558

INTERNATIONAL JOURNAL

OF

SOCIAL PSYCHIATRY 56(5)

HIKIKOMORI: A NEW DIAGNOSIS OR A SYNDROME ASSOCIATED WITH A PSYCHIATRIC DIAGNOSIS?

ANGELES MALAGN 1, PATRICIA ALVARO 1, DAVID CRCOLES 1, LUIS M. MARTN-LPEZ 1 AND ANTONIO BULBENA 1

Dear Editor In the March issue Dr. Alan R. Teo (2010) reviewed the syndrome of hikikomori described in Japan. The interest of the paper is provided by the impact of the problem, the controversy in the diagnosis and the fact that this subject has never before been reviewed in the English medical literature. In our country there has recently been published a case that has also motivated controversies: hikikomori is a new diagnosis (Garcia-Campayo et al., 2007) or a syndrome associated with a psychiatric diagnosis (Gariup et al., 2008). We agree with Teo (2010) that the limited number of case studies is due to underdetection and also, in our opinion, the symptom of isolation and the difculties families have in asking for help. This argument is made from our experience in implementing a specialized psychiatric mobile unit: over four years of practice and 475 cases, social isolation has been the third most common reason for consultation. We now report a severe case of social isolation which demonstrates the seriousness of the problem, the difculty of access and management of these patients and the diagnostic difculties. The case concerns a 46-year-old male, who remained at home alone for 25 years, with no psychiatric history. When he was 20 years old he suffered from a sexual assault. Since then he has refused to go outside and remains locked in his room, listening to the radio or reading. During the reclusion he has completely neglected his personal hygiene and keeps a hoard of newspaper clippings. After the death of his mother, his father asked for help from hospital psychiatry services and the specialized mobile unit was activated. After several home visits, a rst diagnostic approach was made of obsessive compulsive disorder (OCD) and an unspecied depressive disorder. We planned follow-up home visits and prescribed treatment with uoxetine 20 mg/day. In the course of followup, the patient was less cooperative and he left the drug treatment. He expressed ideation of death and autolysis and displayed life-threatening behaviours (such as going several days without eating or sleeping). This prompted admission to an acute unit. In a mental status examination, the patient presented obsessive symptoms, rituals concerning personal hygiene and daily activities, mainly related to clothes (folding clothes and making the bed sheets) and putting things in order.
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Institute Neuropsychiatric and Addictions (INAD), Hospital del Mar, Barcelona International Journal of Social Psychiatry. The Author(s), 2010. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav Vol 56(5): 558559 DOI: 10.1177/0020764009376612

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Neuropsychological testing revealed no cognitive abnormalities. Personality testing, Minnesota Multiphasic Personality Inventory (MMPI-2) and SCID-II revealed personality traits characterized by a threatening and negative perception of the media, low frustration tolerance, social inhibition and hypersensitivity to negative evaluation proles consistent with a pattern of cluster C, according to DSM-IV-TR. Clinical interviews and the Yale-Brow ObsessiveCompulsive Scale (Y-BOCS) also revealed the existence of symptoms of obsessive rituals related to both personal care and daily activities. Therefore, the diagnostic approach was OCD. In this period he did not meet the diagnostic criteria for post-traumatic stress disorder. During hospital admission the patient was treated with uvoxamine and risperidone at low doses. He began to leave the hospital, which showed progression and also led to sharing different activities with his father. At discharge he was referred to day hospital with the idea to normalize his habits and behaviour. In this case the isolation syndrome supports the argument that social isolation is a symptom associated with a variant of psychiatric diagnoses (OCD, schizophrenia, personality disorder). Independent of the controversy, the need for research in this area is of great importance (Watts, 2002). It is a very serious medical condition for which the patient cannot always be properly assessed. Without treatment the disorder can evolve to become more refractory, causing further deterioration.

REFERENCES Garcia Campayo, J., Alda, M., Sobradiel, N. and Sanz Abs, B. (2007) A Case Report of Hikikomori in Spain. Medicina Clinica (Barc) 129(8), 318319. Gariup, M., Parellada, E., Garcia, C. and Bernardo, M. (2008) Hikikomori or Simple Schizophrenia? Medicina Clinica (Barc) 130(18), 718719. Teo, A.R. (2010) A New Form of Social Withdrawal in Japan: A Review of Hikikomori. International Journal of Social Psychiatry 56(2), 178185. Watts, J. (2002) Public Health Experts Concerned about Hikikomori. The Lancet 30(359), 113. Corresponding author: Luis M. Martn-Lpez, Institute Neuropsychiatric and Addictions (INAD), Hospital del Mar, Barcelona. Email: 94779@parcdesalutmar.cat