It was Aristotle who said, "Man is by nature a social animal, an individual who is unsocial naturally and not accidentally is either beneath our notice or more than human." While the validity of the latter part of the quote is debatable, the first half is certainly true. Human beings thrive off of social interactions, it directly influences their mental health and promotes overall well-being. It is habitual for people to undermine the importance of this aspect of human life. But it is when they are faced with the extreme manifestation of neglecting social interactions that they understand its significance.
Hikikomori has been an emerging topic of study in psychiatry since the 1990s, and is characterised by physical isolation in one's home, compounded by significant functional impairment or distress related to this isolation, and a sustained duration of symptoms for at least six months. While patients with Hikikomori require unique consideration, studies spanning the globe have revealed that comorbidity of Hikikomori with various other psychiatric disorders, such as autism spectrum disorder and major depressive disorder, is common.
Although originally described and defined in the Japanese subcontinent, Hikikomori is now a worldwide phenomenon that affects millions of individuals. But unlike other commonly faced transcultural and transcontinental phenomena like depression or anxiety, Hikikomori has no formal standardised diagnostic procedure or treatment prescribed. The most obvious reason is that social withdrawal is scarcely considered within existing tools such as the Structured Clinical Interview for DSM-5 (SCID-5), the Composite International Diagnostic Interview (CIDI) and the Mini-International Neuropsychiatric Interview (MINI). The SCID-5 AND MINI are used as screening tools for major personality and psychiatric disorders respectively, whilst the CIDI consists of a series of structured modules that screen for somatoform disorders, anxiety, depression, mania, schizophrenia, eating disorders, impairments in cognition, and substance use disorders. It is thus apparent that social withdrawal does not meet the criteria of diagnostic labels according to current standardised international psychiatric assessment tools.
In 2013, the Kyushu University Hospital established the world's first outpatient clinic for Hikikomori in the hopes of researching the pathology and finding better methods of treatment. With the recent COVID-19 pandemic and the social isolation it brought along with it, it's all but natural that there must have been a global rise in Hikikomori patients. Thus, it is the need of the present to introduce a diagnostic procedure to assess the same. The new HiDE assessment tool, developed by Associate Professor Takahiro A. Kato of the Graduate School of Medical Sciences and published in World Psychiatry, is intended to be the next step in a transcultural tool to help identify and assess Hikikomori individuals.
The HiDE is a clinician-administered tool that requires 5 to 20 minutes to complete. It is suggested that the full HiDE be administered to patients who:
a) spend 1 hour or less outside their house at least three days per week
b) feel bothered by this behaviour (or those around the patient feel bothered by it).
Kato and his team report that the tool is divided into two sections, the first focuses on essential features required to diagnose Hikikomori. Interestingly, researchers found patients to have overemphasised brief social outings (like taking out the trash) as evidence of leaving the house. Thus researchers have laid emphasis on the purpose and duration of outings. Concerns by others (like family or friends) regarding functional impairment are counted as a marker for diagnosis as patients tend to deny or undermine their distress.
The second section tries to gather supplementary details that aren't necessarily essential for diagnosis but help provide context to patients’ behaviour. These include social participation, personal interests, attending medical/counselling appointments etc. Researchers lay emphasis on identifying whether social interactions amount to actual conversations for in their experience most patients consider exchanging greetings as meaningful social interactions.
In my opinion, there are numerous anticipated issues behind trying to quantify something as abstract and intangible as social isolation. This is exactly why researchers have taken decades to come up with a diagnostic tool like the HiDE despite the fact that social isolation has been a phenomenon dating far back. Previously discussed however, is the fact that social isolation is not currently formally diagnosable and thus not treatable. As Alan Teo, lead author of the paper proposing HiDE says: “You can’t treat something if you can’t agree on what it is, and if you can’t diagnose it in the first place”. The Kyushu University researchers have thus implemented the HiDE as a tool in their practice for diagnostic and future treatment purposes.
But just like any research study, there is a need for further empirical studies to confirm the tool’s validity beyond just the Kyushu hospital practice. Kato and his team have hence urged colleagues across the globe to help test HiDE’s reliability and validity and thus help introduce necessary changes if need be. They hope that a collective effort in this direction will help move hikikomori into the mainstream of diagnostic assessment in psychiatry.
Picture Credits: https://images.app.goo.gl/iY4aNRjGM6TvzztH6
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