Yatan Pal Singh Balhara

Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary international investigation

PurposeTo explore whether the ‘hikikomori’ syndrome (social withdrawal) described in Japan exists in other countries, and if so, how patients with the syndrome are diagnosed and treated.MethodsTwo hikikomori case vignettes were sent to psychiatrists in Australia, Bangladesh, India, Iran, Japan, Korea, Taiwan, Thailand and the USA. Participants rated the syndrome’s prevalence in their country, etiology, diagnosis, suicide risk, and treatment.ResultsOut of 247 responses to the questionnaire (123 from Japan and 124 from other countries), 239 were enrolled in the analysis. Respondents’ felt the hikikomori syndrome is seen in all countries examined and especially in urban areas. Biopsychosocial, cultural, and environmental factors were all listed as probable causes of hikikomori, and differences among countries were not significant. Japanese psychiatrists suggested treatment in outpatient wards and some did not think that psychiatric treatment is necessary. Psychiatrists in other countries opted for more active treatment such as hospitalization.ConclusionsPatients with the hikikomori syndrome are perceived as occurring across a variety of cultures by psychiatrists in multiple countries. Our results provide a rational basis for study of the existence and epidemiology of hikikomori in clinical or community populations in international settings.

Gender differences in stress response: Role of developmental and biological determinants.

Stress response is associated with manifestations of various psychosomatic and psychiatric disorders. Hence, it is important to understand the underlying mechanisms that influence this association. Moreover, men and women tend to react differently with stress–both psychologically and biologically. These differences also need to be studied in order to have a better understanding in the gender difference observed for many disorders, which are likely to be contributed by the gender difference in stress reactivity and responses. Such an understanding would have a significant impact on our understanding about how adult health is set during early life and how adult disease could be prevented in men and women.

Identification of the hikikomori syndrome of social withdrawal: Psychosocial features and treatment preferences in four countries:

Background: Hikikomori, a form of social withdrawal first reported in Japan, may exist globally but cross-national studies of cases of hikikomori are lacking. Aims: To identify individuals with hikikomori in multiple countries and describe features of the condition. Method: Participants were recruited from sites in India, Japan, Korea and the United States. Hikikomori was defined as a 6-month or longer period of spending almost all time at home and avoiding social situations and social relationships, associated with significant distress/impairment. Additional measures included the University of California, Los Angeles (UCLA) Loneliness Scale, Lubben Social Network Scale (LSNS-6), Sheehan Disability Scale (SDS) and modified Cornell Treatment Preferences Index. Results: A total of 36 participants with hikikomori were identified, with cases detected in all four countries. These individuals had high levels of loneliness (UCLA Loneliness Scale M = 55.4, SD = 10.5), limited social networks (LSNS-6 M = 9.7, SD = 5.5) and moderate functional impairment (SDS M = 16.5, SD = 7.9). Of them 28 (78%) desired treatment for their social withdrawal, with a significantly higher preference for psychotherapy over pharmacotherapy, in-person over telepsychiatry treatment and mental health specialists over primary care providers. Across countries, participants with hikikomori had similar generally treatment preferences and psychosocial features. Conclusion: Hikikomori exists cross-nationally and can be assessed with a standardized assessment tool. Individuals with hikikomori have substantial psychosocial impairment and disability, and some may desire treatment.

Correlates of anxiety and depression among patients with type 2 diabetes mellitus

Context: Research has established the relation between diabetes and depression. Both diabetes and anxiety/depression are independently associated with increased morbidity and mortality. Aims: The present study aims at assessing the prevalence of anxiety/depression among outpatients receiving treatment for type 2 diabetes. Settings and Design: The study was conducted in the endocrinology outpatient department of an urban tertiary care center. Materials and Methods: The instruments used included a semi-structured questionnaire, HbA1c levels, fasting blood glucose and postprandial blood glucose, Brief Patient Health Questionnaire, and Hospital Anxiety and Depression Scale (HADS). Statistical Analysis Used: Analysis was carried out using the SPSS version 16.0. Pearsons correlation coefficient was calculated to find out the correlations. ANOVA was carried out for the in between group comparisons. Results: There was a significant correlation between the HADS-Anxiety scale and Body Mass Index (BMI) with a correlation coefficient of 0.34 (P = 0.008). Also, a significant correlation existed between HADS-Depression scale and BMI (correlation coefficient, 0.36; P = 0.004). Significant correlation were observed between the duration of daily physical exercise and HADS-Anxiety (coefficient of correlation, -0.25; P = 0.04) scores. HADS-Anxiety scores were found to be related to HbA1c levels (correlation-coefficient, 0.41; P = 0.03) and postprandial blood glucose levels (correlation-coefficient, 0.51; P = 0.02). Conclusions: Monitoring of biochemical parameters like HbA1c and postprandial blood glucose levels and BMI could be a guide to development of anxiety in these patients. Also, physical exercise seems to have a protective effect on anxiety in those with type 2 diabetes mellitus.

Diabetes and psychiatric disorders.

Interface of diabetes and psychiatry has fascinated both endocrinologists and mental health professionals for years. Diabetes and psychiatric disorders share a bidirectional association -- both influencing each other in multiple ways. The current article addresses different aspects of this interface. The interaction of diabetes and psychiatric disorders has been discussed with regard to aetio-pathogenesis, clinical presentation, and management. In spite of a multifaceted interaction between the two the issue remains largely unstudied in India.

Heart rate variability study of childhood anxiety disorders

Background: The current study aims at assessment of heart rate variability among children and adolescents with childhood anxiety disorder, using the case-control design. Materials and Methods: The study was carried out at a tertiary care multispecialty hospital. It included 34 children and adolescents with diagnosis of childhood anxiety disorder, in the age range of eight to eighteen years, and 30 age- and sex-matched healthy controls. Heart-rate variability was studied using the standard protocol. Results: Significantly reduced variability of the heart rate was observed in both the time as well as frequency domains in the disorder group as compared to the control group. These findings indicate decreases in the sympathetic and parasympathetic activity in the disorder group, thus representing diminished physiological variability at rest. Conclusions: The notion of autonomic inflexibility, as seen in the current study, has important implications for stability in biological systems. The loss of variability in the physiological systems in general, and in the cardiovascular system in particular, has an association with a number of diseases and dysfunctions.

Introducing the concept of modern depression in Japan; an international case vignette survey

AIM Japanese psychiatrists have increasingly reported patients with depression that does not seem to fit the criteria of the ICD-10 and the DSM-IV, and which has recently been called modern type depression (MTD). We explored whether MTD is frequently seen in Japan and also in other countries, and if so, how patients with MTD are diagnosed and treated. METHODS The questionnaires, with two case vignettes (traditional type depression (TTD) and MTD), were sent to psychiatrists in Australia, Bangladesh, India, Iran, Japan, Korea, Taiwan, Thailand and the USA. Participants rated their opinions about each cases prevalence in their country, etiology, diagnosis, suicide risk, and treatment using Likert scales. RESULTS Out of 247 responses (123 from Japan and 124 from other countries), two hundred thirty-nine valid responses were received. MTD was recognized in all participating countries, and especially in urban areas. Generally, the factor of personality was regarded as the most probable cause of MTD. Whereas about 90% of Japanese psychiatrists applied the ICD/DSM criteria to TTD, only about 60% applied the criteria to MTD. CONCLUSION Our results indicate that Japans MTD seems to be occurring in many other countries, and that the present ICD/DSM criteria may not be sufficient to diagnose MTD. Therefore, it could be an important candidate for a new international diagnostic criterion as a subtype of depression. A clear diagnostic framework and consensus on the interventions to treat MTD would be valuable. Further clinical, psychopathological and international epidemiological studies are needed to confirm our preliminary findings of MTD.

Self-reported mental health problems among adolescents in developing countries: results from an international pilot sample.

Objective: To evaluate the prevalence, pattern, and sociodemographic correlates of self-reported mental health problems among a pilot sample of adolescents from 5 developing countries and to speculate the methodology and design of a larger scale study. Methods: The sociodemographic questionnaire was developed based on extant literature on the sociodemographic correlates of mental health problems among adolescents. Additional information about the socioeconomic status of parents/caregivers of the participants was obtained using the Family Affluence Scale (FAS). Mental health problems were evaluated using the Strength and Difficulty Questionnaire (SDQ). Logistic regression analysis was done to determine independent sociodemographic correlates of mental health problems. Results: A total of 1894 adolescents sampled from 5 countries completed the study. The prevalence of self-reported mental health problems was 10.5% (range, 5.8–15) with conduct and emotional problems being the most prevalent. When the raw total-SDQ scores were adjusted for age, gender, and FAS scores, there was a statistically significant difference in the mean scores among the adolescents from different countries (F = 17.23, p < .001). After controlling for all potential sociodemographic confounders, living with single parents or other nonparent care givers, having a chronic disabling physical condition, lower maternal education, and coming from a family in the lower FAS-score category were all independently associated with higher odds of mental health problems. Conclusions: Study has added to the currently limited data on prevalence of mental health problems among adolescents in developing countries. It further established that socioeconomic and family factors still play a major role in the mental health of children irrespective of region of the world. Significant but surmountable methodological issues for a larger scale study were raised.

Impact of alcohol use on thyroid function.

Alcohol is one of the commonest illicit psychoactive substances consumed globally and is the worlds third largest risk factor for disease and disability. It has been reported to have multiple effects on the hypothalamo-pituitary-thyroid axis and the functioning of the thyroid gland. It has been reported to cause direct suppression of thyroid function by cellular toxicity, and indirect suppression by blunting thyrotropin-releasing hormone response. It causes a decrease of peripheral thyroid hormones during chronic use and in withdrawal. Alcohol use may also confer some protective effect against thyroid nodularity, goiter, and thyroid cancer. This article presents a review of the clinically relevant effects of alcohol on the functioning of the thyroid gland and also discusses the effect of medication used in treatment of alcohol dependence on thyroid function.

Comparison of efficacy between buprenorphine and tramadol in the detoxification of opioid (heroin)-dependent subjects.

AIM/BACKGROUND Tramadol is a synthetic opiate and a centrally acting weak m-opioid receptor agonist. The potential advantages of tramadol include ease of administration, low abuse potential, and being nonscheduled. This study compared tramadol and buprenorphine for controlling withdrawal symptoms in patients with opioid dependence syndrome. METHODS Consenting male subjects between 20 and 45 years of age who fulfilled the ICD-10-DCR criteria for opiate dependence syndrome were randomly assigned in a double-blind, double-dummy placebo-controlled trial for detoxification. Those with multiple drug dependence, abnormal cardiac, renal and hepatic functions, psychosis, or organic mental illness were excluded. Assessments included Subjective Opiate Withdrawal Scale (SOWS), Objective Opiate Withdrawal Scale (OOWS), Visual Analog Scale (VAS), and Side Effect Check List. Subjects were evaluated daily and study duration was 10 days. RESULTS Sixty two subjects were enrolled. The mean SOWS and OOWS and VAS were significantly lower in the buprenorphine group on second and third day of detoxification as compared to the tramadol group. Although the retention rate was higher for buprenorphine group throughout the study, when compared with tramadol the difference was not significant on any day. Three subjects in the tramadol group had seizures. CONCLUSIONS Tramadol was found to have limited detoxification efficacy in moderate to severe opioid withdrawal and substantial risk of seizures as compared to buprenorphine. Further studies are warranted to examine its efficacy in mild opioid withdrawal symptoms and its potential use in outpatient settings where its administration advantages may be valuable.