SOCIAL WITHDRAWAL

Severe social withdrawal also termed as Hikikomori is a serious socio-psychological disorder that mainly affects adolescents and young adults who live cut off from the world, locked in their bedrooms for days, month and even years on end. Hikikomori is defined as complete withdrawal from society for 6 months or longer.  They refuse to interact even with their family, use internet profusely, and only venture out to deal with their most imperative bodily needs. Many such person turn to internet and sometimes spend more than 12 hours daily in front of the computer. More than half of such patients (hikikomori) are at risk of internet addiction and about 10% will fit into the diagnostic criteria for such an addiction.        

Though the disease originally described in Japan, it is found in several other countries including India. Due to prejudice and lack of knowledge, family members do not respond directly to the patient with social withdrawal. They are unable to intervene at all and tend to turn blind eye for many years without seeking any professional help. 

Diagnosis:

The diagnosis of social withdrawal is based on medical history and clinical evaluation only. Social withdrawal can be classified into “primary hikikomori” or “secondary hikikomori”. Primary social withdrawal is not associated with any underlying psychiatric disorder whereas secondary social withdrawal is causes by an established psychiatric disorder like depression, social anxiety disorder, social phobia etc. The doctor should differentiate between primary and secondary social withdrawal by excluding any concurrent psychiatric disease to effectively manage the disease.   

In the proposed criteria there is some overlap in the diagnosis of Hikikomori and internet addiction. Loss of interest in social activity and difficulty in interpersonal relationship is common is both the conditions. Up to 56% of people with social withdrawal may be at risk of developing internet addiction.

Recently there are reports of few biomarkers in blood to diagnose this disease but it requires further evaluation and confirmation.      

Causes:

Psychological factors are extremely common causes of hikikomori. Other causes associated with social withdrawal are biological (brain), cultural (extreme dependence on parents), social, parental influences, personality traits (introverted, temperamental shyness), mood disorder, and psychiatric diseases. Poor academic performances combined with high expectations is also one of the factor for hikikomori. Breakdown of social cohesion, urbanization, technological progress and globalization may have a role in the phenomenon of social withdrawal. A major contributing factor may be the evolution of communication from direct to indirect and physically isolating. Social interaction which used to require face to face contact in mutual physical space can now occur in virtual world. A preference for online communication may play in the role of social withdrawal.  The disease is more prevalent in urban population.

Management of Social Withdrawal:

Management of social withdrawal is usually delayed in the course of the disease due to family resistance to address the issue for reasons of guilt, shame, fear, social stigma and lack of knowledge. The goal of the treatment is to break their physical and social isolation and push them to adopt an active role in the society.

Most important part of the management of social withdrawal is to differentiate between primary and secondary disease i.e. exclude the presence of any underlying psychiatric illness. If there is any psychiatric disease, relevant treatment of the same should be offered. Hospitalization may be required in certain cases with serious functional impairment and appropriate drug treatment and/or psychotherapy for depression, schizophrenia or social phobia may be indicated. The management of primary social withdrawal (when no evidence of any psychiatric illness) is mainly done through home visits and psychotherapy. Evidence for benefit of any drug in primary disease is very limited.  Physical exercises may have a favorable effect in this disorder. The treatment is usually lengthy as sustained engagement in therapeutic process is uncommon and only minority of cases achieves full social participation.       

Within few years, following advances in internet society, more and more people may come live a hikikomori like existence, which may or may not be seen as a pathological condition at that time. Hikikomori is a hidden epidemic in many countries and to grasp its worldwide relevance, diagnostic criteria should be included.     

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