By Channing Joseph

When Tohepo turned 26, he locked himself inside his bedroom and did not come out again for four years. Unable to work, date or make friends, he had lost all his self-confidence. Suddenly, behind the four cramped walls of his room, time seemed to stop. The outside world became unreal.

Only after a long-awaited reunion with his grandmother did it finally dawn on him how much time had passed. “She had gotten much older than I had expected,” he said, “and yet I was thinking that I had stayed young.”

Tohepo is one of about 230,000 people in Japan who are experiencing a severe form of social withdrawal that scientists are struggling to understand. It is called “hikikomori” (hee-kee-koh-moh-ree). The word -- Japanese for “withdrawal” -- is defined by the Japanese government as isolation lasting for more than six months.

The Option To Opt-Out

Since the phenomenon gained recognition in the 1990s, concern about it has grown. But avoidance of human contact is only one part of what it means to have hikikomori. Many people with hikikomori grapple with painful feelings of anxiety over their isolation and over their future. According to Yuichi Hattori -- a psychologist who specializes in treating them -- people with hikikomori typically have difficulty communicating their thoughts and feelings. He told MTV News that the resulting distress and alienation that this causes can be so intense that, “it’s not unusual to hear a client [of mine] say: ‘Actually, I’m not a human being.’”

For some, the withdrawal from society comes quickly, after what would appear to be a minor incident -- such as an insult from a school bully or a look of disapproval from a supervisor at work. For others, there is no single trigger -- as with Tohepo’s gradual loss of confidence. There is a tendency for some to slink out of their homes in the middle of the night to wander the streets when they are sure that no one they know will see them, while some others spend every waking moment alone -- typically cared for by their mothers, who assiduously bring meals to their bedroom doors each day and who always clean up afterward.

Dr. Alan Teo, an assistant professor of psychiatry at Oregon Health & Science University and a leading U.S. specialist on hikikomori, noted that while Western parents might object to caring for a grown child in this way, the arrangement can sometimes be more acceptable in Japan, where parents are often reluctant to force their children to leave the home.

And interestingly, some people with hikikomori say that their isolation can be pleasurable -- at least sometimes.

Tohepo told MTV News that people with hikikomori love to “spend all of our time not for other people but only for ourselves.”

“We can completely seclude ourselves from society, and we enjoy this situation,” he added. “At the same time, strong anxiety and fear about the future seizes us.”

A Symptom Of A Cultural System

So what exactly is hikikomori? Is it biological or psychological? Is it an anxiety disorder? A form of depression? Schizophrenia? At this point, no one can answer those questions with great certainty.

Even the precise definition of hikikomori is being debated: The Japanese psychiatrist Tamaki Saito, who coined the term in 1998, defined it to mean those young people who withdraw completely from society by the latter half of their 20s and for whom no other psychiatric disorders are a better explanation.

On the other hand, Teo, the professor from Oregon, does not include age in his definition. He said a person with hikikomori requires four features: “physical isolation, profound avoidance of social contact, significant distress or impairment in one's daily life, and persistence of symptoms for at least six months.” Still other researchers in Korea disagree with him, saying it takes just three months rather than six to count as hikikomori.

So far, one thing that the experts do agree on is that the phenomenon is a result of many different factors.

Some, like Teo, believe that hikikomori is a psychiatric condition called a “cultural syndrome.”

"There is sufficient evidence now to describe hikikomori as a cultural concept of distress in Japan," he explained. "Hikikomori is both a recognizable cluster of symptoms (a so-called cultural syndrome), and a well-understood term for isolative behavior (a cultural idiom of distress) in Japan."

He continued, "But I would also emphasize that even with strong cultural influences in Japan on hikikomori, we have more and more tantalizing evidence of hikikomori well beyond the confines of Japan."

One tendency Teo sees with people with hikikomori is that many have had strained relationships with their mothers and distant or nonexistent relationships with their fathers. It is a common issue across Japan, where husbands are expected to spend more time at work than at home.

Other experts -- like Dr. Takahiro Kato, an associate professor of neuropsychiatry at Kyushu University -- include the rise of the Internet and video games as factors in the development of the phenomenon. Such technologies, Kato observed, “have brought about a lessened need to make upfront contact with other human beings” and “create a sense of satisfaction” in the absence of that contact.

Kato also points to Japan’s practice of shaming those who fail to conform to expectations as well as its high-pressure education system, known for intense school bullying and months of cramming for high school and college entrance tests -- a ritual widely referred to as “exam hell.”

“The somewhat pathological schooling system in Japan” leads to “not only hikikomori but also young-age suicide,” he added.

The job market appears to play a role too: Many Japanese college grads have had trouble snagging full-time positions in the sluggish economy. In 2011, the number of university students who expected not to have a job by graduation reached a record high of nearly one-third. Within the country’s labor system, that is a potential crisis because a person’s first job out of college is a crucial step to securing lifelong employment at a particular company, along with guaranteed pay raises for each year of service. Graduates who miss that first step may never be able to find permanent work, and even if they do, they may never catch up with their higher-paid peers. That knowledge can lead them to crippling shame and self-doubt -- and thus to hikikomori.

Japanese economists, like Yuji Genda of the University of Tokyo, are concerned that these lonely, unemployed young adults are weighing down the country’s economy during what should be their prime working years. In a 2013 paper in Japan Labor Review, Genda urged the Japanese authorities to “do everything possible to stop increasing isolation among nonemployed individuals.”

“Unless we expand such efforts steadily,” he wrote, “we will be unable to end the decrease in the number of working individuals in their prime age.”

Supporting, Recovering, Relapsing, and Withdrawing

There is obvious concern about who will care for the isolated when their parents die. In fact, government officials have been so worried about the long-term ramifications of hikikomori that they have opened support centers across the country to help treat people with it and to integrate them back into society.

Suguru Matsusaka, a 28-year-old man from Osaka, sought help from one such center after being isolated for three years because he felt so ashamed about not being able to find a job after college graduation. During that period, he stayed at home, cared for by his mother, who brought him every meal.

Suguru told MTV News that at times, he even contemplated suicide.

Fortunately, though, he worked up the nerve to call the local center. The social workers there have since helped him get a job as a landscaper, but he still wrestles with his need to withdraw, which he calls his “mental disease.”

About two years ago, Tohepo, now 33, left his room -- after four years of isolation -- and also sought help in a local support center, called Yokayoka, in his hometown of Fukuoka City. That is where he met Kato, the Kyushu University professor and one of the foremost experts on the study and treatment of hikikomori. Kato later put him in contact with MTV for this report, and Tohepo agreed to tell his story on the condition that we not print his full name.

For a brief period, after getting counseling and participating in Yokayoka’s organized group activities -- which included things like going to the gym, telling stories and visiting local coffee shops -- Tohepo actually felt well enough to get a part-time job.

But in the last year, he has relapsed.

“I strongly want to recover from my state of withdrawal,” he said, “however, I still don’t have enough courage to go back to society.”

Until relatively recently, hikikomori was believed to be unique to Japan, but researchers have now documented hikikomori and hikikomori-like cases in several other countries -- including France, Hong Kong, India, Korea, Oman, Spain and the United States -- raising fears that the poorly understood condition is spreading.

“It is predominant in Japan, but it is not exclusive to Japan,” Teo said.

The Spread Of Hikikomori

Kato -- who lives in Japan but works closely with Teo in Oregon -- believes hikikomori outside of Japan will continue to increase as the world’s cultures, lifestyles and ideas become more similar and interconnected. In fact, hikikomori has already achieved a certain fame and allure within some sectors of pop culture in the U.S. and elsewhere, and that has apparently inspired some people to identify with the condition.

For example, Tatsuhiko Takimoto’s critically acclaimed 2002 novel “Welcome to the N.H.K.” features a 22-year-old hero who battles hikikomori for four years after dropping out of college. The book was later adapted into a beloved anime series, and since the show’s premiere in 2006, it has been easy to find message boards with fans wondering whether they are experieincing hikikomori.

“I am not depressed …,” one commenter wrote. “I have never thought of committing suicide or [harming] myself, but I am a hikikomori. I didn't know that there was a term for what I am until I watched the anime … .”

Two characters with hikikomori also appear in Ernest Cline’s award-winning 2011 science-fiction novel “Ready Player One” -- about a dystopian world in which millions of young people spend every free moment hooked into a virtual reality video game. Warner Bros. is now adapting the cult favorite into a major feature film, which Steven Spielberg signed on to direct in March.

“Mr. H.,” the first reported patient with hikikomori in the United States, was one such fan of Japanese culture who came to identify with the phenomenon he had seen portrayed in books and movies.

“He was very into Japanese culture and a Buddhist,” Teo told MTV News, “and thus I think hikikomori particularly resonated with him.”

Teo described “Mr. H.” in a 2012 paper in the International Journal of Social Psychiatry. According to the report, he was a 30-year-old white man who identified himself as having hikikomori after being unable to leave his apartment for a period of three years. For the first year of that time, he had stayed inside a walk-in closet -- playing video games, and eating packaged food provided by his housemate.

“Mr. H.” told Teo that he kept himself so isolated because of a contempt for society, yet he also expressed a strong desire to overcome that feeling and go out again.

After undergoing only 25 psychotherapy sessions and receiving some medication to relieve his anxiety, he was able to leave his apartment and find a part-time job. But the case of “Mr. H.” is somewhat unusual. As with Tohepo and Suguru, recovery from hikikomori is often much more difficult, even with psychotherapy, and many do not seek treatment at all. Of those who do, only a few improve significantly.

“What we know so far is that recovery is hard,” Teo said. “It’s in the range of less than a third who recover.”

Finding A Way To Blossom

Successful recovery is one of the riddles that scientists would like to solve and why their research is continuing.

In a recent project, Teo and his colleagues asked themselves whether hikikomori might not be a new phenomenon at all but just a more socially accepted term to refer to a variety of different illnesses, like schizophrenia or depression. But in a new paper, just accepted for publication in the journal Psychiatry Research, the team presents evidence that hikikomori may indeed be a separate condition.

After testing 22 self-identified patients with hikikomori for about 50 recognized mental conditions, the researchers found that most of the socially issued participants in the study did show symptoms of other problems, like post-traumatic stress and bipolar disorders. A few, however, did not meet the established criteria for any recognized illness -- they seemed to have pure hikikomori.

Teo hopes that future studies, including some looking at images of hikikomori brains, will help scientists decide whether the condition should be officially classified as a new “disorder” in the next version of the DSM, the manual used by psychiatrists. That new classification would bring much broader attention to the condition as well as more help to those who are fighting to emerge from their often painful isolation.

Noriko Ohashi, a Tokyo artist who provided artwork for this story, told MTV News that she hopes young people contending with the condition today -- like Tohepo and Suguru -- will get the message that they can get better.

During her own bout with hikikomori when she was 17, she avoided all human contact and did nothing but read and sleep for eight months. “My mind was full of fear, abandonment, a sense of guilt and anger,” she said. “I was thinking I was a loser.”

Eventually, with the help of a friend, Noriko came out of her isolation, and looking back on the experience, she mused, “I think I was in a kind of cocoon, or a bud.”

Years later, her teenage daughter went through a hikikomori period too. Noriko worried about her at first but soon knew that everything would be okay, she said -- because something interesting happens in the life of every bud.

“Someday it blooms.”