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Clinical Neurosciences
Hikikomori : Multidimensional understanding, assessment,
and future international perspectives
Takahiro A. Kato, MD, PhD ,1* Shigenobu Kanba, MD, PhD1 and Alan R. Teo, MD, MS2,3,4
Hikikomori, a severe form of social withdrawal, has long
been observed in Japan mainly among youth and adoles-
cents since around the 1970s, and has been especially
highlighted since the late 1990s. Moreover, hikikomori-like
cases have recently been reported in many other countries.
Hikikomori negatively influences not only the individual’s
mental health and social participation, but also wider educa-
tion and workforce stability, and as such is a novel urgent
global issue. In this review, we introduce the history, defini-
tion, diagnostic evaluation, and interventions for hikikomori
and also the international prevalence of hikikomori outside
Japan. We propose a hypothesis regarding the globalization
of hikikomori based on domestic and international
Appearance of hikikomori
The Japanese word hikikomori has long and widely been used in its
verb form – hikikomoru – within Japanese society. Hikikomoru is a
compound verb made up of the two characters for ‘to pull back’
[hiku] and ‘to seclude oneself’ [komoru]. Collectivism is strongly
rooted in Japan and this allows for an easy formation of groups, but
when a situation arises where an individual has left the group and is
isolated, they are described as ‘that person who has withdrawn into
seclusion!’ [hikikomotta; i.e., the past tense of hikikomoru]. In this
way, individuals who have withdrawn from the group, in particular
school or the workplace, for days, weeks, or months, spending most
of the day within their home, are referred to in Japan as hikikomori.
Hikikomori became widely used as a noun in the latter half of the
1990s when a Japanese psychiatrist, T. Saito, published ‘Hikikomori
– Adolescence Without End.’1 Saito tentatively defined hikikomori as
a person who has ceased to go to school or work for more than
6 months and has stayed at home for most of this time.
Initially hikikomori was seen as a phenomenon unique to Japa-
nese society but more recently similar cases have been reported in
many other countries and have been widely reported in the interna-
tional media.2–4 In 2010, the Oxford Dictionary published a new entry
for the word hikikomori, signifying its presence and acceptance out-
side of a purely Japanese context. The Oxford Dictionary’s definition
is: ‘(in Japan) the abnormal avoidance of social contact, typically by
adolescent males.’ Hitherto hikikomori had been discussed as a
culture-bound syndrome unique to Japan (as it is defined in the
Oxford Dictionary) but we, the authors, now consider the condition to
be far more global and perhaps better understood as a ‘contemporary
society-bound syndrome.’5 Hikikomori negatively impacts not only
the affected individual’s mental health, but also population-level
1
Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
2
VA Portland Health Care System, HSR&D Center to Improve Veteran Involvement in Care, Portland, USA
3
Department of Psychiatry, Oregon Health & Science University, Portland, USA
4
School of Public Health, Oregon Health & Science University and Portland State University, Portland, USA
* Correspondence: Email: takahiro@npsych.med.kyushu-u.ac.jp
Psychiatry and Clinical Neurosciences © 2019 Japanese Society of Psychiatry and Neurology
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
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PCN FRONTIER REVIEW
perspectives. In addition, we introduce our latest assess-
ment system for hikikomori (including the latest version of
the ‘proposed diagnostic criteria of hikikomori for the future
DSM/ICD diagnostic systems’) and propose therapeutic
strategies, including family approaches and individualized
therapies. Finally, we present future challenges that may
lead to solutions for an internationalized hikikomori.
Keywords: amae, hikikomori, modern-type depression, social anxiety,
social isolation.
http://onlinelibrary.wiley.com/doi/10.1111/pcn.12895/full
education and workforce stability and as such is an urgent issue in
the administration of health, welfare, and labor in Japan.6–9
In this review, we introduce the history, definition, diagnostic
evaluation, and interventions for hikikomori and also the international
prevalence of hikikomori outside Japan. We also propose a hypothesis
regarding the globalization of hikikomori based on our domestic and
international research, and present our latest assessment system for
hikikomori. Finally, we present future challenges that may lead to
solutions for an internationalized hikikomori.
A clinical case
Mr A: A 38-year-old man lived with his elderly mother and younger
brother. He did not suffer from any particular issue from birth or early
development, but as an elementary school student he began to copy
the stutter of a popular comedian, which then became a habit. In the
second year of middle school, he was separated from a group class-
mates who he had known from elementary school and came to be
ostracized by his new classmates.
An average student, he was accepted to a local high school. He
led a typical student lifestyle and regularly socialized with friends.
During his first year of high school, his father suddenly passed away
due to an acute physical illness. Upon graduating from high school,
despite not having any particular motivation or goals, he followed his
friends who were all going on to university by applying and being
accepted to a relatively easy-to-enter local university.
He hardly attended classes preferring to go out with friends. At
the end of his second year, he dropped out of school. From 20 to
30, he worked as a casual shop assistant. According to his own
account, he worked quite diligently at this job. The reason he quit this
job was that he could not bare the fact that he was over 30 and still
doing an unstable part-time job. After quitting he began to look for
© 2019 The Authors 427

Hikikomori: Overview & novel assessments
permanent full-time work (called seishain in Japanese society) but
was constantly unsuccessful, finally losing confidence in himself and
finding it harder and harder to continue his job search. No longer
looking for work, for the past 5 years he has been living in a socially
withdrawn way at home, mainly inside his own small room playing
online games.
He continues to live with his mother and younger brother, but a
few years ago he quarreled with his brother over a trivial matter and
has not spoken to him since then. He continues to spend his time idly
playing online games until midnight. Avoiding face-to-face human
interaction, he continues to be socially withdrawn. He finds it hurtful
when his family or relatives say, ‘You should hurry up and get mar-
ried’ and when he himself thinks of work or marriage he is
distressed.
This past year has been particularly hard and he often feels
depressed. He eats and sleeps enough but at irregular times. An
acquaintance has attempted suicide and he is worried that he himself
may also end up the same way. He hopes to be freed from this life as
a ‘loser’ soon. After researching online, he himself came to think that
he might have avoidant personality disorder. His worried mother came
to seek advice from a Hikikomori Support Center and after several
consults by her, he too has come to feel that he would like to get help.
At the recommendation of the support center, he has now visited the
specialty hikikomori outpatient clinic of a university hospital. His
main complaints are: (i) the future (when he thinks of his social
responsibilities he becomes depressed); (ii) he has no confidence in
himself and is reluctant to do anything; and (iii) he cannot connect
with his friends as he cannot initiate contact with them. After several
assessment interviews by psychiatrists and clinical psychologists, he
was assigned to start a weekly psychodynamic group psychotherapy
session.
Hikikomori phenomenon and epidemiology in Japan
The above is a real hikikomori case (for reasons of confidentiality
some changes have been made). In Japan, the phenomenon of
hikikomori can be traced back to what was sometimes referred to as
‘truancy’ or ‘school refusal’ (called futoko in Japanese) in the 1970s
and 1980s. In the latter half of the 1990s, many of these cases came
to be widely recognized under the term ‘social withdrawal’ or
hikikomori by T. Saito.1 A World Health Organization epidemiologi-
cal survey in Japan between 2002 and 2006 targeting individuals aged
between 15 and 49 years found that 1.2% of the population has expe-
rienced social withdrawal (hikikomori) for a period greater than
6 months.10 One review of three population-based studies in Japan
involving a total of 12 cities and 3951 people showed that between
0.9% and 3.8% had a history of hikikomori.11 Japan’s Cabinet Office
Survey reported in 2016 revealed that ‘persons socially withdrawn for
more than six months,’ even when limited to those aged between
15 and 39 years, numbered 540 000 in Japan.12 In all the above epi-
demiological data, males outnumber females by a 3:1 margin or more.
Furthermore, due to prolonged periods of social withdrawal, some-
times over years and even decades, there are new concerns for an
ageing hikikomori population. In fact, including individuals over the
age of 40 years would increase the number of hikikomori sufferers
even further. Just recently, the Cabinet Office announced that the esti-
mated number of hikikomori aged between 40 and 65 years is
610 000 in Japan.13 It should be noted that these epidemiological sur-
veys are based on simple questionnaires (only one or two questions)
and further investigation based on more exact definitions are required
in order to grasp a more accurate awareness of the current situation.
Definition of hikikomori
In 1998, T. Saito described hikikomori as ‘those who become recluses
in their own home, lasting at least six months, with onset by the latter
half of the third decade of life, and for whom other psychiatric disor-
ders do not better explain the primary symptom of withdrawal.’1
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The first guideline for hikikomori published by the Ministry of
Health, Labour, and Welfare (MHLW) in 2003 (organized by J. Ito)
did not clearly define the parameters of hikikomori.14 This first guide-
line described a variety of causes that may lead to an individual with-
drawing from society in a hikikomori state; however, it was not
proposed as a medical diagnosis, noting that:
In reality, some individuals that may fit into the category of
hikikomori have a variety of illnesses and conditions. In other words,
it may be said that the argument over whether a particular person has
hikikomori is not all that meaningful. Rather what is important to
keep in mind realistically is that (i) a variety of people as a reaction
to stress may present in a ‘condition of hikikomori,’ (ii) separate from
the existence or nonexistence of mental illness in the narrow sense,
the fact that the condition is prolonged, and (iii) as a general charac-
teristic of hikikomori, it is often considered the case that even before
understanding the detailed nature of an individual and their psycho-
logical state it is often the case that it is necessary to initiate some
kind of aid.14
In the 2010 guideline of hikikomori for evaluation and supports
by the MHLW (organized by K. Saito), the definition of hikikomori
was described as:
As a result of various factors, a withdrawal from social participation
(schooling including compulsory education, employment including
part-time jobs and other interactions outside of the home), which in
principle has continued under the condition of being house-bound for
a period of more than 6 months (this may include leaving the home
while still avoiding interactions with others). In general, hikikomori is
considered to be a non-psychotic phenomenon that is distinguishable
from the withdrawal state based on the positive or negative symptoms
of schizophrenia, but it should be noted that it is not unlikely that in
fact it may include schizophrenia before definitive diagnosis.15
As such, based on the guidelines, hikikomori is a concept that
does not generally include schizophrenia, but according to a survey
by Kondo et al. conducted before the establishment of guidelines, the
DSM-IV-based psychiatric diagnosis of sufferers under the condition
of hikikomori attending mental health welfare centers showed a wide
coexistence with psychiatric disorders, including schizophrenia, mood
disorders, anxiety disorders, personality disorders, and pervasive
developmental disorder.16 There is considerable debate as to whether
to include psychosis within the definition of hikikomori. As will be
described in detail later, for example, we would consider different
treatment approaches for hikikomori that is mainly based on psycho-
sis, hikikomori that is mainly based on depression, and hikikomori
that is mainly based on autism. Therefore, we believe that it is vital to
clarify the coexistence of psychiatric disorders when evaluating
hikikomori.
Hikikomori-like condition in psychiatric disorders
and other physical and social situations
As described above, there are reports of hikikomori coexisting with a
variety of psychiatric disorders.16 At the present time, whether it is
such psychiatric disorders that give rise to hikikomori as a symptom
or whether it is indeed the condition of hikikomori that is the cause of
coexistent psychiatric disorders has not been clearly answered; thus, it
could be argued that both possibilities exist. Below, we briefly
describe comorbidity issues in each psychiatric disorder that is con-
sidered to include hikikomori-like symptoms.
Schizophrenia and psychotic disorders
In patients with schizophrenia, it is not unusual to retreat into a situa-
tion of physical withdrawal due to positive or negative symptoms:
‘I’m being chased by Yakuza [Japanese mafia],’ ‘My neighbors are
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spying on me,’ or ‘Electromagnetic waves are coming in from out-
side’– such hallucinations and delusions may make venturing outside
a frightening experience and lead to withdrawal. ‘Social withdrawal’
is a typical negative symptom of schizophrenia, which is difficult to
distinguish from non-psychotic hikikomori. It would be especially dif-
ficult to make a distinction in the case of the previously proposed
‘simple schizophrenia’ in which no hallucinations or delusions are
observed.17,18 In the 2010 guideline, schizophrenia was in principle
not considered within the definition of hikikomori; however, the defi-
nition was somewhat ambiguous, as it did not rule out its possible
inclusion. As indicated in this 2010 guideline, physical withdrawal is
often observed in prodromal-stage cases of psychosis, and careful
attention is required in evaluation. It is necessary to now debate as to
whether or not to include schizophrenia in the definition of
hikikomori.
Depression
In depression, other than depressed mood, decreased motivation and
activity (anhedonia) are major symptoms that may present in the form
of withdrawal-like outcomes. Similar hikikomori-like behaviors are
observed during the depression phase of bipolar disorder.
Social anxiety disorder and other anxiety-related
disorders
Anxiety in social interactions may precipitate hikikomori, and social
anxiety disorder is a high comorbid psychiatric disorder among per-
sons with hikikomori.19 In Japan, taijin kyofusho [disorder involving a
strong fear of others] has long been identified as a Japanese cultural-
bound syndrome in which the sufferer experiences fear of interper-
sonal relations, especially face-to-face interactions, and is included in
the DSM-IV-TR appendix of culture-bound syndromes.20,21 Interest-
ingly, several commonalities exist between taijin kyofusho and
hikikomori.18 Taijin kyofusho is common among the same youthful
age group and is more prevalent among males.22 A previous case
series study of consecutive taijin kyofusho patients who were treated
at an inpatient unit revealed that about 30% of the patients fit what
they regarded to be a ‘hikikomori subtype.’23 The core feature of
taijin kyofusho is fear of offence or hurting others through awkward
social interaction or because of perceived physical defects, such as
body odor, blushing, and eye-to-eye contact,24 while such features
may not obviously be expressed by typical cases of hikikomori.
Personality disorders
In our previous small-sample-size survey based on the Structured
Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-
II), avoidant, paranoid, dependent, schizoid, antisocial, borderline,
narcissistic, and schizotypal personality disorder may be comorbid
with hikikomori.19 From this survey and our recent clinical experi-
ence, avoidant personality disorder seems to appear with the highest
frequency among personality disorders.
Post-traumatic stress disorder and trauma-related
disorders
Hikikomori sufferers in Japan, especially those with the experience of
truancy or school refusal [futoko] at the initial stage of their
hikikomori, often also have the traumatic experience of bullying
[ijime]. Bullying itself may not meet the diagnostic criteria of post-
traumatic stress disorder (PTSD); however, in addition to direct physi-
cal violence from peers, indirect violence, such as being ignored or
ostracized (typical forms of ijime), is in many teen cases, a trigger for
hikikomori.
Autism spectrum disorder
Comorbidity of hikikomori with autism spectrum disorder (ASD) has
recently been suggested.16,25 The meaning of the Japanese characters
that comprise the word ‘autism’ [jihei] are very similar to the word
hikikomori. Due to ASD-like tendencies, including the inability to
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Hikikomori: Overview & novel assessments
perceive the feelings of others, which often results in social malad-
justment, the above-mentioned susceptibility to bullying and a loss of
a ‘place to be,’ there are many cases which result in hikikomori.
Other mental illnesses and neurodevelopmental
disorders
In addition, there is a recognition of comorbidity of hikikomori with
other mental illnesses and neurodevelopmental disorders, including
intellectual developmental disorder.
Adjustment disorder
Some persons with the hikikomori condition may not be diagnosed
with any psychiatric disorders, and such persons can be labeled with
adjustment disorder based on the DSM-5. Previously, such persons
with the hikikomori state were named as ‘ideopathic [ichijisei]
hikikomori’ by a Japanese psychoanalyst, T. Kinugasa.26,27
Suicide
Suicide is perhaps the most drastic behavior seen in a variety of psy-
chiatric disorders. Even though no epidemiological data exist, there
have been a number of cases of hikikomori persons who have com-
mitted suicide. Although the relationship between hikikomori and sui-
cide is yet to be adequately elucidated, we believe that the act of
hikikomori may be considered a precursor symptom of suicide.28 We
are proposing that the act of wanting to escape from the real world is
common to both suicide and hikikomori. Hikikomori may be an
alternative-suicidal behavior. Interestingly, a recent second-analysis
study using the data from a survey of young people’s attitudes of
5000 residents in Japan (aged 15–39 years) has suggested that the
hikikomori condition is one of the risk factors of suicide.29 We
believe that further investigations focusing on this perspective should
be conducted.
Hikikomori caused by physical illness
In cases of great physical fatigue and pain when it is physically
impossible to walk or physically impossible to move, an individual
may find themselves in a hikikomori-like state. Furthermore, based on
our clinical observation, in certain cases of skin diseases, including
dermatitis (especially atopic dermatitis), extreme skin rashes (urti-
caria), and other strong facial skin conditions, an individual may
avoid social relationships and fall into a hikikomori-like situation.30
Furthermore, gastrointestinal diseases, such as irritable bowel syn-
drome, ulcerative colitis, and Crohn’s disease, are suggested to be
possible comorbid disorders with hikikomori.31
Hikikomori-like condition caused by social situations
In Japan, the severing of social interactions is sometimes seen as a
calling or particular way of life. Examples of this are the mountain
recluse and hermit, who have constituted mysterious entities through-
out Japanese history. Certain artists have also avoided society during
their creative processes but we would not think to label them as path-
ological hikikomori.
In Japanese society, adult-age daughters who have no external
jobs and live with their parents are called Kajitetsudai [domestic
helpers]. Some Kajitetsudai and some shufu [housewives] do not have
social interactions with people outside their immediate family and are
in a hikikomori-like condition. We suspect that such women may have
a strong sense of loneliness.
On the other hand, the issue of kodoku-shi [death by loneliness]
amongst the elderly has become a major social issue in Japan.28 In
such cases, single elderly are left to live alone after the death of a
partner with no social interactions and ultimately pass away them-
selves, remaining undiscovered for days, weeks, or even months. We
can suppose that at least several months before death they might have
been in a hikikomori-like condition.28
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Multidimensional model of hikikomori conditions
In sum, up to this point we have outlined the mental and social bases
that give rise to hikikomori and hikikomori-like conditions. In reality,
most persons with hikikomori exhibit various psychiatric
symptoms/signs and it is important to make a multiaxial evaluation.
Our current conceptualization of hikikomori in the field of psy-
chiatry is proposed in Figure 1. We suppose that even in the absence
of a clear diagnosis of psychiatric disorders, many persons with
hikikomori find themselves in a ‘gray zone’ and the fact that no for-
mal diagnosis of psychiatric disorders has been made does not equate
to the absence of mental suffering (distress); therefore, we strongly
believe that above all, due consideration should be made of this
suffering.
On the other hand, we believe that hikikomori can be regarded
as a reaction to stress that may present in a ‘condition of hikikomori’
and that it might be separate from the existence or nonexistence of
mental illness in the narrow sense. Some types of hikikomori might
be a particular kind of coping strategy, which is similar to an avoid-
ance strategy in response to stressful situations involving social situa-
tions and social judgments. In this sense, these types of hikikomori
may not be a disorder in themselves. Yet, at the same time, because
of their prolonged condition, they can eventually turn themselves into
a disorder. We believe this way of understanding the hikikomori phe-
nomenon helps to clarify the nature of the phenomenon to some
extent in contrast to simply treating it as a disorder in itself or as a
symptom of another disorder, like autism.
Proposing the novel diagnostic system of hikikomori
In 2015, we initially developed and published to announce the first
semi-structural interview system for hikikomori diagnosis32 based on
the 2010 diagnosis standards in Japan15 as well as proposals from
Teo and Gaw.27 In this diagnostic system, we proposed that the fol-
lowing four criteria should be included and observed for 6 months or
more: (A) physical withdrawal (the person stays at home almost all
day, almost every day); (B) avoidance of social participation (the per-
son avoids nearly all social situations, such as school and work);
(C) avoiding social relationships (the person avoids direct social inter-
action with family or acquaintances); and (D) distress in social life
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(the above hinders the individual’s social life). Individuals who fulfill
all four of these criteria would be defined as hikikomori.
Persons with hikikomori who had been diagnosed with the above
semi-structured interviews employing the four criteria also underwent
DSM-IV psychiatric evaluation using the SCID-I and SCID-II, which
revealed the coexistence of various psychiatric diseases.19 These find-
ings are similar to those reported by Kondo et al.16 In particular,
many hikikomori sufferers were comorbid with avoidant personality
disorder and major depressive disorder.19 However, some persons
with the hikikomori condition did not fall into any psychiatric diagno-
sis based on the SCID-I/II diagnostic criteria.19
We believe that now is the time to reexamine the definition of
hikikomori.
Regarding Criterion A (physical withdrawal),32 hikikomori is in
a state of diversification. People with severe hikikomori cannot leave
their homes at all, while the majority of people with hikikomori can
occasionally go out for shopping and the like. For example, there are
cases of people who are physically withdrawn indoors during the day
but venture out at night to convenience stores when there are few peo-
ple about. As we exist within an ‘Internet society,’ it is necessary to
reconsider what constitutes social withdrawal. It is now possible to
study and work without leaving home as hikikomori-like physical sit-
uations, especially owing to information technologies (IT).5
Criterion B (avoidance of social participation)32 should be care-
fully reconsidered. In the case of housewives, it may be difficult to
use the label of ‘work.’ In Japan, though the numbers may not be
great, there are some housewives [shufu] who have no connection to
people outside of their family and experience a strong sense of loneli-
ness. It may be possible to consider this as a group with a tendency
towards hikikomori.
Regarding Criterion C (the avoidance of social relationships),32
it is assumed that there is direct interaction as a condition of the diag-
nosis. However due to the proliferation of the Internet in modern soci-
ety, ‘indirect’ communication via web-based or other technologies is
increasingly common. In our clinical practice, some individuals with
hikikomori describe having friends while the majority of them are rev-
ealed to be friends who can meet only during online games.
Reexamination of future diagnostic criteria for hikikomori may be
Fig.1 Location of hikikomori in psychiatry:
Bio-psycho-socio-cultural model. IT, infor-
mation technology; PTSD, post-traumatic
stress disorder.
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Table 1. Revised diagnostic criteria for hikikomori (cited and modified from Kato et al.33)
[Definition] Hikikomori is a form of pathological social withdrawal or social isolation whose essential feature is physical isolation in one’s home.
The person must meet the following criteria:
1 Marked social isolation in one’s home.
2 Duration of continuous social isolation for at least 6 months.
3 Significant functional impairment or distress associated with the social isolation.
Individuals who occasionally leave their home (2–3 days/week), rarely leave their home (1 day/week or less), and rarely leave a single room may be
characterized as mild, moderate, and severe, respectively. Individuals who leave their home frequently (4 or more days/week), by definition, do not
meet criteria for hikikomori. The estimated continuous duration of social withdrawal should be noted (e.g., 8 months). Individuals with a duration
of continuous social withdrawal of at least 3 (but not 6) months should be noted as pre-hikikomori. The age at onset is typically during
adolescence or early adulthood. However, onset after the third decade is not rare, and homemakers and elderly who meet the above criteria can
also be considered.
The following specifiers are not mandatory criteria; however, they may be useful for additional characterization of hikikomori:
A With lack of social participation. The individual occasionally (2–3 days/week) or rarely (1 day/week or less) participates in activities, such as
attending school, going to a workplace, or going to medical appointments. This specifier would likely apply to hikikomori who are also not in
education, employment, or training (i.e., ‘NEET’).
B With lack of in-person social interaction. The individual occasionally (2–3 days/week) or rarely (1 day/week or less) has meaningful in-person
social interactions (conversations) with people outside home. In severe cases, the individual rarely has in-person social interaction even with
cohabitating people, such as family members. This specifier would likely apply to individuals with hikikomori who have social interactions that
primarily occur via digital communication technologies (e.g., social media, online gaming).
C Indirect communication. Due to the proliferation of the Internet in modern society, ‘indirect’ communication via web-based or other
technologies is increasingly common. Thus, such indirect communication should be assessed in accordance with direct communication. Some
cases have daily bidirectional indirect communication via online tools such as social networking services and/or online games.
D With loneliness. The individual endorses feeling lonely. The presence of loneliness tends to be more common as the length of hikikomori
increases.
E With a co-occurring condition. Hikikomori may co-occur with numerous psychiatric disorders, such as avoidant personality disorder (e.g.,
isolation due to fears of criticism or rejection), social anxiety disorder (e.g., avoidance of social situations because of fear of embarrassment),
major depressive disorder (e.g., avoidance of social situations as a reflection of neurovegetative symptoms), autism spectrum disorder (deficits
in social interactions and communication), or schizophrenia (e.g., isolation due to positive and negative symptoms of psychosis).
F Age at onset. In many cases, the age at onset is adolescence and early adulthood; however, cases with onset after the third decade are not rare.
G Family pattern and dynamics. Socioeconomic status and parenting styles may influence the development of hikikomori. For instance,
overprotective parenting and/or absence of paternal involvement are suggested to be linked to the occurrence of this phenomenon.
H Cultural background. Pathological social withdrawal was originally characterized and described in Japan and more recently has been identified
in other countries, especially in East Asia and Europe. Sociocultural situation may influence this condition.
I Intervention. Even though no evidence-based interventions have been established, pharmacotherapy (if the individuals are comorbid with
psychiatric disorders), a variety of psychotherapy, social work, and family approach have been provided. Precision (individualized) approach is
recommended based on the above assessments.

warranted in light of the fact that physical social withdrawal will
likely still involve social interactions in virtual space. Whether this
kind of interaction should change the diagnostic criteria for
hikikomori or not may be a theoretical issue that is worth fleshing
out. Some might argue that virtual relationships should not count as
social interactions, especially if it involves interacting through a fic-
tionalized avatar that is completely different in character from how
one would interact in person. Another question is: should the diagnos-
tic criteria distinguish between virtual relationships with people with
whom face-to-face interactions generally occur (e.g., Facebook) ver-
sus those for whom face-to-face interactions do not generally occur
(online gaming)? Further investigation should be conducted to answer
such remaining questions.
Regarding Criterion D (distresses in social life),32 especially at
the beginning, there are many people who actually feel happy to have
achieved a situation of social withdrawal. In other words, a sense of
relief at being able to escape from a life of painful reality. However,
when the situation of withdrawal continues after a few months or a
year or two, there are many cases that result in suffering with feelings
of loneliness. Different therapeutic approaches might be provided for
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
persons with hikikomori according to whether or not they have their
own distress, especially loneliness.
In hikikomori, more detailed evaluation for each of these criteria
is of growing importance. Even without satisfying all four
items/categories, some form of hikikomori may exist and it is impor-
tant to develop a system that can evaluate individuals that fall below
these thresholds and constitute ‘pre-hikikomori’ and/or ‘semi-
hikikomori’ groups.
To reflect the above-mentioned current issues in assessing
hikikomori, just recently we have developed and introduced a
novel diagnostic set of criteria in World Psychiatry.33 Table 1 is
the latest and most detailed version of our proposed hikikomori
diagnostic criteria. The main points of our revised criteria are as
follows:
Hikikomori is a form of pathological social withdrawal or social
isolation whose essential feature is physical isolation in one’s home.33
The person must meet the following criteria: (i) marked social isola-
tion in one’s home, (ii) duration of continuous social isolation for at
least 6 months, and (iii) significant functional impairment or distress
associated with the social isolation. We have proposed that
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Hikikomori: Overview & novel assessments
Fig.2 Multidimensional therapeutic approaches based on the physical/social situation of hikikomori (modified from Kato et al.34). Individuals with hikikomori can be
classified into the following five stages based on living with others (mainly family members [X category]) or living alone (Y category): (3X) rarely leaves own room and
rejects cohabitating family; (2X) rarely leaves own home but some communication with cohabitating family; (1X) sometimes leaves own home and/or some interaction
with others; (2Y) lives alone and mostly does not interact with others; and (1Y) lives alone but some interaction with others.
individuals with a duration of continuous social withdrawal of at least
3 (but not 6) months should be noted as pre-hikikomori. We have
decided to exclude several specifiers (lack of social participation, lack
of in-person social interaction, existence of loneliness, and a co-
occurring psychiatric condition) from the necessary criteria; however,
we believe that these specifiers are useful for additional characteriza-
tion of hikikomori, especially in the process of assessing the severity
and considering the treatment strategy.
Classification of the hikikomori stages based on
physical/social situations
In addition, we have herein included the classification of hikikomori
based on the physical/social situations following the latest version of
our proposed hikikomori diagnostic criteria (Fig. 2). In Japan, many
persons with hikikomori live with their families, but a portion of such
individuals live alone.34 As shown in Figure 2, we herein propose that
individuals with hikikomori can be classified into five stages based
on living with others (mainly family members [X category]) or living
alone (Y category).34
Here, we briefly focus on hikikomori persons who live alone. Our
previous pilot survey has shown that most people with hikikomori live
with their families with a much smaller percentage living alone.32
Some hikikomori persons living alone are supported by government
welfare programs in addition to the support they receive from their par-
ents. In Japan, the unemployed can obtain full economical support to
live alone, if certain conditions are satisfied (such as poverty and men-
tal/physical illnesses) through the governmental social welfare system
called seikatsu-hogo and shogai-nenkin. With such support, unem-
ployed single-person households are increasing among younger and
middle-aged people in addition to the elderly.35 In many cases, young
people start living alone when entering university or finding employ-
ment, but even if they drop out of school or quit their jobs and become
unemployed, many continue to receive financial assistance from their
parents and/or the social welfare system enabling them to remain shut
in alone. Human relationships become diluted, contact with family
432
Psychiatry and
PCN Clinical Neurosciences
members, friends, and colleagues become scarce and a solitary condi-
tion is cemented. When this situation lasts more than 6 months, the
individual may be included within the definition of hikikomori. Such
individuals sometimes go out to shop at convenience stores and super-
markets, and occasionally go out for fun, but they usually stay at home
and spend most of their time watching TV and surfing the Internet.
The existence of such single hikikomori persons has been further facil-
itated by the development of IT mainly based on the Internet. With the
development of the Internet, most shopping can be done via the Net
(and ‘Net shopping’ coupled with advanced delivery networks is espe-
cially advanced in Japan), making it possible to live without going out.
Furthermore, withdrawn persons may still easily enjoy various forms
of entertainment, such as online games, in complete isolation. Indeed,
more and more daily life activities can be achieved without going out
and without directly contacting others.
Multidimensional understandings of hikikomori
International relevance of hikikomori
Do hikikomori sufferers exist outside of Japan? Hikikomori-like clini-
cal cases have come to be reported in countries such as Oman and
Spain since 2000.36,37 In 2010, we conducted the first international
hikikomori survey targeting psychiatrists in Australia, Bangladesh,
Iran, India, Japan, South Korea, Taiwan, Thailand, and the USA
using two case vignettes in a self-reporting format and showed the
possibility of a hikikomori-like phenomenon in all the countries sur-
veyed.9,18 Thereafter, the cases of hikikomori sufferers in countries
including France, Spain, Italy and Brazil were reported.38–44 Epidemi-
ological surveys of hikikomori outside Japan are very limited. In
Hong Kong, a telephone-based epidemiological survey has revealed
that hikikomori sufferers (duration 6 months and over) account for
1.9% of the population.45 Just recently, we conducted an epidemio-
logical survey focusing on young people in urban areas of mainland
China – Beijing, Shanghai, and Shenzhen – through social-
networking services and revealed the existence of hikikomori in main-
land China.46,47
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
 Psychiatry and
PCN Clinical Neurosciences
Interestingly, the semi-structured diagnostic interviews
employing our previously proposed four criteria conducted in the
USA, South Korea, India, and Japan revealed hikikomori sufferers in
each country who met the criteria for diagnosis.32 Compared with
Japanese hikikomori sufferers, hikikomori sufferers in the USA expe-
rienced a stronger sense of loneliness and had a higher level of dis-
ability at home. In India, social networks were fairly well maintained
but the level of functional impairment was generally great. In South
Korea, sufferers experienced a strong sense of loneliness, fewer inter-
actions with friends, and high levels of functional impairment. For
hikikomori sufferers in the USA and Japan, we also conducted a
SCID-I/II clinical interview. Compared to sufferers in Japan, US
hikikomori sufferers were significantly more likely to have been diag-
nosed with mood disorder, substance use disorder and anxiety disor-
der.19 Such differences may be reflective of sociocultural influences
in each country. Hikikomori may be thought of more as a coping
strategy than a disorder and may not be as highlighted in some
societies/countries, including the USA, and thus tends not to be as
pathologized. In this pilot study, as the numbers of participants were
extremely small and case entry methods varied, sampling bias might
have influenced this result. It is now important to rectify these points
and verify our findings in a large international survey.
Is hikikomori a modern-society-bound syndrome?
Hikikomori, previously considered a culture-bound syndrome, is now
seen as having ‘spread’ worldwide,7,18,27,48 and we herein discuss the
ailment as a ‘modern society-bound syndrome.’5
Haji [shame]
As an environment that easily gave rise to the phenomenon of
hikikomori had long existed in Japan along with sufferers of this ail-
ment, it was easy to consider hikikomori as a culture-bound syn-
drome. While requiring a leap of imagination, the ultimate roots of
hikikomori might be found with the mythical goddess Izanami, who
shut herself away in the land of Yomi.49 The Japanese have tended to
form social groups and structures that have emphasized indirect com-
munication, and behind this has been the influence of particular
values emphasized within Japanese society such as haji [shame].49,50
Generally, for Japanese, in situations where one is shamed, the idea
of ‘making oneself disappear’ has long been considered a kind of vir-
tue. We suppose that this kind of mindset may be linked not only to
the high prevalence of suicide but also hikikomori.34 Are these
shame-related behaviors limited to Japanese? In Beauty and the Beast,
a monster cuts himself off from contact with the outside world due to
his perceived ugliness in a story that we can perhaps all sympathize
with and understand across the world. In this modern society, we may
live in times where shame as a pathology has reached the surface.
Amae [overdependence]
Amae [a culturally accepted ‘overdependence’] as proposed by a psy-
choanalyst, T. Doi, may be a major influence on the occurrence of
hikikomori in Japanese society.51 To a great extent, dependent behav-
iors related to amae are conducted with the belief that the parent will
forgive all. Doi believed that Western societies tend to consider such
dependence in children to be something that should be overcome or
corrected, whilst in Japan amae remains an acceptable mode of
behavior even in adult life.51 Doi discussed ‘sullenness’ or a sullen
withdrawal as one transformation of amae; thus, the behaviors of
hikikomori may be seen to be a close relation to the classic behavior
of amae. Hikikomori persons especially living with families may be
affected by amae to the extent that parents accept their child staying
at home for prolonged periods of time.18 Interestingly, our latest
case–control study using the Rorschach Comprehensive System has
revealed some deeper psychological characteristics and society-based
unconscious aspects related to amae, indicating that the hikikomori
phenomenon may have the aspect of coping behaviors to satisfy one’s
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
Hikikomori: Overview & novel assessments
desire for dependence in at least some persons with the hikikomori
condition.52
Emergence of hikikomori from the world historical
viewpoint
The phenotype of mental illness and psychiatric symptoms’ manifes-
tation forms have changed throughout eras, cultures, and socie-
ties.5,53,54 From the end of the 19th century to the beginning of the
20th century, Europe experienced a period of great tension between
nations and ethnic groups resulting in forms of social chaos. It is dur-
ing this period that hysteria seemed to be of epidemic proportions,
especially among the ladies of society.55,56
S. Freud, the founder of psychoanalysis, travelled abroad to
study under J. M. Charcot, who himself is considered to be the father
of hysteria research predating psychoanalysis.55 Freud engaged in the
treatment of hysterical patients and these experiences largely contrib-
uted to the development of psychoanalysis with its emphasis on ‘trac-
ing the unconscious source of mental symptoms.’ In the 1950s, as the
USA led the way with the era of mass consumption, eating disorders
began to emerge and also came to be visible in Japan in the
1970s.57–59 At the same time, borderline personality disorder
emerged, becoming a major epidemic in the 1980s and 1990s in
Japan.60–62 However, in recent years, at least in Japan, it seems to be
rare to see borderline personality disorder patients with severe acting-
out behaviors.63,64
Instead, since around the late 1990s, hikikomori and a novel psy-
chiatric syndrome called ‘modern-type depression’ (MTD) have
become a growing issue, especially among adolescents, initially in
Japan.9 We believe that the world historical shift of psychiatric disor-
ders is of great importance to understanding the psychopathology of
hikikomori and MTD in this era.9,65 Based on the reports of
S. Tarumi66,67 and our clinical observations, persons with MTD tend
to express depressive mood just after stressful events and also have a
tendency towards avoidance and social evasion in school and work
environments. People with MTD easily complain about their depres-
sive feelings without hesitation, easily escape from social situations,
and once escaped their symptoms are quickly relieved, this being the
most highlighted feature of MTD. Prolonged social difficulties based
on such symptoms can induce social withdrawal condition; thus, we
have recently been proposing MTD as a ‘gate-way disorder’ to more
serious adjustment problems, especially hikikomori (see Kato
et al.68,69). The commonality between hikikomori and MTD is social
evasion tendency and we have proposed that the prolongation of
MTD may be an important factor in the occurrence of hikikomori.68,69
The premorbid characteristics of MTD are self-centeredness, socially
evasive and narcissistic tendencies, easy traumatization, and low resil-
ience, which correspond to hikikomori features.70,71
Phenotypes of mental illness have undergone significant trans-
formations that are far greater than possible changes in human DNA
in a mere 100 years. We believe that such changes in phenotypes are
greatly influenced by lifestyles characteristic of each era and society,
and especially the environments we are raised in as children, as Freud
proposed more than 100 years ago. Interestingly, J. Kitanaka has dis-
cussed Japan’s depression based on her medical anthropological anal-
ysis.72 She pointed out that the diagnosis of depression in general
became more prevalent in the 2000s in order to address the problem
with overwork, death from overwork, and suicide from overwork in
Japan. By recognizing depression, organizations had to recognize that
workers needed some time off from work. Considering this social
background, to some extent, an exploitation of the function that
depression has served in this context may be one possible reason why
MTD has emerged in this era in Japan.
Impact of IT-based indirect communication on mental
development
What were the factors that caused the emergence of hikikomori suf-
ferers outside of Japan and thereby transformed our understanding of
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Hikikomori: Overview & novel assessments
hikikomori from a culture-bound syndrome to an international psychi-
atric disorder or related condition? We have advocated, as important
factors, modernization, globalization, the spread of the Internet, and
the international diffusion of indirect communication through the IT
revolution. In particular, the way children play has shifted from
‘direct’ to ‘indirect,’ and this may strongly affect the behavioral char-
acteristics of modern youth. In 1983, Nintendo ‘Famicom’ was
released and since then the way children play has shifted significantly
to the indoors. Children who played dodgeball and soccer outdoors
while sometimes fighting with each other suddenly began to assemble
at the home of a child with a Famicom station and to play indirectly
via a TV monitor. Today it is possible through the Internet to play
fighting games online even when physically we are totally removed
from each other. Thus, worldwide, the youth of today (although not
necessarily limited to youth) have far fewer opportunities for direct
communication. With social media and texting replacing other activi-
ties, such youth spend less time with their friends in person, which is
perhaps why they may be experiencing unprecedented levels of anxi-
ety, depression, and loneliness.73 Is it actually the case that there are
fewer children who physically fight with each other? On the other
hand, the problem of ‘bullying’ via indirect communication has
become a major social issue not only in Japan but also in other coun-
tries.74,75 The Japanese saying ‘Rain strengthens the foundation’
means that adversity or conflict can strengthen what came before, and
it was not rare that a direct fight between youths could lead to a stron-
ger friendship. The question becomes to what degree can communica-
tion skills and trustful relationships be established and built only
through ‘indirect’ communication/playing/gaming experiences?
Biological understandings of hikikomori
There is almost universal consensus that the pathogenesis of mental
illness cannot be explained solely through the DNA we receive from
our parents. Various historical, cultural, and sociological factors
(in particular psychosocial stress) cause a variety of changes in the
brain, including epigenetic and nerve–glial correlation, which may
express a characteristic phenotype that it is one with the time and the
society in which it occurs.76 Interestingly, just recently, a meta-
analysis has revealed that stressful life events and maltreatment are
strongly associated with the occurrence of conversion disorder
(known as ‘hysteria’ in the Freudian era) in later life.77 Similar but
somewhat different biopsychosocial mechanisms may underlie the
occurrence of hikikomori in the 21st century.
Biological bases of hikikomori have not been clarified at all. As
an initial step, we are searching for biomarkers of hikikomori using
human blood by recruiting actual individuals with hikikomori. We
have recently reported that individuals with hikikomori have higher
avoidant personality scores in both sexes, and show lower serum uric
acid (UA) levels in men and lower high-density lipoprotein choles-
terol (HDL-C) levels in women compared with healthy volunteers.78
This is the first report showing possible blood biomarkers for
hikikomori. In addition, we have revealed that avoidant personality
traits, which are strongly linked to hikikomori, are negatively associ-
ated with HDL-C and UA in men, and positively associated with
fibrin degeneration products and high-sensitivity C-reactive protein in
women among non-hikikomori volunteers, mainly young-adult univer-
sity students.78 High-sensitivity C-reactive protein and fibrin degener-
ation products are inflammatory markers,79 and HDL-C and UA are
known to have antioxidative effects.80,81 On the other hand, a non-
clinical randomized control trial with healthy volunteers showed that
endotoxin treatment by intravenous bolus increased blood-level
inflammatory cytokines – interleukin-6 and tumor necrosis factor-α –
and also increased self-reported feelings of depression and social dis-
connection, such as ‘I feel like being alone’ compared to the placebo
group,82 suggesting the importance of inflammation in social with-
drawal behaviors.
On the basis of such pilot investigations, we have hypothesized
that inflammation and oxidative stress may be linked to the
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Psychiatry and
PCN Clinical Neurosciences
underlying pathophysiology of hikikomori, similarly to other psychiat-
ric disorders.76,83–87 Microglia play crucial roles in brain inflamma-
tion via releasing free radicals and inflammatory cytokines, such as
interleukin-6 and tumor necrosis factor-α,88,89 and activation of
microglia has recently been proposed to exist in various psychiatric
disorders, including schizophrenia, depression, bipolar disorder, and
autism.76,86,90–97 In addition, microglial overactivation is proposed to
exist in the brains of suicide victims and suicidal individuals, espe-
cially via the tryptophan–kynurenine pathway.98–103 As noted above,
a recent epidemiological data analysis showed that hikikomori suf-
ferers are more likely to have suicide risk,29 thus similar biological
mechanisms via microglial activation may exist in hikikomori.104,105
Figure 3 presents our current hypothesis/understanding of the
theoria generationis of hikikomori.
Therapeutic approaches for hikikomori
Providing support to hikikomori sufferers who have withdrawn from
society over a long period of time is challenging. According to Kondo
et al., the average period from the start of withdrawal to the initiation
of first-time support in Japan is 4.4 years.106 Various forms of sup-
port, such as telephone consultations, the creation of ‘meeting spaces’
for people with hikikomori, and job-placement support have been
undertaken for hikikomori sufferers, mainly through mental health
welfare centers and more than 50 MHLW-funded community support
centers for hikikomori located throughout all the prefectures of
Japan.7 In addition, a variety of private institutions provide support
for sufferers with hikikomori and their parents, but there is yet to be a
unified evidence-based method for these public/private interventions.
A four-step intervention is recommended by the 2010 MHLW Guide-
line for Hikikomori: Step 1, family support, first contact with the indi-
vidual and his/her evaluation; Step 2, starting individual support; Step
3, training with intermediate-transient group situation (such as group
therapy); and Step 4, social participation trial.15 We have recently
established a hikikomori clinical research unit in a university hospital
to develop evidence-based therapeutic approaches with the collabora-
tion of public hikikomori support centers, partially by a public
research fund. Here, we introduce hikikomori support materials,
including our current programs.
Family support
Initially, it is unlikely that hikikomori sufferers themselves will seek
treatment, and therefore family interventions are crucial in cases of
living with family members. Due to a lack of knowledge (about men-
tal illness in general and hikikomori in particular) and prejudices
against such mental conditions, in many cases family members cannot
respond directly to individuals with these ailments, are unable to
intervene at all, and tend to turn a blind eye for many years without
seeking help. Many parents refuse to receive any professional help
because of social stigma, such that ‘I don’t want to be known to
neighbors as having a son/daughter who is a hikikomori and/or who
has a mental illness.’ Due to a lack of knowledge about mental ill-
nesses, parents tend to worry that their child might be locked in a
strange and fearful psychiatric hospital for life. Moreover, some indi-
viduals with hikikomori have violent tendencies toward their parents,
and in such situations, parents tend to fear their reprisals after con-
sulting professional help. We suspect that facing the new issue of
longer-term hikikomori of ever increasing age is due to these parents’
behavioral tendencies. Thus, it is important for family members to
acquire the appropriate knowledge and techniques for dealing with
individuals with hikikomori for early intervention.
We are now developing an educational program for parents of
individuals with hikikomori partially based on Mental Health First
Aid (MHFA). The MHFA was originally developed as a 12-h educa-
tional course that teaches participants (mainly laypeople) how to iden-
tify, understand, and respond to signs of mental illness and crisis,
including suicidal and violent behaviors.107,108 The five-steps of the
MHFA (3rd version) are as follows: Step 1, Approach the person,
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
 Psychiatry and
PCN Clinical Neurosciences Hikikomori: Overview & novel assessments

Fig.3 Hypothetical model in the occurrence of hikikomori in Japan and worldwide (modified from Kato et al.70). There is a great possibility that sociocultural influences
acted as vital factors in the appearance of hikikomori in Japan. Japanese people tend to be especially sensitive to shame, acutely conscious of others, and highly valu-
ing of harmony with preference for indirect exchanges. Family dynamics have long pointed to a particularly strong maternal relationship, which has been discussed as
amae [overdependence] and kahogo [overprotection by parents]. On the other hand, the theme of the ‘absent father’ has also been emphasized. Such family dynamics
make it difficult for children to detach from their mothers and provide children with an environment where it is easy to ‘stay at home.’ Even in education, with the intro-
duction of yutori-kyoiku [relaxed education policy] for a time, at least superficially, competitiveness was no longer emphasized. However, in reality, many students
began to attend ‘cram schools’ and find themselves caught in what the media came to term ‘exam hell.’ On the other hand, a prolonged recession has led to increased
unemployment, a collapse of the long-established lifetime employment system, and a shift to a merit-based pay system and non-regular employment. Such school
and work environments in Japan tend to induce a variety of stressful life events. Young people may have difficulty in entering the university or company of their choice,
or even if they are accepted to such institutions come into conflict with their schoolmates or colleagues, which may induce bullying. When such situations arise, the
possibility of an avoiding response occurs. This may cause weaker/avoiding stress responses, possibly based on childhood experiences resulting in a tendency for
poor resilience and more traumatization. Emotional and cognitive reactions, such as depression, decreased motivation, social phobia, distrust, anger (indirect), amae
(overdependence), and shame are likely to occur. Such emotional cognitive reactions are thought to cause hikikomori-related behaviors, such as avoidance of social
participation, escapism from the realities of life, and withdrawal to the world of the Internet. When such a situation continues for a period greater than 6 months, it may
be termed as hikikomori. In addition, we propose that hikikomori-like conditions are likely to result from prolonged modern-type depression (MTD), which has many
commonalities, such as avoidant tendency and personality traits. IT, information technology.

assess and assist with any crisis; Step 2, Listen non-judgmentally;
Step 3, Give support and information; Step 4, Encourage the person
to get appropriate professional help; and Step 5, Encourage other sup-
port.109 We have been promoting usage of the MHFA in
Japan,110–114 and are now in the process of developing an evidence-
based educational support model that enables families (especially
parents) of persons with hikikomori to obtain specific skills and
knowledge in dealing with hikikomori based on the MHFA. In this
program, we are especially focusing on how to assess one’s child and
bring them to professional support places smoothly and safely using
the MHFA-based materials, including hikikomori-case role-play
scenarios.
Also of interest is the Community Reinforcement and Family
Training (CRAFT) that was originally developed for family
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
members of individuals with substance use disorders as a
cognitive-behavioral therapy (CBT)-based family interventional pro-
gram.115,116 The CRAFT has been highlighted as another powerful
intervention tool for family members dealing with hikikomori
individuals.117
We believe that the combination of MHFA and CRAFT along
with other intervention materials may provide a dynamic approach for
family intervention in hikikomori cases.
Home visits
Home visits by physicians, nurses, psychologists, and social workers
also play an important role as an initial stage of hikikomori support.
In some situations, home visits are carried out following a parental
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Hikikomori: Overview & novel assessments
consultation, but this is still rare in Japan118 In South Korea, young
people exhibiting hikikomori-like behavioral characteristics are
referred to as Oiettolie and the existence of a hikikomori-like condi-
tion has been pointed out.119 A social-worker home-visit program has
been developed for people withdrawn into their homes and a pilot
intervention study has demonstrated that this has allowed for appro-
priate psychological evaluations to be conducted and for such individ-
uals to more efficiently access the next treatment steps, including
direct psychotherapy.119 A general hesitancy regarding home visits
exists in Japan but given the research in South Korea, the develop-
ment of an effective home visit approach may be important in the
support of hikikomori sufferers in Japan and other countries.
Multidimensional assessment and therapeutic strategies
Before providing therapeutic materials to sufferers of hikikomori
themselves, multidimensional assessment is essential. In our
hikikomori research clinic, we have been evaluating a variety of
aspects based on the biopsychosocial model.
Age of onset, triggering life events, severity of hikikomori condi-
tions (withdrawal duration, frequency of going out from their own
room/house, contact with family members and friends, etc.) are evalu-
ated. As shown above, we have just developed the novel hikikomori
diagnostic criteria (Table 1). To shorten the evaluation time, we have
just recently developed a self-rated questionnaire called the
Hikikomori Questionnaire (HQ)-25,120 which takes just 2–3 min to
complete and is thus expected to be more widely and easily used at
hikikomori supporting faculties even in the absence of hikikomori
experts. In addition, we are preparing an online version of the HQ-25,
which hopefully can be accessed by pre-stage and/or severe cases of
hikikomori.
In addition, psychiatric diagnostic interviews based on the DSM-
5/ICD-11 should be conducted due to high comorbidity of psychiatric
disorders, and those under the threshold levels should also be evalu-
ated. Psychometrics, especially to grasp personality, attachment, and
Internet addiction tendency, are recommended.121–125 To assess
behavioral characteristics, economic games, especially trust games,
can evaluate unconscious decision-making and consequently estimate
interpersonal relationships.126 Biological assessments, including
blood tests, and brain functional analysis, such as electroencephalog-
raphy, may help to understand the biological bases of hikikomori.
According to the results of such assessments, various supports
are provided respectively. If hikikomori sufferers have psychiatric dis-
orders, the guidelines of each disorder should be followed, using
pharmacotherapy, psychotherapy, and/or psychosocial interventions.
To our knowledge, the majority of hikikomori persons require not
only pharmacotherapy but also psychosocial supports.
Here we introduce up-to-date individual therapeutic approaches
against hikikomori in Japan and other countries.
Animal and robot therapy
Looking outside of Japan, in Hong Kong it is reported that hikikomori
sufferers account for 1.9% of the population,45 and that social with-
drawal is widely seen as an expanding social issue of concern. As a
result, led by social workers and occupational therapists, a variety of
hikikomori support measures are being developed. For example,
under the hypothesis that hikikomori sufferers may be adverse to
direct contact with other people, an animal therapy program has been
introduced as a stepping-stone in alleviating this reluctance. Coming
in direct contact with animals, such as dogs and cats, can also be a
step towards leaving the confines of one’s home and this has been
demonstrated in a pilot study.127
Furthermore, pet-like robots, such as Sony’s Aibo, a dog-like
robot, have been developed based on advanced technologies, which
might enable humans to communicate with emotional satisfaction.128
These robots have been utilized in a variety of situations to combat
social difficulties with psychiatric disorders, especially autism and
dementia.129–131 We believe that these robots can resolve loneliness
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Psychiatry and
PCN Clinical Neurosciences
at least to some degree, especially for single-person households with
hikikomori.2,132 The development of pet-like robots capable of con-
versation on an emotional level is progressing at a fast pace and there
is hope that such robots can assist hikikomori cases with the allevia-
tion of loneliness and serve as a first step towards increased social
interactions/sociability.
Online-based intervention
The online game Pokémon Go, which was released in the summer of
2016 and utilizes location information and augmented reality, became
a global hit. Augmented reality is a technique of superimposing
sound and graphics on images reflecting and expanding the real
world, and this technique may be useful in the support of hikikomori
sufferers. Some people with hikikomori who have not gone out for
years are leaving their homes in search of Pokémons.133 Surprisingly,
in our clinical practice, a male patient who previously was barely able
to go out and who lives alone has begun to venture out daily with the
emergence of Pokémon GO.134 Unfortunately, after a few months, he
grew tired of the game, and thus its effect was transient, but we
believe a hikikomori support approach based on such technology has
the possibility of being particularly effective during the early stages
of the condition, and much can be expected from the development of
such tools through industry–academia collaboration.
Furthermore, the question should be asked: ‘Are hikikomori suf-
ferers themselves seeking treatment?’ Interestingly, our international
survey has revealed that many hikikomori sufferers show a preference
for psychotherapy over drug therapy that would allow them to have a
breakthrough.32 We had previously assumed that they may have a
preference for online treatment using web cameras and similar tech-
nologies (as telepsychiatry-style) but contrary to our expectations,
there were significantly more people who expressed a desire for direct
face-to-face treatment.
Psychoanalysis and psychodynamic psychotherapy
Generally, psychotherapy is suggested to be effective for
hikikomori.15 The concept of hikikomori was originally developed by
psychoanalysis-oriented psychiatrists in Japan, centering on Tamaki
Saito, Kazuhiko Saito, and Naoji Kondo. Even now, many hikikomori
experts in Japan are psychoanalysis-oriented psychiatrists, psycholo-
gists, and psychopathologists. Psychoanalytic (psychodynamic)
approaches are not fully empirically validated, but based on the above
foundations we herein introduce psychoanalytic understandings and
approaches.
We propose that psychodynamic individual/group approaches
are especially effective toward individuals with hikikomori in
resolving their difficulties with interpersonal relationships between
family members and future school/workplace colleagues in the out-
side world. Until now, we have described hikikomori as a pathological
phenomenon and behavior, but is it sufficient to regard social with-
drawal only as a negative thing in the first place? From psychoana-
lytic research into war neurosis (present day PTSD), the British
psychoanalyst W. D. Fairbairn imagined only two personality compo-
nents in all human beings, including healthy individuals: the Exciting
Object and the Rejecting Object.135 The hikikomori phenomenon may
be an extreme expression of the Rejecting Object. According to
Fairbairn’s theory, the tendency to withdrawal is intrinsic to what it is
to be a human being. With the popularization of the Internet, mobile
phones, and other mobile devices, we are connected to someone
wherever we are. In such situations, hidden (private) worlds are sud-
denly in clear (public) view creating a modern society where it is near
impossible to ‘be (comfortably) alone.’ Perhaps exactly because we
exist in a society where we are constantly connected and without
delineation between private and public that ‘withdrawal’ takes on an
extreme form. The action of hikikomori (hikikomoru as a verb in Jap-
anese) may be an unconscious but desperate acting out of the primi-
tive desire of a modern person who has lost the space to withdraw.5
We believe that the key to rescuing sufferers with the hikikomori
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
 Psychiatry and
PCN Clinical Neurosciences
condition is the ‘reacquisition of the mental space where a person can
be comfortably/safely alone’ and this reacquisition may be achieved
by advocating the usefulness of psychoanalysis. In psychoanalytic
psychotherapy, especially psychoanalysis by the non-face-to-face
‘couch’ method, extremes of ambivalent feelings of ‘wanting to
engage’ and ‘wanting to leave out’ are shared by both patient and
therapist often in silent moments during a therapy session. When two
people create a space–time when they are together but in silence, this
gives birth to what D. W. Winnicott advocated as the ‘capacity to be
alone,’136 and we believe that this approach relieves the person from
defensive physical withdrawal. In addition to individual psychother-
apy, psychoanalytic group psychotherapy allows sufferers with the
hikikomori condition to experience the above ambivalence inside a
group while observing the other and is thus highly effective.137,138
Biological intervention
Until now, no biological interventions have been investigated in the
treatment of hikikomori. As inflammation and oxidative stress are
possible contributing factors of hikikomori,78 anti-inflammatory
and/or anti-oxidative agents may help to improve hikikomori condi-
tions. We have previously reported that minocycline, an antibiotic
drug with a suppressing effect on microglia, can change social
decision-making in times of strong social stress139–141; thus, such
agents targeting microglial activation may also work for solving
hikikomori behaviors. Clinical trials are warranted to clarify the effec-
tiveness of such drugs in the future.
Future perspectives
Before concluding, we propose some important aspects that should be
considered.
Hikikomori is still a hidden epidemic in many countries, and in
order to grasp its worldwide relevance, hikikomori diagnostic criteria
should be included in the future ICD/DSM systems. At least, we pro-
pose that, similar to ‘catatonia’ in the DSM-5, subtyping and/or a
specifier code for ‘hikikomori (social withdrawal)’ should be added
and applied for each diagnosis of psychiatric disorders33 in such a
way as previously existed for ‘adjustment disorder with withdrawal’
in the DSM-III. Based on such future systems, international and
population-level epidemiological surveys should be conducted. We
expect that our newly developed self-rated questionnaire, the HQ-25,
may help to evaluate risk factors of hikikomori and effectiveness of
interventions.120
In addition, as shown in the previous section, hikikomori is now
understood to have links to heterogeneous mental illnesses, and we
suppose that some common psychopathological mechanisms may
exist in the act of ‘shutting-in’ regardless of psychiatric diagnosis.
The Research Domain Criteria (RDoC) approach beyond conven-
tional psychiatric classification has attracted much attention142,143 and
we believe that hikikomori may fit well within the RDoC framework
because of coexistence of hikikomori within various psychiatric disor-
ders. Beyond psychiatric diagnosis, such as schizophrenia, depres-
sion, and ASD, some common mechanisms relating to
biopsychosocial factors may exist, and multidimensional research
should be conducted. Until now, the majority of hikikomori reports
have been empirical; thus, theoretical and scientific studies should be
encouraged to understand the multidimensional phenomenon of
hikikomori.
Conclusion
In this review article, we have described up-to-date knowledge about
hikikomori within and outside Japan and have presented our recent
hypothesis of ‘hikikomori as a modern-society syndrome.’ With the
IT revolution, the need for direct communication has diminished and
it may be that the future will bring a society where it is easier to
hikikomoru (becoming hikikomori). For this reason, a continuous
international collaboration and multidirectional approach to the
hikikomori phenomenon will be required.
Psychiatry and Clinical Neurosciences 73: 427–440, 2019
Hikikomori: Overview & novel assessments
Acknowledgments
The authors would like to thank Dr Tae Young Choi, Dr Paul
W.C. Wong, Dr Masaru Tateno, and Dr Yatan P.S. Balhara for inter-
national collaborative research; Dr Ryo Kawano, Dr Yoko Honda,
and Ms Michiko Asami at the Fukuoka City Mental Health Welfare
Center/Hikikomori Support Center; and Dr Kohei Hayakawa, Dr
Nobuki Kuwano, Mr Hiroaki Kubo, Mr Keita Kurahara, Ms Ryoko
Katsuki, Ms Hiromi Urata, Ms Sakumi Kakimoto, and Ms Yoko
Zushi at Kyushu University for their research support and/or assis-
tance. This work was partially supported by a Grant-in-Aid for Scien-
tific Research on (i) Innovative Areas ‘Will-Dynamics’ of the
Ministry of Education, Culture, Sports, Science, and Technology,
Japan (JP16H06403 to T.A.K.), (ii) the Japan Agency for Medical
Research and Development (AMED; Syogaisya-Taisaku-Sogo-
Kenkyu-Kaihatsu-Jigyo to T.A.K. and S.K.; JP17dk0307073 and
JP18dk0307075), and Yugo-No to T.A.K. (JP18dm0107095);
(iii) KAKENHI – the Japan Society for the Promotion of Science
(JP26713039, JP15K15431, JP16H03741, and JP18H04042 to
T.A.K., and JP16H02666 to S.K.); (iv) SENSHIN Medical Research
Foundation (to T.A.K. and S.K.); and (v) the JSPS Bilateral Joint
Research Project between USA-Japan (to T.A.K. and A.R.T). Dr Teo
is supported by a Career Development Award (CDA 14-428) from
the Veterans Health Administration Health Service Research and
Development (HSR&D) and the HSR&D Center to Improve Veteran
Involvement in Care (CIVIC), the Department of Veterans Affairs.
The views expressed in this article are those of the authors and do not
necessarily reflect the position or policy of the Department of Vet-
erans Affairs or the US government. None of the funders had a role
in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Disclosure statement
All the authors have declared that no conflicts of interest exist.
Author contributions
T.A.K. drafted the article, and A.R.T. and S.K. revised it critically for
important intellectual content. All of the authors provided final
approval of the version to be published.
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