Social Withdrawal The to be or Not to be of Hikikomori

- Stefan Peyda

INTRODUCTION
By the early 1980s, a new phenomenon known as hikikomori began to be
reported in traditional media and medical journals in Japan (1,2). A hikikomori
turns from society, usually by retiring into his or her own home, and do not
participate in human interactions or social situations such as attending school or
going to a workplace for a substantial period of time (3). In 1998, the Japanese
psychologist Tamaki Sait coined the term shakaiteki hikikomori which spread to
the general public with the simultaneous publishing of his book on the topic of
hikikomori (4). Since then, hikikomori has come to constitute a serious issue in the
Japanese society, gaining increasing attention (1,5). To the present date, the number
of hikikomori has been estimated to total up to as much as one million or more
individuals (6). In recent years, the concept of hikikomori has also spread outside of
Japan and gained increasingly international interest (713).
DEFINITION
In English, shakaiteki hikikomori has become known as social withdrawal.
Originally, hikikomori was not used as a psychiatric term (14). The word stems from
the Japanese hiku (to pull, to draw) and komoru (to retire, to seclude oneself)
(15). According to the Meiky National Language Dictionary, hikikomori means to
seclude oneself into one's own home or room to avoid such things as human
relations and participation in society 1 (16). The Oxford Dictionary of Psychology
describes hikikomori as a culture-bound syndrome characterized by extreme
social withdrawal and near-total severance of contact with the outside world,
without any other evidence of psychiatric or neurological disorder, usually

triggered by an upsetting experience, such as being bullied, failing an examination,

or experiencing a broken love affair (17).
Psychiatrically however, a single definition has yet to be agreed upon.
Furthermore, the concept of hikikomori is not included in the current, fifth edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Commonly
utilized criteria for social withdrawal stipulated by the Japanese Ministry of Health,
Labor and Welfare (MHLW) (18) are listed below:
A. A living centered at the own house
B. Not participating in (or having an inability to participate in) societal
activities such as being employed or attending school
C. Such a condition has been continuous for a minimum of six months
D. The condition cannot be explained by other psychiatric disorders and/or
moderate-to-severe mental retardation
E. Apart from with other family members, intimate human relationships
are not being maintained nor formed
Suggestions have been made to distinguish primary hikikomori (as defined by the
MHLW-criteria above) from secondary hikikomori (14), or a hikikomori-like state
(19), where the latter could be explained by another psychiatric diagnosis, for
instance major depressive disorder (MDD), obsessivecompulsive disorder (OCD),
personality disorder, schizophrenia, generalized anxiety disorder (GAD), mental
retardation, addiction et cetera.
EPIDEMIOLOGY
While the phenomenon is mainly found in Japan, it is not exclusive to the Land of
the Rising Sun; cases have been reported in Spain(2022), France (23), Italy (24),
Oman (25), the USA (26), the Republic of Korea (27) and Hong Kong (28) to name a
few other countries. Age of onset is usually around the 20s, and rarely past the late
30s (18,29). A majority of hikikomori is male, but a noteworthy amount is female,
with a ratio of 3:1 in favor of the men (18). Although the real number of hikikomori
world-wide is difficult to tell, assessments have been made ranging from 200,000 to
1,000,000 people in Japan alone (1,6,3032). According to an estimate based upon
a questionnaire issued by The Japanese National Cabinet Office in 2010, there could
be as many as 700,000 hikikomori between ages 15 and 39 nationwide (30). Are
these numbers to be correct, they would mount up to over 0.5% of the total
population (33). In addition, one study carried out by researchers affiliated with the

National Institute of Mental Health found that 1.2% of respondents (n = 1,660) in a

survey had experienced hikikomori in their lifetime (32).
ETIOLOGY
The etiological factors of hikikomori remain unclear, but several pre-disponing
factors have been suggested. One such factor might be school truancy (futk 2)
(2,34,35). The number varies greatly, but between 33-86% of hikikomori have a
history of school truancy during their years of elementary school and/or high school
(4,18,34,36,37). The reasons for school truancy are also several, but common causes
might be bullying (2,38) or falling behind ones peers (39). Problems within or
regarding the family structure might also be a risk factor (40,41).
It has also been suggested that hikikomori arise from a background of other
psychiatric disorders such as schizophrenia, personality disorder or anxiety disorder
(42), and thus might be considered a symptom of a pre-existing mental illness. To
build on this, one study found that there might exist what was called an affinity
group of individuals prone to entering a state of hikikomori. For these individuals,
factors such as depression, social phobia, refusal towards autonomy and a history of
violence stood out compared to a control group of mentally healthy youths (43).
Yet others think of hikikomori as a symptom which can be explained by the
sociocultural features of Japan; 1) The relatively rapid reformation and economic
development in Japan brought with it changes that affected that family constitution,
making fathers more absent from the home as well as ensuring enough money to
support a child at home until, or ever after, marriage (14,39). 2) A highly
mainstreamed and competitive educational system puts a lot of youngsters under
severe pressure to succeed in school (and later, in life) and fails to adequately
address those who trail behind (39,44). 3) With the burst of the economic bubble in
the 1990s, forcing a change from the traditionally secure and predicable careertracks to more unclear winding roads, together with a severe reduction of 88% of job
offers to high school graduates in little more than a decade (44), young adults in a
major transitional phase in life (i.e. the one from being a student and teenager to
being an employee and adult) were left disillusioned and without the proper tools to
address the unfamiliar and radically changed demands of the labor market (1). 4)
Sociocultural paradigms such as uchi to soto (in-groups and out-groups), amae
(the dependence on the benevolence of others, such as family members) and

Similar to hikikomori, futk is characterized by a reluctance to leave the home and an unwillingness to partake in a societal
role, in this case that of an elementary or high school student.

gambari (the keeping of a mindset of being determined and to be making

persistent efforts, to always endure, to have a highly set goal and to work hard as to
not disappoint oneself or others) as well as the thought incorporated in the proverb
deru kui ha utareru (lit. the stake that sticks out gets hammered back down, i.e.
the constant overhanging feeling of always having to stay conformal in order to keep
the overall societal harmonious and an awareness to both behave and appear as to
not stand out in a group) might help explaining why hikikomori would emerge (and
is being maintained) in Japan (1,39,45,46). (1) (39) (45) (46).
COMORBIDITY AND DIFFERENTIAL DIAGNOSES
Several studies with the aim of diagnosing comorbidity in hikikomori have been
done. As the main feature of hikikomori is withdrawal from society and avoidance of
human interaction, a variety of already established psychiatric diagnoses can be
conceived as the underlying cause of isolation. Indeed, Kondo et al. found that
hikikomori could be diagnosed and classified in principle, according to the current
diagnostic criteria (DSM-IV) (37) and later noted that a staggering 80.3% of
hikikomori (n = 148) seeking help at Mental Health Centers could be diagnosed with
a psychiatric disorder, most notably schizophrenia, mood disorders, anxiety
disorders and personality disorders as well as having family problems (29).
A study by Koyama et al. found that 54.5% (p = 0.08) of hikikomori cases fulfilled
the diagnostic criteria for at least one psychiatric disorder3 in their lifetime, where
mood disorders stood out among the cases (OR = 6.1, p <0.001). Koyama et al. also
studied the onset of comorbid psychiatric disorders in these hikikomori and found
that social phobia was the most common specific disorder prior to the episode of
hikikomori, while MDD was the most common specific disorder that developed in
the same year as the individual withdrew him- or herself from society4 (32). Suwa &
Suzuki found mental illness (such as social phobia, OCD, ADHD and depression) in
12 out of 14 studied hikikomori cases (48). In 2003, the Japanese MHLW found
psychiatric comorbidity in 33-36% of hikikomori cases (18).
CHARACTERISTICS
The typical image of a hikikomori is a male in his mid-20s from a middle-class
family background, spending all day sleeping and staying up at night using the
Internet, playing games, reading books, watching television or similar indoor3

Namely GAD, mood disorder, substance-related disorder, intermittent explosive disorder, social phobia, specific phobia, hypomanic
episode, MDD, dysthymic disorder and psychiatric disorder. Note that schizophrenia was not included in the study.
4
That is, disregarding the broad and unspecific diagnosis of psychiatric disorder also listed in their study which overall was the most
common disorder prior to, during and after the onset of hikikomori.

activities not depended upon interaction with others (2,8,49). Disillusions of the
future and apathy are common traits. Despite being adults, they rely more-or-less
exclusively on their family members for survival in regards of food and shelter as
they rarely manage to keep, or even get, a job (37,43). Such dependence is known as
amae 5 in Japanese (46). However, it should be noted that there are different
degrees of severity of hikikomori; some actually never leave their room, while others
might just stay indoors. Some will even go outdoors at night when the risk of
encountering others is low (1,26). The MHLW reported that as many as 20% have
used violence against themselves or other members of the family (18).
TREATMENT AND AID
Due to the nature of the condition, it has been difficult to investigate and evaluate
options for treatment. A frequently occurring opinion found in the literature
advocates that the hikikomori must receive treatment customized for the individual,
as there is no one common cause of social withdrawal. Pharmacological treatment
(such

as

anti-psychotic

drugs,

anti-depressants,

lithium,

Adderall

etc.),

rehabilitation, Cognitive behavioral therapy (CBT), psychotherapy/counseling,

group therapy, training of social skills, meeting with or engaging in activities with
other hikikomori outside of the house, home visitation programs, resting at
hospitals, a space free of time constraints, renting a sibling or a combination of
these tools have been tested in the search for a treatment (1,5,18,27,29,37,39,42,50).
The supporting of family members has also been mentioned as a necessary aid.
Fathers in particular seem to not be receiving adequate support from professionals
(3,51).
DISCUSSION
The point of having an actual diagnosis for hikikomori would be to be able to
diagnose the individuals suffering from a primary, or essential, hikikomori, who
otherwise would poorly fit the criteria of existing diagnoses. By distinguishing these
patients, they would be eligible for a very specific treatment or support aiming to
relieve them, fully or partially, from the state of hikikomori. Unfortunately, the
problems surrounding hikikomori are several. A main problem is to pinpoint what
hikikomori really is; is it a psychiatric disorder of its own, a symptom of another

An approximate translation of amae could be to depend and presume upon the benevolence or affection of others. Amae creates a
bond between individuals, such as between a child and a parent, a doctor and patient, or between elderly and their adult children.
Relationships based on amae are unstable; that is, people hesitate to refuse others for fear of breaking [such] bonds. To some extent, a
sense of one-sided debt or guilt can also be said to be a trait of an amae-relationship.

mental illness or retardation, a state of psychological moratorium6 brought on by

socioeconomic factors or something completely different? If hikikomori is a primary
psychiatric disorder, how should the diagnostic criteria be formulated in order to
guarantee high sensitivity and specificity and thereby reducing the risk of over- or
underdiagnosing patients? Furthermore, what is the exact psychopathogenesis of
such a diagnosis and what are the predisposing risk factors or triggers? Also, despite
being known for well over two decades, no experiments (such as randomized clinical
trials) have been done in order to distinguish one or several treatments or
interventions for hikikomori that have been proven to have effect clinically or to
have any scientific foundation backing up their efficiency. The lack of concrete proof
of disturbance or impairment in the central nervous system, such as
neuroanatomical deviations observable with current modern medical imaging
methods (e.g. CT, fMRI, EEG, MEG, PET etc.), genetic factors, neurochemical
imbalances et cetera, also makes it difficult to give a proper and objective
explanation of what is going on inside the head of hikikomori.
In 2010, Teo & Gaw (19) made a proposal to include hikikomori in the fifth
edition of DSM, possibly as a culture-bound syndrome7. They presented three main
arguments, summarized in short below;
1.

Hikikomori are often, but not always, classifiable as a variety of existing psychiatric
disorders Arguing that a majority of cases suffer from an Axis I or II disorder, Teo &
Gaw presents the idea of calling such conditions hikikomori-like states.

2.

Hikikomori may be considered a culture-bound syndrome They further argue that

data is strong enough for the remaining cases where another psychiatric disorder is
not present to entitle hikikomori as a culture-bound syndrome in the sense of the
8

definition used by the American Psychiatric Association . Additionally, they state that
hikikomori is a discrete, well-defined syndrome which is recognized as a specific illness
with higher prevalence in its primary culture that in other societies and which can be
expected as a response to certain precipitants.
3.

Hikikomori merits further consideration an research whether it is a new psychiatric

disorder This would, according to Teo & Gaw, be because a few cases of hikikomori
do not fit into the classical psychiatric framework and the request studies aimed to find

The term psychological moratorium was used by the American psychologist E.H. Erikson in 1968 to describe the process of discovering
and reestablishing a path for life and the construction a new identity in young adults after losing ones direction during a transitional phase
in life.
7
They also present a proposal for the diagnostic criteria of hikikomori which were available in the article. Similar to those formed by the
MHLW in 2003, they stress confinement to the home (minimum of 6 months if the individual is younger than eighteen years of age),
avoidance of social interaction, social withdrawal interfering with normal functioning and routines, an ego-syntonic perception by the
individual and the absence of another simultaneous psychiatric disorder.
8
A recurrent, locality specific patterns of aberrant behavior and troubling experience that is best comprehended in a cultural context.

genetic explanations, a predictable and consistent course and response to

treatment, and eliciting a well-understood etiology and pathophysiology.

Teo & Gaw carry good intentions and are doing a fine work spreading the word of
hikikomori and trying to include the condition in the DSM. However, their
arguments are not convincing in every aspect. As I stated above, hikikomori is not a
well-defined concept, much less a full-fledged and clear diagnosis. Also, because it is
not well understood, the certain precipitants or triggering factors expected to
cause hikikomori remains ambiguous. However, I do agree with Teo & Gaw in that
hikikomori might be a good candidate for the notion of a culture-bound syndrome
with regard to the sociocultural environment of Japan, and that further investigation
is needed concerning the many problematic aspects noted in the beginning of this
section.
In the case of a secondary hikikomori, that is, when another psychiatric diagnosis
can explain the social withdrawal, the cause as well as solution might be known and
thus solving the condition renders rather straight-forward. However, in the case of
primary hikikomori, every aspect of the concept gets more complicated.
The existence of cases where hikikomori cannot be explained by the co-occurrence of
another psychiatric diagnosis might indicate that there indeed exists a separate form
of hikikomori, or a primary hikikomori as noted by Suwa. Suwa describes the five
characteristics of primary hikikomori as follows (14):
1) An episode of surrendering without putting up a fight the individual
experiences a set-back in life (such as failing an entrance-exam for a desired
university, failing to get a particular job, suffering from a broken romance etc.)
which leads to a feeling of inferiority towards friends and peers. This in turn
makes the individual distance him- or herself from them. The individual then
deviates from the ideal path in life which he or she originally ought to follow,
and without putting up a fight somehow adapts to the new situation of being
disoriented.
2) Preservation of the ideal image of oneself by withdrawing without struggling,
9

the individual may think of his- or herself as someone who does not fail , and
thus he or she manages to preserve the ideal, should be-self.
3) Parental cathexis of that ideal image The parents thinks highly of their child
and continues to keep high expectations for them, just as they have done since

One might argue that, if one choose not fight, one is not faced with the risk of defeat or failure

both childhood and adolescence.

10

Thus, the parents contribute to the

preservation of the ideal image of the individual.

4) The ideal images weakness is due to the own desire The chosen path (for
school, employment etc.) was decided in order to please the parents or
appointed by the parents, and therefore the hikikomori lacks a clear wish of his
or her own. When the individual is forced to stray from this path due to the
setback, he or she becomes disillusioned.
5) A behavioral principle centered on avoidance in order to protect the values of
others fearing anything that might endanger the preservation of the ideal
image, he or she require a status quo from people and avoids the exaggerated
self-consciousness. Behaving like this helps with protecting the values set by
other people.

Suwas explanation of the processes behind primary hikikomori manages to

somewhat appropriately answer two key questions; 1) Why would an otherwise
physically fit and mentally apt individual suddenly withdraw from society (Answer:
Due to some event in life causing a deviation from the main target in life leaving
the individual severely disillusioned), and 2) how come such an individual can
experience

spontaneous

resolution

without

any

pharmacological

or

psychotherapeutic intervention, and never occur again during the remainder of the
individuals life-time? (Answer: Because the individual has regained a sense of
purpose in life, made peace with the fact that the old ideal-self, at least to some
extent, is no more, found a somewhat stable identity and found a new objective for
him- or herself). These processes would resonate well with the ideas of hikikomori a
condition caused by sociocultural factors (as mentioned earlier) which would lead to
a state of identity moratorium in young people.
Furlong (1), a British professor in sociology, addresses hikikomori from a
sociological viewpoint by discussing the socioeconomic changes, the nature of
Japanese inter-human relations, the Japanese educational system and the problems
of medicalization of hikikomori in a rather successful attempt to explain the
phenomenon. The process of shutting out the world describes the hikikomori
situation well, with key triggers represented by various crossroad in the transitional
process, Furlong writes and continues by comparing the Western and Japanese
approaches towards an individual experiencing an identity moratorium: Essentially,
in many western societies, false-starts are not considered problematic as there are
frequently second chances and alternative routes without [risking] long-term
10

Suwa gives examples of thoughts such as in reality, he/she is a superior and good child or he/she is not a
child who ends with this

damage, where as in Japan the stakes are higher and it is much more important
to make direct transitions [into adulthood].
Furlong also suggests the existence of five sub-categories of hikikomori with
common traits and features (1);
1) The psychologically impaired young people in need of psychiatric treatment
2) The anxious travelers young people undergoing difficult transitions in life,
experiencing identity moratoria and withdraw into their own home or room
3) The Otaku

11

socially incompetent geeks with a nearly obsessive interest

in manga, gaming and/or internet culture without any psychiatric diagnosis

4) The alternative scene individuals unwilling to conform to existing social norms
idealizing education and employment
5) The lonely and isolated young people who have not chosen to withdraw from
society and human interaction but whom are socially isolated, a state they
strive to break free from.

In my interpretation, sub-category 2 could be perceived as primary hikikomori

as described by Suwa, and sub-category 1 as secondary hikikomori. On the other
hand it is not clear as to why Furlong wants to include sub-categories 3, 4 and 5 to
this phenomenon as a clear, common denominator is lacking in all three of them.
Individuals that could be included in sub-categories 3-5 do not wish to seclude
themselves from society. Categories 3 and 4 in particular can simply be seen as a way
to hold a very personal identity, to express oneself and ones opinions, and these
individuals do not suffer from their behavior.
Similarily, Borovoy (39) in her paper on hikikomori argue that hikikomori is
best understood as the outcome of multiple kinds of social, medical and emotional
problems and continues by describing the mainstreaming of Japanese education,
the general structure and methods of practice in mental health care clinics and
institutions, the view of mental illness in Japan and mindsets more or less unique to
the Japanese people12 to fit hikikomori into the sociocultural framework.
Presented with what is known so far, I reason that a sociocultural explanation
(such as offered by Suwa, Furlong and Borovoy and others) currently are the best
attempts to describe the etiology of, as well as the behavior, seen in hikikomori. This

11

Otakuliterally meaning your honorable home, has come to be used as a term for describing individuals
with a strong interesting in (or the subculture revolving around) manga and anime, often spending their free time in their rooms watching
anime, reading manga, playing video games or surfing the internet. Such otaku have a varying degree of social interaction.
12
E.g. how nobody in anyway ought to deviate from what is considered normal, how the parents are responsible for the care of their
children and so on

also helps explaining why hikikomori mainly is seen in Japan and has not occurred
to any greater extent in economically comparable countries. I do not trivialize the
fact that hikikomori to some extent (33-80%) may suffer from some mental
diagnosis; on the contrary. I believe it is absolutely necessary to do a full psychiatric
screening for such diagnosis in hikikomori cases in order to be able to provide the
proper treatment and support to these individuals (and their families) with the aim
of improving or resolving their medical/psychiatric disorder. However, in these
cases, hikikomori is merely a symptom of other disorders, and should not be
considered as something that in itself has a solution separate from the psychiatric
diagnosis ascribed to that patient. As such, I find it might be a bit excessive to
problematize around such secondary hikikomori, as the social withdrawal might
be eased or even discontinued with proper treatment or aid. Moreover, I fail to see
the true benefits of utilizing the terms secondary hikikomori or hikikomori-like
state as these will just widen the concept instead of narrowing it down, which is
crucial at this point to minimize confusion and misunderstandings. As mental illness
is highly stigmatized in Japan (partly due to the aforementioned deru kui ha
utareru proverb), it has been argued that the concept of hikikomori might in fact
act as an acceptable cover for other, actual psychological disorders such as
schizophrenia, mental retardation, ADD/ADHD or MDD (39), due to the frequent
appearance of hikikomori in Japanese media (1). In my opinion, it is better for the
patient and the family members in the long run to clearly mention the primary
diagnosis by its rightful name, although it indeed will be difficult for them to face
initially, and to not label these patients as secondary hikikomoris. Doing so is
nothing short of simply masking the patients condition. This might also help
bringing up the topic of mental health issues and lessen the taboo surrounding
psychiatric diagnoses in the general public in Japan.
CONCLUSION
I have here presented the background and current hypotheses regarding the
phenomenon of hikikomori, or social withdrawal. With an estimated 700,000
individuals, many in their prime of working age, secluded from society, the
socioeconomic effects of hikikomori are to be considered as substantial and the
problem needs to be address with seriousity even in the future. Current theories
based on sociological approaches suggest that changes on a high social level
(reformation of the educational system, providing information on mental disorders,
preparing the youth for the transition into adulthood etc.) might be needed to avoid
future cases of hikikomori. Suggestions for main objectives of future research would

be to determine the sociological psychopathological factors leading to hikikomori,

organize and execute RCTs in order to find the ideal psychological or
pharmacological interventions and to evaluate and improve the support given to
relatives. Long-term studies on hikikomori cases (regarding mental health,
improvement, risk of relapse and so on) might be worth carrying out as well. Finally,
would a definite diagnosis of essential hikikomori to be formed in the future, it is
important to inform patients, families and the general public of the true nature of
such hikikomori, not to be mistaken for hikikomori-like states of other mental
disorders, especially highly stigmatized diagnoses such as schizophrenia, depression,
anxiety disorders or mental retardation.
As for now, hikikomori remains a puzzle to be solved by further psychiatric,
psychological and sociological research. To be or not to be, that is the question
waiting to be answered in the case of hikikomori.

List of References
1.

Furlong A. The Japanese hikikomori phenomenon: acute social withdrawal among young people. Sociol Rev. 2008;56(2):30925.

2.

Teo AR. A new form of social withdrawal in Japan: a review of hikikomori. Int J Soc Psychiatry. Mar 2010;56(2):17885.

3.

Sait T. Hikikomori no rikai (Tokushk | Imadoki no wakamonotachi).Gekkan Fukushi. Nov 2012;95(13):203.

4.

Sait T. Shakaiteki hikikomori: Owaranai shishunki.Tky: PHP Kenkyjo; 1998.

5.

Suwa M., Hara K. Hikikomori among young adults in Japan: the importance of differential diagnosis between primary hikikomori
and hikikomori with high-functioning pervasive developmental disorders. Iry Fukushi Kenky Iry Fukushi Gakubu ronsh
henshi'inkai hen. 2007;(3):94101.

6.

Sait T. "Hikikomori"no genzaikei. Kokoro no rinsh a la carte. 2001;(20):1625.

7.

Kato TA, Shinfuku N, Sartorius N, Kanba S. Are Japans hikikomori and depression in young people spreading abroad? Lancet. 17 Sep
2011;378(9796):1070.

8.

Jones M. Shutting Themselves In. The New York Times [Internet]. 15 Jan 2006 [cited 18 Jan 2015]; Available from:
http://www.nytimes.com/2006/01/15/magazine/15japanese.html

9.

Gozlan M. The growing band of young people living a reclusive life. The Guardian [Internet]. 17 Jul 2012 [cited 18 Jan 2015]; Available
from: http://www.theguardian.com/world/2012/jul/17/growing-band-young-people-reclusive-life

10.

Grisafe M. Can Culture Create Mental Disease? The Rise of Hikikomori in Japan in the Wake of Economic Downturn [Internet]. 2012
[cited 18 Jan 2015]. Available from: http://www.mindthesciencegap.org/2012/11/16/can-culture-create-mental-disease-the-rise-ofhikikomori-in-the-wake-of-economic-downturn-in-japan/

11.

Hornyak T. A world of fear for Japans shut-ins [Internet]. 2014 [cited 18 Jan 2015]. Available from:
http://www.japantimes.co.jp/culture/2014/09/13/books/book-reviews/world-fear-japans-shut-ins/

12.

Thunqvist J. Hikikomori - barnen som stnger in sig. [Internet]. Barnen. 2009 [cited 18 Jan 2015]. Available from:
http://sverigesradio.se/sida/avsnitt/81912?programid=787

13.

Lagerblad A. Hikikomori, del 2 - Starka familjeband leder till isolering. SvD.se [Internet]. 21 Oct 2014 [cited 18 januari 2015]; Available
from: http://www.svd.se/nyheter/idagsidan/starka-familjeband-leder-till-isolering_4030443.svd

14.

Suwa M. `Hikikomori(Social Withdrawal) Phenomenon. J Med Welf JMW. 2006;2:239.

15.

Konishi T., Minamide K.. Jniasu Waei Jiten dai 2 han. 2 edition.Tky: Taishkan shoten; 2003.

16.

Kitahara Y. Meiky Kokugo Jiten. Tky: Taishkan shoten; 2002.

17.

Colman AM. Oxford Dictionary Of Psychology. Oxford; New York: Oxford University Press; 2009.

18.

Ministry of Health, Labour and Welfare. 10 dai 20 dai wo chshin to shita hikikomori wo meguru chiki seishin hoken katsud no
gaidorain. Tky: Ksei rd sh; 2003.

19.

Teo AR, Gaw AC. Hikikomori, a Japanese culture-bound syndrome of social withdrawal? A proposal for DSM-5. J Nerv Ment Dis. juni
2010;198(6):4449.

20.

Garca-Campayo J, Alda M, Sobradiel N, Sanz Abs B. [A case report of hikikomori in Spain]. Med Clnica. 08 Sep 2007;129(8):3189.

21.

Ovejero S, Caro-Caizares I, de Len-Martnez V, Baca-Garcia E. Prolonged social withdrawal disorder: a hikikomori case in Spain. Int J
Soc Psychiatry. September 2014;60(6):5625.

22.

Malagn-Amor A, Crcoles-Martnez D, Martn-Lpez LM, Prez-Sol V. Hikikomori in Spain: A descriptive study. Int J Soc Psychiatry.
09 Oct 2014;

23.

Furuhashi T, Figueiredo C, Pionni-Dax N, Fansten M, Vellut N, Castel P-H. [Pathology seen in French Hikikomori]. Seishin
Shinkeigaku Zasshi. 2012;114(10):11739.

24.

De Michele F, Caredda M, Delle Chiaie R, Salviati M, Biondi M. [Hikikomori: a culture-bound syndrome in the web 2.0 era]. Riv
Psichiatr. augusti 2013;48(4):3548.

25.

Sakamoto N, Martin RG, Kumano H, Kuboki T, Al-Adawi S. Hikikomori, is it a culture-reactive or culture-bound syndrome?
Nidotherapy and a clinical vignette from Oman. Int J Psychiatry Med. 2005;35(2):1918.

26.

Teo AR. Social isolation associated with depression: a case report of hikikomori. Int J Soc Psychiatry. Jun 2013;59(4):33941.

27.

Lee YS, Lee JY, Choi TY, Choi JT. Home visitation program for detecting, evaluating and treating socially withdrawn youth in Korea.
Psychiatry Clin Neurosci. May 2013;67(4):193202.

28.

Wong PW et al. The prevalence and correlates of severe social withdrawal (hikikomori) in Hong Kong: A cross-sectional telephonebased survey study. Int J Soc Psychiatry. 24 Jul 2014;

29.

Kondo N, Sakai M, Kuroda Y, Kiyota Y, Kitabata Y, Kurosawa M. General condition of hikikomori (prolonged social withdrawal) in
Japan: psychiatric diagnosis and outcome in mental health welfare centres. Int J Soc Psychiatry. February 2013;59(1):7986.

30.

II Hikikomori-gun, hikikomori shinwa-gun no teigi [Internet]. [cited 18 Jan 2015]. Available from:
http://www8.cao.go.jp/youth/kenkyu/hikikomori/pdf/gs2.pdf

31.

Miyake Y. A survey of hikikomori based on an epidemiological study. Tokyo Rep Health Labour Sci Res Grants Board. 2002;

32.

Koyama A et al. Lifetime prevalence, psychiatric comorbidity and demographic correlates of hikikomori in a community population
in Japan. Psychiatry Res. 30 Mar 2010;176(1):6974.

33.

UNdata | Country profile | Japan [Internet]. [cited 18 Jan 2015]. Available from:
http://data.un.org/CountryProfile.aspx?crname=Japan

34.

Sait T. Hikikomori to futk(Tokush Wakamono no seishinhoken(1)). Ksheisei. May 2013;77(5):3559.

35.

Kuramoto H. Hikikomori no yogo.Seishin igaku. 2003;45:2416.

36.

It J. Shakaiteki hikikomori ni kan suru sdan enjo jky jittaichsa chiikiseishinhokenkatsud ni okeru kainy no arikata ni kan suru
kenky sgkenkyjo hkokusho [Internet]. 2003 [cited 17 Jan 2015]; Available from: http://ci.nii.ac.jp/naid/80016386954

37.

Kondo N et al. The Psychiatric background of Social Withdrawal in Adolescence. Psychiatr Neurol Jpn. Sep 2007;109(9):83443.

38.

Kitamura A et al. An investigation about progress of school inattendance and dropout in senior high schools. Bull Nara Univ Educ Nat
Sci. Oct 2007;56(2):218.

39.

Borovoy A. Japans hidden youths: mainstreaming the emotionally distressed in Japan. Cult Med Psychiatry. Dec 2008;32(4):55276.

40.

Kobayashi et al. Shakaiteki hikikomori wo kakaeru kazoku ni kan suru jittaichsa. Seishin igaku. Jul 2003;45(7):74956.

41.

Suwa M, Suzuki K, Hara K, Watanabe H, Takahashi T. Family features in primary social withdrawal among young adults. Psychiatry Clin
Neurosci. Dec 2003;57(6):58694.

42.

Kondo N. Social Withdrawal in the Adolescent and Young Adult. Psychiatr Neurol Jpn. Jul 2001;103(7):55665.

43.

Watanabe A et al. An examination of the determinants of social withdrawal and affinity for social withdrawal. Jpn J Psychol.
2010;81(5):47884.

44.

Inui A et al. Fuantei wo ikiru wakamono-tachi [Internet]. Tokyo, Japan: tsuki-shoten; 2006 [cited 18 Jan 2015]. Available from:
http://eprints.gla.ac.uk/54432/

45.

Nakamura K. Taijinkyfush to hikikomori. Rinsh seishinigaku. 1997;26:116976.

46.

Davies RJ, Ikeno O. The Japanese mind: understanding contemporary Japanese culture. Boston: Tuttle Pub.; 2002.

47.

Kondo et al. The Psychiatric background of Social Withdrawal in Adolescence. Psychiatr Neurol Jpn. Sep 2007;109(9):83443.

48.

Suwa M, Suzuki K. Psychopathological Features of Primary Social Withdrawal. Psychiatr Neurol Jpn. Dec 2002;104(12):122841.

49.

Ikeuchi N. Life of the people who have experienced hikikomori (social withdrawal). Dec 2012;18:2739.

50.

Kaneko S. Japans Socially Withdrawn Youths and Time Constraints in Japanese Society. Time Soc. 2006;15(2-3):23.

51.

Funakoshi A, Miyamoto Y. Significant factors in family difficulties for fathers and mothers who use support services for children with
hikikomori. Psychiatry Clin Neurosci. 12 Aug 2014;