Social Withdrawal and Mental Health: An Interdisciplinary Approach

Social isolation may be considered as a risk factor for health. It may contribute to the development of a mental health disease. In this chapter, social withdrawal is defined as voluntary isolation prolonged in time that involves the cessation of any form of social relationship and contact with people and the outside. Clinical psychology, psycho-educational interventions, and social neuroscience research tries to understand what happens when social isolation is experienced. Therefore an interdisciplinary perspective can help to better understand this phenomenon. The deepening of these aspects can help to create new forms of theoretical perspective and of a clinical and psycho-educational intervention to better arrange for this new type of maladaptive condition.


Introduction
Social relationships represent a very important dimension during adolescence [1]; for this reason social withdrawal is an actual phenomenon that needs to be examined in detail. As very little is known about it, the risk that may contribute to the formation of a mental health disease may be ignored. Additionally, it is critical to remember that social withdrawal may also occur as a complication of an existing mental health disorder. Social withdrawal is defined as the lack of social relations with one's family and friends. This situation may create very important damages in interpersonal relations and social relations at an individual level and that may affect the society in general. Barzeva et al. [2] in line with Rubin et al. [3] report that it is "an umbrella term referring to an individual's voluntary self-isolation from familiar and/or unfamiliar others through the consistent display of solitary behaviors such as shyness, spending excessive time alone, and avoiding peer interaction." The intensive use of the Internet or video games is also associated with social withdrawal. This may be indicative of a form of adaptation of social isolation, but it becomes a real addiction. The use of interactive media for games is very frequent among adolescents, and is increasingly on the rise [4,5]. It is estimated that the number of teenagers using smartphones have rapidly increased in recent years, the percentage has gone from 73 to 95% in the last 4 years. In particular, the use is associated with video games and the use of social media such as YouTube (85%), Instagram (72%), and Snapchat (69%) [4,5].
The frequency of Internet addiction that has been estimated in various countries is very different in Western and Asian cultures with respect to social norms and the culture of using social media [6,7], varying from 0.8% in Italy to 14% in China and from 12% and up to 26.7% in Hong Kong.

Social withdrawal
In recent years, a new social phenomenon has been observed. Many adolescents voluntarily isolate themselves by withdrawing, and become recluses in their families, and in their social environment. Until 2008, this manifestation was considered as a symptom of other psychopathological situations in DSM-IV * (Statistical diagnostic manual of mental disorders) [8,9] such as psychosis. Although this state of social withdrawal leads to such a serious consequence in adults, the adolescents who show a social withdrawal do not meet the criteria for a diagnosis.
The phenomenon of well-known social withdrawal in Japan is called Hikikomori, a term coined by a psychiatrist, Saito. Saito [10,11] described Hikikomori as withdrawing from contact with family, having almost no friends, and not attending school for adolescents. Beginning from late 1970s, Hikikomori has been a silent epidemic among teens and young adults in Japan. Currently, Japanese scholars differentiate the phenomenon of Hikikomori from social withdrawal as being as a consequence of a psychiatric psychopathology that occurs together with the diagnosis of depression, personality disorder, anxiety disorder etc. Social withdrawal and the difficulty in creating social relationships do not manifest themselves as a primary symptom but do not meet the criteria of diagnostic labels so far theorized by international psychiatry [12]. To overcome this diagnostic gap, the Japanese Ministry of Health created guidelines in 2003 to help identify the Hikikomori phenomenon, by establishing the presence of certain criteria: • home-confined lifestyle; • lack of motivation to attend school or work; • absence of criteria for the other psychiatric diagnoses such as agoraphobia, schizophrenia, etc.
• duration of symptoms more than 6 months.
The phenomenon of social withdrawal in Italy has been handled from a different perspective than that of the Japanese Hikikomori. Initially, the attention to adolescent withdrawal was addressed as a consequence of the even more extensive phenomenon of Internet addiction. For example, in Italian literature [13], Internet users differ in their action: (a) those who use the Web to achieve economic, relational, or social success and are the socially overexposed and (b) Internet addicts who use the Web to escape from anxieties and depressive experiences. The latter are social retreats. Berne [14] defines the script as: "A life plan bases on a decision taken during childhood, reinforced by parents, justified by subsequent events, and culminating in a final choice." During childhood, each child creates a script of life that becomes the supporting structure of the identity with which the person gives form and meaning to himself and to the world [14]. In his life script, the child will insert the expectations, injunctions, and thrusts that come from the most important attachment figures. The injunctions are the limits that the person perceives in childhood from the attitudes of the parental figures who exercise restrictions in being able to freely express themselves. The pushes, also called orders, are prescriptive commands, insistent, that the parental figures send verbally to their children. Current families are often composed of a single child; it may happen that parents pour out numerous projections and expectations in the line of "being perfect" and they push the child to try desperately. Thus the child is required to be precise in everything he does; in school and in relationships, inaccuracies are not tolerated. These inducing attitudes may be accompanied by injunctive messages sent by parents during childhood. The cognitive structures of parents, often formed before the birth of the baby, are too full of fantasies and expectations that they unwittingly create a deep predisposition to make things go wrong. These parental messages may generate feelings of shame. Shame is an emotion of a relational nature in which the person oscillates between the desire to be admired by the other and the fear of failing, between the desire to be accepted and the feeling of being excluded [15]. Sometimes shame may become a process of protection to avoid feeling the emotions of humiliation and vulnerability linked to the loss of the relationship with the other. Shame may lead to a denial of anger to allow the child/adolescent to keep the relationship with the person who carried out the humiliating transactions. When anger is denied, an important need of the person is lost, that of being taken seriously, with respect, and being important to others. Self-esteem may remain extremely compromised. The emotions of sadness and fear are also hidden in the feeling of shame. Some examples may be the sadness of not being accepted, with one's needs, desires and behaviors and the fear of being abandoned, of losing the relationship with the other because of what one is [16]. During puberty, the antiscript is experienced [14]; the exact opposite of the Life script that the child together with the parents and the environment was built during the first years. Experiencing the opposite is a healthy strategy to try and find the right balance between extremes. But it may happen that the boy in this attempt to experience his tolerance or his possibilities of decision arrives at extreme behaviors, such as solitude and isolation [17]. From the existential crisis, the boy can find new ideas about his identity or he may get stuck in the copycat decisions made in childhood. In scripts where parental injunctions have unwittingly created a strong feeling of shame, it may happen that the child considers his body and his abilities to face the world to be unsuitable. All the expectations that parents and the child had built in childhood collapse. This transactional analytical perspective agrees with other psychological theories in which therapeutic work with the child is considered necessary to help him in the long work of building an identity capable of tolerating confrontation with others.

Social withdrawal in Italy
In recent years, a new social phenomenon has been observed in Italy. Unlike the first Japanese Hikikomori who adopted a lifestyle of social exclusion long before the arrival of the Internet, in Italy, social withdrawal has been studied as a consequence of Internet addiction because this condition is often accompanied by the use and abuse of the network. This is the obvious symptom that alarms parents and forces them to ask for help. Therefore, the abuse of the network was studied as a cause of social withdrawal initially. Currently, scholars claim that the abuse of the Internet Social Isolation -An Interdisciplinary View is linked to social withdrawal as a strategy to survive an extreme lifestyle. The use of the Internet as well as allowing access to information allows the symbolization of the world through the construction of avatars and role-playing games and allows a protected relationship with others, in which it is not necessary to use the body, for example in online games [18].
Living virtually allows being in relationships with others maintaining the considered right distance by secluded teenager, which allows them to keep away the feeling of anxiety and the sense of inadequacy that comes from inter-relational confrontation [19]. Two important components need to be considered: the age of onset of seclusion and gender. The debut usually takes place in two timelines that coincide with two important changes in the life of the students: the first is the passage in the secondary school between the first degree (middle school) and the second degree (high school); the second delicate passage occurs at the end of high school with a leap into the university world. Depending on the time of onset, the setting and the therapeutic work change. Dealing with the gender components, social withdrawal appears predominantly as a male symptomatology. It seems that the two disorders are complementary, even though in recent years the cases of male anorexia and female social withdrawal are increasingly widespread [19].

Reactivate the growth process: interdisciplinary intervention
Taking charge of the withdrawn social adolescent requires special attention given the complexity of the phenomenon. Currently, there are no guidelines shared by the different theoretical approaches, as is the case for other clinical pictures such as attempted suicide and anorexia. The point on which the different approaches converge is that the treatment of social withdrawal consists in a global management of the adolescent's life context and that it is necessary to work on the relational emptiness that the boy has created around him. If on the one hand, the secluded teenager tends to eliminate and abandon relationships and spaces of movement, the parents try to create, expand, and add both physical and mental space, respecting the boy's timing and propensity to change [20].
In Italy, there are public and private services such as associations, cooperatives, foundations, and various types of organizations that deal with socially isolated adolescents. The interventions for social withdrawal cases in Italy vary. Despite the diversity of approach, generally an open intervention is addressed both to the boy and the context. The family is invited, then the detailed anamnesis is taken including not only the parents but also other significant persons in the family environment. The sessions are carried out by psychotherapists, in some cases the collaboration with a neuropsychiatrist to foresee and to exclude possible psychopathologies or to place side by side, if necessary, a pharmacological cure. Professional educators within the multi-professional team are those who perform home interventions in the most extreme situations in which significant social isolation makes an intervention outside the family setting impossible.

An Italian example of clinical intervention
Different kinds of interventions vary depending on the theoretical approach and the different tools available including public and private practices in Italy. One of the consolidated interventions is implemented in a private clinic in Milan, at the Minotauro Institute. The ultimate goal is to reactivate the evolutionary path where the adolescent resides. The first step is the alliance with the boy and his lifestyle, a symptom of anguish and unacceptable pain. The assumption of the Minotauro team is that the unconscious drive to live pushes these teenagers to find alternative, albeit virtual, ways to madness or death. In fact, in the most serious cases, withdrawal is the only way to manage the fragility, saving one's own body. The escape of one's body is the decision taken by the secluded boy to remain alive, both psychologically and physically. For this reason, the alliance with the symptom is fundamental for the Minotauro method. Only in this way is a therapeutic path possible in which the boy rediscovers the real self with the resources and the evolutionary capacities that allow him to imagine and therefore invest in a future perspective. The therapist explores the adolescent's signals and communications, helps him to transform anguish and pain into words, to promote the transformation of family dynamics and to create alternatives for eliminating the voluntary withdrawal [19].
The experience of the Minotaur indicates as a first step the taking in charge of the parents who usually turn to the center without being accompanied by the boy. Parental care provides with extreme attention the figure of the father who plays a fundamental role in the context of social withdrawal. The intervention method foresees that parents follow individual psychotherapy.

Social withdrawal and social brain
During puberty, the neurophysiological development of the prefrontal cortex occurs very quickly [1]. The prefrontal cortex deals with not only cognitive abilities such as planning and executive functions [21], but also the regulation and management of emotions. In particular, it deals with regulating behavior with respect to the emotions evoked by group dynamics such as the sense of belonging to one's own group [22,23]. In other words prefrontal cortex corresponds to a social brain. Spear [24] stresses that during this period there is a qualitative change in social relations with an increase in contacts with peers, in particular, in salience of social rewards. From the hormonal point of view, the adolescent's brain responds differently to that of adults. According to the Walker et al. [25], an adolescent's stress may interfere with the regulatory development of the brain system that includes the area associated with social rewards. In fact, a dysregulation of these involves an alteration of the functioning activated by addictive behaviors like that of electronic devices-Internet. The same structures are involved in substance abuse cases. Even if it has not been included in the DSM-5, "Internet addiction (IA)" is a global issue [26], a behavioral dependence derived from the human-machine interaction with serious consequences such as loss of control and feelings of anger. Internet addiction may favor a clinically severe condition.

Conclusion
The aim of this chapter is to give some information on interdisciplinary interventions such as clinical psychology, educational approach, and social neuroscience practices in order to contribute a better understanding of the social withdrawal concept. This can help to better understand the potential risk for mental and physical health. In accordance with the information given in this chapter, working with secluded adolescents has revealed that their families should be included in the therapeutic relationship. It has been also detected that the characteristics found in the secluded adolescents can be traced back to relationships within the family. For example, there is often an intense mother/child relationship that promotes dependence and obstacle in the natural processes of separation and individuation, a distant or absent paternal figure who initially idealizes and places numerous expectations in the child and when that happens, when these expectations are not satisfied, it becomes debasing. Following the evolutionary theory, it is possible to observe a block in the growth process and in the realization of the evolutionary tasks accompanied by a narcissistic fragility in the boy, lacking not only the evolutionary task of separation-individuation necessary for the construction of identity but also a process in mentalization of the body and a block in the social birth outside the family nucleus [19]. In addition to the family aspect, environmental and cultural factors that may affect and support vulnerable adolescents on such important aspects should also be addressed. Considering interdisciplinary aspects may preserve the social exclusion processes [27]. In this regard, an interdisciplinary point of view can lay the foundations for opening new theoretical and intervention perspectives on the phenomenon.
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