Pathological Social Withdrawal (Hikikomori) in Indian Adolescents: A Case Series

Abstract

Hikikomori, a form of pathological social withdrawal, has gained international recognition beyond its initial description in Japan. The COVID-19 pandemic has heightened awareness of social withdrawal behaviors globally, yet data from India remains limited. We present three cases of adolescents aged 16 years who met the updated diagnostic criteria for hikikomori: marked social isolation at home for ≥6 months with significant functional impairment. All three cases presented with concurrent psychiatric comorbidities, including major depressive disorder, obsessive-compulsive disorder, and social anxiety disorder. Duration of social withdrawal ranged from 8 to 24 months. Functional impairment was evident across educational, social, and occupational domains. Treatment response was partial despite multimodal interventions including pharmacotherapy and cognitive-behavioral therapy. These cases met updated hikikomori criteria and fit secondary hikikomori, with persistent withdrawal despite symptom relief, implying need for targeted exposure-based, family-informed, and engagement-focused care. COVID-19 context likely precipitated but did not fully explain persistence, supporting a pathological pattern in a high-expectation family milieu. These cases demonstrate the clinical presentation of hikikomori in the Indian context, highlighting the need for early recognition and specialized interventions for pathological social withdrawal in adolescents.

Introduction

Adolescence represents a critical developmental period characterized by significant psychological, social, physiological, and cognitive transformations. ¹ This developmental stage is also marked by the emergence of various psychiatric disorders, often presenting initially with non-specific symptoms such as school absenteeism and social withdrawal. ² The COVID-19 pandemic has significantly amplified behavioral problems in children and adolescents, including excessive internet usage, online gaming addiction, and consequent social isolation.^3,4 Hikikomori, originally described in Japan, refers to a condition of severe social withdrawal typically affecting adolescents and young adults. Initially conceptualized as a culture-bound syndrome unique to Japanese society, hikikomori has subsequently been reported across diverse cultural contexts worldwide, challenging its culture-specific classification.^5,6 The phenomenon has gained increasing attention from the international psychiatric community, particularly following the social isolation measures implemented during the COVID-19 pandemic.^7,8

The most recent proposed diagnostic criteria for hikikomori, established by Kato et al. in 2020, define the condition as: marked social isolation in one’s home, continuous social isolation for at least 6 months, and significant functional impairment or distress associated with social isolation. ⁹ Age of onset typically occurs during adolescence or early adulthood, though later onset has been documented.^9,10 Additional specifiers may include lack of social participation, absence of in-person social interaction, reliance on indirect communication, and feelings of loneliness. ⁹ A critical distinction has emerged between primary and secondary hikikomori.^11,12 Primary hikikomori refers to social withdrawal occurring without concurrent psychiatric illness, while secondary hikikomori describes withdrawal that occurs in the context of other mental health conditions.^11,13,14 This classification is crucial for treatment planning and understanding the heterogeneity of presentation.^12,15 The development of standardized assessment tools, particularly the 25-item Hikikomori Questionnaire (HQ-25), has facilitated more systematic evaluation of this condition. ¹⁶ The HQ-25 has been validated across multiple cultures and languages, demonstrating good psychometric properties. ¹⁷ More recently, the Hikikomori Diagnostic Evaluation (HiDE) has been proposed as a structured diagnostic interview to standardize clinical assessment. ¹⁸

Despite growing international recognition, there remains a paucity of literature describing hikikomori in the Indian context. One case report from India documented a presentation of hikikomori with internet gaming disorder in an adolescent male. ¹⁹ Here, we present three cases of adolescents who presented with severe social withdrawal meeting the diagnostic criteria for hikikomori, occurring concurrently with various psychiatric comorbidities. These cases highlight the complexity of differentiating primary from secondary hikikomori and underscore the challenges in the management of pathological social withdrawal in the Indian context.

Case Presentations

Case 1

A 16-year-old male presented with 2 years of history of persistent low mood, decreased social interaction, and suicidal ideation. Past history included childhood attention difficulties, concealed bullying during secondary school, and Tourette syndrome at the age of 10 years, which remitted following tetrabenazine and clonazepam treatment. Severe social withdrawal began during the COVID-19 lockdown (2020-2021), concurrent with enrollment in open schooling for medical entrance preparation. He progressively isolated himself to his room, engaging only with online classes or mobile gaming, stopped playing basketball and other activities, and developed irregular sleep-eating patterns with rare home exits. Academic engagement declined with the cessation of online attendance. Over the next 2-3 months, he started to complain of being a “failure” and that he did not see a good future, unlike his siblings, both of whom were medical professionals. He also had ideas of self-harm and expressed it to his parents, who sought psychiatric help for him. Multiple outpatient trials of antidepressants along with low doses of anti-psychotics and benzodiazepines proved ineffective, necessitating hospitalization. Mental state examination revealed depressed mood with blunted affect, suicidal ideation without specific plans, and adequate insight. Comprehensive evaluation excluded ADHD, autism spectrum disorder, and Asperger’s syndrome. Treatment included escitalopram up to 30 mg, etizolam up to 1.5 mg, and aripiprazole 10 mg/day, as well as ketamine injections along with cognitive-behavioral therapy (CBT). Beck Depression Inventory scores showed inconsistent patterns. During the course of CBT, one specific cognitive theme of the patient stood out during most of the clinical interviews that he “did not like any human contact” and that living with even his family was burdensome. Cognitive distortions identified were labeling, catastrophization, and emotional reasoning. He often expressed his desire to live alone in a rented accommodation in the same housing society where his family lived. Despite family agreement, financial constraints prevented separate living. He resided in a separate room in the same house with minimal social contact. After 1 year, he enrolled in a Bachelor’s psychology program, but social withdrawal persisted despite therapeutic interventions.

Case 2

A 16-year-old male presented with 5 years of trichotillomania history, 2 years of compulsive reading/rewriting behaviors, and 1.5 years of depressive symptoms. COVID-19 lockdown precipitated an escalation from four to five daily gaming episodes to eight to nine hours daily. Academic obsessive doubts emerged, requiring four to five repetitions for memorization, causing anxiety when the pattern was disrupted. School avoidance developed with progressive mood deterioration and reduced social interaction. Paradoxically, trichotillomania decreased untreated. After 10th grade, he enrolled in private coaching but avoided classes, claiming peer weight-based ridicule. This triggered repetitive weight-checking behaviors. Complete home confinement ensued, with daily activities restricted to 7-8 hours of gaming and television. Parental limit-setting attempts caused irritability, necessitating hospitalization. Mental state examination revealed body image preoccupation, obsessive doubts, academic-specific compulsions requiring four to five repetitions, and poor insight. Treatment comprised fluvoxamine 250 mg, clomipramine 50 mg, aripiprazole 2 mg with CBT. An activity schedule was formulated in consultation with the patient, and his mother was made a co-therapist to assist in ensuring his compliance. Behavioral strategies such as graded-task assignment were utilized to increase his academic and non-academic engagement and prevent solitary confinement in his room. His mood would be rated on a mood diary, and cognitive distortions were identified (predominantly selective abstraction, dichotomous reasoning, and personalization), and he was trained to generate alternate positive thoughts. Yale-Brown Obsessive-Compulsive Scale improved (24 to 16), Hamilton Depression Rating Scale scores reduced (17 to 6). Despite symptomatic improvement, academic re-engagement remained absent. The academic stream was changed as per the patient’s request, yet school attendance continued to be absent. He engaged in gaming for most of his waking hours and had no social connections. This pattern persisted for 6-8 months with irregular compliance for psychotherapy.

Case 3

A 16-year-old male presented with a history of intrusive thoughts and low mood for 8 months, and anger outbursts for 4 months, precipitated by academic stress after enrollment in competitive exam coaching in 11th grade. He had maintained above-average academic performance, completing 10th grade with 90% marks. Initially, he managed coursework appropriately for approximately 1 month. Gradually, concept comprehension became difficult, and homework completion became challenging. Persistent low mood developed, present throughout most days. Separation anxiety emerged, with reluctance to go anywhere without his mother. Intrusive thoughts developed involving fears of choking himself to death. These ego-dystonic thoughts were recognized as his own but occurred against his will. Similar aggressive obsessions emerged on seeing knives, leading to requests for their removal from sight. Additional intrusive thoughts involved fears of running away, resulting in clinging behavior toward parents. These thoughts persisted throughout most of the day, causing anxiety. Initial psychiatric inpatient treatment with fluvoxamine 100 mg, risperidone 2 mg, clonazepam 0.5 mg, and thought-stopping techniques provided limited improvement. Academic engagement ceased, and he remained confined to his home. Irritability and anger outbursts intensified, becoming unmanageable at home, prompting re-admission. Pharmacological management involved cross-tapering fluvoxamine with escitalopram up to 20 mg, risperidone with haloperidol up to 10 mg (for aggression management), and gradual clonazepam increase to 1 mg daily followed by slow tapering. A structured behavioral therapy plan was implemented. Interventions included activity scheduling and graded-task assignment to address academic avoidance, exposure-based strategies for anxiety and separation behaviors, and stimulus control techniques to reduce reassurance-seeking. For aggression management, anger monitoring, relaxation training (deep breathing and progressive muscle relaxation), and parent-mediated contingency management were employed to reinforce adaptive behaviors and reduce outbursts. After discharge, aggressive outbursts improved; however, no improvement was noted in academic re-engagement and social isolation.

Discussion

These three cases illustrate a distinct pattern of prolonged social withdrawal that is not adequately accounted for by standardized diagnostic systems alone. This complex presentation can be explained by the phenomenon of hikikomori in Indian adolescents, highlighting several important clinical and theoretical considerations. All cases met the updated diagnostic criteria proposed by Kato et al., ⁹ : marked social isolation at home, duration exceeding 6 months, and significant functional impairment across multiple domains. The classification of these cases as secondary hikikomori is supported by the presence of concurrent psychiatric disorders, consistent with the distinction proposed by Li and Wong. ¹¹ Case 1 presented with major depressive disorder, Case 2 and 3 with obsessive-compulsive disorder and associated conditions. Secondary hikikomori may respond to treatment of underlying psychiatric conditions, although, as demonstrated in these cases, resolution of primary symptoms does not necessarily translate to improved social functioning. This suggests that social withdrawal may become a self-perpetuating pattern requiring specific interventions beyond treatment of comorbid conditions. The temporal relationship between COVID-19 lockdown measures and the onset or exacerbation of social withdrawal in these cases reflects broader global patterns.^7,8 The pandemic created conditions conducive to social withdrawal, including enforced isolation, increased digital engagement, and disrupted educational routines.^20,21 Post-pandemic research has emphasized the need to distinguish between adaptive temporary withdrawal during public health emergencies and pathological social withdrawal requiring clinical intervention. The persistence of withdrawal behaviors beyond pandemic restrictions, as demonstrated in these cases, supports a pathological rather than adaptive interpretation.

These cases demonstrated limited response to conventional psychiatric treatments, despite apparent improvement in primary psychiatric symptoms. This suggests that social withdrawal may require specialized interventions targeting specific mechanisms maintaining avoidance behaviors. CBT approaches specifically adapted for hikikomori, including graded exposure and family-based interventions, may be more effective than general CBT approaches. ²² The resistance to treatment engagement noted in Case 2 reflects a common challenge in hikikomori populations. Motivational interviewing techniques and family-based interventions may be crucial for engagement and retention in treatment. Digital and telepsychiatry approaches, which gained prominence during the pandemic, may offer acceptable alternatives for individuals reluctant to engage in face-to-face treatment.

Family dynamics played significant roles in all cases, ranging from supportive accommodation of withdrawal behaviors to conflict over academic and career expectations. The emphasis on academic achievement and professional success in Indian families may contribute to social withdrawal when adolescents perceive themselves as unable to meet these expectations. Cultural factors influencing family cohesion, individual autonomy, and social expectations require consideration in understanding hikikomori in Indian contexts. The accommodation of withdrawal behaviors by families, while initially supportive, may inadvertently maintain avoidance patterns. Family psychoeducation and training in exposure-based interventions may be crucial components of treatment. ²³

A few limitations of this case series include a small sample size and retrospective assessment, precluding the use of standardized hikikomori-specific instruments. Follow-up periods were relatively short, preventing assessment of long-term outcomes. Selection bias toward more severe cases presenting to tertiary care settings may not represent the broader spectrum of hikikomori presentations.

Conclusion

This case series provides a detailed description of hikikomori presentations in Indian adolescents using updated diagnostic criteria and highlights the need for increased awareness of hikikomori among Indian mental health professionals. Early identification and intervention may prevent progression to more severe and treatment-resistant presentations. The COVID-19 pandemic appears to have facilitated the onset or exacerbation of withdrawal behaviors in vulnerable adolescents. Future research should focus on prospective studies using validated assessment instruments, examination of prevalence in community samples, and development of culturally adapted treatment interventions.