Gadelha, Ary

Passos, Ives Cavalcante

Roza, Thiago Henrique

Spritzer, Daniel Tornaim

Brazilian Journal of Psychiatry

English

Lume 5.8

The lack of instruments or scales developed or vali-dated in Portuguese for the Brazilian cultural context,as well as the impossibility of objectively identifying andmeasuring tokophobia, make adequate therapeutic gui-dance difficult.A systematic review and meta-analysis was performedof the risk factors. The perception of tokophobia wasassessed among pregnant women and prenatal healthcare professionals to identify the peculiarities of tokopho-bia in the Brazilian socio-cultural and clinical-obstetric con-text. The conceptual and psychometric analysis processallowed the development and validation of the TokophobiaAssessment Questionnaire (Questionário de Avaliação daPartofobia) in Brazilian Portuguese, available from theauthors upon request. This research project was approvedby the Universidade do Sul de Santa Catarina researchethics committee (protocol 87312818.0.0000.5369).The Tokophobia Assessment Questionnaire has beenvalidated5; its reliability was measured with the Pearsoncorrelation coefficient (0.766) and the intraclass correla-tion coefficient (0.856). Bland-Altman analysis showed acentral tendency between the difference and mean of thetwo Tokophobia Assessment Questionnaire applicationsin almost the entire sample. The general Cronbach’salpha was 0.935 (Table 1). The Kappa index was 0.444and the Pearson correlation coefficient between the firstapplication of the Tokophobia Assessment Questionnaireand the Depression, Anxiety and Stress Scale was 0.607.Exploratory factor analysis identified six factors categor-ized into conceptual groups: physical repercussions(factor 1); feeling of panic (factor 2); social involvement(factor 3); interference in daily habits (factor 4); pregnancyavoidance (factor 5); self-perception of tokophobia (factor6) (Table 1). Use of the item response theory demon-strated the suitability of all items (Figure 1).Therefore, the 25-item Tokophobia Assessment Ques-tionnaire is reliable and valid and is the first instrument forassessing the clinical, emotional and psychiatric mani-festations of tokophobia. Although developed for theBrazilian population, the instrument may have worldwideapplicability.Rodrigo Dias Nunes,1,20000-0000-0000-0000 Eliane Traebert,1,20000-0000-0000-0000 MayaraSeemann,10000-0000-0000-0000 Jefferson Traebert1,20000-0000-0000-00001Faculdade de Medicina, Universidade do Sul de Santa Catarina(Unisul), Palhoça, SC, Brazil. 2Programa de Pós-Graduação emCiências da Saúde, Unisul, Palhoça, SC, Brazil.Submitted May 25 2020, accepted Jul 03 2020, Epub Aug 07 2020.AcknowledgementsThis study was partially funded by the Coordenação deAperfeiçoamento de Pessoal de Nı́vel Superior (CAPES;financing code 001).DisclosureThe authors report no conflicts of interest.How to cite this article: Nunes RD, Traebert E, SeemannM, Traebert J. Tokophobia Assessment Questionnaire:a new instrument. Braz J Psychiatry. 2021;43:112-114.http://dx.doi.org/10.1590/1516-4446-2020-1252References1 Aksoy AN, Aydin F, Kucur SK, Gözükara I. Maternal and fetal Dopplervelocimetry in women diagnosed with fear of childbirth. Niger J ClinPract. 2016;19:632-5.2 Thomson G, Stoll K, Downe S, Hall WA. Negative impressions ofchildbirth in a North-West England student population. J PsychosomObstet Gynaecol. 2017;38:37-44.3 Hamama-Raz Y, Sommerfeld E, Ken-Dror D, Lacher R, Ben-Ezra M.The role of intra-personal and inter-personal factors in fear of child-birth: a preliminary study. Psychiatr Q. 2017;88:385-96.4 Smith V, Gallagher L, Carroll M, Hannon K, Begley C. Antenatal andintrapartum interventions for reducing caesarean section, promotingvaginal birth, and reducing fear of childbirth: an overview of sys-tematic reviews. PLoS One. 2019;14:e0224313.5 Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, KnolDL, et al. COSMIN checklist manual [Internet]. 2012 Jn [cited 2020Jul 13]. fac.ksu.edu.sa/sites/default/files/cosmin_checklist_manual_v9.pdfHikikomori and the COVID-19 pandemic: not leavingbehind the sociallywithdrawnBraz J Psychiatry. 2021 Jan-Feb;43(1):114-116doi:10.1590/1516-4446-2020-114500000000-0002-7316-1185The coronavirus disease 2019 (COVID-19) pandemic,which started in China in December 2019 and rapidlyspread worldwide, has required most world leaders totake measures to contain and control the spread of thevirus, including social distancing and mass quarantine.1However, these interventions are likely to produce aconsiderable burden on the mental health of affectedpopulations.2 In the past few months, teams of investiga-tors have been joining efforts to arrive at a more com-prehensive understanding of the mental health conse-quences of the COVID-19 outbreak. Nevertheless, itwould be important to add discussion about the potentialimpact that such measures may have on the prevalenceof a relatively new psychiatric disorder called hikikomori or‘‘pathological social withdrawal.’’Hikikomori was initially reported in Japan in the 1990sand is described as a condition of prolonged and severesocial withdrawal lasting for at least six months, appar-ently not better explained by co-occurring severe psy-chiatric disorders.3,4 In most cases, the affected indivi-dual, usually a young male, remains isolated in hisown house, or in his own room in more severe cases.4Although it was initially considered a Japanese cultural114 Letters to the EditorsBraz J Psychiatry. 2021;43(1)syndrome, over the years it has been reported in a varietyof countries around the world, gaining the status of apublic health problem in Asia, with prevalence estimatesin community populations varying from 0.87 to 2.3%.3-5Although it is not possible to make inferences aboutcausality in hikikomori cases, it seems that technologyand the Internet are associated with this diagnosis.4,6Additionally, comorbid psychiatric conditions have beenreported in many hikikomori cases, and these patientsmay be at increased suicide risk.4,6 Family interventions,comorbidity treatment, online interventions, physical acti-vity, multiple psychotherapeutic approaches, social skillstraining, etc., have been indicated as potentially usefulstrategies for hikikomori cases.3,7-11 Nevertheless, theevidence to support these treatment approaches is weak,mainly due to a lack of studies on the topic.3,6In 2020, updated diagnostic criteria4 were proposed forhikikomori, with the inclusion of a severity classificationbased on the weekly frequency the individual leaves hishome or room. Physical isolation at home is regarded asthe central characteristic of the syndrome, which can bediagnosed only when all the following criteria are met:‘‘a) marked social isolation in one’s home; b) duration ofcontinuous social isolation of at least 6 months; c)significant functional impairment or distress associatedwith the social isolation.’’ Per definition, only individualswho leave home 3 or less days/week, for a prolongedperiod of time as stated above, can be defined ashikikomori.4 Even though loneliness is not one of the man-datory diagnostic criteria of the syndrome, it is a charac-teristic that becomes more pronounced with increasingcontinuous social withdrawal.4,10The prevalence of hikikomori in Brazil is unknown dueto a lack of empirical research on the phenomenon;however, the syndrome has been reported three times inBrazilian patients.9,12,13 Recently, our group describedthe complete treatment program for one of these cases.The patient reported substantial clinical improvementafter a multimodal intervention strategy, including pharma-cological treatment of comorbidities, family psychoeduca-tion, and the use of different psychotherapy techniques.9Considering this scenario, we hypothesized that strictconfinement measures may have relevant negative con-sequences on hikikomori cases, and the syndrome islikely to grow in prevalence. Young people, not only thosewith pathological social withdrawal, may increase the timespent gaming or on the Internet, factors potentially asso-ciated with the syndrome.4,6 In Italy, for instance, empiricaldata described an increase in the use of digital media nearbedtime during the lockdown.14 Another important point ofdiscussion is the expected increase of new technology-dependent habits during the COVID-19 pandemic that maypersist in the aftermath of the pandemic, such as onlineshopping, food delivery, online education courses, exclu-sively online social interaction, and online medical andpsychological appointments. Such life habits may be asso-ciated with hikikomori cases and could further increasetheir prevalence in the near future.6,8 The rise in preva-lence of psychiatric symptoms and disorders also mayresult in more hikikomori cases. Studies from Chinahighlighted a substantial increase in anxiety and depres-sion15 during the COVID-19 outbreak, with a depressionprevalence of 43.7% among Chinese adolescents.16It is also necessary to assess how painful andemotionally distressing quarantine and social distancingmeasures are for hikikomori cases in comparison to otherpopulations. Although it could be that populations thatwere socially withdrawn prior to the pandemic may notsuffer as much, empirical data from Spain indicatedloneliness as the strongest predictor of depression, PTSDand anxiety during the COVID-19 outbreak.17Despite the lack of empirical data, families and healthprofessionals should be vigilant about the potentialincreased risk of hikikomori among young people duringand after the COVID-19 pandemic. Exercising at home,maintaining a healthy diet, and limiting screen time are alllifestyle behaviours that have been recommended duringthis pandemic18 and are likely to promote better mentalhealth outcomes. They may also have a positive impacton individuals at risk for hikikomori. In addition, once thepandemic is over, parents could focus on fostering out-door activities and face-to-face interaction.Social isolation has been growing in prevalence overthe past decades, which has led some authors to say thatwe have been facing a silent and rising epidemic, poten-tially associated with other serious contemporary epi-demics such as suicide and opioid use, called the‘‘modern behavioral epidemic of loneliness.’’19 Hikikomori,likewise, could be considered a rising and silent epidemicduring and in the aftermath of the COVID-19 pandemic,since physical and social isolation is likely to increase.Therefore, it is essential not to further isolate this popu-lation in terms of clinical and scientific efforts.Thiago H. Roza,1,20000-0000-0000-0000 Daniel T. Spritzer,2,3Ary Gadelha,4 Ives C. Passos1,2,51Laboratório de Psiquiatria Molecular, Centro de PesquisaExperimental (CPE) and Centro de Pesquisa Clı́nica (CPC), Hospitalde Clı́nicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.2Programa de Pós-Graduação em Psiquiatria e Ciências doComportamento, Faculdade de Medicina, Universidade Federal doRio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. 3Grupo deEstudos sobre Adições Tecnológicas, Porto Alegre, RS, Brazil.4Programa de Esquizofrenia (PROESQ), Departamento dePsiquiatria, Universidade Federal de São Paulo, Escola Paulista deMedicina (UNIFESP-EPM), São Paulo, SP, Brazil. 5InstitutoNacional de Ciência e Tecnologia Translacional em Medicina (INCT-TM), Porto Alegre, RS, Brazil.Submitted May 19 2020, accepted Jul 09 2020, Epub Aug 21 2020.DisclosureThe authors report no conflicts of interest.How to cite this article: Roza TH, Spritzer DT, GadelhaA, Passos IC. Hikikomori and the COVID-19 pandemic:not leaving behind the socially withdrawn. Braz J Psy-chiatry. 2021;43:114-116. http://dx.doi.org/10.1590/1516-4446-2020-1145Letters to the Editors 115Braz J Psychiatry. 2021;43(1)References1 Wilder-Smith A, Freedman DO. Isolation, quarantine, social distan-cing and community containment: pivotal role for old-style publichealth measures in the novel coronavirus (2019-nCoV) outbreak. JTravel Med. 2020;27:taaa020.2 Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S,Greenberg N, et al. The psychological impact of quarantine and howto reduce it: rapid review of the evidence. Lancet. 2020;395:912-20.3 Li TM, Wong PW. Youth social withdrawal behavior (Hikikomori):a systematic review of qualitative and quantitative studies. Aust N Z JPsychiatry. 2015;49:595-609.4 Kato TA, Kanba S, Teo AR. Defining pathological social withdrawal:proposed diagnostic criteria for hikikomori. World Psychiatry. 2020;19:116-7.5 Pozza A, Coluccia A, Kato T, Gaetani M, Ferretti F. The ‘Hikikomori’syndrome: worldwide prevalence and co-occurring major psychiatricdisorders: a systematic review and meta-analysis protocol. BMJOpen. 2019;9:e025213.6 Kato TA, Shinfuku N, Tateno M. Internet society, internet addiction, andpathological social withdrawal: the chicken and egg dilemma for inter-net addiction and Hikikomori. Curr Opin Psychiatry. 2020;33:264-70.7 Kubo H, Urata H, Sakai M, Nonaka S, Saito K, Tateno M, et al.Development of 5-day Hikikomori intervention program for familymembers: a single-arm pilot trial. Heliyon. 2020;6:e03011.8 Wong JC, Wan MJ, Kroneman L, Kato TA, Lo TW, Wong PW, et al.Hikikomori phenomenon in East Asia: regional perspectives, chal-lenges, and opportunities for social health agencies. Front Psychiatry.2019;10:512.9 Roza TH, Spritzer DT, Lovato LM, Passos IC. Multimodal treatmentfor a Brazilian case of Hikikomori. Braz J Psychiatry. 2020;42:455-6.10 Kato TA, Kanba S, Teo AR. Hikikomori: multidimensional under-standing, assessment, and future international perspectives. Psy-chiatry Clin Neurosci. 2019;73:427-40.11 Nishida M, Kikuchi S, Fukuda K, Kato S. Jogging therapy for Hiki-komori social withdrawal and increased cerebral hemodynamics:a case report. Clin Pract Epidemiol Ment Health. 2016;12:38-42.12 Gondim FA, Aragão AP, Holanda Filha JG, Messias EL. Hikikomori inBrazil: 29 years of voluntary social withdrawal. Asian J Psychiatr.2017;30:163-4.13 Prioste CD, de Siqueira RC. Fetichismo virtual na vida de um Hiki-komori brasileiro: um estudo de caso. DOXA: Rev Bras Psicol Educ.2019;21:4-16.14 Cellini N, Canale N, Mioni G, Costa S. Changes in sleep pattern,sense of time and digital media use during COVID-19 lockdown inItaly. J Sleep Res. 2020 May 15;e13074. doi: http://10.1111/jsr.13074.Online ahead of print.15 Li J, Yang Z, Qiu H, Wang Y, Jian L, Ji J, et al. Anxiety and dep-ression among general population in China at the peak of the COVID-19 epidemic. World Psychiatry. 2020;19:249-50.16 Zhou SJ, Zhang LG, Wang LL, Guo ZC, Wang JQ, Chen JC, et al.Prevalence and socio-demographic correlates of psychologicalhealth problems in Chinese adolescents during the outbreak ofCOVID-19. Eur Child Adolesc Psychiatry. 2020;29:749-58.17 González-Sanguino C, Ausı́n B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during theinitial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain.Brain Behav Immun. 2020;87:172-6.18 Balanzá-Martı́nez V, Atienza-Carbonell B, Kapczinski F, De Boni RB.Lifestyle behaviours during the COVID-19 – time to connect. ActaPsychiatr Scand. 2020;141:399-400.19 Jeste DV, Lee EE, Cacioppo S. Battling the modern behavioral epi-demic of loneliness: suggestions for research and interventions.JAMA Psychiatry. 2020 Mar 4. doi: http://10.1001/jamapsychiatry.2020.0027. Online ahead of print.Working during pandemics:the need for mental healthefforts to prevent theoutbreak of mentaldisorders at the workplaceBraz J Psychiatry. 2021 Jan-Feb;43(1):116-117doi:10.1590/1516-4446-2020-112000000000-0002-7316-1185The coronavirus disease 2019 (COVID-19) pandemic hasimposed an imperative need for immediate changes inmany economic, educational, religious, cultural, and otherpractices of daily life. This outbreak has specific potentialto heighten stressful conditions at work because ofeconomic instability and uncertainty, the need to reconcileold and new demands, and the aforementioned changesin the workplace. According to Hamouche,1 COVID-19has the potential to expose workers to stressful conditionssuch as infobesity (information overload), financial loss,job insecurity, the negative effects of social distan-cing, and potential stigma directed to those associatedwith the disease because of their ethnicity or occupation(e.g., health professionals). As pointed out by Burdorfet al.,2 the COVID-19 pandemic poses an enormousoccupational health challenge, since the risk of becomingcontaminated is a reality for several jobs which involveworking in close proximity with colleagues and/or thegeneral population, as well as, in some occupations,regular exposure to the disease. This very real scenario ofrisk introduces a new stressor – namely, the fear ofcontagion among employees. Furthermore, even thosejobs amenable to working from home pose the challengeof having to adapt one’s routine, leading to additionalwork-related stress.The pandemic is affecting the mental health of thegeneral population, and this impact is expected to begreater in some individuals (e.g., specific age groups,people with underlying diseases which place them in thehigh-risk group, people with preexisting mental healthdisorders) than in others.3 In some cases, occupationaldemands may cause additional distress by preventingworkers from following social distancing recommenda-tions, placing them at permanent risk of contagion. Suchworkers must remain constantly vigilant of preventivemeasures, which increases their risk of psychologicaloverload and distress. Health professionals are particu-larly susceptible to this, since they are exposed to a highrisk of contagion through contact with patients and are116 Letters to the EditorsBraz J Psychiatry. 2021;43(1)

Hikikomori and the COVID-19 pandemic : not leaving behind the socially withdrawn

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Hikikomori and the COVID-19 pandemic : not leaving behind the socially withdrawn

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