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'Hikikomori' disorder could complicate Japan quake recovery

By Paul Ballas

As the crisis due to the radiation leak, earthquakes, and tsunami in Japan deepens and the problems with displacement of Japanese citizens increases, the psychiatric phenomenon in Japan known as "hikikomori" could cause a unique concern for the country’ s relief and restoration efforts.

In the early 1990s, this extreme form of social withdrawal was identified in Japan, where young people would seclude themselves in their homes for months or even years at a time. Researchers initially estimated over a million people in Japan had been experiencing this withdrawal, leading to the phrase in the media “ the missing million.”

"Hikikomori" commonly have symptoms of depression, anxiety, and unusual sleep patterns. Japan’ s Ministry of Health, Labor and Welfare created a definition of "hikikomori" that included the following:

  1. The person does not take part in society and remains at home.
  2. The person does not take part in or have interest in going to school or work.
  3. The person does not have any close relationships other than with family.
  4. The withdrawal is not a symptom of a psychotic disorder.
  5. These symptoms persist for at least six months.

This definition includes complete home isolation, however for the most part, psychiatrists and researchers I spoke with in Japan typically used a more broad conception of isolation to include people who can leave their home but are not gainfully employed or have any close relationships.

"Hikikomori" I met in Japan would often stay awake all night using the Internet, playing computer games, or watching TV and sleep throughout the day. Patients would use social media to communicate, but did not engage in a great deal of face-to-face interactions with others. When I saw patients who were "hikikomori," they usually only sought help when they were unable to maintain their isolation, either because their parents were ill or passed away or the family finances changed and they could no longer afford to support the isolated family member.

"Hikikomori" has almost exclusively been identified in Japan, although some researchers believe it is a worldwide phenomenon. The recent crises in Japan could result in many "hikikomori" asking for help for the first time, this in addition to the undoubtedly tens of thousands of people already at high risk of trauma related psychiatric disorders due to trauma resulting from the death, medical illness, loss of housing and forcible displacement caused by the tsunami, radiation leak in Fukushima Prefecture, and the recent earthquakes.

The change in the job market has been a factor often pointed to as a cause of "hikikomori." Before 1990, it was generally understood that a person in Japan would complete school, interview once with one company, then stay with that same company until retirement. After the stock market crash in 1990, this situation changed dramatically.

Lifetime employment at one company is no longer guaranteed, young people interview at several organizations and do not secure employment immediately after graduation. The issue that occurs is that many young people are reacting as if this is cause for shame and guilt and if the family has the means, these feelings can lead to people becoming "hikikomori" or exacerbate more mild forms of social isolation.

New psychiatric disorders are not quickly acknowledged by the psychiatric community. Often there is a great deal of skepticism, especially if there is a lack of a robust body of clinical research as is the case with "hikikomori." However, people suffered for generations before disorders like post-partum depression and seasonal affective disorder were formally recognized by psychiatric organizations.

Whether it is called extreme social isolation or "hikikomori," this phenomenon, in my opinion, will be a very relevant variable in any sustained outreach or relief effort for the Japanese people in the coming months and years. It is likely that there will be an incredibly high need for psychiatric services in the aftermath of the earthquakes, tsunami, and radiation leak due to "hikikomori."

Paul Ballas is a practicing child psychiatrist in the Philadelphia area and serves as a medical adviser and writer of pro-social, pro-health and educational video games for children and adults. He won a travel fellowship to Japan through the Noguchi Medical Research Institute and Thomas Jefferson University Hospital, during which he saw patients in the Osaka City Hospital system.

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I don't see a connection

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Yes, probably some of them will seek help. Many of them never had to work because Daddy paid the mortgage, and there was always Mom to bring them their food to their rooms.

It's great to be able to afford the luxury of doing absolutely nothing. TV, internet, free food and laundry service, but if you like you can go down the road to the combini for smokes and beer.

Inter-family violence will increase when the parents of the hikkikomori get older.

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Way too many of these basket cases here in Japan.

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Before 1990, it was generally understood that a person in Japan would complete school, interview once with one company, then stay with that same company until retirement. After the stock market crash in 1990, this situation changed dramatically.

It used to be like that in America, but I think that thinking went out in the 60's.

Lifetime employment at one company is no longer guaranteed, young people interview at several organizations and do not secure employment immediately after graduation. The issue that occurs is that many young people are reacting as if this is cause for shame and guilt and if the family has the means,

Not that I am really athletic, but don't these same "young turks" learn that you can't win all the time and no shame in trying? Don't they ever see sports teams who take to the field after a loss and continue to play?

One question I have, are these mostly men? Are there many women who fit this category also?

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Hikikomori is just an extreme case of Avoidant Personality Disorder, the DSM 4 criteria are as follows: (1) avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection (2) is unwilling to get involved with people unless certain of being liked (3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed (4) is preoccupied with being criticized or rejected in social situations (5) is inhibited in new interpersonal situations because of feelings of inadequacy (6) views self as socially inept, personally unappealing, or inferior to others (7) is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Note that even Dr. Ballas writes that this condition only becomes severe, "if the family has the means". In other words if the family doesn't have the means to support a "hikikomori" lifestyle then these individuals may be socially inhibited, restrained, etc, but do manage to lead more normal lives.

It is my opinion that there is no need for a new diagnosis for this condition, it is merely Avoidant Personality Disorder where the individual has the option to avoid all social contact and as such takes the easiest path and pursues this life-style. Note that these individuals are capable of social contact, like heading down to the combini to buy a pack of beers or cigarettes, and online contact, so all that we're dealing with here is an apparent difference.

... oh, and psychiatrists may be able to prescribe anti-depressants and anti-anxiety medication to help deal with the stress of getting out the front door, but this sort of condition really is the proper province of psychologists who are the people who would sit down with the individual and their family and talk through the situation and actually get the person out the front door. In short a psychiatrist might be an important part of supporting treatment, but a psychiatrist taking the lead role here is inappropriate.

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I'm no expert, but Frungy's analysis seems right to me. These are mentally ill people with known pathologies. The 'hikkomori' thing seems like a combination of mental illness and a particular ohtaku culture that attracts dysfunctional young males.

The change in the job market must be a red herring. I think more generally, Japanese society can feel oppressive and constraining, especially for people who can't really deal with everyday life, so they stay inside. Mental illness may manifest differently depending on culture and such, but people with emotional issues are a universal phenomenon.

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Good post Frungy.

I guess this society doesn't hep neither, you have to be exactly like everyone else here if you want to be in, if you don't follow every rule you are out of the game

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I think also that Japanese society permits this kind of avoidance of social interaction more than other societies will. Not only is it less peculiar to live with your parents into your 30s, but avoiding other people is pretty much a national pasttime in Japan.

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I have a question, specifically for Frungy since that post was so informative. Is it possible that the writer is referring to the people left homeless as a group rather than individuals? I can understand some individuals wanting to "avoid" facing recovery from the earthquake however it seems that whole groups of folks are avoiding recovering. I keep reading about how they don't want to move, they want to stay, the youth suddenly want to stay and rebuild, etc... Basically, they don't want to move to places where work exists, house exists, and relative safety exists. To me this sounds like "Avoidant group Personality Disorder" if I may make up a new category. Anyhoo, could this be what the author is not directly referring to? Just curious.

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hikkikomori existed before the big quake etc, this article just wonders how they will do being forced outside so to speak

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1) Terminate their internet connection - to make them feel the need for human interaction. 2) Make them move out from their parents' house - so they have to shop for food, and cook for themselves.

problem solved!

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In the article, the worry is about Japan recovering. The ACCP website says there are still 154,000 people in shelters. Psychology Today says only 1 percent of the population suffers from hikikomori / Avoidant Personality Disorder. So how on earth "could" 1540 people "cause a unique concern for the country’ s relief and restoration efforts"? And if the author is talking about hikikomori from north to south what effect could they possibly have on Japan's recovery from radiation, earthquake, and tsunami. I'm with thepro on this one, "I don't see a connection" whatsoever. Unless the author is implying the evacuees are tending toward hikikomori by staying hunkered down in their evacuation centers and not moving out, and moving on.

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Before 1990, it was generally understood that a person in Japan would complete school, interview once with one company, then stay with that same company until retirement.

This is simply not true. It says "a person in Japan." But that system didn't apply to women, 50% of the population. And many people interviewed at more than one firm. And, that lifetime employment system only held for about 50% of Japanese male full time workforce.

Certainly not the majority.

I would appreciate a rewrite, or at least that this sentence be publicly denounced and rejected.

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Just like I posted in another thread, people use events like 3/11 and associate them with causes they are promoting when the link is tenuous at best and completely unconnected at worst. I had to read the entire article until I found any semblance of an attempt to link hikikomori with the relief effort, after the initial suggestion in the first paragraph, and even then it was a pure assertion with no evidence or argument as to why this should be. This is terrible writing and argument stating, it's purely a description of something with no attempt to tie in or explain the connection to the assertion.

As kyrie and Frungy said, approx. 1500 people who don't even have a psychiatric condition but a psychological one and who only even officially have the condition because they are able to be supported by their parents are not going to be at the top of the list of rescuers' worries. If anything this could be a life turning event for them for the better, showing them what really matters in life.

I also find it quite repulsive that he asserts in the last line that there will be a huge need for psychiatric services in the aftermath of the disaster due to hikikomori when there will be far more pressing psychiatric problems due to the death of friends and family, not having a place to call home, the shock of the disaster itself, etc etc, that will need to be carefully monitored. A few people who decided, maybe quite rightly, that they didn't want to be involved in society, can wait their turn.

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Dont worry about it, even some Japanese even bought the whole lifetime employment thing, & it applied to way way less than 25% of the men in the workforce I wud guess 15-20% max. And we have seen the last 10yrs or so how many got either let go, or forced to retire & then re-hired at much lower wages.

Only a few at very big companies had a shot at real lifetime employment, most J-companies are small & lifetime employment was never in the cards, its a myth many even Japanes like to trot out on occassion.

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Has anyone highlighted internet addiction as being a possible cause? It's only starting to be recognized as a major problem in most countries..

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My daughter has Internet addiction, and we don't know what to do about it. While you can't control what people do, having cool terms like Hikikomori or Fujoshi aren't helpful.

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I think that the hikikomori disorder stems from events in childhood. Quake victims will suffer from PTS. The quake actually gives actual hikikomori sufferers an opportunity to readapt to social life. Hikikomori isn't easy to live with. I can just hope that all those suffering from it will get help. All they need is someone being nice to them and accept them to their circle to get rid of those anxieties.

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Am I the only one to feel no sympathy at all for these so-called "Hikikomori"? Where I come from we have a word for these people: LOSERS. They are able to go shopping for Ramen and cigarettes, and of course are manipulative and/or smart enough to keep that internet bill paid each month. Too much energy and money is being wasted on these people. If they want to stay cooped up in some wretched room all their life, so be it. Spend the resources on those who actually want and need the help.

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Darwin would like to say hi. If someone refuses to wear a seatbelt when they drive and die as a result, that's their own fault. This is no different except taken to a further extreme.

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kyrie at 02:58 PM JST - 25th April I have a question, specifically for Frungy since that post was so informative. Is it possible that the writer is referring to the people left homeless as a group rather than individuals?

The writer may have been referring to them collectively, but in people with this sort of disorder they're unlikely to form a group. The additional stress of the tsunami, earthquakes, radiation fears, etc is unlikely to have a positive effect on people who are simultaneously experiencing a forced transition from a very comfortable sheltered lifestyle to one with enforced social interaction (in a crowded shelter there's simply no escaping a degree of social interaction, even in Japan where there's a greater concern for others' privacy than in most countries). How individuals react would depend largely on circumstances and their own individual temperment, worst case they might become angry and violent or (given the genetic predisposition) lapse into catatonia to escape the repeated invasions of their personal space, best case they might find the cameraderie and unconditional acceptance in the evacuation centers very positive and they might make considerable progress in re-integrating. It's impossible to say really.

The key assumption here though is that these hikikomori even left their houses. In many cases I'd say they probably didn't and are now amongst the casualties rather than the survivors.

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Hikikomori has always been a silent epidemic with tens, perhaps hundreds, thousands of cases now estimated in Japan. It is well known to both the psychiatric community and general public in Japan but it has never been reviewed much in the English medical literature. The differential diagnosis includes anxiety and personality disorders, but current nosology in the Diagnostic and Statistic Manual of Mental Disorder may not adequately capture the concept of hikikomori. As a practioner of human development, I can tell you a number of empirical studies have emerged from Japan recently. However, a notable subset of cases with substantial psycholopathology does not meet the criteria for any existing psychiatirc disorder. Although this syndrome closely parallels the western term avoidant personality disorder and social anxiety disorder also known as social phobia. Therefore, hikikomori is most likely considered a culture-bound syndrome and merits furthur international research into whether it meets accepted criteria as a new psychiatric disorder. Treatment strategies are varied and lack solid evidence base, but often include milieu, family, and exposure therapy. As I understand, much furthur research criteria for the condition are being proposed, including population-based and prospective studies to characterize and provide an evidence base for treatment of this condition.

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By the 5 definitions given I am a "Hikikomori" though I do not consider myself one. LEt me see...I do not go out. I do not drink which is part of the reason I do not go out. I have not dated in almost 4 years. I do have to go shopping because my daughter hates doing it for me. I primarily have no contact with others except at work & I have been in this branch of the Government for 18 years and it is the job I will retire from.

However I think Symptom description number two applies almost to everyone. Which is "does not take part in or have interest in going to school or work". It is true I have no interest in going to work but we I bills to pay. Think about it..I have never woke up and thought "I can not wait to go in and see what kind of crap they feed me. Today is going to be an exciting and interesting work day".

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I experienced this myself after the Christchurch earthquakes in 2010 and 2011. It wasn't quite so severe and it was in response to the trauma of the quakes. I have since for the most part recovered but there have been permanent and noticeable changes to my personality and I still exhibit PTSD-like symptoms.

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