Social Anxiety

Asian Journal of Psychiatry 55 (2021) 102526

Available online 15 December 2020 1876-2018/© 2020 Elsevier B.V. All rights reserved.

Brief cognitive behavior group therapy for social anxiety among medical students: A randomized placebo-controlled trial

Narendra Nath Samantaray a, d,*, Bijaylaxmi Nath a, Nirupama Behera a, Abinash Mishra a, Preeti Singh b, Paulomi Sudhir c

a Dept. of Clinical Psychology, Mental Health Institute (Centre of Excellence), SCB Medical College & Hospital, Cuttack, 753007, India b Dept. of Psychiatry, Pt. Jawaharlal Nehru Memorial Medical College, Raipur, 492001, India c Consultant Behavioural Medicine Unit, Department of Clinical Psychology, M.V.Govindaswamy Building, NIMHANS, Bengaluru, 560029, India d Dept. of Clinical Psychology, Institute of Psychiatry & Human Behaviour, Bambolim, Goa, 403202, India

A R T I C L E I N F O

Keywords: Social anxiety disorder Social phobia Cognitive-behavioral group therapy Brief Randomized placebo-controlled trial Medical students College

A B S T R A C T

Objective: To compare brief cognitive behavior group therapy (bCBGT) for social anxiety disorder (SAD) to a credible placebo, psychoeducational-supportive therapy (PST), in a sample of medical students. Method: This was a single-center, rater-blind, randomized, attention placebo-controlled, parallel-group study. Participants were 50 consenting undergraduate medical students of a state government medical college in Cuttack, India having a primary diagnosis of SAD, who recieved 6 weekly 2-h group sessions. Assessments were carried out at baseline, post intervention and at two-month follow. Independent raters assessed the participants on the Liebowitz Social Anxiety Scale and Clinical Global Impression- Improvement scale (CGI-I). Social Phobia Inventory (SPIN), a self-rated measure, was administered in the same periods. Results: bCBGT group improved significantly across periods from pre-treatment to post-treatment and from pre- treatment to two-month follow-up. bCBGT was statistically superior to PST at the post-treatment and follow-up assessments and showed large effect sizes at both post-treatment and follow-up. Conclusions: A 6-session bCBGT is an efficacious treatment for SAD among medical students. A longer follow-up and replication in other groups, and clinical settings are necessary for generalization to a broader SAD population.

1. Introduction

SAD is a significant problem in the student population as indicated by prevalence studies carried out in India (Honnekeri et al., 2017) and elsewhere (Agha Mohammad Hasani et al., 2016; Desalegn et al., 2019) where a high prevalence of SAD among health science students; ranging from 7.8% to 32% are reported. Studies on student populations have reported a significant association of SAD with impaired quality of life (Ratnani et al., 2017) alcohol-related problems (Schry and White, 2013), suicidal ideation (Buckner et al., 2017) and academic underachievement (Brook and Willoughby, 2015).

SAD is characterized by the fear of negative evaluation, fear of social interactions, and avoidance and distress. These can be particularly disabling and distressing in student populations, as expectations to engage in social interactions, and public speaking is part of most

academic settings (Brook and Willoughby, 2015). The inability to fulfill these requirements and the experience of anxiety are likely to interfere with learning (Russell and Topham, 2012), clinical training, and a further choice of training (Gill and Mohammad, 2010). Furthermore, compared to other anxiety and mood disorders, SAD begins earlier (31%–81% onset) (Stein et al., 2017) and is likely to be evident in or before college. Hence, researchers (e.g., Nordstrom et al., 2014) have called for early identification and treatment of SAD in college populations.

Despite available treatments for SAD, their use are limited (Wang et al., 2005). Randomized controlled trials (RCT) (Leichsenring et al., 2013; McEvoy et al., 2012) and meta- analyses (Barkowski et al., 2016; Mayo-Wilson et al., 2014) have shown cognitive- behavioral therapy (CBT) in both individual and group formats to be the treatment of choice for SAD. Cognitive behavioral group therapy (CBGT) has demonstrated;

* Corresponding author at: Dept. of Clinical Psychology, Institute of Psychiatry & Human Behaviour, Bambolim, Goa, 403202, India. E-mail addresses: [email protected] (N.N. Samantaray), [email protected] (B. Nath), [email protected] (N. Behera),

[email protected] (A. Mishra), [email protected] (P. Singh), [email protected] (P. Sudhir).

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

https://doi.org/10.1016/j.ajp.2020.102526 Received 28 August 2020; Received in revised form 18 November 2020; Accepted 11 December 2020

Asian Journal of Psychiatry 55 (2021) 102526

2

a) statistical equivalence to individual CBT in meta-analyses (Barkowski et al., 2016; Mayo-Wilson et al., 2014; Powers et al., 2007) b) mainte- nance of treatment gains for an extended period (4–6 years after the conclusion of treatment) (Fogarty et al., 2019; Heimberg et al., 1993); and c) cost-effectiveness (McCarthy et al., 2013).

However, there has been a demand for briefer format for pragmatic reasons. Briefer treatment may be more cost-effective, which can in- crease treatment accessibility (Hazlett-Stevens and Craske, 2008) and, therapeutic compliance (Lin et al., 2008). It may also be more likely to be offered in settings in which resources are scarce or demand is high. Furthermore, stigma related to mental health treatment is a hindrance to accessibility and compliance (Kardas et al., 2013); hence, brief treat- ment, offered on campus, might be especially helpful for students.

Although few published studies describe brief CBT in individuals (Wells and Papageorgiou, 2001) or group (Herbert et al., 2002) formats, they provide preliminary evidence for its effectiveness. However, placebo-controlled evaluations of bCBGT have yet to be conducted. Thus, we studied the effects of bCBGT on social anxiety among medical students. To our knowledge, this is, perhaps, the first RCT of bCBGT in the medical student population.

2. Method

2.1. Design

This was a single-center, rater-blind, randomized, attention placebo- controlled study.

2.2. Participants

Participants were 50 consenting undergraduate adults attending a medical school in Cuttack, India, with a primary diagnosis of SAD, as per DSM-IV (American Psychiatric Association, 1994), who were enrolled at a medical college. Table 1 presents detailed information on their de- mographic and clinical characteristics. The exclusion criteria were cur- rent severe depression, substance dependence, and pharmacotherapy for SAD, and exposure to CBT for SAD in the preceding six months. Par- ticipants were randomized to receive either the bCBGT or psychoeducational-supportive therapy (PST) in groups using a manual method of picking folded chits consisting of participants’ names from a bowl and putting them equally in two groups. In the bCBGT group, twenty participants were treatment completers, having completed six weeks of treatment, out of which eighteen participants were available at the two-month follow-up (FU). In the PST group, 18 and 16 participants were available at the post-treatment assessment and two-month FU, respectively.

2.3. Procedure

Of 460 students, 131 participants scored 19 or higher on the self- rated Social Phobia Inventory (SPIN), which has been previously vali- dated as a clinical cut-off score (Connor et al., 2000). Nineteen in- dividuals did not report further for the Mini International Neuropsychiatry Interview (MINI) (Sheehan et al., 1998) administered by the authors (BL, NB and AM) under the supervision of the first author. Twenty-one participants did not meet study

criteria; hence. Ninety-one potential participants, meeting the study criteria, were called for an additional diagnostic interview by the au- thors (as done for MINI) using the SAD module of Anxiety Disorders Interview Schedule (ADIS-IV) (DiNardo et al., 1994) to which only 68 reported. The MINI and SAD module of ADIS-IV were administered to ensure a robust SAD diagnosis. However, eighteen of them declined further participation because of the time commitment and unknown reasons. The remaining fifty participants were then randomized to bCBGT or PST, in groups of 8–9 (Fig. 1).

The Institute Ethics Committee approved the study, which was, subsequently, registered in the clinical trials registry of the Indian Council for Medical Research (ICMR; CTRI/2018/10/016,122). Two independent raters assessed the participants at baseline, post- inter- vention, and two-month follow-up.

2.4. Interventions

Six weekly bCBGT sessions, each of two hours, in three groups, were administered by NNS, a clinical psychologist with over five years of experience in CBT training and supervision, aided by two co-therapists, (NB and BL), who were advanced master trainees in clinical psychology, with more than one year experience in CBT.

The therapeutic program was based on Heimberg and Becker’s (2002) group protocol, which is typically conducted over 12 weeks. We abbreviated the protocol’s length as done by Herbert’s et al., (2002), barring the use of social skill training (SST). Other attempts to evaluate short versions of Heimberg and Becker’s treatment have been reported (Bjornsson et al., 2011; Damer et al., 2010).

The first session consisted of sharing the treatment conceptualiza- tion, including the role of negative automatic thoughts, avoidance, af- fective imagery, and safety behaviors. This was done with the help of a metaphor, reported in a case study (see Samantaray et al., 2019), intended to provide a sound rationale of the treatment and reflection from patients that exposure to feared situations without the use of safety behaviors is the appropriate strategy. Cognitive restructuring (CR) was then introduced. The first session ended with the assignment of personalized homework for CR, related to situations rated on the Lie- bowitz Social Anxiety Scale (LSAS; see below), and other negative thoughts.

The second session consisted of a discussion of homework and the introduction of in- session exposures. For all the exposures, in session, or for homework, participants were asked to keep a record consisting of i) thought/s or feared consequences before the task ii) description of the task and iii) what happened or was learned with respect to the feared consequences. We emphasized formulating observable behavioral goals for daily exposure tasks, dropping safety behaviors, and avoiding comparing self-generated distorted mental images with others’ expected standards. In the end, personalized homework tasks for exposure and use of CR skills before, during, and after exposures was assigned.

The remaining sessions consisted of exposure tasks, of increasing difficulty, post- exposure cognitive debriefing, additional CR, and assignment of individualized homework tasks for both exposure and CR. Review of participants’ progress and discussion of relapse prevention strategies were conducted at the end of the final session.

Psychoeducational-Supportive Therapy (PST), based on the protocol by Heimberg et al., (Heimberg et al., 1990), was considered a credible placebo, and used to control for the common factors in group

Table 1 Baseline demographic and clinical characteristics of the Samples.

Variables bCBGT (n = 25)

PST (n = 25)

t value/X2/*Fisher Exact test

p

Age, mean (SD) 20.44 (1.93) 20.6 (1.84)

− .299 .766

Age of onset, mean (SD)

15.92 (1.65) 16.2 (1.7) − .588 .559

Duration of SAD, mean (SD)

4.52 (2.45) 4.4 (1.73) − .2 .842

Sex 14 (56) 12 (48) .321 .571 Female, n (%) Severity, n (%) Mild *11.92 .098 Moderate Severe

Very severe 2 5

12 11 8 6 3 3

N.N. Samantaray et al.

Asian Journal of Psychiatry 55 (2021) 102526

3

psychotherapy. PST included discussions on topics relevant to SAD and provided support, but no specific advice, skills training, problem-solving, or exposures were included.

2.5. Measures

The LSAS (Liebowitz and Pharmacopsychiatry, 1987), the primary outcome measure, is a clinician-rated measure of social anxiety con- sisting of 24 items assessing both fear and avoidance in a range of social situations using a 4-point Likert scale. It has well demonstrated psy- chometric properties (Fresco et al., 2001; Heimberg et al., 1999). The Clinical Global Impression- Improvement scale (CGI-I) (Guy, 1976) is a widely used single-item measure to assess improvement in SAD (Zaider et al., 2003) on a 7-point scale. Rating of 1 or 2 was classified as re- sponders, suggesting clinically significant improvement. Those rated three or higher were classified as non-responders; here, it was scored by the blind-rater. The SPIN (Connor et al., 2000) is a 17-item patient-reported measure of severity in social anxiety rated on a 5- point scale. It has excellent psychometric properties (Antony et al., 2006). The total score for the SPIN ranges from 0 to 68. Scores between 21–30, 31–40, 41–50, and 51–68 correspond to mild social anxiety, moderate social anxiety, severe social anxiety, and very severe social anxiety respectively.

2.6. Data analysis

Intent-to-treat analysis was conducted. Simple mean imputation (Dziura et al., 2013) was used to handle missing data. As appropriate Chi-square tests, Fisher’s exact tests and independent-sample t-tests were conducted on baseline data. Linear mixed model analyses of

variance (ANOVAs) were used to analyze differences in the magnitude of symptom change across the two groups. For within-group analyses, paired-sample t-tests were calculated for each treatment groups. Follow-up analyses of co-variance (ANCOVAs) were carried out utilizing respective pre-treatment scores as a covariate. Statistical significance was set at p < .05. We calculated effect sizes using the formula for Cohen’s d (Cohen, 1992) for pre-to-post treatment and pre-treatment-to-follow-up for both treatments. Analyses were completed using SPSS version 20.0.

3. Result

3.1. Baseline profile

The distribution of age, gender, duration of illness, age at onset, and severity of SAD was similar in the two treatment groups (see Table 1). Also, there were no significant differences in baseline scores between groups on LSAS and SPIN.

3.2. Treatment outcome and effect size

Linear-mixed model ANOVAs analyzed the magnitude of symptom change across the two groups from pre- to post-treatment and follow-up. Since Mauchley’s Test of Sphericity was significant, the Greenhouse- Geisser correction was used. A significant treatment interaction be- tween group and time {F (1.09, 52.68) = 6.14, p = .014} on the primary clinician-administered outcome variable (LSAS) was seen. On the self- report outcome, the SPIN, there was a significant interaction between group and time {F(1.13, 54.27) = 6.63, p =0.01}.

Within-group analyses (paired-sample t-tests) (see Table 2),

Fig. 1. Particpants flow chart throughout the trial.

N.N. Samantaray et al.

Asian Journal of Psychiatry 55 (2021) 102526

4

demonstrated that the bCBGT group improved significantly from pre-to- post-treatment and from pre-treatment to follow-up on the LSAS {t(24) = 3.1, p = 0.005, and t(24) = 3.32, p = 0.003} and SPIN {t(24) = 3.27, p = 0.003, and t(24) = 3.5, p = 0.002} whereas the PST group did not improve on either the LSAS {t(24) = 1.54, p = 0.137, and t(24) = 1.7, p = 0.101} or SPIN {t(24) = 1.12, p = 0.275,

and t(24) = 1.98, p = 0.06}. Furthermore, paired-sample t-tests, in the bCBGT group, found no significant improvement from the post- treatment to follow-up on the LSAS {t(24) = 0.96, p = 0.347} and SPIN {t(24) = 0.95, p = 0.354}.

Of the 20 treatment completers (attending all 6 sessions) in bCBGT, on the basis of CGI-I, 12 (60 %) and 9 (45 %) in the post-assessment and follow-up intervention and of 18 treatment completers in PST, 5 (28 %) in both post-assessment and follow-up assessment were classified as significant clinical responders.

While these results showed the superiority of bCBGT over PST, we further calculated within-group effect sizes (see Table 3) using Cohen’s d formula for examining the magnitude of treatment effect. Using Cohen’s threefold classification of effect sizes: small (0.20–0.49), me- dium (0.50–0.79), and large (0.80 and above), we found large effect sizes in both measures, LSAS and SPIN, in bCBGT group at pre-post (0.86 and 0.96) and pre-two- month follow-up (0.89 and 1.01).

ANCOVAs with pre-treatment scores as the covariate also found a significant effect of bCBGT at post-test and follow-up on LSAS, F (1, 47) = 5.28, p = 0.026, and F (1. 47) = 6.02, p = 0.018, respectively. Similar effects were demonstrated for the SPIN, F (1, 47) = 6.18, p = 0.017, and F (1. 47) = 5.8, p = 0.02, respectively.

4. Discussion

The present study demonstrated that brief CBGT is an efficacious treatment for SAD among undergraduate medical students in India. Participants receiving bCBGT improved significantly on two measures of social anxiety. bCBGT treatment effects were maintained over a two-

month follow-up as compared to the placebo condition. Large effect sizes were achieved in the six-week treatment and at the two-month follow-up in the bCBGT group.

Our findings of treatment efficacy are consistent with other studies (Herbert et al., 2002; McEvoy, 2007) using an abbreviated CBGT pro- tocol, but a few differences are worth mentioning. Unlike Herbert et al.’s study, we did not include SST. Further they found a modest effect size after six weeks of intervention. McEvoy’s (2007) study involved seven four-hour sessions of CBGT as compared to our six two-hour sessions. However, in Bjornsson’s study (2011), on a college population, abbre- viated CBGT was not superior to the placebo condition, group psycho- therapy (GPT). Such a difference is difficult to explain, but a few differences might shed light on this. They used a placebo, GPT, which capitalized on group dynamics and consisted of group exposure; and lower attrition (4.3 %, 1 participant only) in control condition as compared to ours (28 %, 7 participants). Or simply, the passage of time may be an explanation for the treatment effects observed in the both groups.

Our findings are comparable to studies of individual bCBT on SAD (Pinjarkar et al., 2018; Shirotsuki et al., 2014) in terms of sessions and treatment effects. The study by Shirotuski, consisting of six weekly 50-minutes sessions, reported moderate effect sizes, and Pinjarkar’s study, consisting of six weekly 90-minutes sessions, has reported higher effect sizes.

Even our findings have shown similar encouraging treatments effects in both acute and follow-up stages as compared to other community based (McCarthy et al., 2013; McEvoy et al., 2012) and clinic based (Aderka et al., 2011; Hedman et al., 2011) CBGT studies involving twelve, or more, sessions. The follow-up duration in these studies is longer, varying from six to twelve months, as compared to two months in the present study. Considering these similar effect sizes, lower attri- tion reported in the studies involving longer sessions, we assert that a brief format, requiring fewer therapist hours, too, is an efficient, prag- matic and acceptable treatment for SAD at the college level where adequate resource availability has been a concern (Goodman, 2017).

The interpretations of these findings need to be made, keeping in mind some apparent limitations. We did not directly compare the six- week with standard twelve-week CBGT protocol, which is recom- mended to establish the bCBGT efficacy. In the future, replication with larger sample size is also needed. As reported in other studies, a longer follow-up is required for assessing the durability of the effects of bCBGT’s. Further, we did not include measures of cognitions and non- specific factors of treatment adherence or credibility by participants for either treatment condition. Future studies might include measures of non-specific factors, cognition and behavioral assessment of social anxiety, as we used only clinician-administered and self- report mea- sures. The present findings may not generalize to a broader SAD popu- lation; the current protocol has to be tested in samples with diverse

Table 2 Means, standard deviations, and t-test results for the LSAS and SPIN (intent to treat analysis).

CBGT PST Between group t value (p value) df = 48

Within group t value (p value) df = 24

Pre M (SD) Post M (SD) FU M (SD) Pre M (SD) Post M (SD) FU M (SD) a) Pre b) Post c) FU

CBT a) Pre-post b) Pre-FU

PST a) Pre-post b) Pre-FU

LSAS 78.24 (18.67)

57.95 (27.58)

56.41 (29) 74.52 (14.67)

71.05 (15.28)

70.69 (15.14)

a) t = .78 (.437) b) t = -2.08 (.045)* c) t = -2.18 (.036)*

a) t = 3.1 (.005)

b) t = 3.32 (.003)

a) t = 1.54 (.137)

b) t = 1.7 (.101)

SPIN 40.12 (7.61)

29.65 (13.39)

28.82 (13.78)

38.24 (8.06)

36.89 (9.77)

35.88 (9.81)

a) t = .85 (.401) b) t = -2.18 (.034) c) t = -2.08 (.042)

a) t = 3.27 (.003)

b) t = 3.49 (.002)

a) t = 1.12 (.275)

b) t = 1.97 (.06)

CBGT, cognitive behavioral group therapy; PST, psychoeducational supportive therapy; M, mean; SD, standard deviation; FU, follow-up; LSAS, Liebowitz Social Anxiety Scale; SPIN, Social Phobia Inventory.

* Equal variances not assumed in these two observation; df = 37.46 and df = 36.16.

Table 3 Effect Sizes (Cohen’s d) for LSAS-T at post treatment, and two-month follow-up.

Assessment bCBGT PST

LSAS Post-treatment 0.86 0.23 Two-month follow-up 0.89 0.25 SPIN Post- treatment 0.96 0.15 Two-month follow-up 1.01 0.26

Note: bCBGT = Brief cognitive behavioral group therapy; PST = Psychoeducational-supportive therapy; LSAS, Liebowitz Social Anxiety Scale; SPIN, Social. Phobia Inventory.

N.N. Samantaray et al.

Asian Journal of Psychiatry 55 (2021) 102526

5

characteristics, which we are planning to do.

5. Conclusions

bCBGT is an efficacious treatment for SAD among medical students. It is recommended for a rapid yet clinically substantial and enduring treatment effect, especially where there is a lack of trained professionals. However, a longer follow-up, replications in other student groups and clinical settings need to be done for generalization to a broader SAD population.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors declare to have no conflicts of interest.

Acknowledgement

The authors thank Richard G. Heimberg immensely for his invalu- able review and inputs in the preparation of this manuscript. The au- thors thank Pratiti Pattanaik and Mihir Ranjan Nayak for their assistance on this project.

References

Agha Mohammad Hasani, P., Mokhtaree, M., Asadollahi, Z., Fereidoni, M., 2016. The prevalence of social phobia among students of Rafsanjan University of Medical Sciences, Iran, and its relation with personality traits in 2013. J. Occup. Health Epidemiol. 5 (2), 72–82. https://doi.org/10.18869/acadpub.johe.5.2.72.

American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association.

Antony, M.M., Coons, M.J., McCabe, R.E., Ashbaugh, A., Swinson, R.P., 2006. Psychometric properties of the social phobia inventory: further evaluation. Behav. Res. Ther. 44 (8), 1177–1185.

Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G.M., Barth, J., Rosendahl, J., 2016. Efficacy of group psychotherapy for social anxiety disorder: a meta-analysis of randomized-controlled trials. J. Anxiety Disord. 39, 44–64. https://doi.org/ 10.1016/j.janxdis.2016.02.005. Elsevier Ltd.

Bjornsson, A.S., Bidwell, L.C., Brosse, A.L., Carey, G., Hauser, M., Seghete, Mac Kiewicz, Schulz-Heik, K.L., Weatherley D, R.J., Erwin, B.A., Craighead, W.E., 2011. Cognitive- behavioral group therapy versus group psychotherapy for social anxiety disorder among college students: a randomized controlled trial. Depress. Anxiety 28 (11), 1034–1042. https://doi.org/10.1002/da.20877.

Brook, C.A., Willoughby, T., 2015. The social ties that bind: social anxiety and academic achievement across the university years. J. Youth Adolesc. 44 (5), 1139–1152. https://doi.org/10.1007/s10964-015-0262-8.

Buckner, J.D., Lemke, A.W., Jeffries, E.R., Shah, S.M., 2017. Social anxiety and suicidal ideation: test of the utility of the interpersonal-psychological theory of suicide. J. Anxiety Disord. 45, 60–63. https://doi.org/10.1016/j.janxdis.2016.11.010.

Cohen, J., 1992. A power primer. Psychol. Bull. 112 (1), 155. Connor, K.M., Davidson, J.R.T., Erik Churchill, L., Sherwood, A., Foa, E., Weisler, R.H.,

2000. Psychometric properties of the social phobia inventory (SPIN). New self- rating scale. Br. J. Psychiatry 176 (April), 379–386. https://doi.org/10.1192/ bjp.176.4.379.

Damer, D.E., Latimer, K.M., Porter, S.H., 2010. "Build your social confidence": A social anxiety group for college students. J. Spec. Group Work. 35 (1), 7–22. https://doi. org/10.1080/01933920903463510.

Desalegn, G.T., Getinet, W., Tadie, G., 2019. The prevalence and correlates of social phobia among undergraduate health science students in Gondar, Gondar Ethiopia. BMC Res. Notes 12 (1). https://doi.org/10.1186/s13104-019-4482-y.

DiNardo, P.A., Barlow, D.H., Brown, T.A., 1994. Anxiety Disorders Interview Schedule for DSM-IV. Lifetime Version: Client Interview Schedule. Oxford University Press.

Dziura, J.D., Post, L.A., Zhao, Q., Fu, Z., Peduzzi, P., 2013. Strategies for dealing with missing data in clinical trials: from design to analysis. Yale J. Biol. Med. 86 (3), 343.

Fresco, D.M., Coles, M.E., Heimberg, R.G., Liebowitz, M.R., Hami, S., Stein, M.B., Goetz, D., 2001. The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats. Psychol. Med. 31 (6), 1025–1035. https://doi.org/10.1017/S0033291701004056.

Gill, J., Mohammad, S., 2010. P01-139-Social anxiety among medical undergraduate students in Malaysia. Eur. Psychiatry 25, 347.

Goodman, L., 2017. Mental health on university campuses and the needs of students they seek to serve. Build. Healthy Acad. Communities J. 1 (2), 31–44.

Guy, W., 1976. ECDEU assessment manual for psychopharmacology. US Department of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration. National Institute of Mental Health, Psychopharmacology Research Branch, Division of Extramural Research Programs.

Hazlett-Stevens, H., Craske, M.G., 2008. Brief cognitive-behavioral therapy: Definition and scientific foundations. Handbook of Brief Cognitive Behaviour Therapy. wiley, pp. 1–20. https://doi.org/10.1002/9780470713020 ch1.

Heimberg, R.G., Becker, R.E., 2002. Cognitive Behavioral Group Treatment for Social Phobia: Basic Mechanisms and Clinical Strategies. Guilford Press.

Heimberg, R.G., Dodge, C.S., Hope, D.A., Kennedy, C.R., Zollo, L.J., Becker, R.E., 1990. Cognitive behavioral group treatment for social phobia: comparison with a credible placebo control. Cognit. Ther. Res. 14 (1), 1–23. https://doi.org/10.1007/ BF01173521.

Heimberg, R.G., Salzman, D.G., Holt, C.S., Blendell, K.A., 1993. Cognitive— behavioral group treatment for social phobia: effectiveness at five-year followup. Cognit. Ther. Res. 17 (4), 325–339.

Heimberg, R.G., Horner, K.J., Juster, H.R., Safren, S.A., Brown, E.J., Schneier, F.R., Liebowitz, M.R., 1999. Psychometric properties of the Liebowitz social anxiety scale. Psychol. Med. 29 (1), 199–212.

Herbert, J.D., Rheingold, A.A., Goldstein, S.G., 2002. Brief cognitive behavioral group therapy for social anxiety disorder. Cogn. Behav. Pract. 9 (1), 1–8.

Honnekeri, B.S., Goel, A., Umate, M., Shah, N., De Sousa, A., 2017. Social anxiety and Internet socialization in Indian undergraduate students: an exploratory study. Asian J. Psychiatr. 27, 115–120. https://doi.org/10.1016/j.ajp.2017.02.021.

Kardas, P., Lewek, P., Matyjaszczyk, M., 2013. Determinants of patient adherence: a review of systematic reviews. Front. Pharmacol. 4 (July) https://doi.org/10.3389/ fphar.2013.00091.

Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W., Hoyer, J., et al., 2013. Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. Am. J. Psychiatry 170 (7), 759–767.

Liebowitz, M.R., Pharmacopsychiatry, M.P., 1987. Social phobia. 22, 141–173. Lin, J., Sklar, G.E., Oh, V.M.Sen, Li, S.C., 2008. Factors affecting therapeutic compliance:

a review from the patient’s perspective. Ther. Clin. Risk Manag. 4 (1), 269–286. https://doi.org/10.2147/tcrm.s1458. Dove Press.

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D.M., Ades, A.E., Pilling, S., 2014. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry 1 (5), 368–376.

McCarthy, O., Hevey, D., Brogan, A., Kelly, B.D., 2013. Effectiveness of a cognitive behavioural group therapy (CBGT) for social anxiety disorder: immediate and long- term benefits. Cogn. Behav. Ther. 6.

McEvoy, P.M., Nathan, P., Rapee, R.M., Campbell, B.N., 2012. Cognitive behavioural group therapy for social phobia: evidence of transportability to community clinics. Behav. Res. Ther. 50 (4), 258–265.

Nordstrom, A.H., Goguen, L.M.S., Hiester, M., 2014. The effect of social anxiety and self- esteem on college adjustment, academics, and retention. J. Coll. Couns. 17 (1), 48–63.

Pinjarkar, G.R., Sudhir, P.M., Mariamma, P., Bada Math, S., Wells, A., 2018. Brief cognitive therapy plus treatment as usual for social anxiety disorder: a randomized trial of adults in India. Int. J. Cogn. Ther. 11 (3), 299–310. https://doi.org/10.1007/ s41811-018-0025-x.

Powers, M.B., Sigmarsson, S.R., G Emmelkamp, P.M., 2007. A meta-analytic review of psychological treatments for social anxiety disorder. Int. J. Cogn. Ther. 1 (2). Tay- lor.

Ratnani, I.J., Vala, A.U., Panchal, B.N., Tiwari, D.S., Karambelkar, S.S., Sojitra, M.G., Nagori, N.N., 2017. Association of social anxiety disorder with depression and quality of life among medical undergraduate students. J. Family Med. Prim. Care 6 (2), 243.

Russell, G., Topham, P., 2012. The impact of social anxiety on student learning and well- being in higher education. J. Ment. Health 21 (4), 375–385. https://doi.org/ 10.3109/09638237.2012.694505.

Samantaray, N., Kar, N., Singh, P., 2019. Four-session cognitive behavioral therapy for the management of obsessive-compulsive disorder using a metaphor for conceptualization: a case report. Indian J. Psychiatry 61 (4), 424–426. https://doi. org/10.4103/psychiatry.IndianJPsychiatry_92_19.

Schry, A.R., White, S.W., 2013. Understanding the relationship between social anxiety and alcohol use in college students: a meta-analysis. Addict. Behav. 38 (11), 2690–2706. https://doi.org/10.1016/j.addbeh.2013.06.014.

Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., et al., 1998. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD- 10. J. Clin. Psychiatry.

Stein, D.J., Lim, C.C.W., Roest, A.M., de Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bromet, E.J., Bruffaerts, R., de Girolamo, G., Florescu, S., Gureje, O., Haro, J.M., Harris, M.G., He, Y., Hinkov, H., Horiguchi, I., Hu, C., et al., 2017. The cross-national epidemiology of social anxiety disorder: data from the World Mental Health Survey Initiative. BMC Med. 15 (1), 143. https://doi.org/ 10.1186/s12916-017-0889-2.

Wells, A., Papageorgiou, C., 2001. Brief cognitive therapy for social phobia: a case series. Behav. Res. Ther. 39 (6), 713–720.

Zaider, T.I., Heimberg, R.G., Fresco, D.M., Schneier, F.R., Liebowitz, M.R., 2003. Evaluation of the clinical global impression scale among individuals with social anxiety disorder. Psychol. Med. 33 (4), 611–622. https://doi.org/10.1017/ S0033291703007414.

N.N. Samantaray et al.