Unguided bibliotherapy and digital self-help interventions based on cognitive behavioural therapy for university students with gaze-related anxiety and social anxiety symptoms: a randomised controlled trial

Individual cognitive behavioural therapy (CBT) for social anxiety disorder is effective, but CBT has not become widespread enough. Since young people with social anxiety also experience above a certain level distress and functional impairment, the development of readily available CBT-based self-help interventions is urgently needed. The objective was to evaluate the effectiveness of two five-week, unguided CBT-based self-help interventions in reducing gaze-related anxiety and social anxiety symptoms among university students with elevated gaze-related anxiety. A three-arm, randomised controlled trial was conducted in Japan from April to December 2025. University students with gaze-related anxiety were randomly assigned to bibliotherapy (Bib) or unguided digital self-help interventions (DSI), or to a six-month waitlist control. Social anxiety symptoms were evaluated using several self-report scales, and assessments were conducted at baseline, post-intervention, and at two follow-ups. Of 252 university students enrolled, 244 were included in the modified intention-to-treat analyses, which used linear mixed-effects models. For the primary outcome, the adjusted mean difference in the Gaze Anxiety Rating Scale at post-intervention was −10.09 (95% CI: −14.61 to −5.56, Hedges' g = −0.66) for Bib and − 6.95 (95% CI: −12.11 to −1.79, Hedges' g = −0.47) for DSI, both showing a significantly greater reduction compared to the waitlist control. Similarly, for a secondary outcome, the adjusted mean difference in the Liebowitz Social Anxiety Scale at post-intervention was −13.57 (95% CI: −20.86 to −6.29, Hedges' g = −0.55) for Bib and − 12.47 (95% CI: −20.78 to −4.17, Hedges' g = −0.53) for DSI, which were also significantly higher than the waitlist control. The effectiveness of these two interventions in reducing social anxiety symptoms compared to the waitlist control was maintained at the 3-month and 6-month follow-ups. These findings support brief unguided CBT-based self-help as a potentially accessible low-intensity option for university students with elevated social anxiety symptoms.