INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 35(2) 191-198, 2005
HIKIKOMORI, IS IT A CULTURE-REACTIVE OR
CULTURE-BOUND SYNDROME? NIDOTHERAPY
AND A CLINICAL VIGNETTE FROM OMAN
University of Tokyo
RODGER G. MARTIN
Sultan Qaboos University
University of Tokyo
Sultan Qaboos University
Hikikomori, a form of acute social withdrawal, is becoming a silent epidemic
in Japan. As it has not been reported from other parts of the world, hikikomori
fulfills the criteria for “a culture-bound syndrome.” We report a case from
Oman, in the southern part of Arabia, with all the essential features of
hikikomori. We speculate that the social environment of Japanese and Omani
society could reinforce behavior akin to hikikomori although this condition
may also transcend geography and ethnicity.
(Int’l. J. Psychiatry in Medicine 2005;35:191-198)
A predisposition toward fear in social situations, when coupled with shyness, can
lead to behavioral inhibition . Because of this, these individuals have decreased
? 2005, Baywood Publishing Co., Inc.
social interaction and their avoidant behavior and anti-social nature lead to a
diminished quality of life. Worldwide studies have shown that different groups
vary in their level of social interaction . Such differences in temperament
across different ethnic groups indicate that sociocultural factors may play a role
in shaping antisocial and avoidant behavior. Child rearing practices and other
methods of socialization such as education and religion have been suggested
as possible factors . In Japan, Hikikomori is a recently described condition
characterized by antisocial and avoidant functioning leading to school non-
attendance or withdrawal from society [4, 5]. Community surveys have sug-
gested it as a silent epidemic and it has become the subject of media coverage and
a recent novel in which the leading figure suffers from Hikikomori . It is
considered to be a culture bound trait unique to Japan and linked to the hermetic
nature of traditional Japanese society and its value placed on the nobility of
solitude . We describe a clinical vignette from Oman that is characterized by
social isolation and a reclusive lifestyle. Evaluation did not reveal the presence
of any pervasive and persistent distress. To our knowledge, this is the first case
of hikikomori reported outside Japan.
SD is a 24-year-old Omani who was “coerced” by a family member to seek
consultation at the Department of Behavioral Medicine, Sultan Qaboos Univer-
sity Hospital, Muscat, Oman. A relative said that SD suffered from “prolonged
reclusiveness and loneliness” for the previous five years that resulted in him
having minimal contact with people including his family. Family members
noted that he was resistant to doing work that was arranged by the family.
Similarly, he did not want to go to vocational training. Inquiry into his personal
life revealed normal developmental milestones. He was described as being shy
since childhood. There was no history of psychiatric or neurological disorders
in the family.
On a subsequent visit, when rapport was established and the interview was
conducted without accompanying family members, SD was more proactive. He
denied symptoms indicative of psychological disorder, adverse life experience or
presence of substance abuse. His complaint was simply a preference to be alone.
He had stopped socializing and mingling with other people after being bullied
by other students from his class. In one incident, a teacher abruptly asked him
to give a comment on the topic under discussion in the classroom. He stammered
become even more reclusive. He kept these incidents to himself. Although he had
a dependent relationship with his mother, he was worried that his domineering
father would despise him for “not fighting back” or for being overly “sensitive
192/ SAKAMOTO ET AL.
education with an average performance.
SD was unsuccessful in finding a job and gradually drifted further into reclu-
siveness. He described himself as having no desire for a close bond with his
He preferred to spend his time in his own room and to be left alone undisturbed.
The father often knocked on his door to scold him for being lazy and condemn
him for not praying or doing something meaningful for himself. He told us that
he preferred staying in the dark. He slept during the day time and stayed awake
at night watching satellite television or playing video games. Food was left at
his door and he returned the trays when finished. When family members were
away during working hours or at sleep at night, he was noted to tiptoe into
the kitchen to replenish his supplies for his room.
During our meetings with him, SD complained that his family had taken him to
various hospitals in Oman and nearby countries to get him “treated,” which he
strongly disliked. He had been diagnosed as having “depression” and “negative
type schizophrenia.” But information on how such diagnoses were reached was
patchy. Various psychotropic medications were prescribed but he never took
them. In accordance with the local explanatory model of illness in Oman ,
his behavior was thought to be instigated by spirit possession, so the family
also consulted various religious healers but to no avail. At one point, a local
shaman was consulted with no benefit. On the whole, both traditional and bio-
medical interventions made little impact on his interpersonal functioning that
deviated markedly from the expectations of his family.
Except for his reclusiveness and antisocial behavior, his psychiatric and cog-
nitive assessment elicited no abnormalities (Mini-Mental State Examination 
and non-verbal test of intellectual functioning, Raven’s Standard Progressive
Matrices ). Neuropsychological testing that assessed his temporal organization
of behavior and cognitive rigidity, such as the Modified Wisconsin Card Sorting
Task and Verbal Fluency (Controlled Oral Word Association Test) , were all
normal for his age and education. No neurological abnormalities were found.
We decided to use psychological measures to reduce his reclusiveness.
However, he was resistant. His family sought advice on how they could do
something in the house to help SD. The treating team invited the family for
a session of nidotherapy . Nidotherapy aims to modify the environment
to minimize its impact on an individual’s functioning. Rather than adopting a
hostile attitude toward him, the family was encouraged to be accommodating
and reduce their caustic tone whenever they encountered him in the house. The
father stopped knocking on his door to wake him up. When family members
reduced their criticisms of him, he began to selectively socialize with some
of them. Occasionally he agreed to venture with a family member out for a
drive, picnic, or dining out. In the last year, when a job vacancy opened that
entailed only evening shifts, he agreed to work. His evening shift had minimal
interaction with other people. On our last contact with the family, seven years
after SD had developed reclusive behavior and two years after being brought in
for psychiatric consultation, he remains well and now has been given a full
time job at his workplace.
The clinical vignette above describes a reclusive young man with insidious
and amplified by his shyness. No protracted medical or formal psychiatric illness
was found. He was noted to sleep all day, wake up in the evening, and stay up
all night watching satellite television or playing video games. There was no
indication that this was due to a delayed circadian rhythm disorder, though this
was not formally explored . Since the patient himself did not wish to have
any treatment, as he did not see himself as having a problem, it was decided
to modify his environment using Nidotherapy. Family members were advised
on how to accommodate him using this approach. According to Tyler ,
nidotherapy tries to minimize the problems the targeted “misfit” creates for the
outside world or vice versa. In contrast to traditional psychotherapeutic principle,
nidotherapy requires the environment to adjust itself to the patient since he or
she is intransigent to treatment or unable to change. It is worthwhile to speculate
on why nidotherapy reduced social isolation, in this case from Oman. Antisocial
behavior is characterized by fear of social-evaluation, so when family members
ceased to put conditions on his behavior, he became less antagonist and more
social, which, in turn, reduced his distress and suffering and improved func-
tioning. When the family members adopted a stance of accommodating his
reclusive interpersonal functioning, his distress that made him resort to his reclu-
sive lifestyle gradually abated.
Are there socio or cultural factors that could have further facilitated recovery
of the present case? In a collective-orientated cultural environment as in Oman,
the social life of an individual is contingent upon his/her relationship with the
family or tribe . Individuals in such a society are forced to be conformist and
may detach from their “authentic self” and thus submerge their own wishes in
order to conform to social standards. Environment being central for emotional
and social support, one implication of such a cultural pattern is that the indi-
vidual’s distress and stress would be reduced if the environment changes rather
than the individual. This is particularly true in collective-oriented societies where
afflictions are viewed as a misfortune directed towards the whole community
rather than the sufferer alone. Jilek and Jilek-Aall have suggested that the chronic
course of transient psychoses can be averted when the community responds to
the initial psychotic episode by sympathetic acceptance, benevolently protective
194/ SAKAMOTO ET AL.
attention and assistance in a culturally prescribed way . Similarly, Koenig
has suggested that the psychotherapeutic intervention is likely to be more effec-
tive when it heightens hope and faith and when it capitalizes on the sufferer’s
reliance on his or her social surroundings .
Does this case fit any of the existing criteria for a psychiatric disorder? In the
Diagnostic and Statistical Manual of Mental Disorders (DSM) , personality
disorders are depicted as enduring patterns of inner experiences and behaviors
that deviate markedly from the expectations of an individual’s culture. SD’s
reclusive behavior appears pervasive and constitutes culturally devalued conduct.
In DSM, the tendency for detachment in the present case would suggest a
diagnosis of schizoid personality disorder . Other possible diagnoses could
include anxiety disorder and their variants and chronic or simple schizophrenia.
To our knowledge, this is the first case outside Japan of antisocial functioning
and avoidant behavior that meets the criteria for hikikomori reported from Japan.
Both hikikomori cases from Japan and this case from Oman appear to have an
enmeshed family background with a strong maternal relationship . Evidence
from Japan suggests that psychosocial correlates of hikikomori include aversive
childhood experiences. The case presented here from Oman was related to the
patient being bullied, cajoled by his peer group, and his inadequate academic
performance. The majority of those afflicted with hikikomori are male and the
eldest child in the home, as in the present case from Oman. Similarly, there is a
tendency to prefer darkness, with a reversal of the sleep/wake schedules. This
issue may need to be explored further as hikikomori could be mediated by a
disturbed circadian rhythm as has been reported elsewhere . Being ego-
syntonic, antagonistic, and resistant to psychotherapeutic intervention, persons
with hikikomori will not seek medical care and are more likely to be overlooked
in clinical settings .
Illness or distress are often experienced in a social and cultural context. It is
therefore worthwhile to speculate on cultural variables that are common in both
Oman and Japan that could influence the expression of antisocial behavior such
as hikikomori. Although it is often thought that cultural patterns and beliefs
protect individuals against various adjustment difficulties, such protection is
apparently eroding with the rising tide of acculturation and globalization. In
the words of Watts, the “generation that has been made vulnerable by affluence
and technological advances” [19, p. 1131]. As a result of this new climate, both
Japanese and Omanis are likely to experience what Emile Durkheim called a
breakdown of social cohesion . One obvious consequence of such changes,
according to the Durkheimian model, is the creation of social drift, alienation, and
the proliferation of social misfits. However, another possible cultural explanation
involves the Japanese and Omani ideas of shame, language complexity, and
moral codes. In both Japan and Oman there is a tendency to regard shame as
an important emotional experience [21, 22]. Although it is an important and
adaptive from a cultural perspective, the social prescription of shame could push
some individuals’ behavior toward social phobia or, for that matter, hikikomori.
In those societies where shaming is an integral part of socialization, it appears that
something akin to social phobia can occur as shame generates concealment out
of the fear of rendering the self unacceptable. Okano , writing on shame and
guilt, expressed the view that shame could lead to avoidance of social intercourse
while guilt was likely to invite confession and forgiveness.
Secondly, various factors, including language and social ideals, reinforce how
individuals should conduct themselves in society. Although language facilitates
the expression of emotions, the presence of rich metaphors and abstractions may
promote a feeling that one is been evaluated by others. This is consistent with
the view that ambiguity in language, as in Arabic and Japanese, often fosters the
fear of being misunderstood during social discourse [23, 24]. Some studies have
suggested a strong association between those languages that have an inherent
tendency for ambiguity and a preoccupation with shame and fear .
Finally, the more moral or ethical codes and customs a society carries, the more
likely it is for its people to succumb to fear of being embarrassed, scrutinized,
preoccupation with self-presentation in social situation that, in turn, could lead to
phobic avoidance of interpersonal relationships. As moral and ethical standards
are insidiously socialized, any individual who falls short of the norm is likely to
feel a sense of inadequacy and fear of evaluation by others, possibly leading to
antisocial and avoidant behavior.
Considering that culture influences maladjustment, does hikikomori consti-
tute a culture-bound syndrome? According to Kiev , the “hardware” or
pathology of diseases remains relatively constant throughout the world, irrespec-
tive of the cultural context in which they appear. Reactions to illness (such as
the unique manifestation of hikikomori) is a by-product of socio-cultural factors.
On this basis, one could classify various reactions to stress as “culture-bound
disorders” within the diagnostic categories of the biomedical model. For example,
hikikomori would be similar to social phobia or personality disorder. Because of
the existence of hikikomori in Japan and Oman and its association to prevailing
social-cultural factors, it is possible hikikomori constitutes a form of distress
that transcends culture and ethnic factors.
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Direct reprint requests to:
Dr. Samir Al-Adawi
Department of Behavioral Medicine
College of Medicine and Health Sciences
Sultan Qaboos University
P.O. Box 35
Muscat, Sultanate of Oman
198/ SAKAMOTO ET AL.