Sage Journals: Discover world-class research

Abstract

Background:

Social Anxiety Disorder (SAD) and hikikomori share characteristics of social withdrawal. While childhood trauma is a known risk factor for both conditions, the specific mechanisms linking early trauma to hikikomori through cognitive pathways remain unclear.

Aims:

This study aimed to compare childhood trauma, cognitive distortions, and hikikomori levels in individuals with and without SAD and to examine the mediating role of cognitive distortions in the relationship between childhood trauma and hikikomori.

Methods:

A total of 171 participants were included in the study: 78 patients with SAD and 93 healthy controls (HCs). All participants completed the Childhood Trauma Questionnaire (CTQ-28), Cognitive Distortions Scale (CDS), and 25-item Hikikomori Questionnaire (HQ-25). Group comparisons were performed using t-tests and chi-square tests. Mediation analysis was conducted using the PROCESS macro (Model 4), controlling for age, sex, marital status, education level, and SAD.

Results:

The SAD group had significantly higher CTQ-28, CDS, and HQ-25 scores than the HCs group (p < .001). Mediation analysis revealed that childhood trauma was associated with hikikomori levels both directly (B = 0.33, p = .007) and indirectly through cognitive distortions (Effect = 0.15, 95% bootstrap CI [0.06, 0.26]). The total effect of childhood trauma on hikikomori was also statistically significant (B = 0.48, p < .001). The model, which controlled for age, sex, marital status, education, and SAD status, explained 42% of the variance in hikikomori severity (R² = .42).

Conclusions:

Our findings suggest that childhood trauma is associated with greater hikikomori symptoms, both directly and through the mediating effect of cognitive distortions. Therefore, cognitive distortions may be a potential intervention target for socially withdrawn individuals with a history of childhood trauma.

Keywords

childhood trauma cognitive distortions hikikomori social anxiety disorder

Introduction

Social Anxiety Disorder (SAD) is a chronic mental disorder characterized by intense anxiety in various social or performance situations due to an individual’s fear of negative evaluation, accompanied by avoidance of these situations (American Psychiatric Association, 2013). If left untreated, it can negatively impact various areas of life, such as education, employment, personal development, and social relationships, leading to significant limitations in an individual’s overall functioning (Stein & Stein, 2008). Studies have shown that the lifetime prevalence of this disorder is 12.1% (Kessler et al., 2005). Socially anxious individuals are at a particular risk of feeling lonely due to fears of social isolation and rejection (Cacioppo et al., 2015). Lim et al. conducted a community-based study showing that social anxiety was one of the most important predictors of loneliness (Lim et al., 2016). Therefore, individuals with SAD are more likely to withdraw from social situations because of their fear of being negatively evaluated in social experiences, and therefore their feelings of social isolation and loneliness will be more intense.

Current models suggest that biological predisposition to SAD can interact with negative social learning experiences to play a significant role in the development of this disorder (Heimberg et al., 2014). Family studies have revealed a strong relationship between social anxiety in parents and children (Bögels et al., 2001). Additionally, temperament research shows that a shy temperament in childhood is associated with the development of social anxiety in adolescence (Schwartz et al., 1999). Accumulating evidence suggests that childhood trauma, an important type of social learning, plays a role in the etiology of SAD (Bruch & Heimberg, 1994). Studies examining childhood trauma and SAD suggest that parent-perpetrated emotional abuse (e.g., verbal abuse and humiliation) and emotional neglect (e.g., lack of love and support) are important risk factors for the development of SAD (Kuo et al., 2011).

Response of children and adolescents to traumatic events may vary depending on factors such as their level of development and past experiences. A large proportion of individuals who experience traumatic events exhibit emotional distress and behavioral changes afterwards (Mashalpoure fard et al., 2023). In addition, trauma causes dysfunctional thoughts to emerge in an individual’s cognitive domain, leading to the development of cognitive distortions. According to the current cognitive approach, 10 different types of cognitive distortions are recognized: arbitrary inference, mental filtering, overgeneralization, minimizing the positive, all-or-nothing thinking, personalization, catastrophizing, “should” statements, mind reading, and labeling (Lazarus & Folkman, 1984). These cognitive distortions can emerge in three different areas after trauma: negative thoughts about oneself, negative thoughts about the world, and a tendency to blame oneself. Previous studies have shown that interpersonal trauma causes cognitive distortions (Whiteman et al., 2019). Interpersonal traumatic experiences cause individuals to develop a tendency to blame themselves and have negative cognitions about themselves and their environment (Cromer & Smyth, 2010). In particular, the development of cognitive distortion was shown to be predicted by interpersonal trauma such as violence and assault perpetrated by an intimate partner (Cox et al., 2014). Cognitive distortions can cause individuals to perceive themselves as inadequate, flawed, or doomed to rejection (Gilbert & Miles, 2000). These distortions create a multidimensional experience that causes individuals to avoid social settings and experience intense physical symptoms (e.g., stomach cramps and muscle tension; Swee et al., 2021). As a result, these experiences create a basis for social withdrawal, which triggers feelings of loneliness (O’Day & Heimberg, 2021).

Hikikomori is a concept that has been defined in recent years and describes a more advanced form of social isolation. It is characterized by an individual cutting off contact with the outside world for long periods and completely avoiding social interactions (Nonaka & Sakai, 2021). Although hikikomori was first identified in Japan, it has been reported in different cultures in recent years and represents a significant intersection with disorders such as complete withdrawal from society and social anxiety (Chauliac et al., 2017; Teo et al., 2015). Furthermore, there is a growing consensus that hikikomori is not simply social withdrawal but can cause significant functional impairment in a person’s life. Wakuta et al. reported that traumatic experiences in childhood may be associated with the development of hikikomori (Wakuta et al., 2023). This finding raises the possibility of mechanisms that may lead from childhood trauma to the development of hikikomori. In this context, childhood trauma can profoundly affect an individual’s perception of self and social interactions by shaping their cognitive distortions. While Masuda et al. (2024) suggested that emotional distress stemming from childhood trauma may pave the way for hikikomori, the specific role of cognitive distortions as a primary mechanism remains a key area of interest (Masuda et al., 2024). Although SAD and hikikomori share similar social withdrawal processes, they may differ in their underlying mechanisms. Therefore, our study aimed to investigate the effect of childhood trauma on the development of hikikomori, the mediating role of cognitive distortions, and whether this relationship was independent of the presence of social anxiety.

Method

Participants

The current cross-sectional case-control study aimed to compare individuals with SAD who presented to a psychiatric outpatient clinic with a healthy control group. Participation in the study was voluntary. All participants underwent the Structured Clinical Interview (SCID-5-CV) for diagnosis. Individuals in the SAD group with a history of intellectual disability, serious neurological or physical illnesses that could affect the completion of the scales, psychotic disorders, comorbid alcohol or substance use disorders, and active suicidal ideation were excluded from the study. Individuals in the healthy control group diagnosed with any psychiatric disorder based on the SCID-5-CV assessment were also excluded.

A priori power calculations were carried out using G*Power 3.1, targeting α = .05 and (1−β) = .80 for a two-tailed test. The effect sizes were based on similar findings reported in the hikikomori literature. Specifically, Nonaka and Sakai (2021) reported large differences in psychosocial measures between the hikikomori and control groups, with Hedges’ g ≈ 0.67 to 1.23; therefore, d = 0.70 was adopted as a conservative assumption for group comparisons (≈n = 40–45/arm, total N ≈ 80–90; Nonaka & Sakai, 2021). Considering new findings supporting the relationship between childhood trauma and hikikomori phenotypes, a protective level of r = .30 was assumed for correlation/re-adjusted regression-based analyses (total N ≈ 85; Masuda et al., 2024). For mediation (PROCESS Model 4), small-to-medium standardized path coefficients (|β| ≈ .25–.35) consistent with the reported magnitudes of psychological factors associated with hikikomori were used; in this case, N = 150 to 200 is recommended. Consequently, 78 individuals diagnosed with SAD and 93 healthy controls were included in the study, achieving the target sample size.

Measurement Instruments

Sociodemographic data form: This form was created by the researchers and was used to assess the age, gender, marital status, education and employment status, income level, social environment, psychiatric diagnosis and treatment history, and the presence of chronic physical illness of the participants.

Childhood Trauma Questionnaire (CTQ-28): The CTQ-28 is a 28-item, 5-point Likert-type scale based on self-reporting (Bernstein et al., 1994). Şar et al. (2012) conducted a validity and reliability study for the Turkish version. The scale consists of five subscales: emotional, physical, and sexual abuse, and physical and emotional neglect. Şar et al. recommended cut-off points of 5 for sexual and physical abuse, 7 for physical neglect and emotional abuse, and 12 for emotional neglect. All responses obtained from the scale are added to calculate the total score. In the reliability analysis, the Cronbach’s alpha coefficient was .78 in the first stage and .73 in the second stage (Şar et al., 2012).

Cognitive Distortions Scale (CDS): The CDS was developed by Covin et al. (2011). It is a 20-item, 7-point Likert type self-report scale (1 = never, 7 = always) that assesses 10 cognitive distortions (mind reading, catastrophizing, all-or-nothing thinking, emotional reasoning, labeling, overgeneralization, personalization, “should” statements, and minimizing or disqualifying the positive; Covin et al., 2011). The scale measures cognitive distortions in two contexts: interpersonal (IP) and personal achievement (PA). In the original study, the internal consistency coefficient (Cronbach’s α = .85) was high, and the scale exhibited a single-factor (unitary) structure. The Turkish version of the CDS also has strong internal consistency among individuals with and without depression (Cronbach’s α = .91 and .93; Özdel et al., 2014). The total score is calculated by adding all the scores obtained on the scale.

Liebowitz Social Anxiety Scale (LSAS): The LASA was developed by Liebowitz to assess the level of anxiety and avoidance experienced by individuals in situations requiring social interaction and performance (Liebowitz, 1987). The scale is a 24-item, 4-point Likert-type self-report instrument that measures social anxiety and avoidance behaviors of individuals over the past week. The total score is obtained by summing the scores of all anxiety and avoidance items. Soykan et al. have conducted the Turkish validity and reliability study of the LSAS (Soykan et al., 2003).

Hikikomori Questionnare (HQ-25): HQ-25 was developed by Teo et al. (2018) to assess the tendency of individuals toward long-term social withdrawal (Teo et al., 2018). The scale is a 25-item, 5-point Likert-type self-report instrument (0 = Strongly disagree, 4 = Strongly agree) with three subscales: socialization, isolation, and emotional support. In the original study, the internal consistency coefficient was high (Cronbach’s α = .96), demonstrating strong psychometric properties of the scale. The Turkish validity and reliability study of the HQ-25 was conducted by Gündoğmuş et al. (2021), and the factor structure was found to be consistent with the original version. The internal consistency coefficient of the Turkish version of the scale was 0.91 (Gündoğmus et al., 2021).

Beck Depression Inventory (BDI-II): BDI-II was developed by Beck and colleagues and is a 21-item self-report instrument that measures emotional, cognitive, somatic, and motivational symptoms (Beck et al., 2011). The Turkish validity and reliability study was conducted by Hisli et al., who determined that the scale had high internal consistency (Cronbach’s α = .90). The total score ranges from 0 to 63, and depression levels are classified as minimal (0–12), mild (13–18), moderate (19–28), and severe (29–63; Hisli, 1988).

Procedure of the Study

Individuals who volunteered to participate in the study were provided with detailed information about the purpose, content, and scales to be used in the study, and written informed consent was obtained. Participants had the right to withdraw from the study at any time, and their identity information was kept confidential.

All participants underwent the Structured Clinical Interview for DSM-5 (SCID-5-CV) for the confirmation of their diagnosis. Individuals diagnosed with SAD were included in the patient group, while those without any psychiatric diagnosis were included in the healthy control group. The study had a cross-sectional design, and all the scales were completed by the participants in a single session. The study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the relevant Institutional Ethics Committee prior to the commencement of the study.

Statistical Analysis

The data were analyzed using the SPSS v. 27 statistical program (IBM, Chicago, IL, USA). The normality of the continuous variables was first assessed using visual (histogram and Q-Q plot) and statistical (Kolmogorov-Smirnov) tests. Continuous variables are presented as mean ± standard deviation (mean ± SD), while categorical data are presented as frequency and percentage (n, %).

In intergroup comparisons (SAD and control groups), the independent samples t-test (t) was used for continuous variables that met the normality assumption, and the Mann-Whitney U test (U) was used for the variables that had a non-normal distribution. Categorical data were compared using the chi-square test (χ²). Additionally, the relationships between the scales were assessed using Spearman’s correlation analysis. The main hypothesis of the study, that is, cognitive distortions play a mediating role in the relationship between childhood trauma and hikikomori, was tested using Hayes’ PROCESS macro (Model 4; v 4.2) with 5,000 repeated bootstrap methods (Hayes, 2017). This mediation model included the sociodemographic variables (gender, marital status, education, and age) and the presence of SAD as covariates to control for confounding effects. The significance level was set at p < .05 for all statistical analyses, while indirect effects were considered to be significant when the 95% confidence interval did not include the zero value.

Results

Sociodemographic Characteristics and Group Comparisons

The current study included 171 participants, comprising a patient group (n = 78) and a control group (n = 93). Comparative data on the sociodemographic characteristics and scale scores of the groups are presented in Tables 1 and 2. Examination of the sociodemographic data indicated no statistically significant difference in the main variables such as age (p = .132) and sex (p = .319) between the patient and control groups. However, a significant difference was found in the level of education (χ² = 14.3(3), p = .003) between the two groups. A comparison of the psychometric test results indicated that the patient group had significantly higher scores on all scales compared to the control group, including the CTQ Total score (43.69 ± 11.75 vs. 34.61 ± 7.24). In particular, the differences in BDI scores (25.58 ± 11.49 vs. 12.56 ± 8.73) and HQ Total scores (50.21 ± 17.13 vs. 32.86 ± 15.93) were highly significant (p values = .001 for all comparisons). No significant differences were found in the incidence of physical (p = .22) and sexual abuse (p = .169).

Table 1.

Sociodemographic Characteristics of the Patient and Control Groups.

Variable	Patient group (n = 78)	Control group (n = 93)	U/χ²(df)	p
Age (Mean ± SD)	25.3 ± 6.98	25.5 ± 4.05	3,143	.132
Sex (n, %)
Male	30 (38.5)	29 (31.2)	0.99 (1)	.319
Female	48 (61.5)	64 (68.8)
Education level (n, %)
Primary school	10 (12.8)	5 (5.4)	14.3 (3)	.003
High school	28 (35.9)	15 (16.1)
University	35 (44.9)	61 (65.6)
Postgraduate	5 (6.4)	12 (12.9)
Monthly income (n, %)
Low	22 (28.2)	26 (28.0)	3.64 (2)	.162
Medium	54 (69.2)	58 (62.4)
High	2 (2.6)	9 (9.7)
Marital status (n, %)
Single	50 (64.1)	70 (75.3)	3.23 (2)	.199
Married	25 (32.1)	22 (23.7)
Divorced/Widowed	3 (3.8)	1 (1.1)
Employment status (n, %)
Student	28 (35.9)	44 (47.3)	5.94 (2)	.051
Employed	20 (25.6)	29 (31.2)
Unemployed	30 (38.5)	20 (21.5)
Living situation (n, %)
With family	68 (87.2)	70 (75.3)	7.24 (3)	.065
Alone	2 (2.6)	13 (14)
Dorm/shared apartment	4 (5.1)	6 (6.5)
With friends	4 (5.1)	4 (4.3)

Note. Bold values indicate statistical significance (p < 0.05).

Table 2.

Comparison of Scale Scores Between Patient and Control Groups.

Variable	Patient (n = 78)mean ± SD	Control (n = 93)mean ± SD	t / U	df	p
Emotional abuse	9.71 ± 4.15	7.22 ± 2.36	2,352^u	—	<.001
Physical abuse	6.12 ± 2.39	5.56 ± 1.31	3,328^u	—	.220
Physical neglect	7.96 ± 2.99	6.49 ± 1.97	2,402^u	—	<.001
Emotional neglect	14.28 ± 4.73	10.14 ± 3.82	6.33^t	169	<.001
Sexual abuse	5.63 ± 2.52	5.20 ± 0.76	3,369^u	—	.169
CTQ-28 Total	43.69 ± 11.75	34.61 ± 7.24	1,930^u	—	<.001
CDS Total	83.27 ± 24.17	69.55 ± 23.39	3.76^t	169	<.001
LSAS—Anxiety	60.88 ± 13.72	49.57 ± 15.27	2,130^u	—	<.001
LSAS—Fear	56.51 ± 14.05	46.99 ± 15.74	2,288^u	—	<.001
BDI	25.58 ± 11.49	12.56 ± 8.73	1,333^u	—	<.001
HQ-25 Total	50.21 ± 17.13	32.86 ± 15.93	6.85^t	169	<.001

Note. ^t = independent samples t-test; ^u = Mann–Whitney U test; CTQ = Childhood Trauma Questionnaire; CDS = Cognitive Distortions Scale; LSAS = Liebowitz Social Anxiety Scale; BDI = Beck Depression Inventory; HQ = Hikikomori Questionnaire. Bold values indicate statistical significance (p < 0.05).

Correlation Analysis

The relationships between the psychometric scales were examined using Spearman’s correlation analysis (Table 3). A moderate, positive, and significant relationship was found between the CTQ Total score and the HQ Total score (ρ = .44, p < .001). The strongest correlation was observed between HQ and the BDI score (ρ = .69, p < .001), while a positive and significant relationship was also found between HQ and the CDS score (ρ = .48, p < .001). The CTQ Total score showed a significant positive correlation with both mediating variables, CDS (ρ = .30, p < .001) and BDI (ρ = .49, p < .001). These findings confirmed the preconditions for the mediation analysis.

Table 3.

Correlations Among the Different Psychometric Scales.

Variable	1	2	3	4	5	6	7	8	9	10
1. EA	—
2. PA	.48***
3. PN	.49***	.36***
4. EN	.63***	.39***	.59***
5. SA	.24**	.31***	.10	.19*
6. CDS	.32***	.15	.17*	.25***	.05
7. LSAS-Anx	.15*	.04	.12	.17*	.14	.50***
8. LSAS-Fear	.17*	.07	.12	.15*	.14	.52***	.88***
9. BDI	.44***	.19*	.35***	.45***	.14	.61***	.54***	.56***
10. HQ	.41***	.16*	.31***	.40***	.11	.48***	.56***	.62***	.69***
11. CTQ	.83***	.56***	.75***	.90***	.29***	.30***	.19*	.19*	.49***	.44***

Note. EA = Emotional Abuse; PA = Physical Abuse; PN = Physical Neglect; EN = Emotional Neglect; SA = Sexual Abuse; CDS = Cognitive Distortions Scale; LSAS-Anx = Liebowitz Social Anxiety Scale—anxiety subscale; LSAS-Fear = Liebowitz Social Anxiety Scale—fear subscale; BDI = Beck Depression Inventory; HQ = Hikikomori Questionnaire; CTQ = Childhood Trauma Questionnaire.

p < .05. **p < .01. ***p < .001. Spearman test was used.

Mediation Analysis

The mediating role of cognitive distortions (CDS) in the effect of childhood trauma (CTQ) on hikikomori (HQ) was tested using PROCESS Model 4 (Figure 1, Table 4). Sex, marital status, education, SAD, and age were included as covariates in the analysis.

Figure 1.

Cognitive distortions as a mediator in the relationship between childhood trauma and hikikomori.

Table 4.

Indirect Effects of Childhood Trauma on Hikikomori.

Pathway	B	SE	t	p	95% CI
Main paths
Path a (CTQ → CDS)	0.58	0.19	3.15	.002	[0.22, 0.95]
Path b (CDS → HQ)	0.26	0.05	5.32	<.001	[0.17, 0.36]
Total effect (CTQ → HQ)	0.48	0.13	3.82	<.001	[0.23, 0.73]
Direct effect (CTQ → HQ)	0.33	0.12	2.73	.007	[0.09, 0.57]
Indirect effect	Effect	Boot SE	—	—	Boot 95% CI
CTQ → CDS → HQ	0.15	0.05	—	—	[0.06, 0.26]

Note. Bootstrap confidence intervals were based on 5,000 samples. Covariates included sex, marital status, education, SAD status, and age.

CTQ = Childhood Trauma Questionnaire; CDS = Cognitive Distortions Scale; SE = Standard Error; CI = Confidence Interval.

The results indicated that the total effect of childhood trauma on hikikomori was significant (β = .48, p < .001). After adjustment for covariates, the indirect effect of childhood trauma on hikikomori through cognitive distortions remained statistically significant (effect = 0.15, BootSE = 0.05, 95% bootstrap CI [0.06, 0.26]). The direct effect of childhood trauma on hikikomori also remained significant (β = .33, p = .007), indicating a partial mediation. Overall, the model accounted for a substantial proportion of the variance in hikikomori severity (R² = .42).

Reverse Mediation Analysis

A mediation analysis in the opposite direction was also conducted to address the limitations of the cross-sectional design in determining causality and to support the robustness of our theoretical model. In this control analysis, hikikomori (HQ) was tested as the independent variable, childhood trauma (CTQ) as the dependent variable, and cognitive distortions (CDS) as the mediating variable (HQ → CDS → CTQ). The reverse mediation pathway did not reach statistical significance (Effect = 0.036, BootSE = 0.020, 95% bootstrap CI [−0.004, 0.078]).

Discussion

Childhood trauma, cognitive distortions, and hikikomori levels were compared between individuals with SAD and a healthy control group in the current study. Subsequently, the mediating role of cognitive distortions in the relationship between childhood trauma and hikikomori were tested. Our results show that childhood trauma, cognitive distortions, depression, and hikikomori levels were higher in the SAD group. Mediation analysis showed that after controlling for the presence of social anxiety and sociodemographic data, childhood trauma predicted hikikomori levels both directly and through the mediating effect of cognitive distortions. These findings suggest that while cognitive distortions act as a significant partial mediator, childhood trauma also has a direct impact on the development of hikikomori symptoms.

Traumatic experiences in early life, particularly physical and sexual abuse, facilitate the development of symptoms such as social isolation and withdrawal (Johnson et al., 2003). Trauma affects the cognitive structure of an individual, and negative coping styles that develop later may also contribute to this process. For example, one study reported that women with a history of childhood sexual abuse tended to maintain more distance in interpersonal relationships and isolated themselves more (Futa et al., 2003). However, Harmelen et al. reported that emotional abuse could predict negative self-perceptions more than physical and sexual abuse (van Harmelen et al., 2010). Therefore, traumatic experiences in early life can lay the groundwork for the development of negative schemas and cognitive distortions in later life (Browne & Winkelman, 2007). The deterioration of internal self-perception associated with trauma causes individuals to distort their perception of themselves and others, in addition to their environment (Browne & Winkelman, 2007). Studies have shown that childhood trauma increases cognitive distortions, which can cause the development of psychopathologies after the trauma. In addition, trauma often causes avoidant and anxious attachment styles, which can increase cognitive distortions (Demir-Kaya et al., 2023). Therefore, negative experiences in early life can affect the inner world of an individual, and profoundly affect their perception and assessment of events.

According to cognitive theory, negative schemas and cognitive distortions constitute core cognitive vulnerabilities that shape individuals’ emotional and behavioral responses to adverse experiences. Cognitive distortions such as overgeneralization, catastrophizing, and negative interpretations of interpersonal situations have been shown to emerge early following traumatic experiences and to persist over time (Jacobs et al., 2008). For example, generalizations that may develop after a trauma, such as “no one can be trusted” or “the world is a dangerous place,” can lead to feelings of hopelessness and social isolation, along with a constant sense of threat and avoidance behavior. Essentializing, catastrophizing and mindreading may act as key mechanisms that perpetuate social isolation (Floyd et al., 2025). Within this framework, previous studies have demonstrated that dysfunctional coping styles, low self-esteem, and negative self-related cognitions are associated with hikikomori-related behaviors (Nonaka et al., 2022; Ranieri et al., 2015). Furthermore, due to cognitive distortions and negative emotions, non-suicidal self-harm may develop as a coping strategy in individuals who have experienced trauma (Weismoore & Esposito-Smythers, 2010). Development of cognitive distortions can cause individuals to use dysfunctional emotion regulation strategies and further exacerbates negative affect (Browne & Winkelman, 2007). Taken together, these findings suggest that childhood trauma may contribute to the development of hikikomori primarily through enduring cognitive distortions that shape how individuals perceive themselves, others, and the social world, thereby directly fostering avoidance and chronic social withdrawal.

Our data suggests that individuals with SAD experienced more childhood trauma (excluding physical and sexual trauma) than the control group. It is widely accepted that negative experiences during childhood can lead to the emergence of various psychopathologies in later years. Consistent with our findings, Gibb et al. showed that emotional abuse in particular was a stronger predictor of social anxiety than other types of trauma (Gibb et al., 2007). Similarly, Kuo et al. reported that emotional abuse was more common among those with social anxiety (Kuo et al., 2011). Negative life experiences during childhood may lead to negative self-attribution, low self-esteem, and dysfunctional self-references (Beck, 2008). These associations can cause trauma victims to recall past experiences when entering new situations and increase their prejudices, thereby dragging the abused individual into a vicious cycle of abuse (van Harmelen et al., 2010). Traumas, especially those experienced in early life, can lead to a decrease in self-esteem and self-worth, weaken basic trust, and cause individuals to experience insecurity in social situations. Therefore, individuals who have experienced trauma may be more prone to developing SAD.

Our findings also indicate that cognitive distortions are more prevalent in patients with SAD. According to the cognitive theory, information is processed in a biased manner owing to dysfunctional schemas in anxiety disorders (Özdemir & Kuru, 2023). Overestimation of perceived threats is a common cognitive pattern seen in anxiety disorders (Clark & Beck, 2011). As social anxiety increases, negative beliefs about one’s own behavior and others’ evaluations of that behavior can distort the individual’s experience, leading to cognitive errors (Beck, 2005). Trauma can lead to cognitions such as “worthlessness” and “expectation of rejection” in an individual’s self-perception, which can cause them to avoid social situations or experience anxiety. Kuru et al. also reported that patients with SAD had more cognitive distortions than a control group, and that these cognitive distortions were associated with depression and anxiety (Kuru et al., 2018). As a result, cognitive distortions in SAD can negatively affect how experiences are interpreted, trapping the individual in a vicious cycle. Excessive sensitivity to others’ evaluations and exaggerated attention to social threats can cause individuals to feel inadequate and constantly judged, leading to the persistence and reinforcement of social anxiety. Furthermore, data from experimental studies indicate that interventions targeting these cognitive distortions may be an effective strategy for coping with social anxiety (Smits et al., 2006).

Our results are consistent with our initial hypothesis and show that the incidence of hikikomori was more prevalent among individuals with SAD. A recent meta-analysis reported that the prevalence of hikikomori in the general population was approximately 8%, but this rate reached 20% in the presence of SAD (Zhang et al., 2025). Individuals with SAD often tend to limit themselves from social activities because of their belief that others will judge them negatively (Koyama et al., 2010). This may lead to increased feelings of isolation in the long term and ultimately pave the way for the development of the hikikomori phenomenon (Li & Wong, 2015). Furthermore, depression, which often accompanies SAD, can negatively affect a person’s interest and motivation in various activities, leading to social isolation. However, there is still debate as to whether hikikomori is a primary psychiatric diagnosis or a form of SAD (Amendola, 2024; Tolomei et al., 2023). Some authors consider hikikomori to be an advanced form of social anxiety or a phenomenon shaped by the cultural context, while others argue that it should be considered as a separate psychiatric diagnosis because of its unique etiology and distinct clinical features. Ultimately, although social isolation is a common phenomenon in both cases, further research is needed to clarify whether these two conditions are different manifestations of the same pathology or separate diagnostic entities.

When considering childhood trauma as a risk factor for hikikomori, interventions targeting trauma-related cognitive distortions and maladaptive avoidance patterns may be particularly relevant. Cognitive distortions stemming from childhood trauma (e.g., shame, self-blame, and perceived social threat) and experiential avoidance can be considered as potential areas for intervention. Cognitive processing therapies that target negative cognitions developed after trauma and trauma-focused cognitive behavioral therapy may help reduce trauma-related cognitive distortions and alleviate severe social withdrawal (Walsh et al., 2010). Behavioral experiments developed to test restructuring related to trauma-related distortions and perceptions of social threats may also help reverse this process (Liu et al., 2023). In addition to correcting distorted cognitions related to trauma, social rehabilitation programs and interventions are promising in addressing social withdrawal (Fowler et al., 2021). Additionally, case presentations have reported that interventions targeting family members and online cognitive behavioral therapy may also be beneficial for hikikomori (Kubo et al., 2020; Sakai et al., 2024).

Although our study revealed striking results, it is critically important to consider certain limitations when evaluating these findings. Although the relationships tested in our study have a theoretical basis, the cross-sectional nature of our study does not allow us to draw definitive conclusions. Furthermore, the single-center nature of our study and the relatively small sample size require caution when generalizing the findings to the general population and different cultural settings. Consequently, we were unable to carry out subgroup analyses. Additionally, the self-reported nature of the scales used in our study raises the issue of response bias. Furthermore, the effects of factors that may play a role in this relationship, such as temperament, regulation of emotions, cognitive schemas, and dissociation, should not be overlooked. Future studies addressing these limitations may provide a better understanding of our results.

Conclusion

The current study indicates that childhood trauma is associated with greater severity of hikikomori symptoms, both directly and through its effect on cognitive distortions. Cognitive distortions emerged as a significant partial mediator in this relationship, highlighting their central role in linking early adverse experiences to persistent social withdrawal. These findings suggest that hikikomori cannot be understood solely as social withdrawal, but rather as a complex condition shaped by trauma-related cognitive vulnerabilities. Furthermore, in individuals with SAD, cognitive distortions and childhood trauma are associated with higher levels of hikikomori. Therefore, cognitive distortions may be potential targets for intervention for patients in whom hikikomori develops due to traumatic experiences. Multicenter, longitudinal studies that also include active intervention strategies are needed to address the limitations of the current study and to support and better understand the study data.

Footnotes

Acknowledgements

The authors thank all participants who took part in this study.

ORCID iDs

Mustafa Karaağaç

Betül Bakay

Fadime Şimşek

Eda Ferahkaya

Ethical Considerations

The necessary ethical committee approval was obtained from the Necmettin Erbakan University Non-Drug and Non-Medical Device Research Ethics Committee (IRB no: 2025/5678, date: 11.04.2025) prior to the commencement of the study.

Consent to Participate

Written informed consent was obtained from the participants.

Author Contributions

M.K. contributed to the conceptualization, methodology, formal analysis, writing—original draft, and supervision of the study. B.B. and F.Ş. were involved in data curation and investigation. F.Ç.K. contributed to literature review and visualization. E.F. provided resources and participated in writing—review and editing. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data are available from the corresponding author upon reasonable request.*

References

Amendola

(2024). Clarifying the position of hikikomori in mental health: Is hikikomori a variant of already-known mental health disorders? A review of the literature. Journal of Pacific Rim Psychology, 18, 1–18. https://doi.org/10.1177/18344909241274808

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. https://doi.org/10.1176/APPI.BOOKS.9780890425596

Beck

A. T.

(2005). The current state of cognitive therapy: A 40-year retrospective. Archives of General Psychiatry, 62(9), 953–959. https://doi.org/10.1001/ARCHPSYC.62.9.953

Beck

A. T.

(2008). The evolution of the cognitive model of depression and its neurobiological correlates. American Journal of Psychiatry, 165(8), 969–977. https://doi.org/10.1176/APPI.AJP.2008.08050721

Beck

A. T.

Steer

R. A.

Brown

(2011). Beck Depression Inventory–II. PsycTESTS Dataset. https://doi.org/10.1037/T00742-000

Bernstein

D. P.

Fink

Handelsman

Foote

Lovejoy

Wenzel

Sapareto

Ruggiero

(1994). Initial reliability and validity of a new retrospective measure of child abuse and neglect. The American Journal of Psychiatry, 151(8), 1132–1136. https://doi.org/10.1176/AJP.151.8.1132

Bögels

S. M.

Van Oosten

Muris

Smulders

(2001). Familial correlates of social anxiety in children and adolescents. Behaviour Research and Therapy, 39(3), 273–287. https://doi.org/10.1016/S0005-7967(00)00005-X

Browne

Winkelman

(2007). The effect of childhood trauma on later psychological adjustment. Journal of Interpersonal Violence, 22(6), 684–697. https://doi.org/10.1177/0886260507300207

Bruch

M. A.

Heimberg

R. G.

(1994). Differences in perceptions of parental and personal characteristics between generalized and nongeneralized social phobics. Journal of Anxiety Disorders, 8(2), 155–168. https://doi.org/10.1016/0887-6185(94)90013-2

10.

Cacioppo

Grippo

A. J.

London

Goossens

Cacioppo

J. T.

(2015). Loneliness: Clinical import and interventions. Perspectives on Psychological Science, 10(2), 238–249. https://doi.org/10.1177/1745691615570616

11.

Chauliac

Couillet

Faivre

Brochard

Terra

J. L.

(2017). Characteristics of socially withdrawn youth in France: A retrospective study. International Journal of Social Psychiatry, 63(4), 339–344. https://doi.org/10.1177/0020764017704474

12.

Clark

Beck

(2011). Cognitive therapy of anxiety disorders: Science and practice. Guilford Publications.

13.

Covin

Dozois

D. J. A.

Ogniewicz

Seeds

P. M.

(2011). Measuring cognitive errors: Initial development of the cognitive distortions scale (CDS). International Journal of Cognitive Therapy, 4(3), 297–322. https://doi.org/10.1521/IJCT.2011.4.3.297

14.

Cox

K. S.

Resnick

H. S.

Kilpatrick

D. G.

(2014). Prevalence and correlates of Posttrauma distorted beliefs: Evaluating DSM-5 PTSD expanded cognitive symptoms in a national sample. Journal of Traumatic Stress, 27(3), 299–306. https://doi.org/10.1002/JTS.21925

15.

Cromer

L. D. M.

Smyth

J. M.

(2010). Making meaning of trauma: Trauma exposure doesn’t tell the whole story. Journal of Contemporary Psychotherapy, 40(2), 65–72. https://doi.org/10.1007/S10879-009-9130-8

16.

Demir-Kaya

Kaya

Eroğlu

(2023). Interpersonal cognitive distortions: What is the role of childhood trauma and attachment? Journal of Education in Science, Environment and Health, 9(4), 292–309. https://doi.org/10.55549/JESEH.1381214

17.

Floyd

Ray

C. D.

Boumis

J. K.

(2025). Cognitive distortions associated with loneliness: An exploratory study. Behavioral Sciences, 15(8), 1061. https://doi.org/10.3390/BS15081061

18.

Fowler

Berry

Hodgekins

Banerjee

Barton

Byrne

Clarke

Fraser

Grant

Greenwood

Notley

Parker

Shepstone

Wilson

French

(2021). Social recovery therapy for young people with emerging severe mental illness: The Prodigy RCT. Health Technology Assessment, 25(70), 1–98. https://doi.org/10.3310/HTA25700

19.

Futa

K. T.

Nash

C. L.

Hansen

D. J.

Garbin

C. P.

(2003). Adult survivors of childhood abuse: An analysis of coping mechanisms used for stressful childhood memories and current stressors. Journal of Family Violence, 18(4), 227–239. https://doi.org/10.1023/A:1024068314963

20.

Gibb

B. E.

Benas

J. S.

Crossett

S. E.

Uhrlass

D. J.

(2007). Emotional maltreatment and verbal victimization in childhood: Relation to adults’ depressive cognitions and symptoms. Journal of Emotional Abuse, 7(2), 59–73. https://doi.org/10.1300/j135v07n02_04

21.

Gilbert

Miles

J. N. V.

(2000). Sensitivity to social put-down: It’s relationship to perceptions of social rank, shame, social anxiety, depression, anger and self-other blame. Personality and Individual Differences, 29(4), 757–774. https://doi.org/10.1016/S0191-8869(99)00230-5

22.

Gündoğmus

Unsal

Alma

Kul

Aydin

Bolu

Oznur

(2021). Reliability and validation of Turkish version of the 25-item hikikomori questionnaire. Psychiatry and Behavioral Sciences, 11(4), 235–242. https://doi.org/10.5455/PBS.20210919124046

23.

Hayes

A. F.

(2017). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford Publications.

24.

Heimberg

R. G.

Brozovich

F. A.

Rapee

R. M.

(2014). A cognitive-behavioral model of social anxiety disorder. In Hofmann

S. G.

DiBartolo

P. M.

(Eds.), Social anxiety: Clinical, developmental, and social perspectives (pp. 705–728). Academic Press. https://doi.org/10.1016/B978-0-12-394427-6.00024-8

25.

Hisli

(1988). Beck Depresyon Envanterinin gecerliligi uzerine bit calisma (A study on the validity of Beck Depression Inventory). Psikoloji Dergisi, 6, 118–122.

26.

Jacobs

R. H.

Reinecke

M. A.

Gollan

J. K.

Kane

(2008). Empirical evidence of cognitive vulnerability for depression among children and adolescents: A cognitive science and developmental perspective. Clinical Psychology Review, 28(5), 759–783. https://doi.org/10.1016/j.cpr.2007.10.006

27.

Johnson

D. M.

Sheahan

T. C.

Chard

K. M.

(2003). Personality disorders, coping strategies, and posttraumatic stress disorder in women with histories of childhood sexual abuse. Journal of Child Sexual Abuse, 12(2), 19–39. https://doi.org/10.1300/j070v12n02_02

28.

Kessler

R. C.

Wai

T. C.

Demler

Walters

E. E.

(2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627. https://doi.org/10.1001/ARCHPSYC.62.6.617

29.

Koyama

Miyake

Kawakami

Tsuchiya

Tachimori

Takeshima

(2010). Lifetime prevalence, psychiatric comorbidity and demographic correlates of “hikikomori” in a community population in Japan. Psychiatry Research, 176(1), 69–74. https://doi.org/10.1016/J.PSYCHRES.2008.10.019

30.

Kubo

Urata

Sakai

Nonaka

Saito

Tateno

Kobara

Hashimoto

Fujisawa

Suzuki

Otsuka

Kamimae

Muto

Usami

Honda

Kishimoto

Kuroki

Kanba

Kato

T. A.

(2020). Development of 5-day hikikomori intervention program for family members: A single-arm pilot trial. Heliyon, 6(1), Article e03011. https://doi.org/10.1016/J.HELIYON.2019.E03011

31.

Kuo

J. R.

Goldin

P. R.

Werner

Heimberg

R. G.

Gross

J. J.

(2011). Childhood trauma and current psychological functioning in adults with social anxiety disorder. Journal of Anxiety Disorders, 25(4), 467–473. https://doi.org/10.1016/J.JANXDIS.2010.11.011

32.

Kuru

Safak

Özdemir Tulacı

R. G.

Özdel

Özkula

N. G.

Örsel

(2018). Cognitive distortions in patients with social anxiety disorder: Comparison of a clinical group and healthy controls. The European Journal of Psychiatry, 32(2), 97–104. https://doi.org/10.1016/J.EJPSY.2017.08.004

33.

Lazarus

R. S.

Folkman

(1984). Stress, appraisal, and coping. Springer Publishing Company.

34.

T. M. H.

Wong

P. W. C.

(2015). Youth social withdrawal behavior (hikikomori): A systematic review of qualitative and quantitative studies. Australian and New Zealand Journal of Psychiatry, 49(7), 595–609. https://doi.org/10.1177/0004867415581179

35.

Liebowitz

M. R.

(1987). Social phobia (pp. 141–173). S.Karger AG. https://doi.org/10.1159/000414022

36.

Lim

M. H.

Rodebaugh

T. L.

Zyphur

M. J.

Gleeson

J. F. M.

(2016). Loneliness over time: The crucial role of social anxiety. Journal of Abnormal Psychology, 125(5), 620–630. https://doi.org/10.1037/ABN0000162

37.

Liu

Tan

R. H. S.

Chang

S. S. H.

Teh

W. L.

Shahwan

Lee

Y. W.

Chandwani

Chan

C. Y. W.

Tor

P. C.

Subramaniam

(2023). Pathological personality explains individual differences in global emotion dysregulation within the pathway between child maltreatment and severe depressive symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 16, S233–S241. https://doi.org/10.1037/TRA0001581

38.

Mashalpoure fard

Fallah Neudehi

Jamshiddoust Mianroudi

Solgi

. (2023). The role of childhood trauma, cognitive flexibility, and cognitive distortions in predicting self-harming behaviors among female adolescents. Caspian Journal of Health Research, 8(2), 85–92. https://doi.org/10.32598/CJHR.8.2.445.1

39.

Masuda

Katsuki

Matsushima

Kyuragi

Nakao

Kato

T. A.

(2024). Does childhood maltreatment affect hikikomori via traits of modern-type depression? Journal of Affective Disorders, 360, 50–54. https://doi.org/10.1016/J.JAD.2024.05.094

40.

Nonaka

Sakai

(2021). Psychological factors associated with social withdrawal (Hikikomori). Psychiatry Investigation, 18(5), 463–470. https://doi.org/10.30773/PI.2021.0050

41.

Nonaka

Takeda

Sakai

(2022). Who are hikikomori? Demographic and clinical features of hikikomori (prolonged social withdrawal): A systematic review. Australian and New Zealand Journal of Psychiatry, 56(12), 1542–1554. https://doi.org/10.1177/00048674221085917

42.

O’Day

E. B.

Heimberg

R. G.

(2021). Social media use, social anxiety, and loneliness: A systematic review. Computers in Human Behavior Reports, 3, Article 100070. https://doi.org/10.1016/J.CHBR.2021.100070

43.

Özdel

Taymur

Guriz

S. O.

Tulaci

R. G.

Kuru

Turkcapar

M. H.

(2014). Measuring cognitive errors using the Cognitive Distortions Scale (CDS): Psychometric properties in clinical and non-clinical samples. PLoS One, 9(8), Article e105956. https://doi.org/10.1371/JOURNAL.PONE.0105956

44.

Özdemir

İ.

Kuru

. (2023). Investigation of cognitive distortions in panic disorder, generalized anxiety disorder and social anxiety disorder. Journal of Clinical Medicine, 12(19), Article 6351. https://doi.org/10.3390/jcm12196351

45.

Ranieri

Andreoli

Bellagamba

Franchi

Mancini

Pitti

Sfameni

Stoppielli

(2015). Extreme social withdrawal in early adolescence: Epidemiological data on Italian hikikomori. European Psychiatry, 30, Article 1199. https://doi.org/10.1016/s0924-9338(15)30942-1

46.

Sakai

Yoshinaga

Thew

G. R.

Clark

D. M.

(2024). Successful remote treatment of a client with hikikomori using internet-delivered cognitive therapy for social anxiety disorder: A case report. Frontiers in Psychiatry, 15, Article 1368722. https://doi.org/10.3389/FPSYT.2024.1368722

47.

Şar

Öztürk

Ikikardeş

(2012). Çocukluk çaği ruhsal travma ölçeğinin türkçe uyarlamasinin geçerlilik ve güvenilirliği [Validity and reliability of the Turkish version of the Childhood Trauma Questionnaire]. Türkiye Klinikleri Tıp Bilimleri Dergisi, 32(4), 1054–1063. https://doi.org/10.5336/MEDSCI.2011-26947

48.

Schwartz

C. E.

Snidman

Kagan

(1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38(8), 1008–1015. https://doi.org/10.1097/00004583-199908000-00017

49.

Smits

J. A. J.

Rosenfield

McDonald

Telch

M. J.

(2006). Cognitive mechanisms of social anxiety reduction: An examination of specificity and temporality. Journal of Consulting and Clinical Psychology, 74(6), 1203–1212. https://doi.org/10.1037/0022-006X.74.6.1203

50.

Soykan

Ç.

Özgüven

H. D.

Gençöz

. (2003). Liebowitz Social Anxiety Scale: The Turkish version. Psychological Reports, 93(3_suppl), 1059–1069. https://doi.org/10.2466/PR0.2003.93.3F.1059

51.

Stein

M. B.

Stein

D. J.

(2008). Social anxiety disorder. Lancet, 371(9618), 1115–1125. https://doi.org/10.1016/s0140-6736(08)60488-2

52.

Swee

M. B.

Hudson

C. C.

Heimberg

R. G.

(2021). Examining the relationship between shame and social anxiety disorder: A systematic review. Clinical Psychology Review, 90, Article 102088. https://doi.org/10.1016/j.cpr.2021.102088

53.

Teo

A. R.

Chen

J. I.

Kubo

Katsuki

Sato-Kasai

Shimokawa

Hayakawa

Umene-Nakano

Aikens

J. E.

Kanba

Kato

T. A.

(2018). Development and validation of the 25-item Hikikomori Questionnaire (HQ-25). Psychiatry and Clinical Neurosciences, 72(10), 780–788. https://doi.org/10.1111/PCN.12691

54.

Teo

A. R.

Fetters

M. D.

Stufflebam

Tateno

Balhara

Choi

T. Y.

Kanba

Mathews

C. A.

Kato

T. A.

(2015). Identification of the hikikomori syndrome of social withdrawal: Psychosocial features and treatment preferences in four countries. International Journal of Social Psychiatry, 61(1), 64–72. https://doi.org/10.1177/0020764014535758

55.

Tolomei

Masi

Milone

Fantozzi

Viglione

Narzisi

Berloffa

(2023). Hikikomori (Severe Social Withdrawal) in Italian Adolescents: Clinical features and follow-up. Children, 10(10), Article 1669. https://doi.org/10.3390/CHILDREN10101669

56.

van Harmelen

A. L.

de Jong

P. J.

Glashouwer

K. A.

Spinhoven

Penninx

B. W. J. H.

Elzinga

B. M

. (2010). Child abuse and negative explicit and automatic self-associations: The cognitive scars of emotional maltreatment. Behaviour Research and Therapy, 48(6), 486–494. https://doi.org/10.1016/J.BRAT.2010.02.003

57.

Wakuta

Nishimura

Osuka

Tsukui

Takahashi

Adachi

Suwa

Katayama

(2023). Adverse childhood experiences: Impacts on adult mental health and social withdrawal. Frontiers in Public Health, 11, Article 1277766. https://doi.org/10.3389/FPUBH.2023.1277766

58.

Walsh

Fortier

M. A.

DiLillo

(2010). Adult coping with childhood sexual abuse: A theoretical and empirical review. Aggression and Violent Behavior, 15(1), 1–13. https://doi.org/10.1016/J.AVB.2009.06.009

59.

Weismoore

J. T.

Esposito-Smythers

(2010). The role of cognitive distortion in the relationship between abuse, assault, and non-suicidal self-injury. Journal of Youth and Adolescence, 39(3), 281–290. https://doi.org/10.1007/S10964-009-9452-6

60.

Whiteman

S. E.

Kramer

L. B.

Petri

J. M.

Weathers

F. W.

(2019). Trauma type and suicidal ideation: The mediating effect of cognitive distortions. Traumatology, 25(4), 262–268. https://doi.org/10.1037/TRM0000192

61.

Zhang

Chen

M. Y.

Feng

Cheung

Jackson

Zhang

Xiang

Y. T.

(2025). Epidemiology of hikikomori: A systematic review and meta-analysis of 19 studies. Psychiatry and Clinical Neurosciences, 79(4), 138–146. https://doi.org/10.1111/PCN.13768

Childhood Trauma and Hikikomori in Social Anxiety Disorder: The Mediating Role of Cognitive Distortions

Abstract

Background:

Aims:

Methods:

Results:

Conclusions:

Keywords

Introduction

Method

Participants

Measurement Instruments

Procedure of the Study

Statistical Analysis

Results

Sociodemographic Characteristics and Group Comparisons

Correlation Analysis

Mediation Analysis

Reverse Mediation Analysis

Discussion

Conclusion

Footnotes

Acknowledgements

ORCID iDs

Ethical Considerations

Consent to Participate

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References