Original Article

The Mediating Effects of Self-Esteem and Harm Avoidance on the Association between Social Anxiety Symptoms and Adult Attention Deficit Hyperactivity Disorder Symptom Severity in Turkish Inpatients with Alcohol Use Disorder


Objective: The first objective of this research was to examine the association of the symptom severity of social anxiety with the adult attention deficit hyperactivity disorder (ADHD) symptom severity in Turkish patients with alcohol use disorder (AUD). The second objective was to examine if harm avoidance and self-esteem mediated this relationship.

Method: This cross-sectional analysis was performed among 151 inpatients with AUD at the Bakirkoy/AMATEM, a treatment center for substance use disorder, in Istanbul. Patients were examined with the Liebowitz Social Anxiety Scale (LSAS), the Adult ADHD Self-Report Scale (ASRS), the Rosenberg Self-Esteem Scale (SES), and the temperament dimension of Harm Avoidance (HA). Using SPSS-20 software, the data was analyzed using Pearson correlations, multivariate analysis of covariance (MANCOVA), and multiple linear regressions.

Results: The scales scores were mildly correlated with each other. The low self-esteem and high HA were related with the inattentive (IN) dimension of ADHD, whereas low self-esteem solely predicted hyperactivity/impulsivity (HI) dimension of ADHD in MANCOVA. In the linear regression analysis, the severity of social anxiety, particularly avoidance dimension, was associated with the symptom severity of ADHD. In the second step of the analysis, together with the avoidance dimension of social anxiety, self-esteem was associated with the symptom severity of ADHD. However, in the third step, after including HA as an independent variable in the analysis, the avoidance dimension of social anxiety was no longer associated with the severity of adult ADHD symptoms, whereas self-esteem together with HA (particularly “anticipatory worry and pessimism” [HA-1], and “asthenia and fatigability” [HA-4]) predicted.

Conclusion: Findings of the present study shows that although the symptom severity of social anxiety is associated with the severity of ADHD symptoms among inpatients with AUD, among dimensions of social anxiety, the avoidance dimension plays a main role in this relationship. Also, while the self-esteem partially mediates this relationship, HA seems to have a full mediator effect on this relationship.

1. Klein RG, Mannuzza S, Olazagasti MA, Roizen E, Hutchison JA, Lashua EC, et al. Clinical and functional outcome of childhood attention-deficit/hyperactivity disorder 33 years later. Arch Gen Psychiatry. 2012;69(12):1295-303.
2. Ivanov I, Yehuda R. Optimizing fitness for duty and post-combat clinical services for military personnel and combat veterans with ADHD-a systematic review of the current literature. Eur J Psychotraumatol. 2014;5.
3. Johann M, Bobbe G, Putzhammer A, Wodarz N. Comorbidity of alcohol dependence with attention-deficit hyperactivity disorder: differences in phenotype with increased severity of the substance disorder, but not in genotype (serotonin transporter and 5-hydroxytryptamine-2c receptor). Alcohol Clin Exp Res. 2003;27(10):1527-34.
4. Ohlmeier MD, Peters K, Te Wildt BT, Zedler M, Ziegenbein M, Wiese B, et al. Comorbidity of alcohol and substance dependence with attention-deficit/hyperactivity disorder (ADHD). Alcohol Alcohol. 2008;43(3):300-4.
5. Evren C, Umut G, Bozkurt M, Can Y, Evren B, Agachanli R. Partial mediator role of physical abuse on the relationship between attention-deficit/hyperactivity disorder symptoms and severity of dissociative experiences in a sample of inpatients with alcohol use disorder. Indian J Psychiatry. 2017;59(3):306–12.
6. Estévez N, Dey M, Eich-Höchli D, Foster S, Gmel G, Mohler-Kuo M. Adult attention-deficit/hyperactivity disorder and its association with substance use and substance use disorders in young men. Epidemiol Psychiatr Sci. 2015;20:1–12.
7. Ercan ES, Coşkunol H, Varan A, Toksöz K. Childhood attention deficit/hyperactivity disorder and alcohol dependence: a 1-year follow-up. Alcohol Alcohol. 2003;38(4):352–6.
8. Grella CE, Hser YI, Joshi V, Rounds-Bryant J. Drug treatment outcomes for adolescents with comorbid mental and substance use disorders. J Nerv Ment Dis. 2001;189(6):384–92.
9. Bozkurt M, Evren C, Umut G, Evren B. Relationship of attention-deficit/hyperactivity disorder symptom severity with severity of alcohol-related problems in a sample of inpatients with alcohol use disorder. Neuropsychiatr Dis Treat. 2016;12:1661–7.
10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Washington DC: American Psychiatric Association; 2013.
11. Stein MB, Stein DJ. Social anxiety disorder. Lancet (London, England). 2008;371(9618):1115–25.
12. Thomas SE, Thevos AK, Randall CL. Alcoholics with and without social phobia: A comparison of substance use and psychiatric variables. J Stud Alcohol. 1999;60(4):472–9.
13. Perugi G, Frare F, Madaro D, Maremmani I, Akiskal HS. Alcohol abuse in social phobic patients: is there a bipolar connection? J Affect Disord. 2002;68(1):33–9.
14. Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM. Social phobia: Comorbidity and morbidity in an epidemiological sample. Arch Gen Psychiatry. 1992;49:282–8.
15. Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch Gen Psychiatry. 1996;53(2):159–68.
16. Evren C, Can S, Evren B, Cakmak D. The relationship between alexithymia and depression, anxiety and erectile dysfunction in a sample of male alcoholic inpatients: a controlled study. Klin Psikofarmakol Bul - Bull Clin Psychopharmacol. 2002;12(4):165–73.
17. Eken B, Evren C, Saatcioglu O, Cakmak D. Relationship of personality disorders with sociodemographic characteristics, depression and anxiety among alcohol dependents. Dusunen Adam J Psychiatry Neurol Sci. 2003;16:71–9.
18. Crum RM, Pratt LA. Risk of heavy drinking and alcohol use disorders in social phobia: a prospective analysis. Am J Psychiatry. 2001;158(10):1693–700.
19. Mancini C, van Ameringen M, Oakman JM, Figueiredo D. Childhood attention deficit/hyperactivity disorder in adults with anxiety disorders. Psychol Med. 1999;29(3):515–25.
20. Van Ameringen M, Mancini C, Simpson W, Patterson B. Adult attention deficit hyperactivity disorder in an anxiety disorders population. CNS Neurosci Ther. 2011;17(4):221–6.
21. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–23.
22. Park S, Cho MJ, Chang SM, Jeon HJ, Cho SJ, Kim BS, et al. Prevalence, correlates, and comorbidities of adult ADHD symptoms in Korea: Results of the Korean epidemiologic catchment area study. Psychiatry Res. 2011;186(2–3):378–83.
23. Koyuncu A, Ertekin E, Yüksel Ç, Aslantaş Ertekin B, Çelebi F, Binbay Z, et al. Predominantly inattentive type of ADHD is associated with social anxiety disorder. J Atten Disord. 2015;19(10):856–64.
24. Koyuncu A, Celebi F, Ertekin E, Kok BE, Tukel R. Clinical effects of ADHD subtypes in patients with social anxiety disorder. J Atten Disord. 2015;pii: 1087054715617533.
25. Koyuncu A, Celebi F, Ertekin E, Kok BE, Tukel R. Attention deficit and hyperactivity in social anxiety disorder: relationship with trauma history and impulsivity. ADHD Atten Deficit Hyperact Disord. 2016;8(2):95–100. doi: 10.1007/s12402-016-0189-2
26. Koyuncu A, Alkin T, Tukel R. Development of social anxiety disorder secondary to attention deficit/hyperactivity disorder (the developmental hypothesis). Early Interv Psychiatry. 2016.
27. Evren C, Dalbudak E, Ozen S, Evren B. The relationship of social anxiety disorder symptoms with probable attention deficit hyperactivity disorder in Turkish university students; impact of negative affect and personality traits of neuroticism and extraversion. Psychiatry Res. 2017;254:158–63.
28. Kose S. A psychobiological model of temperament and character: TCI. Yeni Symp. 2003;41(2):86–97.
29. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry. 1993;50(12):975–90.
30. Salgado CAI, Bau CHD, Grevet EH, Fischer AG, Victor MM, Kalil KLS, et al. Inattention hyperactivity dimensions of ADHD are associated with different personality profiles inattention and hyperactivity dimensions of ADHD are associated with different personality profiles. Psychopathology. 2009;42(2):108–12.
31. Jacob C, Gross-Lesch S, Jans T, Geissler J, Reif A, Dempfle A, et al. Internalizing and externalizing behavior in adult ADHD. ADHD Atten Deficit Hyperact Disord. 2014;6(2):101–10.
32. Perroud N, Hasler R, Golay N, Zimmermann J, Prada P, Nicastro R, et al. Personality profiles in adults with attention deficit hyperactivity disorder (ADHD). BMC Psychiatry. 2016;16(1):199.
33. Kim KM, Nam S, Kim SY, Lee SM, Choi J-W, Kang T, et al. Psychopathological, temperamental, and characteristic factors in adults with remaining childhood attention-deficit hyperactivity symptoms. Int J Psychiatry Clin Pract. 2017;21(3):236–41.
34. Faraone S V, Kunwar A, Adamson J, Biederman J. Personality traits among ADHD adults: implications of late-onset and subthreshold diagnoses. Psychol Med. 2009;39(4):685–93.
35. Gomez R, Woodworth R, Waugh M, Corr PJ. Attention-deficit/hyperactivity disorder symptoms in an adult sample: Associations with Cloninger’s temperament and character dimensions. Pers Individ Dif. 2012;52(3):290–4.
36. Merwood A, Asherson P, Larsson H. Genetic associations between the ADHD symptom dimensions and Cloninger’s temperament dimensions in adult twins. Eur Neuropsychopharmacol. 2013;23(6):416–25.
37. Pélissolo A, André C, Pujol H, Yao SN, Servant D, Braconnier A, et al. Personality dimensions in social phobics with or without depression. Acta Psychiatr Scand. 2002;105(2):94–103.
38. Kim SW, Hoover KM. Tridimensional Personality Questionnaire: Assessment in patients with social phobia and control group. Psychol Rep. 1996;78(1):43–9.
39. Chatterjee S, Sunitha TA, Velayudhan A, Khanna S. An investigation into the psychobiology of social phobia: personality domains and serotonergic function. Acta Psychiatr Scand. 1997;95(6):544–50.
40. Marteinsdottir I, Tillfors M, Furmark T, Andenberg UM, Ekselius L. Personality dimensions measured by the Temperament and Character Inventory (TCI) in subjects with social phobia. Vol. 57, Nordic Journal of Psychiatry. 2003. p. 29–35.
41. Hofmann SG, Loh R. The Tridimensional Personality Questionnaire: changes during psychological treatment of social phobia. J Psychiatr Res. 2006;40(3):214–20.
42. Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry. 1987;22:141–73.
43. Evren C, Evren B, Dalbudak E. Alexithymia and personality in relation to social anxiety symptoms in male alcohol-dependent inpatients. Arch Neuropsychiatry. 2008;45(3):72–7.
44. Rosenberg M. Society and the adolescent self-image. Princeton: Princeton University Press; 1965.
45. Newark PE, Elsässer M, Stieglitz RD. Self-esteem, elf-efficacy, and resources in adults with ADHD. J Atten Disord. 2016;20(3):279–90.
46. Dittmann RW, Wehmeier PM, Schacht A, Minarzyk A, Lehmann M, Sevecke K, et al. Atomoxetine treatment and ADHD-related difficulties as assessed by adolescent patients, their parents and physicians. Child Adolesc Psychiatry Ment Health. 2009;3(1):21.
47. Bussing R, Zima BT, Perwien AR. Self-esteem in special education children with ADHD: relationship to disorder characteristics and medication use. J Am Acad Child Adolesc Psychiatry. 2000;39(10):1260–9.
48. Philipsen A, Richter H, Peters J, Alm B, Sobanski E, Colla M, et al. Structured group psychotherapy in adults with attention deficit hyperactivity disorder: results of an open multicentre study. J Nerv Ment Dis. 2007;195(12):1013–9.
49. Ramsay JR, Rostain AL. Cognitive behavioral therapy for Adult ADHD: An integrative psychosocial and medical approach. New York, NY: Routledge; 2008.
50. Young S, Bramham J. ADHD in adults. A psychological guide to practice. Chichester: UK: Wiley; 2007.
51. Newark PE, Stieglitz R-D. Therapy-relevant factors in adult ADHD from a cognitive behavioural perspective. Atten Defic Hyperact Disord. 2010;2(2):59–72.
52. De La Ronde C, Swann WB. Self-esteem: The puzzle of low self-regard. In: Baumeister R, editor. Self-esteem: The puzzle of low self-regard. New York: Plenum Press; 1993. p. 147–65.
53. van Tuijl LA, de Jong PJ, Sportel BE, de Hullu E, Nauta MH. Implicit and explicit self-esteem and their reciprocal relationship with symptoms of depression and social anxiety: a longitudinal study in adolescents. J Behav Ther Exp Psychiatry. 2014;45(1):113–21.
54. Shaffer R, Kipp K, Wood E, Willoughby T. Developmental Psychology: Childhood and Adolescence. Toronto: Nelson Education Ltd; 2010.
55. Iancu I, Bodner E, Ben-Zion IZ. Self esteem, dependency, self-efficacy and self-criticism in social anxiety disorder. Compr Psychiatry. 2015;58:165–71.
56. Soykan C, Ozguven HD, Gencoz T. Liebowitz Social Anxiety Scale: The Turkish version. Psychol Rep. 2003;93(3_suppl):1059–69.
57. Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35(2):245–56.
58. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27.
59. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association; 2000.
60. Adler LA, Spencer T, Faraone S V, Kessler RC, Howes MJ, Biederman J, et al. Validity of pilot Adult ADHD Self- Report Scale (ASRS) to rate adult ADHD symptoms. Ann Clin Psychiatry. 2006;18(3):145–8.
61. Dogan S, Oncu B, Saracoglu G, Kucukgoncu S. Validity and reliability of the Turkish version of the Adult ADHD Self-Report Scale (ASRS-v1.1). Anadolu Psikiyatr Derg. 2009;10:77-87. (Turkish).
62. Evren C, Umut G, Teksin-Unal G, Agachanli R, Evren B. Psychometric properties of the Turkish version of the Adult ADHD Self-Report Scale (ASRS) in a sample of ınpatients with alcohol use disorder. Dusunen Adam J Psychiatry Neurol Sci. 2016;33(2):109–19.
63. Kose S, Sayar K, Ak I, Aydin N, Kalelioglu U, Kirpinar I, et al. Turkish version of the Temperament and Character Inventory (TCI): Reliability, validity, and factorial structure. Klin Psikofarmakol Bul - Bull Clin Psychopharmacol. 2004;14(3):107-131. (Turkish).
64. Cuhadaroglu F. Self-esteem in adolescence. Hacettepe University, Ankara, Turkey; 1986.
65. Yen C-F, Yang P, Wu Y-Y, Cheng C-P. The relation between family adversity and social anxiety among adolescents in Taiwan: effects of family function and self-esteem. J Nerv Ment Dis. 2013;201(11):964–70.
66. Tillman R, Geller B, Craney JL, Bolhofner K, Williams M, Zimerman B, et al. Temperament and character factors in a prepubertal and early adolescent bipolar disorder phenotype compared to attention deficit hyperactive and normal controls. J Child Adolesc Psychopharmacol. 2003;13(4):531–43.
67. Sizoo B, van den Brink W, van Eenige MG, van der Gaag RJ. Personality characteristics of adults with autism spectrum disorders or attention deficit hyperactivity disorder with and without substance use disorders. J Nerv Ment Dis. 2009;197(6):450–4.
68. Minelli A, Pedrini L, Magni LR, Rotondo A. Personality traits in an Italian sample: relationship with anxiety and depression. Clin Pract Epidemiol Ment Health. 2009;5(1):26–30.
69. Nyman E, Miettunen J, Freimer N, Joukamaa M, Mäki P, Ekelund J, et al. Impact of temperament on depression and anxiety symptoms and depressive disorder in a population-based birth cohort. J Affect Disord. 2011;131(1–3):393–7.
70. Farmer RF, Seeley JR. Temperament and character predictors of depressed mood over a 4-year interval. Depress Anxiety. 2009;26(4):371–81.
71. Pierò A. Personality correlates of impulsivity in subjects with generalized anxiety disorders. Compr Psychiatry. 2010;51(5):538–45.
72. Corruble E, Duret C, Pelissolo A, Falissard B, Guelfi JD. Early and delayed personality changes associated with depression recovery? A one-year follow-up study. Psychiatry Res. 2002;109(1):17–25.
73. Borman PD, Zilberman ML, Tavares H, Surís AM, el-Guebaly N, Foster B. Personality changes in women recovering from substance-related dependence. J Addict Dis. 2006;25(4):59–66.
74. Ramsay RJ, Rostain AL. Adapting psychotherapy to meet the needs of adults with attention-deficit/hyperactivity disorder. Psychother Theory, Res Pract Train. 2005;42(1):72–84.
75. Stevenson CS, Whitmont S, Bornholt L, Livesey D, Stevenson RJ. A cognitive remediation programme for adults with attention deficit hyperactivity disorder. Aust N Z J Psychiatry. 2002;36(5):610–6.
76. Virta M, Vedenpää A, Grönroos N, Chydenius E, Partinen M, Vataja R, et al. Adults with ADHD benefit from cognitive-behaviorally oriented group rehabilitation: a study of 29 participants. J Atten Disord. 2008;12(3):218–26.
IssueVol 16 No 3 (2021) QRcode
SectionOriginal Article(s)
DOI https://doi.org/10.18502/ijps.v16i3.6253
Alcohol Use Disorder Attention Deficit Hyperactivity Disorder Social Anxiety Disorder Self Concept

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Evren C, Cicekci E, Umut G, Evren B, Durmus Cicekci K. The Mediating Effects of Self-Esteem and Harm Avoidance on the Association between Social Anxiety Symptoms and Adult Attention Deficit Hyperactivity Disorder Symptom Severity in Turkish Inpatients with Alcohol Use Disorder. Iran J Psychiatry. 16(3):281-289.