COULD IT BE AGORAPHOBIA OR HIKIKOMORI?

By Carol W. Berman, M.D.

Imagine being stuck in your house. Every time you attempt to leave, terrible fear grips you. So, it’s just easier to hide inside, instead of going out. The term for it in English is “agoraphobia” from the Greek words “agora,” meaning marketplace; and “phobia,” which means fear. The Japanese call it “hikikomori.” They believe it occurs mostly in adolescents, although many older adults suffer from it too.

A patient of mine, who I’ll call Alice,* was a tall, pleasant woman whom I’d treated for depression for years. She was in her late sixties when she was struck by a severe depression that didn’t respond to her usual antidepressants. We tried various medications until one finally worked. Fortunately, the medication relieved her of her blues, insomnia, and lack of appetite. Even though she went back to normal emotionally, one aspect of her wasn’t normal. She couldn’t go out of her apartment! She had been a fulltime administrator in a big company, a totally involved citizen in charity projects, a mother and a wife, but suddenly she was completely housebound.

At first, her husband tried to encourage her to go out with him on what had been daily walks. She refused. The only time she went out was to see me. Then her husband had to drive her to my office, even though I was only half a mile away. She wore dark sunglasses and a hat to cover her hair, making her look like a 50’s starlet in disguise. She had enjoyed going to her hairdresser once per month, but now she said she was ashamed to go there and let the hairdresser see her all grey. She also was embarrassed to walk past the doormen in her building, afraid they’d criticize her.

Alice* didn’t have panic attacks which is the usual scenario for people with agoraphobia. Patients with panic attacks are afraid they will have one while they’re outside. Escape from a situation in which they’re having a panic attack could be difficult or embarrassing. Anxiety leads to a pervasive avoidance of being outside alone.

Alice* stayed in her apartment, frustrating her husband, who was accustomed to going everywhere with her. She also avoided her daughter and other family members who wanted to do things with her. I tried my best to work with her on this problem.

She explained that she felt embarrassed to be out because people would see that she had grown fat and didn’t dye her hair. I recommended exercise which would take care of the weight gain and she could go to the hairdresser and get her hair done as usual. She refused to do any of her normal activities outside the apartment.

She finally agreed to try CBT [cognitive behavioral therapy], which is recommended for patients with agoraphobia. The CBT psychologist tried desensitization and flooding by walking Alice* outside, trying to desensitize her to the outdoors and flooding her system with outdoor activities over a period of several weeks. Alice hated it. When she was done with the therapy, she still refused to go outside.

Seven years later she is still housebound. Her husband and family have given up on trying to get her to change. In fact, they may even be enabling her to be in this condition, because they do everything for her, i.e., shopping, instead of forcing her to do it herself. I have to resign myself to the fact that this is one patient who does not respond to medications or therapy. She is stuck in her position and she is most like hikikomori sufferers in Japan.

In Japan, people with hikikomori are more common than here. These patients are stuck in their houses, watching movies, obsessed with the internet, and computer games. In Japan, it is assumed that the patient’s family will handle the situation so how many cases actually exist is uncertain. Attempts to assess, diagnose, or explain the phenomenon have been met with controversy.

While the hikikomori phenomenon is similar to agoraphobia and shut-in behavior in our country, the Japanese culture seemingly enables it to the extreme. In the West, people will usually go to a psychiatrist if they're having mental troubles. In Japan, it's shameful to have a child or even an adult in the family who requires a psychiatrist; hikikomori sufferers are kept secret.

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*Not her real name.