Examining the Mediating Effects of Self-Concealment and Social Anxiety on the Relationship Between Substance Use Disorders and Food Addiction

Examining the Mediating Effects of Self-Concealment and Social Anxiety on the Relationship Between Substance Use Disorders and Food Addiction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Examining the Mediating Effects of Self-Concealment and Social Anxiety on the Relationship Between Substance Use Disorders and Food Addiction Somayeh Naghavi, Mohammad Niroumand Sarvandani, Monazah Zare Rashnu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6981948/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Addiction is one of the most complex issues that the whole world is facing. Psychological variables are related to substance use and food addictions. This study aimed to investigate the mediating role of social anxiety and self-concealment between substance use disorder and food addiction. Method A total of 1329 people participated in this study, all of whom were over 18 years of age. The assist questionnaire was used to assess substance use disorder, the mYFAS was used for food addiction, the self-concealment scale was used for self-concealment, and the mini-social phobia inventory was used to assess social anxiety. SPSS-24 software and the structural equation modelling were used to analyse the data. Results The results showed that the standardized coefficients of the proposed model for investigating the mediating roles of social anxiety and self-concealment in the relationship between substance use disorder and food addiction are fit. The correlation between substance use disorder, food addiction, self-concealment and social anxiety is positive and significant. The correlation between food addiction and social anxiety is also positive and significant whereas the relationship between food addiction and self‐concealment is not significant. Conclusions The mediation model showed that substance use disorder’s relevance with food addiction is not only a direct relationship but is essentially channeled through these underlying psychological factors. In other words, Self-concealment can start a path in which social anxiety develops as a result of internal distress and, consequently, addictive behaviors emerge in the individual. Biological sciences/Drug discovery Biological sciences/Psychology Anxiety Disorders Food Addiction Self-Concealment Substance-Related Disorders Figures Figure 1 Plain English Summary This study examines how two psychological factors- self-concealment (hide personal thoughts and feelings from others) and social anxiety (feeling uncomfortable in social situations)- explain the relation between substance use disorders (drug or alcohol addiction) and food addiction (uncontrollable eating behaviors). This study wants to answer this question: Do people with substance use problems develop food addiction partly because they hide their feelings or struggle with social anxiety? By understanding how these hidden feelings and social anxiety affect the link between substance use and food addiction, the study hopes to offer better insight into how these issues are connected and how treatment might be improved. Introduction Addiction still is one of the most important problems faced by societies all over the world [ 1 ]. Both substance use disorder and food addiction have a profound impact on the well-being and functioning of society [ 2 , 3 ]. Although the two types of addiction appear to differ in their symptoms—substance use disorder is typically associated with compulsive use of psychoactive substances, which can have severe physiological, psychological, and social consequences [ 4 ] while food addiction is characterized by uncontrolled overeating and loss of control over food intake, ultimately contributing to obesity and metabolic disorders [ 5 ]. But both substance use disorders and food addiction activate the dopamine-based reward pathway and dopamine release reinforces repeated consumption behaviours [ 6 ]. Recent studies have increasingly emphasized the importance of psychological processes in the formation and persistence of addictive behaviours [ 7 – 9 ] and emerging evidence suggests that factors such as secrecy and social anxiety may act as mediators that bridge the gap between substance use disorder and food addiction [ 10 , 11 ]. Self-concealment, defined as the persistent tendency to conceal personal information, especially that which is distressing or negative [ 12 ], has been recognized as a maladaptive strategy that can exacerbate psychological problems. Individuals who conceal aspects of their inner experiences may experience feelings of isolation, lack of social support, and increased internal distress[ 13 ]. In addition to increasing stress and anxiety levels, this internalization of unpleasant emotions may make individuals more likely to resort to unhealthy coping mechanisms. Confidentiality can be a double-edged sword in the context of addiction: it can temporarily protect against perceived social judgment, but it can also interfere with the natural processes of social connection and emotional regulation that are essential for mental health [ 14 , 15 ]. Social anxiety—essentially the fear of being judged or humiliated in social situations [ 16 ]—is introduced as a major risk factor for addictive behaviours [ 17 ] somewhat similar to self-concealment [ 18 , 19 ]. When individuals experience social anxiety, they often avoid interactions and cut themselves off from supportive systems that could otherwise help them manage stress. And that isolation? It can drive them toward quick fixes like substance use disorders or food addiction [ 11 ]. Some might use substance use disorders to calm the nerves brought on by socializing, while others turn to food for comfort during solitary moments [ 17 , 20 ]. People who are socially apprehensive often keep their emotions to themselves. The more they repress their feelings, the more stressed they become due to this self-concealment, which makes them use these unhealthy coping strategies even more [ 21 ]. Confidentiality is encouraged by social anxiety, which intensifies psychological suffering and eventually heightens addictive behaviors [ 22 ]. This link between social anxiety and the suppression of emotions provides a clear explanation for why addiction to food and substance use disorders often occurs simultaneously. This idea has been named the self-medication hypothesis. Essentially, it means that individuals turn to substance use disorders or overeating as a way to cope with unpleasant emotions or avoid social awkwardness [ 23 ]. However, hiding away simply makes people feel lonelier, worsening their anxiety significantly [ 15 , 24 ]. The necessity to look at common mediators like social anxiety and self-concealment is further highlighted by the fact that people with one type of addiction frequently display vulnerabilities that raise the chance of getting the other [ 25 ]. More integrated intervention techniques that focus on the underlying emotional and cognitive processes causing both forms of addictive behaviour can be created by understanding these common mechanisms. These results have important therapeutic outcomes. By clarifying the mediating role of social anxiety and self-concealment, researchers and practitioners can more precisely identify people who are at risk and create treatments that explicitly target these psychological processes. The cycle of addiction may be broken by social skills training and cognitive-behavioural therapy (CBT), two therapeutic approaches that have demonstrated promise in lowering social anxiety and maladaptive self-concealment [ 26 ] [ 27 ]. Furthermore, preventive interventions may be made possible by early detection of rising levels of social anxiety and self-concealment in groups that are prone to addictive behaviours. This would lessen the chance that single substance use or overeating will turn into a full-comorbid addiction [ 25 ]. In light of these variables, the current study investigates how social anxiety and self-concealment mediate the link between substance use disorder and food addictions. By integrating contemporary theoretical viewpoints and using reliable scientific methods. In the end, figuring out how social anxiety and self-concealment drive addictive behaviors can help create better prevention and intervention strategies, enhance treatment results, and promote long-term recovery. Methods Participants and Procedure This study follows a cross-sectional design. Inclusion and exclusion criteria were limited to ensuring a relatively equal number of men and women living in Iran were recruited across age groups covering the adult lifespan. In the sampling section, convenience sampling was used. All the data was collected through an online questionnaire from March 2024 to December 2024. Data collected from 1327 that completed mYFAS, Assist, Social anxiety, Self concealment questionnaires. As for demographics, age, sex, Marital Status, having children, number of children they have, having an infant, education, Employment status, height, weight, history of Physical and mental condition, menstrual cycle. All methods were performed in accordance with the relevance guidelines and regulations. Data analysis: Statistical analysis of the study was performed using the IBM SPSS Amos 29, SPSS-24. Mean, standard deviation, and skewness were used as descriptive statistics of the study variables. Prior to analysis, data were screened for missing values, outliers, and assumptions of normality. Cases with missing data were excluded. The measurement model was first evaluated through Confirmatory Factor Analysis (CFA) to assess the validity and reliability of latent constructs. Model fit was assessed using multiple fit indices, including the Chi-square statistic (χ²), Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). Following confirmation of an adequate measurement model, the structural model was tested to evaluate hypothesized relationships between constructs. Path coefficients, standard errors, and significance levels were reported. All statistical tests were two-tailed, and significance was set at p < 0.05. Measures : mPYFAS The 13 items that make up the mPYFAS are scored on an 8-point Likert scale, with zero denoting "never" and seven denoting "daily." Together with two extra questions that gauge the clinical importance of these symptoms (distress/impairment), these items evaluate the 11 criteria for substance use disorder listed in the DSM-5. The cut-off value for each item is unique and determines whether the criterion is met or not. If the criterion is satisfied, a score of 1 is given; if not, a score of 0 is given. The sub-scores of the clinical significance and symptom criteria can be used to compute two cumulative scores. The total number of symptoms recorded is represented by the symptom count score, which runs from 0 to 11. The clinical significance score, which goes from 0 to 2, shows if the clinical significance requirement is satisfied. The criterion is deemed satisfied and is given a score of 1 if the clinical significance score is 1 or 2. Otherwise, the condition is unmet and gets a score of 0 if the score is 0. The criteria for diagnosing FA include meeting the clinical significance requirement and reporting two or more symptoms (symptom count score between two and eleven) [ 28 , 29 ]. Zhang et al (2021) in their study showed that the chinese version of mYFAS 2.0 has adequate internal consistency, good test–retest reliability and satisfactory construct validity[ 30 ]. In a large-scale study operated by Mohammad Niroumand Sarvandani et al. involving 9,606 participants, the Persian conformity of the modified Yale Food Addiction Scale 2.0 (mPYFAS 2.0) showed strong psychometric performance, confirming its reliability and validity for evaluating food addiction among Persian-speaking individuals. Confirmatory factor analysis (CFA) supported the sufficiency of a single-factor model, with fit indices—CFI and TLI—exceeding 0.95, SRMR at or below 0.09, and RMSEA under 0.03, all indicating a good model fit. Reliability measures were also significant, as shown by Cronbach's alpha of 0.83, ordinal alpha of 0.93, and composite reliability of 0.86, consistent across both genders and the overall sample. Concurrent validity was further supported by significant correlations with other relevant psychological scales: binge eating severity (BES, r = 0.59, p < 0.001), impulsivity (BIS-11, r = -0.16, p < 0.001), and resilience (CD-RISC, r = 0.22, p < 0.001). These results collectively highlight the mPYFAS 2.0 as a valid and reliable tool for assessing food addiction in Persian-speaking populations. The original Yale Food Addiction Scale 2.0 (YFAS 2.0), which is part of the DSM-5 criteria for substance use disorder (SUD), served as the model for the Persian version of the mYFAS 2.0. It has 13 items, two of which evaluate the clinical relevance of those symptoms and 11 of which correspond to the SUD diagnostic criteria. An 8-point Likert scale, with 0 denoting "Never" and 7 denoting "Daily," is used to gather responses. To ascertain whether each condition is satisfied, particular cut-off values are employed. At least two symptoms and one or more clinically significant signs must be present for food addiction (FA) to be diagnosed. Mild (2–3 symptoms), moderate (4–5 symptoms), and severe (6–11 symptoms) are the three severity degrees of FA [ 31 ] [ 32 ]. Assist : An international team of researchers and clinicians created the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) for the World Health Organization (WHO) as a technical tool to help with early detection of substance use disorders and health risks associated with substance use in primary care, general medical care, and other settings. It was created to be utilized in basic care settings where clients' use of dangerous and deadly substances may go unnoticed or worsen. The ASSIST program is designed to be student-neutral and can be used in a variety of settings to screen for the use of the following substances: 1) Tobacco 2) Cannabis 3) Opioid compounds 4) Amphetamine stimulants 5) Alcohol 6) Hallucinogens 7) Inhalants 8) Cocaine 9) Other substances. Participants' history and previous three months of substance use and comorbidities are gathered by the ASSIST. Acute intoxication, substance usage, addiction or "hazardous" substance use, and substance abuse are among the comorbidities that the test can detect [ 33 ]. The average test-retest reliability coefficients (Kappas) of ASSIST 0.90 (consistency of reporting 'ever' usage of substance use disorder) and the reliabilities of substances fell between good and excellent, according to the Who Assist Working Group (2002) [ 34 ]. The ability of ASSIST scores to detect problematic use was shown to be strong by Shmulewitz et al. (2023), with little variation by age or gender. Additionally, ASSIST-FC demonstrated strong agreement, adequate sensitivity, high speciality, and positive predictivity. This study used 10 questions related to substance use that were included in the ASSIST [ 35 ]. This screen test has been translated in Iran in to Persian by the Ministry of Health and Medical Treatment and Education Organization and made available to health workers. Social anxiety (Mini-Social Phobia Inventory (Mini-SPIN) The Mini-Social Phobia Inventory (Mini-SPIN) is a brief, self-report screening tool designed by Connor et al (2001) to assess core symptoms of social anxiety disorder. The Mini-SPIN is used to quickly identify individuals who may be experiencing social anxiety disorder. It’s derived from the longer Social Phobia Inventory (SPIN), the Mini-SPIN hold the essential features needed to receive social anxiety symptoms, making it a convenient option when time is limited. The Mini-SPIN consists of 3 items that focus on key aspects of social anxiety, such as fear of negative evaluation, avoidance of social situations, and the emotional distress linked to social interactions. Each item is typically rated on a Likert-type scale (often 0 to 4), leading to a total possible score ranging from 0 to 12. A score of 6 or higher is commonly used as a threshold to indicate a potential case of social anxiety disorder, though the exact cut-off can vary slightly depending on the population being assessed. Research has demonstrated that the Mini-SPIN has good internal consistency (with Cronbach’s alpha values often reported around 0.85 or higher) and satisfactory test-retest reliability [ 36 ]. Studies support its convergent validity, as scores on the Mini-SPIN correlate well with other established measures of social anxiety, ensuring that it effectively identifies those at risk. Mörtberg, Jansson Fröjmark (2018) in their study showed that the Mini-SPIN was associated with satisfactory convergent validity [ 37 ]. The result of Hathway & et al. (2024) demonstrated that The Mini-SPIN showed good criterion group validity, internal consistency and construct validity across caregiver and child report and the findings from their study showed further support for the use of the Mini-SPIN as a screening tool for SAD [ 38 ]. Ebrahim Rezaei Dogaheh (2013) in a study which was about Psychometric Properties of Farsi Version of the Social Phobia Inventory (SPIN) reported that Internal consistency of social phobia inventory (Cronbach's α = 0.66 and 0.87 for clinical and non-clinical group respectively) and 2-week test-retest reliability in non-clinical sample (r = 0.89) were both good [ 39 ]. Self-concealment Scale This questionnaire was designed by Larson and Chastain in 1990 with the aim of self-concealment as a self-report [ 40 ]. In the original version, it was designed for youth and adults and was standardized on Iranian adolescents. It has 10 questions and has no subscales. The scoring of this questionnaire uses a 5-point Likert scale, in which the answer “I completely agree” is given a score of 5, “I agree” is given a score of 4, “I neither agree nor disagree” is given a score of 3, “I disagree” is given a score of 2, and “I completely disagree” is given a score of 1. The lowest score is 10 and the highest score is 50. In this questionnaire, obtaining a higher score indicates greater self-concealment. In a study by Larson and Chastain in 1990, the reliability of this questionnaire using the internal consistency method of Cronbach's alpha coefficient was reported to be 0.83, which was 0.87 for youth and 0.84 for the adult group, and the test-retest reliability with a 4-week interval of correlation between the scores administered twice was calculated and reported to be 0.81. In another study, fan et al. (2023) reported the Cronbach's alpha coefficient of this questionnaire in the community of Chinese older adults was 0.923. In their study, The Self-Concealment Scale (SCS) was found to have good reliability and validity in the Chinese elderly population, and can be used as a valid tool to assess the tendency of older people to conceal negative or painful information [ 41 ]. Fan et al. (2024) found the factor loadings of SCS items ranged from 0.62 to 0.73 and The scale showed a Cronbach’s α coefficient value of 0.895, McDonald’s Omega coefficient of 0.893, and a split-half reliability coefficient value of 0.861 [ 42 ]. Ghaffari, Ghasemi-Nejad, and Cherami (2021) reported a Cronbach's alpha of 0.84 for this scale . Results Table 1 Demographic information Age Sex Marital Statues Education Employment Statues 18–20 196 21–30 554 31–40 320 41–50 159 51–60 60 More than 60 17 Women 875 Men 431 Single 704 Married 540 Divorced 52 Elementary School 30 Middle School 65 High School 288 Postgraduate Diploma 106 Bachelor Degree 440 Master of Degree 322 Phd 55 Unemployment 187 Studying 356 Full-time Job 316 Part-time Job 183 Freelancer 65 Retired 46 Other 153 Table 1 , showed demographics of age, sex, marital status, education and employment statues in participants. Table 2 Descriptive Statistics for Study Variables Variable M SD Skewness Kurtosis Substance use disorder 11.08 1.31 0.91 –0.54 Food Addiction 20.24 4.60 0.25 –0.40 Social Anxiety 8.31 2.53 0.26 –0.52 Self-Concealment 28.20 9.07 0.04 –0.46 Based on the values in Table 2 , skewness and kurtosis for all variables are within the range of − 1 to + 1, indicating that the data are normally distributed. Table 3 Correlation Matrix of Study Variables Variable 1. Substance use disorder 2. Food Addiction 3. Social Anxiety 4. Self-Concealment 1. Substance use disorder 1.00 .078** .093** .107** 2. Food Addiction – 1.00 .168** .050 3. Social Anxiety – – 1.00 .102** 4. Self-Concealment – – – 1.00 **p < .01; *p < .05. Based on these results in Table 3 , the correlation between substance use disorder and food addiction is positive and significant (r = .078, p < .01). In addition, substance use disorder is significantly related to social anxiety (r = .093, p < .01) and self-concealment (r = .107, p < .01). The correlation between food addiction and social anxiety is also positive and significant (r = .168, p < .01), whereas the relationship between food addiction and self‐concealment is not significant. Prior to testing the research model with structural equation modeling (SEM) using Amos24, univariate outliers were identified via boxplots and multivariate outliers were examined using Mahalanobis statistics; such cases were removed from the dataset. Skewness and kurtosis were computed using SPSS24, and all values fell within the acceptable range (± 1), confirming the assumption of normality. Once these assumptions were met, SEM was used to evaluate the proposed model. The standardized coefficients of the final model—which examines the mediating roles of social anxiety and self-concealment in the relationship between substance use disorder and food addiction—are presented in Fig. 1 . In Fig. 1 , the standardized coefficients of the proposed model for investigating the mediating roles of social anxiety and self-concealment in the relationship between substance use disorder and food addiction are shown. The model fit indices are provided in the table below. Table 4 Fit Indices for the Tested Model Fit Index Acceptable Range Observed Value χ²/df 1–5 3.73 CFI > .90 0.935 IFI > .90 0.935 NFI > .90 0.914 RMSEA < .10 0.046 Table 4 showed that the chi-square/df ratio falls within the acceptable range, and the CFI, IFI, and NFI values exceed .90. An RMSEA of 0.046 is well below .10, all of which indicate a good model fit. Table 5 Direct, Indirect, and Total Effects Among Variables Path Direct Effect Indirect Effect Total Effect Significance Substance use disorder → Social Anxiety 0.14 – 0.14 p < .001 (*** ) Substance use disorder → Self-Concealment 0.015 – 0.015 p = .62 Substance use disorder → Food Addiction 0.33 0.04 0.37 p < .001 (*** ) Social Anxiety → Food Addiction 0.26 – 0.26 p < .001 (*** ) Self-Concealment → Food Addiction 0.052 – 0.052 p = .061 Table 5 showed that substance use disorder has a significant direct effect on food addiction (β = 0.33, p < .001) and a significant indirect effect via social anxiety and self-concealment (β = 0.04, p < .001), resulting in a total effect of 0.37. Table 6 Bootstrap Results for the Indirect Effects (Total Sample) Path Standardized Coefficient Unstandardized Coefficient 95% CI Lower Bound 95% CI Upper Bound Significance Substance use disorder → Food Addiction via Social Anxiety and Self-Concealment 0.04 0.070 0.023 0.059 p < .001 Table 6 showed that the confidence interval for the indirect effect does not include zero, indicating that the indirect effect of substance use disorder on food addiction via social anxiety and self-concealment is statistically significant. In total, the results indicate that substance use disorder exerts both a significant direct and an indirect (mediated by social anxiety and self-concealment) positive effect on food addiction. Discussion The present study aimed to find the mediating roles of self-concealment and social anxiety in the relationship between substance use disorder and food addictions. The findings showed that both self‐concealment and social anxiety may play important roles in the development of maladaptive coping behaviors, such as substance use and food addiction, Individuals who engage in higher levels of self-concealment tend to report higher levels of social anxiety, which may increase vulnerability to addictive behaviors. Furthermore, the results of this study showed that substance use disorder is associated with food addiction, and this result could indicate that there is potential comorbidity between behavioral addictions in individuals. This aligns with previous findings that suggest individuals with one type of addiction may be at greater risk of developing another. Given this result, therapeutic approaches can be used to prevent other behavioral addictions. In other researches also indicate there is comorbidity between all kinds of addictions [ 25 , 35 , 43 – 46 ]. In addition to the significant relationship between substance use disorder and food addiction, this study also showed that substance use disorder was associated with higher levels of both social anxiety and self-concealment. When a person does not receive social support, they may use defensive mechanisms to reduce their anxiety and stress, which can be represented as addictive behaviors such as substance use disorder to reduce their anxiety [ 47 – 51 ]. The mediation model in this study suggests that the relationship between substance use disorder and food addiction is not simply a direct relationship, but is essentially guided by these underlying psychological structures. In other words, self-concealment may initiate a path in which social anxiety emerges as a response to internal distress, ultimately making people susceptible to various types of addictive behavior[ 14 , 15 ]. These findings emphasize the role of internal psychological processes in the development and maintenance of addictive behaviors. Previous studies have shown that there is a significant relationship between high self-concealment and increased psychological distress and poorer social functioning [ 18 , 19 ]. And it has also been emphasized that high social anxiety may leads to maladaptive behaviors, including substance use disorder and food addiction [ 11 , 17 , 20 ]. The results of this study showed that a significant relationship between social anxiety and self-disclosure can be a basis for the emergence of substance use disorder and food addiction. This finding suggests that when examining and evaluating behavioral addictions, they should be considered as a whole rather than as a single phenomenon. Clinically, the mediating relationship between social anxiety and self-concealment in behavioral addictions such as substance use disorder and food addiction can be important for clinicians. Treatment approaches that focus on increasing emotional openness and reducing avoidance behaviors may help reduce the risk of developing or maintaining multiple addictive behaviors. Cognitive-behavioral therapies that directly address maladaptive thought patterns (Westhoff, Bhattacharya & Hofmann, 2023), associated with concealment and anxiety can potentially disrupt the pathway from substance use disorder to food addiction. In addition, interventions that promote healthier coping mechanisms and social engagement can not only reduce addictive tendencies but also improve overall psychological well-being. Limitations and Future Directions Despite all the useful information this study provides, it also has limitations, First, the cross-sectional design precludes any determination of causality between the psychological variables and addictive behaviors. Longitudinal studies are needed to investigate whether self-concealment and social anxiety precede the onset of both addictive behaviors or if they develop as consequences of addictive behaviors. Second, the use of self-report questionnaire may have biases related to social desirability or inaccurate self-assessment. Incorporating clinician-administered tools or behavioral assessments in future studies may enhance the robustness of the findings. Third, the emphasis on convenience sampling and data collection through online platforms may limit the generalizability of the results to broader populations. Additionally, variables such as socioeconomic status and cultural context were not controlled for and may influence both self-concealment and social anxiety. Future research should combine multi-method approaches, including clinical interviews and behavioral assessments, to enhance potency of these findings. Furthermore, it is possible that these variables may influence the strength or direction of the mediational pathways observed. Investigating these moderating effects could provide a more nuanced understanding of how individual differences impact the relationship between psychological constructs and addictive behaviors. Conclusion In conclusion, this study contributes to the literature by identifying self-concealment and social anxiety may serve as mediators in the relationship between substance use disorder and food addiction. By clarifying the underlying psychological mechanisms that link these kinds of addictions, these finding offer a engaged direction for both theoretical refinement and clinical intervention. Addressing the emotional and cognitive vulnerabilities associated with self‐concealment and social anxiety may be essential in developing comprehensive strategies to prevent and treat co-occurring addictive behaviors. Although more research is needed to authenticate causal links and examine these models in diverse populations, the results emphasize the importance of incorporating psychological support into addiction treatment. Addressing social anxiety and self-concealment may enhance treatment efficacy and support long-term recovery among individuals facing co-occurring addictive behaviors. Declarations Acknowledgement Not applicable Author contribution S.N. design of the work, the acquisition, wrote the main manuscript. M.N. substantively revised the manuscript. M.Z. analysis the data. F.H. interpretation of data. All authors reviewd the manuscript. Funding The authors declare that there was no financial support for this study. Ethics approval and consent to participate The Shahroud University of Medical Sciences Institutional Review Board approved the study protocol and procedures (IR.SHMU.REC.1399.161). Participants were recruited through an online platform (Digisurvey.net/design/questions/201084), which pays people to complete various surveys and tasks. Participants could view a research participant information and consent form and indicate their willingness to participate by selecting "yes" to a question that was presented after viewing the document. Following informed consent, participants were asked to complete a number of measures related to food addiction, substance use disorder and psychological health. Competing interests The authors declare no competing interests. References Laith, A. E., Kharmah, H. A. & Alghamdi, M. 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Curtiss, J. E. et al. Cognitive-behavioral treatments for anxiety and stress-related disorders. Focus 19 (2), 184–189 (2021). Gearhardt, A. N., Corbin, W. R. & Brownell, K. D. Development of the Yale food addiction scale version 2.0. Psychol. Addict. Behav. 30 (1), 113 (2016). Schulte, E. M. & Gearhardt, A. N. Development of the modified Yale food addiction scale version 2.0. Eur. Eat. Disorders Rev. 25 (4), 302–308 (2017). Zhang, H. et al. Translation of the Chinese version of the modified Yale Food Addiction Scale 2.0 and its validation among college students. J. Eat. Disorders . 9 , 1–13 (2021). Sarvandani, M. N. et al. Validation and psychological properties of the Persian version of DSM 5 Yale food addiction Scale 2.0 (PYFAS 2.0) in non-clinical population. Addict. Health . 14 (3), 175 (2022). Niroumand Sarvandani, M. et al. Confirmatory factor analysis and gender invariance of Persian version of the modified Yale food addiction scale (mPYFAS) 2.0: insight from a large scale Iranian sample. J. Eat. Disorders . 12 (1), 14 (2024). Group, W. A. W. The alcohol, smoking and substance involvement screening test (ASSIST): development, reliability and feasibility. Addiction 97 (9), 1183–1194 (2002). Rodgers, A. et al. World Health report 2002: reducing risks, promoting health life (World Health Organisation, 2002). Shmulewitz, D. et al. Test characteristics of shorter versions of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for brief screening for problematic substance use in a population sample from Israel. Substance abuse treatment, prevention, and policy, 18 (1): p. 58. (2023). Connor, K. M. et al. Mini-SPIN: A brief screening assessment for generalized social anxiety disorder. Depress. Anxiety . 14 (2), 137–140 (2001). Mörtberg, E., Jansson, M. & Fröjmark Psychometric evaluation of the social phobia inventory and the mini-social phobia inventory in a Swedish university student sample. Psychol. Rep. 122 (1), 323–339 (2019). Hathway, T. et al. The psychometric properties of the Mini Social Phobia Inventory in a treatment seeking sample of children and their caregivers. Cogn. Behav. Ther. 54 (2), 171–189 (2025). Dogaheh, E. R. Psychometric properties of Farsi version of the Social Phobia Inventory (SPIN). Procedia-Social Behav. Sci. 84 , 763–768 (2013). Larson, D. G. & Chastain, R. L. Self-concealment: Conceptualization, measurement, and health implications. J. Soc. Clin. Psychol. 9 (4), 439–455 (1990). Fan, Z. et al. Reliability and validity of self-concealment scale in Chinese older adults . Psychol. Res. Behav. Manage. , : pp. 4341–4352. (2023). Fan, Z. et al. Self-concealment scale (SCS) in middle-aged people: psychometric features and cross-age equivalence test. BMC psychiatry . 24 (1), 594 (2024). Sussman, S. et al. Prevalence, co-occurrence, and correlates of substance and behavioral addictions among American Indian adolescents in California. J. Drug Educ. 50 (1–2), 31–44 (2021). Brewerton, T. D. Food addiction and its associations to trauma, severity of illness, and comorbidity, in Compulsive Eating Behavior and Food Addiction p. 449–468 (Elsevier, 2019). Hayashi, D. et al. Associations of Food Addiction Symptomatology with Bariatric Surgical Attrition: A Cross-Sectional Analysis (Surgery for Obesity and Related Diseases, 2025). Tang, C. S. & Koh, Y. Y. W. Online social networking addiction among college students in Singapore: Comorbidity with behavioral addiction and affective disorder. Asian J. psychiatry . 25 , 175–178 (2017). Nardi, W. R. et al. A systematic review and meta-analysis of psychosocial interventions for persons with comorbid anxiety and substance use disorders . J. Subst. Use Addict. Treat. , : p. 209442. (2024). Wolitzky-Taylor, K. Integrated behavioral treatments for comorbid anxiety and substance use disorders: a model for understanding integrated treatment approaches and meta-analysis to evaluate their efficacy. Drug Alcohol Depend. 253 , 110990 (2023). Shmulewitz, D. et al. Comorbidity of problematic substance use and other addictive behaviors and anxiety, depression, and post-traumatic stress disorder: a network analysis. Psychol. Med. 54 (16), 4635–4645 (2024). Marmet, S. et al. Unique versus shared associations between self-reported behavioral addictions and substance use disorders and mental health problems: A commonality analysis in a large sample of young Swiss men. J. Behav. Addictions . 8 (4), 664–677 (2019). Løseth, G., Eikemo, M. & Leknes, S. Opioid Regulation of Social Homeostasis: Connecting Loneliness to Addiction (Biological Psychiatry, 2024). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6981948","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":482720466,"identity":"5970277c-71fb-46a1-85f9-62abdfdee5bf","order_by":0,"name":"Somayeh Naghavi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYFADZuYDQFJChhQtbAkgLTykWMNjACYJqpNvP/vwc0GNtbzBcZ7Pr27UWPAwsB8+ugGfFoMz6cbSM46lG244zLvNOucY0GE8aWk38GphSGOQ5mE7zDizmXebcQ4bUIsEjxleLfL9z5h/8/w7bD+zmeeZcc4/IrQw3Ehjk+ZtO5zYz8zD/Di3jQgtBjeesVnz9qUn9zOzmTHn9knwsBHyi3x/GvNtnm/Wtm38hx9/zvlWJ8fPfvgYfodBADOIYJMAk0Qoh2th/kCk6lEwCkbBKBhhAABkiT97OfrY5gAAAABJRU5ErkJggg==","orcid":"","institution":"Islamic azad University","correspondingAuthor":true,"prefix":"","firstName":"Somayeh","middleName":"","lastName":"Naghavi","suffix":""},{"id":482720471,"identity":"576cc3a1-796a-4f37-9eb8-13be21f4eb5d","order_by":1,"name":"Mohammad Niroumand Sarvandani","email":"","orcid":"","institution":"Shahroud University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Niroumand","lastName":"Sarvandani","suffix":""},{"id":482720472,"identity":"fe893a1e-e27c-4300-b8d3-7a00fb790d3e","order_by":2,"name":"Monazah Zare Rashnu","email":"","orcid":"","institution":"Islamic azad University","correspondingAuthor":false,"prefix":"","firstName":"Monazah","middleName":"Zare","lastName":"Rashnu","suffix":""},{"id":482720473,"identity":"ae94edda-2671-42fe-914f-b79b0dbf3852","order_by":3,"name":"Fatemeh Hasani Adelian","email":"","orcid":"","institution":"Islamic Azad University of Qods City","correspondingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"Hasani","lastName":"Adelian","suffix":""}],"badges":[],"createdAt":"2025-06-26 09:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6981948/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6981948/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86406130,"identity":"9e82c999-45a5-4d2f-833d-49408a4baf12","added_by":"auto","created_at":"2025-07-10 09:52:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":200866,"visible":true,"origin":"","legend":"\u003cp\u003eStandardized coefficients of the final model examining the mediating role of social anxiety and self‐concealment in the relationship between substance use disorder and food addiction.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6981948/v1/efea0be93c1e30c608c936e0.png"},{"id":98779902,"identity":"74a1f77a-cdf6-4aee-aaac-951a1a3e7f58","added_by":"auto","created_at":"2025-12-22 12:30:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1071558,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6981948/v1/2bb84426-af7c-426e-b191-466078a254e8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Examining the Mediating Effects of Self-Concealment and Social Anxiety on the Relationship Between Substance Use Disorders and Food Addiction","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003eThis study examines how two psychological factors- self-concealment (hide personal thoughts and feelings from others) and social anxiety (feeling uncomfortable in social situations)- explain the relation between substance use disorders (drug or alcohol addiction) and food addiction (uncontrollable eating behaviors). This study wants to answer this question: \u0026nbsp;Do people with substance use problems develop food addiction partly because they hide their feelings or struggle with social anxiety? By understanding how these hidden feelings and social anxiety affect the link between substance use and food addiction, the study hopes to offer better insight into how these issues are connected and how treatment might be improved.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAddiction still is one of the most important problems faced by societies all over the world [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Both substance use disorder and food addiction have a profound impact on the well-being and functioning of society [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although the two types of addiction appear to differ in their symptoms\u0026mdash;substance use disorder is typically associated with compulsive use of psychoactive substances, which can have severe physiological, psychological, and social consequences [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] while food addiction is characterized by uncontrolled overeating and loss of control over food intake, ultimately contributing to obesity and metabolic disorders [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. But both substance use disorders and food addiction activate the dopamine-based reward pathway and dopamine release reinforces repeated consumption behaviours [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Recent studies have increasingly emphasized the importance of psychological processes in the formation and persistence of addictive behaviours [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and emerging evidence suggests that factors such as secrecy and social anxiety may act as mediators that bridge the gap between substance use disorder and food addiction [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSelf-concealment, defined as the persistent tendency to conceal personal information, especially that which is distressing or negative [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], has been recognized as a maladaptive strategy that can exacerbate psychological problems. Individuals who conceal aspects of their inner experiences may experience feelings of isolation, lack of social support, and increased internal distress[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition to increasing stress and anxiety levels, this internalization of unpleasant emotions may make individuals more likely to resort to unhealthy coping mechanisms. Confidentiality can be a double-edged sword in the context of addiction: it can temporarily protect against perceived social judgment, but it can also interfere with the natural processes of social connection and emotional regulation that are essential for mental health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSocial anxiety\u0026mdash;essentially the fear of being judged or humiliated in social situations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u0026mdash;is introduced as a major risk factor for addictive behaviours [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] somewhat similar to self-concealment [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. When individuals experience social anxiety, they often avoid interactions and cut themselves off from supportive systems that could otherwise help them manage stress. And that isolation? It can drive them toward quick fixes like substance use disorders or food addiction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Some might use substance use disorders to calm the nerves brought on by socializing, while others turn to food for comfort during solitary moments [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePeople who are socially apprehensive often keep their emotions to themselves. The more they repress their feelings, the more stressed they become due to this self-concealment, which makes them use these unhealthy coping strategies even more [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Confidentiality is encouraged by social anxiety, which intensifies psychological suffering and eventually heightens addictive behaviors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis link between social anxiety and the suppression of emotions provides a clear explanation for why addiction to food and substance use disorders often occurs simultaneously. This idea has been named the self-medication hypothesis. Essentially, it means that individuals turn to substance use disorders or overeating as a way to cope with unpleasant emotions or avoid social awkwardness [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, hiding away simply makes people feel lonelier, worsening their anxiety significantly [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe necessity to look at common mediators like social anxiety and self-concealment is further highlighted by the fact that people with one type of addiction frequently display vulnerabilities that raise the chance of getting the other [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. More integrated intervention techniques that focus on the underlying emotional and cognitive processes causing both forms of addictive behaviour can be created by understanding these common mechanisms.\u003c/p\u003e\u003cp\u003eThese results have important therapeutic outcomes. By clarifying the mediating role of social anxiety and self-concealment, researchers and practitioners can more precisely identify people who are at risk and create treatments that explicitly target these psychological processes. The cycle of addiction may be broken by social skills training and cognitive-behavioural therapy (CBT), two therapeutic approaches that have demonstrated promise in lowering social anxiety and maladaptive self-concealment [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, preventive interventions may be made possible by early detection of rising levels of social anxiety and self-concealment in groups that are prone to addictive behaviours. This would lessen the chance that single substance use or overeating will turn into a full-comorbid addiction [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn light of these variables, the current study investigates how social anxiety and self-concealment mediate the link between substance use disorder and food addictions. By integrating contemporary theoretical viewpoints and using reliable scientific methods. In the end, figuring out how social anxiety and self-concealment drive addictive behaviors can help create better prevention and intervention strategies, enhance treatment results, and promote long-term recovery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eParticipants and Procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study follows a cross-sectional design. Inclusion and exclusion criteria were limited to ensuring a relatively equal number of men and women living in Iran were recruited across age groups covering the adult lifespan. In the sampling section, convenience sampling was used. All the data was collected through an online questionnaire from March 2024 to December 2024. Data collected from 1327 that completed mYFAS, Assist, Social anxiety, Self concealment questionnaires. As for demographics, age, sex, Marital Status, having children, number of children they have, having an infant, education, Employment status, height, weight, history of Physical and mental condition, menstrual cycle. All methods were performed in accordance with the relevance guidelines and regulations.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eData analysis:\u003c/h2\u003e\u003cp\u003eStatistical analysis of the study was performed using the IBM SPSS Amos 29, SPSS-24. Mean, standard deviation, and skewness were used as descriptive statistics of the study variables. Prior to analysis, data were screened for missing values, outliers, and assumptions of normality. Cases with missing data were excluded. The measurement model was first evaluated through Confirmatory Factor Analysis (CFA) to assess the validity and reliability of latent constructs. Model fit was assessed using multiple fit indices, including the Chi-square statistic (χ\u0026sup2;), Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). Following confirmation of an adequate measurement model, the structural model was tested to evaluate hypothesized relationships between constructs. Path coefficients, standard errors, and significance levels were reported. All statistical tests were two-tailed, and significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMeasures\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003emPYFAS\u003c/strong\u003e\u003cp\u003eThe 13 items that make up the mPYFAS are scored on an 8-point Likert scale, with zero denoting \"never\" and seven denoting \"daily.\" Together with two extra questions that gauge the clinical importance of these symptoms (distress/impairment), these items evaluate the 11 criteria for substance use disorder listed in the DSM-5. The cut-off value for each item is unique and determines whether the criterion is met or not. If the criterion is satisfied, a score of 1 is given; if not, a score of 0 is given. The sub-scores of the clinical significance and symptom criteria can be used to compute two cumulative scores. The total number of symptoms recorded is represented by the symptom count score, which runs from 0 to 11. The clinical significance score, which goes from 0 to 2, shows if the clinical significance requirement is satisfied. The criterion is deemed satisfied and is given a score of 1 if the clinical significance score is 1 or 2. Otherwise, the condition is unmet and gets a score of 0 if the score is 0. The criteria for diagnosing FA include meeting the clinical significance requirement and reporting two or more symptoms (symptom count score between two and eleven) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Zhang et al (2021) in their study showed that the chinese version of mYFAS 2.0 has adequate internal consistency, good test\u0026ndash;retest reliability and satisfactory construct validity[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003cp\u003eIn a large-scale study operated by Mohammad Niroumand Sarvandani et al. involving 9,606 participants, the Persian conformity of the modified Yale Food Addiction Scale 2.0 (mPYFAS 2.0) showed strong psychometric performance, confirming its reliability and validity for evaluating food addiction among Persian-speaking individuals. Confirmatory factor analysis (CFA) supported the sufficiency of a single-factor model, with fit indices\u0026mdash;CFI and TLI\u0026mdash;exceeding 0.95, SRMR at or below 0.09, and RMSEA under 0.03, all indicating a good model fit. Reliability measures were also significant, as shown by Cronbach's alpha of 0.83, ordinal alpha of 0.93, and composite reliability of 0.86, consistent across both genders and the overall sample. Concurrent validity was further supported by significant correlations with other relevant psychological scales: binge eating severity (BES, r\u0026thinsp;=\u0026thinsp;0.59, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), impulsivity (BIS-11, r = -0.16, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and resilience (CD-RISC, r\u0026thinsp;=\u0026thinsp;0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These results collectively highlight the mPYFAS 2.0 as a valid and reliable tool for assessing food addiction in Persian-speaking populations. The original Yale Food Addiction Scale 2.0 (YFAS 2.0), which is part of the DSM-5 criteria for substance use disorder (SUD), served as the model for the Persian version of the mYFAS 2.0. It has 13 items, two of which evaluate the clinical relevance of those symptoms and 11 of which correspond to the SUD diagnostic criteria. An 8-point Likert scale, with 0 denoting \"Never\" and 7 denoting \"Daily,\" is used to gather responses. To ascertain whether each condition is satisfied, particular cut-off values are employed. At least two symptoms and one or more clinically significant signs must be present for food addiction (FA) to be diagnosed. Mild (2\u0026ndash;3 symptoms), moderate (4\u0026ndash;5 symptoms), and severe (6\u0026ndash;11 symptoms) are the three severity degrees of FA [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eAssist\u003c/b\u003e: An international team of researchers and clinicians created the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) for the World Health Organization (WHO) as a technical tool to help with early detection of substance use disorders and health risks associated with substance use in primary care, general medical care, and other settings. It was created to be utilized in basic care settings where clients' use of dangerous and deadly substances may go unnoticed or worsen. The ASSIST program is designed to be student-neutral and can be used in a variety of settings to screen for the use of the following substances: 1) Tobacco 2) Cannabis 3) Opioid compounds 4) Amphetamine stimulants 5) Alcohol 6) Hallucinogens 7) Inhalants 8) Cocaine 9) Other substances. Participants' history and previous three months of substance use and comorbidities are gathered by the ASSIST. Acute intoxication, substance usage, addiction or \"hazardous\" substance use, and substance abuse are among the comorbidities that the test can detect [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The average test-retest reliability coefficients (Kappas) of ASSIST 0.90 (consistency of reporting 'ever' usage of substance use disorder) and the reliabilities of substances fell between good and excellent, according to the Who Assist Working Group (2002) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The ability of ASSIST scores to detect problematic use was shown to be strong by Shmulewitz et al. (2023), with little variation by age or gender. Additionally, ASSIST-FC demonstrated strong agreement, adequate sensitivity, high speciality, and positive predictivity. This study used 10 questions related to substance use that were included in the ASSIST [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This screen test has been translated in Iran in to Persian by the Ministry of Health and Medical Treatment and Education Organization and made available to health workers.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSocial anxiety (Mini-Social Phobia Inventory (Mini-SPIN)\u003c/strong\u003e\u003cp\u003eThe Mini-Social Phobia Inventory (Mini-SPIN) is a brief, self-report screening tool designed by Connor et al (2001) to assess core symptoms of social anxiety disorder. The Mini-SPIN is used to quickly identify individuals who may be experiencing social anxiety disorder. It\u0026rsquo;s derived from the longer Social Phobia Inventory (SPIN), the Mini-SPIN hold the essential features needed to receive social anxiety symptoms, making it a convenient option when time is limited. The Mini-SPIN consists of 3 items that focus on key aspects of social anxiety, such as fear of negative evaluation, avoidance of social situations, and the emotional distress linked to social interactions. Each item is typically rated on a Likert-type scale (often 0 to 4), leading to a total possible score ranging from 0 to 12. A score of 6 or higher is commonly used as a threshold to indicate a potential case of social anxiety disorder, though the exact cut-off can vary slightly depending on the population being assessed. Research has demonstrated that the Mini-SPIN has good internal consistency (with Cronbach\u0026rsquo;s alpha values often reported around 0.85 or higher) and satisfactory test-retest reliability [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Studies support its convergent validity, as scores on the Mini-SPIN correlate well with other established measures of social anxiety, ensuring that it effectively identifies those at risk. M\u0026ouml;rtberg, Jansson Fr\u0026ouml;jmark (2018) in their study showed that the Mini-SPIN was associated with satisfactory convergent validity [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The result of Hathway \u0026amp; et al. (2024) demonstrated that The Mini-SPIN showed good criterion group validity, internal consistency and construct validity across caregiver and child report and the findings from their study showed further support for the use of the Mini-SPIN as a screening tool for SAD [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Ebrahim Rezaei Dogaheh (2013) in a study which was about Psychometric Properties of Farsi Version of the Social Phobia Inventory (SPIN) reported that Internal consistency of social phobia inventory (Cronbach's α\u0026thinsp;=\u0026thinsp;0.66 and 0.87 for clinical and non-clinical group respectively) and 2-week test-retest reliability in non-clinical sample (r\u0026thinsp;=\u0026thinsp;0.89) were both good [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSelf-concealment Scale\u003c/strong\u003e\u003cp\u003eThis questionnaire was designed by Larson and Chastain in 1990 with the aim of self-concealment as a self-report [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In the original version, it was designed for youth and adults and was standardized on Iranian adolescents. It has 10 questions and has no subscales. The scoring of this questionnaire uses a 5-point Likert scale, in which the answer \u0026ldquo;I completely agree\u0026rdquo; is given a score of 5, \u0026ldquo;I agree\u0026rdquo; is given a score of 4, \u0026ldquo;I neither agree nor disagree\u0026rdquo; is given a score of 3, \u0026ldquo;I disagree\u0026rdquo; is given a score of 2, and \u0026ldquo;I completely disagree\u0026rdquo; is given a score of 1. The lowest score is 10 and the highest score is 50. In this questionnaire, obtaining a higher score indicates greater self-concealment.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eIn a study by Larson and Chastain in 1990, the reliability of this questionnaire using the internal consistency method of Cronbach's alpha coefficient was reported to be 0.83, which was 0.87 for youth and 0.84 for the adult group, and the test-retest reliability with a 4-week interval of correlation between the scores administered twice was calculated and reported to be 0.81. In another study, fan et al. (2023) reported the Cronbach's alpha coefficient of this questionnaire in the community of Chinese older adults was 0.923. In their study, The Self-Concealment Scale (SCS) was found to have good reliability and validity in the Chinese elderly population, and can be used as a valid tool to assess the tendency of older people to conceal negative or painful information [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Fan et al. (2024) found the factor loadings of SCS items ranged from 0.62 to 0.73 and The scale showed a Cronbach\u0026rsquo;s α coefficient value of 0.895, McDonald\u0026rsquo;s Omega coefficient of 0.893, and a split-half reliability coefficient value of 0.861 [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Ghaffari, Ghasemi-Nejad, and Cherami (2021) reported a Cronbach's alpha of 0.84 for this scale .\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic information\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarital Statues\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEmployment Statues\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e554\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e41\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e51\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMore than 60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e875\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e431\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e704\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e540\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElementary School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e288\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostgraduate Diploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e440\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaster of Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnemployment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudying\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e356\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFull-time Job\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e316\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePart-time Job\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e183\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFreelancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e153\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, showed demographics of age, sex, marital status, education and employment statues in participants.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eDescriptive Statistics for Study Variables\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSkewness\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eKurtosis\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance use disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;0.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFood Addiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;0.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;0.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-Concealment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026ndash;0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBased on the values in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, skewness and kurtosis for all variables are within the range of \u0026minus;\u0026thinsp;1 to +\u0026thinsp;1, indicating that the data are normally distributed.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eCorrelation Matrix of Study Variables\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Substance use disorder\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2. Food Addiction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3. Social Anxiety\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4. Self-Concealment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Substance use disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.078**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.093**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.107**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Food Addiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.168**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.050\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Social Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.102**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Self-Concealment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e**p\u0026thinsp;\u0026lt;\u0026thinsp;.01; *p\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e\u003cp\u003eBased on these results in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the correlation between substance use disorder and food addiction is positive and significant (r\u0026thinsp;=\u0026thinsp;.078, p\u0026thinsp;\u0026lt;\u0026thinsp;.01). In addition, substance use disorder is significantly related to social anxiety (r\u0026thinsp;=\u0026thinsp;.093, p\u0026thinsp;\u0026lt;\u0026thinsp;.01) and self-concealment (r\u0026thinsp;=\u0026thinsp;.107, p\u0026thinsp;\u0026lt;\u0026thinsp;.01). The correlation between food addiction and social anxiety is also positive and significant (r\u0026thinsp;=\u0026thinsp;.168, p\u0026thinsp;\u0026lt;\u0026thinsp;.01), whereas the relationship between food addiction and self‐concealment is not significant.\u003c/p\u003e\u003cp\u003ePrior to testing the research model with structural equation modeling (SEM) using Amos24, univariate outliers were identified via boxplots and multivariate outliers were examined using Mahalanobis statistics; such cases were removed from the dataset. Skewness and kurtosis were computed using SPSS24, and all values fell within the acceptable range (\u0026plusmn;\u0026thinsp;1), confirming the assumption of normality. Once these assumptions were met, SEM was used to evaluate the proposed model. The standardized coefficients of the final model\u0026mdash;which examines the mediating roles of social anxiety and self-concealment in the relationship between substance use disorder and food addiction\u0026mdash;are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the standardized coefficients of the proposed model for investigating the mediating roles of social anxiety and self-concealment in the relationship between substance use disorder and food addiction are shown. The model fit indices are provided in the table below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eFit Indices for the Tested Model\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFit Index\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcceptable Range\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eObserved Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eχ\u0026sup2;/df\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCFI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.935\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIFI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.935\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNFI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.914\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRMSEA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.046\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e showed that the chi-square/df ratio falls within the acceptable range, and the CFI, IFI, and NFI values exceed .90. An RMSEA of 0.046 is well below .10, all of which indicate a good model fit.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eDirect, Indirect, and Total Effects Among Variables\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDirect Effect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIndirect Effect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal Effect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSignificance\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance use disorder \u0026rarr; Social Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.001 (*** )\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance use disorder \u0026rarr; Self-Concealment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance use disorder \u0026rarr; Food Addiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.001 (*** )\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Anxiety \u0026rarr; Food Addiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.001 (*** )\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-Concealment \u0026rarr; Food Addiction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;.061\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e showed that substance use disorder has a significant direct effect on food addiction (β\u0026thinsp;=\u0026thinsp;0.33, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and a significant indirect effect via social anxiety and self-concealment (β\u0026thinsp;=\u0026thinsp;0.04, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), resulting in a total effect of 0.37.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eBootstrap Results for the Indirect Effects (Total Sample)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStandardized Coefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnstandardized Coefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI Lower Bound\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI Upper Bound\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSignificance\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance use disorder \u0026rarr; Food Addiction via Social Anxiety and Self-Concealment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e showed that the confidence interval for the indirect effect does not include zero, indicating that the indirect effect of substance use disorder on food addiction via social anxiety and self-concealment is statistically significant.\u003c/p\u003e\u003cp\u003eIn total, the results indicate that substance use disorder exerts both a significant direct and an indirect (mediated by social anxiety and self-concealment) positive effect on food addiction.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to find the mediating roles of self-concealment and social anxiety in the relationship between substance use disorder and food addictions. The findings showed that both self‐concealment and social anxiety may play important roles in the development of maladaptive coping behaviors, such as substance use and food addiction, Individuals who engage in higher levels of self-concealment tend to report higher levels of social anxiety, which may increase vulnerability to addictive behaviors.\u003c/p\u003e\u003cp\u003eFurthermore, the results of this study showed that substance use disorder is associated with food addiction, and this result could indicate that there is potential comorbidity between behavioral addictions in individuals. This aligns with previous findings that suggest individuals with one type of addiction may be at greater risk of developing another. Given this result, therapeutic approaches can be used to prevent other behavioral addictions. In other researches also indicate there is comorbidity between all kinds of addictions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan additionalcitationids=\"CR44 CR45\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition to the significant relationship between substance use disorder and food addiction, this study also showed that substance use disorder was associated with higher levels of both social anxiety and self-concealment. When a person does not receive social support, they may use defensive mechanisms to reduce their anxiety and stress, which can be represented as addictive behaviors such as substance use disorder to reduce their anxiety [\u003cspan additionalcitationids=\"CR48 CR49 CR50\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. The mediation model in this study suggests that the relationship between substance use disorder and food addiction is not simply a direct relationship, but is essentially guided by these underlying psychological structures. In other words, self-concealment may initiate a path in which social anxiety emerges as a response to internal distress, ultimately making people susceptible to various types of addictive behavior[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese findings emphasize the role of internal psychological processes in the development and maintenance of addictive behaviors. Previous studies have shown that there is a significant relationship between high self-concealment and increased psychological distress and poorer social functioning [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. And it has also been emphasized that high social anxiety may leads to maladaptive behaviors, including substance use disorder and food addiction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The results of this study showed that a significant relationship between social anxiety and self-disclosure can be a basis for the emergence of substance use disorder and food addiction. This finding suggests that when examining and evaluating behavioral addictions, they should be considered as a whole rather than as a single phenomenon.\u003c/p\u003e\u003cp\u003eClinically, the mediating relationship between social anxiety and self-concealment in behavioral addictions such as substance use disorder and food addiction can be important for clinicians. Treatment approaches that focus on increasing emotional openness and reducing avoidance behaviors may help reduce the risk of developing or maintaining multiple addictive behaviors. Cognitive-behavioral therapies that directly address maladaptive thought patterns (Westhoff, Bhattacharya \u0026amp; Hofmann, 2023), associated with concealment and anxiety can potentially disrupt the pathway from substance use disorder to food addiction. In addition, interventions that promote healthier coping mechanisms and social engagement can not only reduce addictive tendencies but also improve overall psychological well-being.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and Future Directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite all the useful information this study provides, it also has limitations, First, the cross-sectional design precludes any determination of causality between the psychological variables and addictive behaviors. Longitudinal studies are needed to investigate whether self-concealment and social anxiety precede the onset of both addictive behaviors or if they develop as consequences of addictive behaviors. Second, the use of self-report questionnaire may have biases related to social desirability or inaccurate self-assessment. Incorporating clinician-administered tools or behavioral assessments in future studies may enhance the robustness of the findings. Third, the emphasis on convenience sampling and data collection through online platforms may limit the generalizability of the results to broader populations. Additionally, variables such as socioeconomic status and cultural context were not controlled for and may influence both self-concealment and social anxiety.\u003c/p\u003e\u003cp\u003eFuture research should combine multi-method approaches, including clinical interviews and behavioral assessments, to enhance potency of these findings. Furthermore, it is possible that these variables may influence the strength or direction of the mediational pathways observed. Investigating these moderating effects could provide a more nuanced understanding of how individual differences impact the relationship between psychological constructs and addictive behaviors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study contributes to the literature by identifying self-concealment and social anxiety may serve as mediators in the relationship between substance use disorder and food addiction. By clarifying the underlying psychological mechanisms that link these kinds of addictions, these finding offer a engaged direction for both theoretical refinement and clinical intervention. Addressing the emotional and cognitive vulnerabilities associated with self‐concealment and social anxiety may be essential in developing comprehensive strategies to prevent and treat co-occurring addictive behaviors.\u003c/p\u003e\u003cp\u003eAlthough more research is needed to authenticate causal links and examine these models in diverse populations, the results emphasize the importance of incorporating psychological support into addiction treatment. Addressing social anxiety and self-concealment may enhance treatment efficacy and support long-term recovery among individuals facing co-occurring addictive behaviors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.N. design of the work, the acquisition, wrote the main manuscript. M.N. substantively revised the manuscript. M.Z. analysis the data. F.H. interpretation of data. All authors reviewd the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there was no financial support for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Shahroud University of Medical Sciences Institutional Review Board approved the study protocol and procedures (IR.SHMU.REC.1399.161). Participants were recruited through an online platform (Digisurvey.net/design/questions/201084), which pays people to complete various surveys and tasks. Participants could view a research participant information and consent form and indicate their willingness to participate by selecting \u0026quot;yes\u0026quot; to a question that was presented after viewing the document. Following informed consent, participants were asked to complete a number of measures related to food addiction, substance use disorder and psychological health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLaith, A. E., Kharmah, H. A. \u0026amp; Alghamdi, M. SNP analysis of stress-related genes reveals significant correlations with drug addiction in Jordan. \u003cem\u003eSaudi Pharm. J.\u003c/em\u003e \u003cb\u003e32\u003c/b\u003e (11), 102171 (2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026ouml;kmen, B. D. \u0026amp; Yılmaz, G. Evaluation of Psychological Well-Being Among Adolescents: A Cross-Sectional Study of Correlation Between Food Addiction and Cognitive Behavioral Physical Activity. \u003cem\u003ePsychiatry Clin. 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Med.\u003c/em\u003e \u003cb\u003e54\u003c/b\u003e (16), 4635\u0026ndash;4645 (2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarmet, S. et al. Unique versus shared associations between self-reported behavioral addictions and substance use disorders and mental health problems: A commonality analysis in a large sample of young Swiss men. \u003cem\u003eJ. Behav. Addictions\u003c/em\u003e. \u003cb\u003e8\u003c/b\u003e (4), 664\u0026ndash;677 (2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eL\u0026oslash;seth, G., Eikemo, M. \u0026amp; Leknes, S. \u003cem\u003eOpioid Regulation of Social Homeostasis: Connecting Loneliness to Addiction\u003c/em\u003e (Biological Psychiatry, 2024).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anxiety Disorders, Food Addiction, Self-Concealment, Substance-Related Disorders","lastPublishedDoi":"10.21203/rs.3.rs-6981948/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6981948/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAddiction is one of the most complex issues that the whole world is facing. Psychological variables are related to substance use and food addictions. This study aimed to investigate the mediating role of social anxiety and self-concealment between substance use disorder and food addiction.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eA total of 1329 people participated in this study, all of whom were over 18 years of age. The assist questionnaire was used to assess substance use disorder, the mYFAS was used for food addiction, the self-concealment scale was used for self-concealment, and the mini-social phobia inventory was used to assess social anxiety. SPSS-24 software and the structural equation modelling were used to analyse the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe results showed that the standardized coefficients of the proposed model for investigating the mediating roles of social anxiety and self-concealment in the relationship between substance use disorder and food addiction are fit. The correlation between substance use disorder, food addiction, self-concealment and social anxiety is positive and significant. The correlation between food addiction and social anxiety is also positive and significant whereas the relationship between food addiction and self‐concealment is not significant.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe mediation model showed that substance use disorder\u0026rsquo;s relevance with food addiction is not only a direct relationship but is essentially channeled through these underlying psychological factors. In other words, Self-concealment can start a path in which social anxiety develops as a result of internal distress and, consequently, addictive behaviors emerge in the individual.\u003c/p\u003e","manuscriptTitle":"Examining the Mediating Effects of Self-Concealment and Social Anxiety on the Relationship Between Substance Use Disorders and Food Addiction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 09:52:33","doi":"10.21203/rs.3.rs-6981948/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e34649dc-e744-48ee-a848-2eae9d082a02","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":51254405,"name":"Biological sciences/Drug discovery"},{"id":51254406,"name":"Biological sciences/Psychology"}],"tags":[],"updatedAt":"2025-12-22T09:55:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-10 09:52:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6981948","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6981948","identity":"rs-6981948","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}