Introduction
Social anxiety disorder (SAD) is a severe and persistent fear of being in social situations, communicating with others, or doing something in the presence of others [1]. It is one of the most common anxiety disorders with a higher prevalence among children and teenagers. With a prevalence of 13%, it affects women more than men (3:2 ratio) [2]. According to the fifth edition of the diagnostic and statistical manual of mental disorders (DSM-5), the global prevalence of SAD is estimated at 1.1-3.6%. In Iran, the prevalence of this disorder was reported as 10% [3]. As the third major mental health problem and the most common anxiety disorder [4], this disorder can cause a decline in academic, social, and professional performance. One of the main cognitive symptoms of this disorder is self-focused attention. It is part of a person’s effort to avoid confusion and humiliation, which causes a bias to negative thoughts and feelings and thus leads to the decline of performance [5]. Recent studies have indicated that attention bias (self-focused attention) plays an important role in the etiology and persistence of SAD [6, 7].
One of the treatment methods for SAD is cognitive behavioral psychodrama group therapy (CBPGT). This approach includes the combination of psychodrama therapy (focusing on theatrical representation) and cognitive behavioral therapy (CBT) and provides an opportunity for group members to use the techniques of both interventions and correct negative thoughts and inappropriate interpersonal behaviors [25]. Each session consists of four stages: warm-up (preparation), enactment, sharing, and analysis. [26]. Several studies have shown the effectiveness of CBPGT alone or in comparison with psychodrama on SAD. One study in Iran by Abeditehrani et al. [27], showed the positive effects of this integrated approach on the SAD of adults [27]. The results of Bakaeian’s study showed the effectiveness of both treatments (CBT and Psychodrama) in treating SAD and self-focused attention [16]. In a meta-analysis, Scaini et al. reported the positive effects of CBT on the SAD of children and adolescents [22]. Gökkaya et al. showed the effectiveness of both psychodrama and CBT in improving SAD [37]. The results of Kooraki et al. showed the effectiveness of CBPGT on interpersonal sensitivity and SAD of adolescent girls [38]. No study was found in Iran on the effectiveness of this approach on the self-focused attention of adolescent girls. Therefore, this study aims to determine the effects of CBPGT on self-focused attention and SAD of adolescent girls in Sirjan, Iran.

Method
This is a randomized controlled clinical trial with a pre-test/post-test/follow-up design. The study population consists of all ninth-grade female students in Sirjan, Iran. Of these, 24 were selected using a convenience sampling method from among those referred to health centers for screening and receiving healthcare, and were divided randomly into two groups: intervention (n=12) and control (n=12). To diagnose their SAD, in addition to screening with the social anxiety scale for adolescents (SAS-A), and focus of attention questionnaire (FAQ), a structural clinical interview was conducted followed by determining the inclusion and exclusion criteria. After the pre-test phase, the intervention group received CBPGT at 9 sessions of 120 minutes in Andisheh Psychology Clinic. After completing the one-month follow-up, the control group received several sessions of similar training. Data were analyzed using descriptive statistics (Mean±SD) and multivariate analysis of covariance (MANCOVA) in SPSS software, version 24.

Results
The results of MANCOVA (Table 1) showed a significant difference between the two groups in at least one of the dependent variables (self-focused attention and SAD).


To analyze the difference, the analysis of covariance (ANCOVA) was carried out and the results (Table 2) showed that CBPGT reduced SAD (P<0.001) and self-focused attention in the intervention group compared to the control group at the post-test (F=27.40 and 15.37, P<0.001) and follow-up (F=52.54 and 24.58, P<0.001) phases.


Therefore, it can be said that CBPGT is effective in treating self-focused attention and SAD of female school students.

 Conclusion
The purpose of the study was to examine the effect of CBPGT On SAD and self-focused attention of adolescent girls in south of Iran. The results showed a significant reduction in SAD and self-focused attention of girls which is consistent with the results of Bakaeian et al [16] and Abeditehrani [27], who showed that CBPGT significantly reduced SAD and self-focused attention of female adolescents. Several studies using the CBPGT have also shown that this intervention leads to the decrease of self-focused attention in people suffering from SAD [16, 38]. CBPGT can balance the focus on cognition and behaviors through CBT techniques, and emotion during psychodrama techniques in action. The reason for the effect of CBPGT on self-focused attention, in addition to discovering and correcting the relationship between thought-feeling and behavior, is role-playing and the use of psychodrama techniques and getting feedback from the group. CBPGT should be considered as a new treatment for female patients with SAD.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Shahid Chamran University (Code: EE/1401.2.24.172133/SCU.AC.IR), and was registered by Iranian Registry of Clinical Trials (ID: IRCT20230228057557N1). The participants and their parents were informed about the study process, and they signed a consent form. Their information kept confidential and they were free to leave the study at any time. 

Funding
This article was extracted from the PhD thesis of Maryam Kooraki, funded by Shahid Chamran University.

Authors contributions
Design, conceptualization, project administration, data collection, data analysis, writing the original draft, and editing: Maryam Kooraki; Design, conceptualization and review: Seyad Esmaeil Hashemi and Mahnaz Mehrabizadeh Honarmand; Supervision and review: Seyad Esmaeil Hashemi, Mahnaz Mehrabizadeh Honarmand, and Bahram Peymannia; Design and implementation of the intervention: All authors.

Conflicts of interest
The authors declared no conflict of interest

Acknowledgements
The authors would like to thank all students and their parents for their cooperation.


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