Hikikomori
A young Japanese man living as a hikikomori in 2004

Hikikomori (Japanese: ひきこもり or 引きこもり, lit. "pulling inward, being confined"), also known as severe social withdrawal,[1][2][3][4][5] is total withdrawal from society and seeking extreme degrees of social isolation and confinement.[6] Hikikomori refers to both the phenomenon in general and the recluses themselves. The concept is primarily recognized only in Japan, although similar concepts exist in other languages and cultures. Hikikomori have been described as loners or "modern-day hermits".[7] Estimates suggest that half a million Japanese youths have become social recluses,[8] as well as more than half a million middle-aged individuals.[9]

Definition

The Japanese Ministry of Health, Labour, and Welfare defines hikikomori as a condition in which the affected individuals refuse to leave their parents' house, do not work or go to school and isolate themselves away from society and family in a single room for a period exceeding six months.[10] The psychiatrist Tamaki Saitō defines hikikomori as "a state that has become a problem by the late twenties, that involves cooping oneself up in one's own home and not participating in society for six months or longer, but that does not seem to have another psychological problem as its principal source".[11]

More recently, researchers have developed more specific criteria to more accurately identify hikikomori. During a diagnostic interview, trained clinicians evaluate for:[12]

  1. spending most of the day and nearly every day confined to home,
  2. marked and persistent avoidance of social situations, and social relationships,
  3. social withdrawal symptoms causing significant functional impairment,
  4. duration of exceeding six months,
  5. no apparent physical or mental etiology to account for the social withdrawal symptoms.

The psychiatrist Alan Teo first characterized hikikomori in Japan as modern-day hermits,[7] while the literary and communication scholar Flavio Rizzo similarly described hikikomori as "post-modern hermits" whose solitude stems from ancestral desires for withdrawal.[13]

While the degree of the phenomenon varies on an individual basis, in the most extreme cases, some people remain in isolation for years or even decades. Often hikikomori start out as school refusers, or futōkō (不登校) in Japanese (an older term is tōkōkyohi (登校拒否)).

Hikikomori has been defined by a Japanese expert group as having the following characteristics:[14]

  1. Spending most of the time at home
  2. No interest in going to school or working
  3. Persistence of withdrawal for more than 6 months
  4. Exclusion of schizophrenia, intellectual disability, and bipolar disorder
  5. Exclusion of those who maintain personal relationships (e.g., friendships)

Common traits

While many people feel the pressures of the outside world, hikikomori react by complete social withdrawal. In some more severe cases, they isolate themselves in their bedrooms for months or years at a time.[15] They usually have few or no friends. In interviews with current or recovering hikikomori, media reports and documentaries have captured the strong levels of psychological distress and angst felt by these individuals.[16]

While hikikomori favor indoor activities, some venture outdoors occasionally.[17] The withdrawal from society usually starts gradually. Affected people may appear unhappy, lose their friends, become insecure and shy, and talk less.

Prevalence

According to Japanese government figures released in 2010, there were at that time 700,000 individuals living as hikikomori within Japan, with an average age of 31.[18] (Population of Japan in 2014 was 127.3 million.) Still, the numbers vary widely among experts. These included the hikikomori who were at that time in their 40s and had spent 20 years in isolation. This group is generally referred to as the "first-generation hikikomori". There is concern about their reintegration into society in what is known as "the 2030 Problem", when they will be in their 60s and their parents begin to die.[18] Additionally, the government estimates that 1.55 million people are on the verge of becoming hikikomori.[18] Tamaki Saitō, who first coined the phrase, originally estimated that there may be over one million hikikomori in Japan, although this was not based on national survey data. Nonetheless, considering that hikikomori adolescents are hidden away and their parents are often reluctant to talk about the problem, it is extremely difficult to gauge the number accurately.[19]

A 2015 Cabinet Office survey estimated that 541,000 recluses aged 15 to 39 existed. In 2019, another survey showed that there are roughly 613,000 people aged 40 to 64 that fall into the category of "adult hikikomori", which Japan's welfare minister Takumi Nemoto referred to as a "new social issue".[9]

While hikikomori is mostly a Japanese phenomenon, cases have been found in the United States,[20] the United Kingdom, Oman, Spain, Germany,[21] Italy, India, Sweden, China, Hong Kong, Taiwan, South Korea, France and Russia.[15][22][23][24][25][26]

Hypotheses on cause

Developmental and psychiatric conditions

Hikikomori is similar to the social withdrawal exhibited by some people with autism spectrum disorder. This has led some psychiatrists to suggest that hikikomori may be affected by autism spectrum disorder and other disorders that affect social integration, but that their disorders are altered from their typical Western presentation because of Japanese sociocultural pressures.[27] Suwa & Hara (2007) discovered that 5 of 27 cases of hikikomori had a high-functioning pervasive developmental disorder (HPDD), and 12 more had other disorders or mental diseases (6 cases of personality disorders, 3 cases of obsessive-compulsive disorder, 2 cases of depression, 1 case of slight intellectual impairment); 10 out of 27 had primary hikikomori. The researchers used a vignette to illustrate the difference between primary hikikomori (without any obvious mental disorder) and hikikomori with HPDD or other disorder.[28] Alan Teo and colleagues conducted detailed diagnostic evaluations of 22 individuals with hikikomori and found that while the majority of cases fulfilled criteria for multiple psychiatric conditions, about 1 in 5 cases were primary hikikomori.[29] To date, however, hikikomori is not included in the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders), due to insufficient data.[30]

According to Michael Zielenziger's book Shutting Out the Sun: How Japan Created Its Own Lost Generation, the syndrome is more closely related to posttraumatic stress disorder. The author claimed that the hikikomori interviewed for the book had discovered independent thinking and a sense of self that the current Japanese environment could not accommodate.[31]

The syndrome also closely parallels the terms avoidant personality disorder, schizoid personality disorder, schizotypal personality disorder, agoraphobia or social anxiety disorder (also known as "social phobia").

Social and cultural influence

Sometimes referred to as a social problem in Japanese discourse, hikikomori has a number of possible contributing factors. Alan Teo has summarized a number of potential cultural features that may contribute to its predominance in Japan. These include tendencies toward conformity and collectivism, overprotective parenting, and particularities of the educational, housing and economic systems.[32]

Severe social withdrawal in Japan appears to affect men and women equally. However, because of differing social expectations for maturing boys and girls, the most widely reported cases of hikikomori are from middle- and upper-middle-class families; sons, typically their eldest, refuse to leave the home, often after experiencing one or more traumatic episodes of social or academic failure.

In The Anatomy of Dependence, Takeo Doi identifies the symptoms of hikikomori, and explains its prevalence as originating in the Japanese psychological construct of amae (in Freudian terms, "passive object love", typically of the kind between mother and infant).[33] Other Japanese commentators such as academic Shinji Miyadai and novelist Ryū Murakami, have also offered analysis of the hikikomori phenomenon, and find distinct causal relationships with the modern Japanese social conditions of anomie, amae and atrophying paternal influence in nuclear family child pedagogy. Young adults may feel overwhelmed by modern Japanese society, or be unable to fulfill their expected social roles as they have not yet formulated a sense of personal honne and tatemae – one's "true self" and one's "public façade" – necessary to cope with the paradoxes of adulthood.

The dominant nexus of hikikomori centres on the transformation from youth to the responsibilities and expectations of adult life. Indications are that advanced industrialized societies such as modern Japan fail to provide sufficient meaningful transformation rituals for promoting certain susceptible types of youth into mature roles. As do many societies, Japan exerts a great deal of pressure on adolescents to be successful and perpetuate the existing social status quo. A traditionally strong emphasis on complex social conduct, rigid hierarchies and the resulting, potentially intimidating multitude of social expectations, responsibilities and duties in Japanese society contribute to this pressure on young adults.[34] Historically, Confucian teachings de-emphasizing the individual and favouring a conformist stance to ensure social harmony in a rigidly hierarchical society have shaped much of East Asia, possibly explaining the emergence of the hikikomori phenomenon in other East Asian countries.

In general, the prevalence of hikikomori tendencies in Japan may be encouraged and facilitated by three primary factors:

  1. Middle class affluence in a post-industrial society such as Japan allows parents to support and feed an adult child in the home indefinitely. Lower-income families do not have hikikomori children because a socially withdrawing youth is forced to work outside the home.[35]
  2. The inability of Japanese parents to recognize and act upon the youth's slide into isolation; soft parenting; or codependency between mother and son, known as amae in Japanese.[36]
  3. A decade of flat economic indicators and a shaky job market in Japan makes the pre-existing system requiring years of competitive schooling for elite jobs appear like a pointless effort to many.[37]

Role of modern technology

Although the connection between modern communication technologies (such as the Internet, social media and video games) and the phenomenon is not conclusively established, those technologies are considered at least an exacerbating factor that can deepen and nurture withdrawal.[38] Previous studies of hikikomori in South Korea and Spain found that some of them showed signs of Internet addiction, though researchers do not consider this to be the main issue.[38] However, according to associate professor of psychiatry at Kyushu University in Fukuoka, Takahiro Kato, video games and social media have reduced the amount of time that people spent outside and in social environments that require direct face to face interaction.[38] The emergence of mobile phones and then smartphones may also have deepened the issue, given that people can continue their addiction to gaming and online surfing anywhere, even in bed.[39]

Japanese education system

The Japanese education system puts great demands upon youth. There is high competition to pass entrance exams into the next tier of education in what could be termed a rigid pass-or-fail ideology, which could induce a high level of stress. Echoing the traditional Confucian values of society, the educational system is viewed as playing an important part in society's overall productivity and success.[40]

In this social frame, students often face significant pressure from parents and the society in general to conform to its dictates and doctrines.[41] These doctrines, while part of modern Japanese society, are increasingly being rejected by Japanese youth in varying ways such as hikikomori, freeter, NEET (Not currently engaged in Employment, Education, or Training), and parasite singles. The term "Hodo-Hodo zoku" (the "So-So tribe") applies to younger workers who refuse promotion to minimize stress and maximize free time.

Beginning in the 1960s, the pressure on Japanese youth to succeed began successively earlier in their lives, sometimes starting before pre-school, where even toddlers had to compete through an entrance exam for the privilege of attending one of the best pre-schools. This was said to prepare children for the entrance exam of the best kindergarten, which in turn prepared the child for the entrance exam of the best elementary school, junior high school, high school, and eventually for their university entrance exam.[42] Many adolescents take one year off after high school to study exclusively for the university entrance exam, and are known as ronin.[43] More prestigious universities have more difficult exams. The most prestigious university with the most difficult exam is the University of Tokyo.[44]

Since 1996, the Japanese Ministry of Education has taken steps to address this 'pressure-cooker' educational environment and instill greater creative thought in Japanese youth by significantly relaxing the school schedule from six-day weeks to five-day weeks and dropping two subjects from the daily schedule, with new academic curricula more comparable to Western educational models. However, Japanese parents are sending their children to private cram schools, known as juku, to 'make up' for lost time.[45]

After graduating from high school or university, Japanese youth also have to face a very difficult job market in Japan, often finding only part-time employment and ending up as freeters with little income, unable to start a family.[46]

Another source of pressure is from their co-students, who may harass and bully (ijime) some students for a variety of reasons, including physical appearance, wealth, or educational or athletic performance. Refusal to participate in society makes hikikomori an extreme subset of a much larger group of younger Japanese that includes freeters.[44][45]

Impact

Japanese financial burden

Some organizations, such as the non-profit Japanese organization NPO lila, have been trying to combat the financial burden the hikikomori phenomenon has had on Japan's economy.[47] The Japanese CD and DVD producer Avex Group produces DVDs of live-action women staring into a camera to help hikikomori learn to cope with eye contact and long spans of human interaction. The goal is to ultimately help hikikomori reintegrate into society by personal choice, thereby realizing an economic contribution and reducing the financial burden on parents or guardians.[48]

"80–50 problem"

The "80–50 problem" refers to hikikomori children from earlier days now entering their 50s, as their parents on whom they rely, enter their 80s.[49] It was first described in Japanese publications and media in the late 2010s.

In 2019, Japanese psychiatrist Tamaki Saitō held a press briefing at the Foreign Press Center Japan on the subject of hikikomori. In view of their rising age, he recommended practical advice to parents with older hikikomori, such as drawing up a lifetime financial plan for them, so they will be able to get by after the parents are gone. He also recommended that parents should not fear embarrassment or be concerned about appearances as they look at the options, including disability pensions or other forms of public assistance for their children. Tamaki emphasized the urgency and necessity for families in these situations to plan ahead; the Japanese government failed to see the urgency of the problem and demonstrated no motion toward developing substantive policies or systems like special safety nets related to the ageing group of hikikomori.[50]

Treatment programs

When it comes to psychosocial support, it is hard for therapists to attain direct access to hikikomori;[51] research to find different and effective treatment plans to aid hikikomori has been ongoing. One such treatment plan is focused on the families of hikikomori. Such focus primarily includes educational intervention programs (e.g. lectures, role-play, etc.) that are geared towards reducing any averse stigma that family members have towards psychiatric disorders like hikikomori.[52] These educational programs are derived from other established family support programs, specifically Mental Health First Aid (MHFA) and Community Reinforcement and Family Training (CRAFT).[53] CRAFT specifically trains family members to express positive and functional communication, whereas MHFA provides skills to support hikikomori with depression/suicidal like behaviour.[53] Studies so far that have modified the family unit's behavioral response to a hikikomori has yielded positive results, indicating that family behavior is essential for recovery, however further research is still needed.[51][53]

Although there has been a primary emphasis on educating family members, there are also therapy programs for the hikikomori themselves to participate in, like exercise therapy. The individual psychotherapy methods that are being stressed in current research are primarily directed towards cultivating self-confidence within the hikikomori.[54] However, studies have delineated that efficacious treatment of hikikomori requires a multifaceted approach rather than the utilization of one individual approach, such as individual psychotherapy or family therapy.[55][56]

COVID-19 pandemic impact

Based on prior outbreaks (e.g. SARS, MERS, etc.), studies have shown that due to increased loneliness, quarantined individuals have heightened stress-related mental disturbances.[52] Considering that political, social, and/or economical challenges already bring people to express hikikomori-like behavior, researchers theorize that since all the aforementioned factors are by-products of a pandemic, a hikikomori phenomenon may become more common in a post-pandemic world.[52][56] In fact, people who do experience mental disturbances in Japan generally view seeking the help of a psychiatrist as shameful or a reason for them to be socially shunned.[52] Experts predict an increase in focus on issues such as the mental health problems now affecting youth, and specifically through effective telemedicine services to either the affected individual and/or their respective family unit.[52][57]

Furthermore, with hikikomori becoming more prevalent amid a pandemic, experts theorize that it will bring out more empathy and constructive attention towards the issue.[52]

See also

References

Notes

  1. ↑ Bowker, Julie C.; Bowker, Matthew H.; Santo, Jonathan B.; Ojo, Adesola Adebusola; Etkin, Rebecca G.; Raja, Radhi (2019). "Severe Social Withdrawal: Cultural Variation in Past Hikikomori Experiences of University Students in Nigeria, Singapore, and the United States". The Journal of Genetic Psychology. 180 (4–5): 217–230. doi:10.1080/00221325.2019.1633618. PMID 31305235. S2CID 196616453.
  2. ↑ Hamasaki, Yukiko; Pionnié-Dax, Nancy; Dorard, Géraldine; Tajan, Nicolas; Hikida, Takatoshi (2020). "Identifying Social Withdrawal (Hikikomori) Factors in Adolescents: Understanding the Hikikomori Spectrum". Child Psychiatry & Human Development. 52 (5): 808–817. doi:10.1007/s10578-020-01064-8. PMC 8405474. PMID 32959142.
  3. ↑ Malagón-Amor, Ángeles; Martín-López, Luis Miguel; Córcoles, David; González, Anna; Bellsolà, Magda; Teo, Alan R.; Bulbena, Antoni; Pérez, Víctor; Bergé, Daniel (2020). "Family Features of Social Withdrawal Syndrome (Hikikomori)". Frontiers in Psychiatry. 11: 138. doi:10.3389/fpsyt.2020.00138. PMC 7061609. PMID 32194459.
  4. ↑ Ovejero, Santiago; Caro-Cañizares, Irene; de León-Martínez, Victoria; Baca-Garcia, Enrique (2014). "Prolonged social withdrawal disorder: A hikikomori case in Spain". International Journal of Social Psychiatry. 60 (6): 562–565. doi:10.1177/0020764013504560. PMID 24101742. S2CID 39990406.
  5. ↑ Hayakawa, Kohei; Kato, Takahiro A.; Watabe, Motoki; Teo, Alan R.; Horikawa, Hideki; Kuwano, Nobuki; Shimokawa, Norihiro; Sato-Kasai, Mina; Kubo, Hiroaki; Ohgidani, Masahiro; Sagata, Noriaki; Toda, Hiroyuki; Tateno, Masaru; Shinfuku, Naotaka; Kishimoto, Junji; Kanba, Shigenobu (13 February 2018). "Blood biomarkers of Hikikomori, a severe social withdrawal syndrome". Scientific Reports. 8 (1): 2884. Bibcode:2018NatSR...8.2884H. doi:10.1038/s41598-018-21260-w. PMC 5811600. PMID 29440704.
  6. ↑ Kremer, William; Hammond, Claudia (5 July 2003). "Hikikomori: Why are so many Japanese men refusing to leave their rooms?". BBC News. BBC. Archived from the original on 22 March 2016. Retrieved 11 March 2016.
  7. 1 2 Teo, Alan (8 November 2012). Modern-Day Hermits: The Story Hikkomori in Japan and Beyond (YouTube). University of Michigan Center for Japanese Studies. Archived from the original on 22 January 2014. Retrieved 26 February 2014.
  8. ↑ Jozuka, Emiko (12 September 2016). "Why won't 541,000 young Japanese leave the house?". CNN News. Archived from the original on 11 November 2017. Retrieved 27 March 2018.
  9. 1 2 "613,000 in Japan aged 40 to 64 are recluses, says first government survey of hikikomori". The Japan Times Online. 29 March 2019. ISSN 0447-5763. Archived from the original on 29 March 2019. Retrieved 29 March 2019.
  10. ↑ Itou 2003.
  11. ↑ Saitō 2012.
  12. ↑ Teo & Gaw 2010; Teo et al. 2015, p. 182.
  13. ↑ Rizzo, Flavio (14 June 2016). "Hikikomori: The Postmodern Hermits of Japan". Warscapes. Archived from the original on 19 June 2016. Retrieved 17 June 2016.
  14. ↑ Stip, Emmanuel (3 March 2016). "Internet Addiction, Hikikomori Syndrome, and the Prodromal Phase of Psychosis". Frontiers in Psychiatry. 7: 6. doi:10.3389/fpsyt.2016.00006. PMC 4776119. PMID 26973544.
  15. 1 2 Teo 2013.
  16. ↑ "Hikikomori: Japan's Lost Generation of Digital Age Hermits". Archived from the original on 12 May 2017. Retrieved 11 May 2017.
  17. ↑ "Articles". vickery.dk. Archived from the original on 8 February 2005.
  18. 1 2 3 Hoffman, Michael (9 October 2011). "Nonprofits in Japan help 'shut-ins' get out into the open". The Japan Times Online. Archived from the original on 28 July 2014. Retrieved 24 July 2014.
  19. ↑ Saitō 1998.
  20. ↑ Chen, Carol W. Berman,Xi (19 January 2022). "COVID Threatens to Bring a Wave of Hikikomori to America". Scientific American. Retrieved 23 January 2022.{{cite web}}: CS1 maint: multiple names: authors list (link)
  21. ↑ "Ein rein japanisches Phänomen?". @GI_weltweit (in German). Retrieved 26 April 2023.
  22. ↑ Kato, Takahiro A.; Kanba, Shigenobu; Teo, Alan R. (2018). "Hikikomori: experience in Japan and international relevance". World Psychiatry. 17 (1): 105–106. doi:10.1002/wps.20497. PMC 5775123. PMID 29352535.
  23. ↑ Gozlan, Marc (9 June 2012). "Des cas d'hikikomori en France". Le Monde (in French). p. 3. Archived from the original on 3 April 2015. Retrieved 7 June 2017.
  24. ↑ McLeod, Hamish J.; Rooksby, Maki; Furuhashi, Tadaaki (29 October 2020). "Hikikomori: understanding the people who choose to live in extreme isolation". The Conversation. Retrieved 2 November 2020.
  25. ↑ Malagón-Amor, Ángeles; Córcoles-Martínez, David; Martín-López, Luis M; Pérez-Solà, Víctor (2015). "Hikikomori in Spain: A descriptive study". International Journal of Social Psychiatry. 61 (5): 475–483. doi:10.1177/0020764014553003. PMID 25303955. S2CID 27277596.
  26. ↑ Андрей Голубь (21 December 2015). "Тяжелая жизнь хикикомори в России". Daily Moscow (in Russian). Retrieved 13 November 2023.
  27. ↑ Kary, Tiffany (2003). "Total Eclipse of the Son: Why are Millions of Japanese Youths Hiding from Friends and Family?". Psychology Today. Retrieved 13 October 2007.
  28. ↑ Suwa & Hara 2007.
  29. ↑ Teo et al. 2015, p. 182.
  30. ↑ Berman, Naomi; Rizzo, Flavio (9 November 2018). "Unlocking Hikikomori: an interdisciplinary approach". Journal of Youth Studies. 22 (6): 791–806. doi:10.1080/13676261.2018.1544416. ISSN 1367-6261. S2CID 150209926.
  31. ↑ Zielenziger 2006.
  32. ↑ Teo, Stufflebam & Kato 2014.
  33. ↑ Doi 1973.
  34. ↑ Rohlen 1989.
  35. ↑ Kudō, Sadaji; Saitō, Tamaki (September 2001). 激論!ひきこもり [Argument! Hikikomori] (in Japanese). Tokyo: ポット出版 [Studio Pot]. ISBN 4-939015-10-6. OCLC 152683407.
  36. ↑ Kudō, Sadatsugu (October 2001). おーぃ、ひきこもり そろそろ外へ出てみようぜ—タメ塾の本 [Hey Hikikomori! It's Time, Let's Go Out] (in Japanese). Tokyo: ポット出版 [Studio Pot]. ISBN 4-939015-10-6.
  37. ↑ Okano & Tsuchiya 1999.
  38. 1 2 3 Gent, Edd (29 January 2019). "The plight of Japan's modern hermits". BBC News. Archived from the original on 29 March 2019. Retrieved 29 March 2019.
  39. ↑ ""Hikikomori": Social Recluses in the Shadows of an Aging Japan". nippon.com. 19 July 2017. Archived from the original on 6 March 2019. Retrieved 29 March 2019.
  40. ↑ Rohlen 1992.
  41. ↑ Rohlen 1996.
  42. ↑ M. White 1987.
  43. ↑ Tsukada 1991.
  44. 1 2 Jones, Maggie (15 January 2006). "Shutting Themselves In". The New York Times Magazine. Archived from the original on 6 April 2016. Retrieved 11 March 2016.
  45. 1 2 "BBC NEWS - Programmes - Correspondent - Japan: The Missing Million". 20 October 2002. Archived from the original on 11 March 2016. Retrieved 11 March 2016.
  46. ↑ Yoshimoto, K, and Japan Institute of Labor. 1996. "High School and Initial Career of Graduates." JIL Report No. 89.
  47. ↑ "NPO法人 楽の会リーラ". NPO lila (in Japanese). Archived from the original on 22 June 2013. Retrieved 18 June 2013.
  48. ↑ "Hikikomori - Japan's Social Ghosts - Kuma Language Services". 18 July 2016. Archived from the original on 29 August 2016. Retrieved 11 August 2016.
  49. ↑ "The '8050 problem' - 'hikikomori' people entering 50s as parents on whom they rely enter their 80s". Japan Today. 14 November 2018.
  50. ↑ "Japan's 'Hikikomori' Population Could Top 10 Million". nippon.com. 17 September 2019.
  51. 1 2 Nonaka, Shunsuke; Shimada, Hironori; Sakai, Motohiro (16 January 2020). "Family Behavioral Repertoires and Family Interaction Influence the Adaptive Behaviors of Individuals With Hikikomori". Frontiers in Psychiatry. 10: 977. doi:10.3389/fpsyt.2019.00977. ISSN 1664-0640. PMC 6976530. PMID 32009999.
  52. 1 2 3 4 5 6 Kato, Takahiro A.; Sartorius, Norman; Shinfuku, Naotaka (27 July 2020). "Forced social isolation due to COVID‐19 and consequent mental health problems: Lessons from hikikomori". Psychiatry and Clinical Neurosciences. 74 (9): 506–507. doi:10.1111/pcn.13112. ISSN 1323-1316. PMC 7404367. PMID 32654336.
  53. 1 2 3 Kubo, Hiroaki; Urata, Hiromi; Sakai, Motohiro; Nonaka, Shunsuke; Saito, Kazuhiko; Tateno, Masaru; Kobara, Keiji; Hashimoto, Naoki; Fujisawa, Daisuke; Suzuki, Yuriko; Otsuka, Kotaro (9 January 2020). "Development of 5-day hikikomori intervention program for family members: A single-arm pilot trial". Heliyon. 6 (1): e03011. Bibcode:2020Heliy...603011K. doi:10.1016/j.heliyon.2019.e03011. ISSN 2405-8440. PMC 6953643. PMID 31938741.
  54. ↑ Nishida, Masaki; Kikuchi, Senichiro; Fukuda, Kazuhito; Kato, Satoshi (29 April 2016). "Jogging Therapy for Hikikomori Social Withdrawal and Increased Cerebral Hemodynamics: A Case Report". Clinical Practice and Epidemiology in Mental Health. 12: 38–42. doi:10.2174/1745017901612010038. ISSN 1745-0179. PMC 4894832. PMID 27346999.
  55. ↑ Ranieri, F.; Andreoli, M.; Bellagamba, E.; Franchi, E.; Mancini, F.; Pitti, L.; Sfameni, S.; Stoppielli, M. (March 2015). "Early Adolescence in Social Withdrawal: Two Hikikomori in Treatment". European Psychiatry. 30: 1198. doi:10.1016/s0924-9338(15)30941-x. ISSN 0924-9338. S2CID 143201325.
  56. 1 2 Wong, Paul W.C. (December 2020). "Potential changes to the hikikimori phenomenon in the wake of the Covid-19 pandemic". Asian Journal of Psychiatry. 54: 102288. doi:10.1016/j.ajp.2020.102288. ISSN 1876-2018. PMC 7352106. PMID 32682300.
  57. ↑ Rooksby, Maki; Furuhashi, Tadaaki; McLeod, Hamish J. (15 September 2020). "Hikikomori: a hidden mental health need following the COVID ‐19 pandemic". World Psychiatry. 19 (3): 399–400. doi:10.1002/wps.20804. ISSN 1723-8617. PMC 7491622. PMID 32931118.

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