Hikikomori, a Japanese culture-bound syndrome of social withdrawal?

A form of severe social withdrawal, called hikikomori, has been frequently described in Japan and is characterized by
adolescents and young adults who become recluses in their parents' homes, unable to work or go to school for months or
years. The aim of this study was to review the evidence for hikikomori as a new psychiatric disorder. Electronic and
manual literature searches were used to gather information on social withdrawal and hikikomori, including studies
examining case definitions, epidemiology, and diagnosis. A number of recent empirical studies have emerged from Japan.
The majority of such cases of hikikomori are classifiable as a variety of existing Diagnostic and Statistical Manual (DSM)
psychiatric disorders. However, a notable subset of cases with substantial psychopathology does not meet criteria for any
existing psychiatric disorder. We suggest hikikomori may be considered a culture-bound syndrome and merits further
international research into whether it meets accepted criteria as a new psychiatric disorder. Research diagnostic criteria for
the condition are proposed.
Taijin kyofusho ( taijin kyfush, TKS, for taijin kyofusho symptoms), is a Japanese culture-specific
syndrome. The term taijin kyofusho translates into the disorder (sho) of fear (kyofu) of interpersonal relations (taijin).
This culture-bound syndrome is a social phobia dealing with social anxiety. Those who have Taijin Kyofusho are likely to
be extremely embarrassed of themselves or displeasing to others when it comes to the functions of their bodies or their
appearances. These bodily functions and appearances include their faces, odor, actions, or even looks. They do not want to
embarrass other people with their presence. This culture-bound syndrome is based on fear and anxiety.
The symptoms of this disorder include avoiding social outings and activities, rapid heartbeat, shortness of breath, panic
attacks, trembling, and feelings of dread and panic when around people. The causes of this disorder are mainly from
emotional trauma or psychological defense mechanism.
Recognizing Mental Illness in Culture-bound Syndromes
Case Scenario:A 24-year-old graduate student from Japan visited our university student health clinic with concerns about
body odor. He reported having an offensive body odor for the past several months, and told me that he bathed daily and
had tried countless deodorants without successfully eliminating the odor. His dental hygiene was also excellent. Despite
living in the United States for the past year, he had made few real friends. Although none of his fellow students
commented about it, he felt increasingly ashamed about his problem and seldom left his apartment except to attend
classes. Now he felt others were starting to avoid him, and he sought medical help out of desperation.
A review of systems was remarkable for difficulty falling asleep and a poor appetite, but no weight loss. He had no
previous health problems and did not take medications. He denied any history of depression, substance abuse, or academic
problems. He also denied having hallucinations or thoughts of self-harm, and adamantly denied being depressed.
However, he asserted that he needed to rid himself of his terrible body odor.
Despite limited English fluency, the patient was a good historian with good grooming. He appeared withdrawn and had a
depressed, anxious affect. No body or breath odor was noted, and his physical examination was unremarkable.
My impression was that the patient was clearly depressed, and his mood was probably complicated by social phobia and
an adjustment disorder (culture shock). The offensive body odor did not appear to be grounded in reality, and likely
represented a manifestation of a mood disorder.
Unfortunately, the patient became very distressed when his problem was attributed to mental health issues rather than a
physical cause. It became clear that he did not want to try antidepressant medications or attend counseling sessions. He
did agree to make a follow-up appointment for a second opinion. How do I help a foreign patient manage his mental
illness, especially when his culture stigmatizes the disease?