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Extreme and long-term social withdrawal, first described in Japan as Hikikomori, has now become a globally recognized mental health problem. Intervention studies severely lag behind epidemiological and phenomenological research. We present two descriptive case reports of Japanese university students with Hikikomori who participated in an early phase test of a structured intervention involving physical activities that was developed and facilitated by clinicians and physical education specialists-Human Movement Consultation (HMC). The two recipients (19- and 29-years old at the start of treatment) completed approximately 40 consultation sessions delivered over 3 years consisting of a combination of outdoor workouts (i.e., walking, running, and cycling) and interpersonal sports (e.g., table tennis, badminton, and tennis). Changes in social withdrawal behavior were independently rated from clinical health records using a structured scale (the Glasgow Hikikomori Scale; GHS). Behavioral observations and scale data for both cases indicated improvements from pre-treatment levels of social withdrawal. At the end of the intervention, both had returned to normative levels of functioning. Case A returned to university and Case B secured a new job upon the completion of HMC. To help advance our understanding of treatment options, these case descriptions analyze potential change mechanisms in order to understand how HMC can support recovery from extreme social withdrawal. One key observation is that both outdoor workouts and interpersonal sports offer a non-threatening method of enabling Hikikomori to engage in interpersonal interactions. Such connections via structured activities may allow the reinstatement of social skills in a graded manner. In addition, an initial focus on physical experiences may help promote psychological and social connectedness without triggering the social fears and challenges that underlie the Hikikomori state. The findings from these two cases offer a framework to guide further research and the development of exercise-based interventions for this hidden and often neglected group.

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This paper will focus on the works of one of Japan's representative psychiatrists, Yomishi Kasahara, particularly on his works in the 1970s in which he proposed the concept of student apathy, and will discuss how this work was carried over into a contemporary topic, the study of "Hikikomori." Kasahara's well-known paper "Clinical Classification of Depression" (Kasahara and Kimura, 1975) described the present state of patients with Type III as "they do not have a complete set of symptoms as in Type I, but sometimes show dependency, strong exaggeration, complication of other neurotic symptoms, little tendency of self-reproaching, and tendency of accusing others"; the two subtypes as Type III-1 "those that remain at the neurotic level" and Type III-2 "those that transiently drop to the psychotic level." We have summarized and introduced below the case presented in the paper with this Type III-1. From today's perspective, where the concept of "Hikikomori" exists, this case could be considered as a typical case of "Hikikomori," that is, a person with a tendency to avoid social roles and responsibilities and to immerse oneself in areas with no responsibilities, such as hobbies. "Hikikomori" was discovered in the late 1980s, but to be precise, it was just that the concept emerged. The same clinical condition had already been brilliantly found by Kasahara in the 1970s under the concept of "apathy syndrome," which was distinguished from depression.

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Increasing evidence indicates that enhanced peripheral carbonyl stress markers exist in subtype of schizophrenia, although it may not be the primary cause. This study aimed to investigate whether plasma concentrations of methylglyoxal, 3-deoxy-glucosone, and glyoxal, which are reactive intermediates of protein metabolism in carbonyl stress, are changed in patients with schizophrenia and can function as potential biomarkers for schizophrenia with enhanced carbonyl stress. Plasma concentrations of these di-carbonyls were simultaneously estimated in 40 patients with schizophrenia and 40 healthy controls. As a result, no statistically significant differences were observed in mean plasma concentrations of three di-carbonyls between patients and controls. However, a remarkable increase in methylglyoxal concentrations was observed in four patients but not in controls. This increase was not found with regard to 3-deoxyglucosone and glyoxal both of patients and controls. Our correlation analysis showed that both the plasma methylglyoxal and glyoxal concentrations were significantly correlated with 3-deoxyglucosone concentrations in 40 patients and 40 controls. However, the plasma methylglyoxal concentrations did not show any significant correlation with the glyoxal concentrations in the patients or the controls. In four patients with extremely high methylglyoxal levels, the plasma methylglyoxal and glyoxal concentrations were not correlated to the 3-deoxyglucosone concentrations. Methylglyoxal is a physiological substrate of the glyoxalase system, and the accelerated accumulation of this compound lowers the glyoxalase I activity. These results suggested that this increase in four patients with high methylglyoxal levels may indicate the presence of a subtype of chronic schizophrenia that is associated with enhanced carbonyl stress.

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The purpose of this study was to chronicle the experiences of teenage girls who stay downtown late at night and are involved in sexual exploitation, and to clarify characteristics of their social circumstances and social determinants of health: socioeconomic status and educational opportunities. Between November 2009 and June 2013, we spoke with 89 adolescents who were loitering late at night in downtown Nagoya, Japan. We focused our research efforts on a case series of 22 girls who were 14-19 years of age and were involved in sexual exploitation. Semi-structured interviews were performed with the use of a questionnaire on the girls' sexual and mental health, families, school life, living conditions, and future aspirations. Along with the questionnaires, we analyzed case series interviews with a qualitative approach (narratives-under-analysis by in-depth understanding in context). Nine girls worked in the sex industry, while thirteen were independent sex workers. Our observations included child maltreatment, unstable families, distressing school life, insufficient education, and inappropriate relationships with gangs and similar organizations. Moreover, an illegal sex market was linked with these gang associations. Despite their severe living conditions, most of them hoped to have happy families someday. To provide support to this vulnerable population and support their life aspirations, improvement of public health, social welfare, education, and school health systems should be considered carefully.

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Young people who meet the definition of "Hikikomori" have come to be seen in France since around 2008. However, simply "fitting the definition" does not necessarily mean that they are the same as "Hikikomori" in Japan. Rather, it is important to ask what kind of young people "fit the definition of Hikikomori in France" and what kind of pathology they have. With these questions, our Japanese-French joint research team comprising specialists in various fields conducted a survey of "Hikikomori" in French youth, with support from a Grant-in-Aid for Scientific Research B (overseas research), and started a comparative joint study on "Hikikomori" in Japan and "Hikikomori" in France. In that study it was found that whereas one aspect of "Hikikomori" in Japan is described by the word déraillement (coming off the "rails"), "Hikikomori" in France is a state closer to dropping out and is accompanied by a type of "sense of insufficiency". This "sense of insufficiency" is above all related to something in the society and culture of France, and an investigation of how it is linked to "Hikikomori" is an issue for the future.

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The phenomenon of imaginary companions, which is usually regarded as normal in children, but which when encountered in adolescence suggests a psychopathologic condition, appears to have had limited investigation. This study indicates some psychopathologic characteristics of imaginary companions by interviewing adolescent patients. Imaginary companions are experienced as one or more invisible persons who have some conversations with patients directly and mutually for a period of time. They consist of vivid images which range between pure perceptions and pure images. The position of these images is not specified, and includes images perceived internally and externally by the patient. Adolescent patients sense the reality of these images and think of them as other persons, but recognize that these are not real people. Generally, imaginary companions are beneficial to the patients. These characteristics indicate that the phenomenon of imaginary companions has a mainly pathologic structure, but some characteristics, such as the patients' recognition of the imaginary aspect of the companion and the benefit for patients, does not fall under the category of psychopathology. We suppose that elucidation of this phenomenon would lead us to productive research in the psychopathologic field.

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