Introduction

Social Anxiety Disorder (SAD) is an important disorder of childhood and adolescence in which a person in different situations feels that society has a negative attitude towards her [1]. This disorder is the third mental health problem and has been reported in some researches as an important factor in drug addiction and depression [2,3]. Individuals with SAD are afraid of the attention of the people around and sometimes feel inferior, therefore, therefore, they try to be always calm and avoid being in such situations [4,5]. This disorder is more prevalent in women and symptoms of this are: rigorous concern about an upcoming social situation, scopophobia, feelings of panic, excessive self-consciousness, inability to make eye contact with others, increased tone of voice and chest pain [6].

The SAD disease affects the quality of life of patients and sometimes leads to job abandonment and educational problems in adolescents [7]. Today, having self-esteem is one of the most important factors in supporting people who face negative events [8,9]. Efforts and strategies are needed to coping with this disease. Many patients are not able to make and pursue these strategies, therefore, their personal lives are endangered or subject to serious changes. These changes can include changes in quality of life, self-esteem, self-concept, anxiety, and stress. A recent research has shown that patients with SAD experience a high level of mental and emotional disorders and difficulties with regulating their anxieties [10].

In general, it has been reported that self-esteem and self-concept in patients with SAD are significantly lower than the healthy population [11,12]. Mindfulness-Based Cognitive Therapy (MBCT) is one of the therapies that has been created for specific medical conditions in patients with psychological problems [13,14]. This method derived from mindfulness-based stress reduction technique, MBCT introduced by Zindel Segal and Mark Williams (2002) and primarily, it has evolved to cover the treatment of depression [15]. This method integrates cognitive approach and mindfulness meditation practices and helps patients to review, recognize, and reassess their thoughts and replace negative thoughts with positive thoughts, and finally improve the quality of life and reduce stress [16,17]. Mindfulness-based cognition therapy is a new promise in explaining the therapeutic-behavioral approach. Mindfulness-based therapies are highly effective in treating clinical disorders and physical ailments because they affect both the physical and mental dimensions [18]. Mindfulness means turning one's consciousness from the past and the future to the present.

Social anxiety is highly prevalent in urban populations and has been reported to be more prevalent among people with low self-esteem and self-concept [19]. People with SAD show less positive beliefs about their personality traits than healthy people [20]. In addition, social anxiety inversely predicts self-concept. Self-concept is a set of attributes, abilities, attitudes, and values that a person believes describes him or her [21]. In general, SAD has been reported to be on the rise in some parts of the world [22]. Despite the clinical effectiveness of cognitive-behavioral therapies in reducing the symptoms of social anxiety, according to the author's review, most of previous studies have used traditional methods and techniques of cognitive-behavioral therapy and few studies have introduced new approaches called third wave cognitive-behavioral therapies in social anxiety. Therefore, due to the increasing prevalence of SAD and the occurrence of psychological problems, psychological tailored intervention is necessary to improve the psychological aspects and quality of life of these patients. In this regard, we aimed to determine the effect of MBCT on self-esteem, self-concept, and social anxiety of people with social anxiety disorder.

Methods

A cross-sectional study was conducted from April to July 2021 in the county town of Shiraz, Iran. Research method was quasi experimental and conducted on experimental and control groups. The participants in this study were 30 individuals with SAD experimental group: 15, control group: 15 referred to counseling and psychotherapy centers of Shiraz located in Fars Province in Iran. Random multi-stage cluster sampling was used for sampling. The experimental group received 8 sessions of MBCT training, once a week for 120 minutes over 56 days and the control group received no interventions. The data collection tool was a questionnaire. In the first session of MBCT therapy, the researcher evaluated the appropriateness of the treatment for the patient, introduced the history of MBCT and highlighted the necessity of this program. Breathing exercise was taught; the importance of being present in the moment was explained. The second session was devoted the study of defective cognitions, practicing body examination for 10-15 minutes, facing obstacles, practicing on the sad senses, mental confusion and repetitive habits of the mind.

Session 3: Introducing the practice of sitting meditation and performing it for 10-15 minutes, reviewing the homework of the last session, talking about the stresses and worries. Session 4: Learning to stay in the present moment without running away and watching the turmoil increase social skills, three-minute breathing technique and the use of yoga poses. Session 5: Teaching full awareness of thoughts and feelings and accepting them without direct judgment and intervention. Session 6: Teaching mood swings and negative thoughts about people by inducing thoughts as just thoughts and not reality. Session 7: Identification of relapse and development warning signs and setting up action plans to deal with this situation. Session 8: Planning for the future and using the present moment technique to continue living and extending it to the whole life Criteria for inclusion in this study were: diagnosis of SAD by a specialist physician, being between 20 and 55 years old, having literacy, not receiving other psychotherapy interventions at the same time, and agreeing to participate in this study in written form. This study was reviewed and approved by the Arsenjan University (No-14001201).

Instruments

Social Phobia Inventory (SPIN)

It is a commonly used measure of Social Anxiety Disorder [23]. This scale was designed by the Psychiatry and Behavioral Sciences Department at Duke University in 2000. The SPIN is a 17-item questionnaire which measures different aspects of Social phobia fear, avoidance, and physiologic symptoms. The SPIN is scored in a 4-point scale from 1 to 4 and the minimum score is 17 and the maximum score is 85. According to a previous study conducted in Iran, internal consistency was 87% Ghaedi, 2010. This scale showed excellent internal consistency in this study (81%).

Self-concept questionnaire

It was prepared to measure the level of self-concept of individuals. This questionnaire includes three aspects of self-concept: self-esteem, self-image and ideal self. Self-worth or self-esteem is an attitude about the own value concerning the some predetermined objects [24]. Self-image indicates that how one look or sees oneself; self-image linked with inner personality. Self-actualization is a state of thought in where restless of mind can get a sustainable state. This scale has 50 items and each item answered based on a seven-point scale, these options are scored from 1 to 7, respectively [25]. A score between 0 and 7 showed that the subject had normal self-concept, and if higher than 7 they were considered to have poor and negative self-concept. For scientific validity of the data collecting tools, the questionnaire was assessed by professors who have sufficient skills in this field. According to previous studies, the reliability of the questionnaire using Cronbach's alpha coefficient were 0.84 and 0.86 [26,27].

Self-esteem scale-10

Self-Esteem Scale -10 is one of the most common measures of self-esteem that measures self-competence and self-liking. Self-competence is feeling you are confident, capable and efficacious and self-liking is feeling you are good and socially relevant. This scale has 10 items and each item answered based on a 4-point Likert scale format ranging from strongly agree to strongly disagree. The scale ranges from 0-30. Scores between 15 and 25 are within normal range; scores below 15 suggest low self-esteem. This scale has stronger correlation coefficients than other related questionnaires and has higher validity in measuring self-esteem levels. Rosenberg reported a scale recurrence of 0.9 and a scalability of 0.7. For scientific validity of the data collecting tools, the questionnaire was assessed by professors who have sufficient skills in this field. According to previous studies, the reliability of the questionnaire using Cronbach's alpha coefficient were 0.81 and 0.87. In the present study, the reliability of the questionnaire using Cronbach's alpha coefficient was 0.83.

In order to analyze the research data, the data obtained from the questionnaires and analyzed in descriptive and inferential sections using SPSS26 software. In the descriptive section, the mean, standard deviation, skewness and elongation for the variables were calculated and the statistical method of analysis of covariance was used to test the hypotheses. The research hypotheses included the following: a) MBCT treatment has a significant impact on self-esteem of people with social anxiety disorder. b) MBCT treatment has a significant impact on self-concept of people with social anxiety disorder. c) MBCT treatment has a significant impact on social anxiety of people with social anxiety disorder.

Results

Before testing the research hypotheses, in order to explain the situation of the studied groups, the normal distribution of research variables was examined using skewness and elongation. In this study, the values of skewness and elongation of variables were between +2 and -2; therefore, the distribution of research variables was normal. Levin test was used to evaluate the homogeneity of variances (Table 1). The results of this test on research variables were calculated and significant level of F statistic was greater than 0.05. Therefore, it should be assumed that the error variance of the groups was equal to each other and no difference was observed between them. Therefore, the homogeneity of variance for all variables in the experimental and control groups was not significantly different and the assumption of variance homogeneity was approved. In this research, the numbers of female and male participants were 8 and 7, respectively for both control and test groups. The mean age of participants in the experimental and control groups were 36.8, and 37.1, respectively. Education levels of 53% of participants were lower than bachelor degree and only 26% of them had a bachelor's degree.

Results of covariance analysis for the effect of MBCT treatment on self-esteem, self-concept, and social anxiety of people with SAD showed in Table 2-4. As shown in Tables 2-4, there was a significant difference between the experimental and control groups for the variables of self-esteem, self-concept, and social anxiety.

The multivariate analysis of covariance to test the main research hypothesis is shown in Table 5. As shown in Table 5, the significance level of the multivariate analysis (P=0.001) is smaller than 0.05. Therefore, Mindfulness-based cognitive therapy (MBCT) has a significant effect on self-esteem, self-concept, and social anxiety in people with social anxiety disorder.

Discussion

The aim of this study was to evaluate the the effect of MBCT on self-esteem, self-concept, and social anxiety of people with SAD. The research hypotheses are examined below.

Hypothese a) MBCT treatment has a significant impact on self-esteem of people with social anxiety disorder.

According to the results shown in Table 2, it was found that the value of F static was significant and MBCT could have an increasing effect on self-esteem of people with SAD [28,29]. Therefore, the first hypothesis of the research was confirmed. Similar findings have been reported in other studies. It has been reported that that high levels of mindfulness are associated with high levels of self-esteem and leads to increased metacognitive awareness and reduced rumination, stress, dysfunctional skills and negative thoughts. Mindfulness can increase self-esteem by promoting self-control and purposeful behavior. Mindfulness leads to a decrease in the frequency of negative automatic thoughts and an increase in the ability to drive out those thoughts and ultimately psychological well-being. Observing, describing, action with awareness, and nonjudgmental acceptance are components that highly correlated to mindfulness skills.

Hypothese b) MBCT treatment has a significant impact on self-concept of people with social anxiety disorder.

About the effect of MBCT treatment on self-concept of people with social anxiety disorder, the results of this study showed that the self-concept score of the MBCT-experimental group was significantly higher than the control group. Therefore, MBCT training has been able to increase self-concept in people with SAD. Consistent with the study results, a significant Positive association between MBCT training and self-concept reported. The philosophy behind cognitive therapy of mindfulness is that our thoughts and feelings play a key and fundamental role in people behavior. Mindfulness-based therapy increases awareness and skillful responses to psychological processes involved in maladaptive emotional and behavioral stress. The MBCT intervention significantly increased the levels of self-concept and self-acceptance and significantly decreased self-criticism in the substance-dependent women [30].

Hypothese c) MBCT treatment has a significant impact on social anxiety of people with social anxiety disorder.

About the effect of MBCT treatment on social anxiety of people with social anxiety disorder, our results revealed a significant relationship between this treatment and social anxiety. Therefore, MBCT treatment reduces social anxiety in patients. The result of our study was consistent with other studies. In explaining the above results, it should be supposed that performing mindfulness exercises creates new patterns of self-regulation. Mindfulness modulates emotions without judgment and increases awareness of psychological emotions, especially negative emotions, and helps to see and accept emotions and physical phenomena clearly as they occur, so it can play an important role in psychological well-being. In fact, continuous mindfulness exercises increase the attention of anxious people to their body, emotions and thoughts. Therefore, social anxiety and its symptoms including physiological symptoms, fear, and avoidance could be improved using MBCT treatment. In different researches it has been reported that trait mindfulness affects social anxiety through various factors including: avoidance behavior, cost/probability bias, rumination and fear of negative evaluation by others in negative cognition.

The main limitations of the study included the following: drugs used by these patients could have an effective role in the process of their recovery; it was not possible to control the drug and eliminate its effect. Inability of the researcher to control all disturbing and interfering variables. Due to the time limitations, the results were not followed up. Lack of proper cooperation of subjects with the researcher. Excessive physical restraint and lack of supervision of members outside of the sessions to prevented them from performing some behavioral exercises. It is recommended that the effect of this treatment on patients be followed for a longer period of time. Also, the response of men and women to this treatment method be measured separately. The effectiveness of this method in other chronic diseases can also be evaluated.

Conclusion

Finally, it can be concluded, that MBCT therapy increases self-esteem and self-concept and reduces social anxiety and its symptoms including physiological symptoms, fear, and avoidance. Therefore, in cases where patients are involved with SAD, the above treatment method can be used as an effective treatment method.

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