this diagram is to serve as a reminder that ONLY 13% count “social misfit” or “Poor social fit” as a factor for opting out, where in all surveys of hikikomori I have yet to read this has been the PRIMARY cause and trigger for hikikomori (    ).  Not necessarily with truancy – usually caused by bullying or a feeling of misfit - but also from failing to adapt to expectations within societal norms (  ).

Key Difference #4

In the following diagram we can see the extreme endurance that families have in dealing with
hikikomori and the extreme length of time that sufferers will retreat to their rooms for. Most commonly over 7 years and very often as long as 15 to 20 years.
When I have presented this slide to clinical psychiatrists, they have found time and again, this to be one of the most alarming and single handedly most clearly differentiating factors in manifestation of social withdrawal.The average length of time as a one off comparison in the USA for hikikomori or its sister name social withdrawal (not counting addiction or schizophrenic related withdrawal but focusing on withdrawal from societal  pressure)  is considered to be approximately a few months to two years  (     ).

Key Difference #5

I will now take a closer look at the very detailed exact symptoms that are presented in the related
non  Japanese disorders that involve social withdrawal and appear on the surface most closely mirroring the outward appearance of hikikomori.

These are:
·         Avoidant Personality Disorder
·         Acute social Withdrawal
·         Agorophobia

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a person diagnosed with avoidant personality disorder needs to show at least four of the following criteria:
  • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
  • Is unwilling to get involved with people unless they are certain of being liked.
  • Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
  • Is preoccupied with being criticized or rejected in social situations.
  • Is inhibited in new interpersonal situations because of feelings of inadequacy.
  • Views self as socially inept, personally unappealing, or inferior to others.
  • Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Hikikomori typically does not involve 4 of these criteria. Many hikikomori people are for example in fact highly intelligent and do not feel they are inferior to others. In fact some have feelings of ‘higher intelligence or non main-stream intelligence” (Zeilinger:  )They may or may not have a fear of being disliked, it is certainly not a critical factor in defining hikikomori. Hikikomori are NOT unusually reluctant to engage in new activities because they may prove embarrassing or avoid personal risk – since statistics of suicide are very high among hikikomori sufferers. Finally, the core “hiding” feature of hikikomori does not necessarily involve a complete breakdown of the willingness to interact because of fears of shame or being criticized. I think these have often been experienced previously but are now not central themes and so, in this way “hikikomori” could be seen as an end game or aftermath of such feelings;  an attitude closer to apathy than panic BUT not apathy and most certainly not panic.

Acute Social Withdrawal.

This is most commonly a secondary symptom in pscyciatric terms.
It arises out of specific triggers which are most commonly:

·         Depression
·         Bi-polar
·         AIDS or other serious illness diagnosis
·         Seasonal Affective Disorder
·         Dementia
·         Schizophrenia or other schizoid affective disorder
·         Autism

In all these cases symptoms are resolved when the primary trigger is resolved or addressed.
None of these primary triggers moreover address the NON COMMUNICATING (refusal or extreme
reluctance to open up and talk) aspect and deep central theme in ALL cases of hikikomori.
In other words, being able to identify the primary cause allows a treatment plan to be more easily
mapped  than hikikomori where so many unknowns and variables are inexplicable because they remain unexplained.

Here is a definition of agoraphobia from Forsyth, Sondra. "I Panic When I'm Alone." Mademoiselle April 1998: 119-24.

Agoraphobia is just one type of phobia, or irrational fear. People with phobias feel dread or panic when they face certain objects, situations, or activities. People with agoraphobia frequently also experience panic attacks, but panic attacks, or panic disorder, are not a requirement for a diagnosis of agoraphobia. The defining feature of agoraphobia is anxiety about being in places from which escape might be embarrasing or difficult, or in which help might be unavailable. The person suffering from agoraphobia usually avoids the anxiety-provoking situation and may become totally housebound.
Agoraphobia is the most common type of phobia, and it is estimated to affect between 5-12% of Americans within their lifetime. Agoraphobia is twice as common in women as in men and usually strikes between the ages of 15-35.

It is clear from this definition that agoraphobia, often also called Acute social withdrawal, usually involves panic attacks as a core symptom, but not always; and always involves anxiety attack or extreme anxiety as a psychiatric disorder that hikikomori adolescents, children and adults do not in the majority do not suffer from as a primary symptom (     ).


In this paper, I have looked at what I believe to be just 5 of the main differences in the symptom of Japanese hikikomori versus the definition of hikikomori and or its synonyms in other countries. There is clearly much more to research and much more to be discussed, including a far wider range of research involving a wider selection of countries and cases. However, I hope that this brief introduction to five of the areas I think need further investigation will provide a platform for further research into my hypothesis that hikikomori is without doubt, a Japanese culture reactive or culture bound syndrome, not to be seen as simply withdrawal and retreat by an individual with a mental health issue, but instead an expression of how the system of education in Japan and expectations in society need to change before we can come closer to reducing hikikomori numbers and ending the immense suffering for hikikomri people and all those families who have been and continue to be prisoners to the powerful destruction of life in the shadow of hikikomori.