10 Chapter 1 (Enter, Spinhoven, & Roelofs, 2014; Giltay et al., 2012), presumably because the hormone is particularly relevant for preparing a person for socially challenging situations (Wingfield, Hegner, Dufty, & Ball, 1990). Therefore, the overarching aim of this dissertation is to test the potential of testosterone as an enhancer for exposure treatment efficacy for SAD. With this dissertation I aimed to build on fundamental research within the field of neuroendocrinology and to link the acquired knowledge to clinical experimental psychology. Concretely, I aimed to translate well-established experimental findings on the social approach-promoting properties of testosterone in healthy individuals and SAD (Enter et al., 2014; Enter, Spinhoven, & Roelofs, 2016; Enter, Terburg, Harrewijn, Spinhoven, & Roelofs, 2016; Radke et al., 2015; Terburg et al., 2016) to a clinical application in order to improve exposure therapy efficacy in SAD. In this general introduction I will first present a description of SAD, followed by an explanation of exposure therapy and one of its proposed mechanisms of action. Next, I will focus on social avoidance. Firstly by discussing avoidance in the maintenance and treatment of SAD, secondly by providing a neuroendocrinal model of avoidance. Following that model, I will zoom in on the potential of testosterone as an enhancer for exposure therapy for SAD. Finally, I will present the rationale and specific aims of this dissertation and I conclude with an outline of the chapters. Social anxiety disorder Social anxiety disorder (SAD) is the most common and burdensome of all anxiety disorders with a lifetime prevalence of 13% and long-term disability (Aderka et al., 2012; Bandelow & Michaelis, 2015; Bruce et al., 2005; Hendriks et al., 2016). SAD is characterized by an intense fear of social situations in which the individual may be scrutinized by others such as interpersonal interactions (e.g., a conversation), being observed (e.g., eating in public) and performing in front of others (e.g., giving a speech). SAD can be specified into a performance only variant when the fear is restricted to public speaking. These social situations are usually avoided or endured with intense fear or anxiety (American Psychiatric Association, 2013). Individuals with SAD fear that their behavior, physical sensations or appearance will be negatively evaluated by others. They realize that their fear is excessive or unrealistic. SAD usually develops during early childhood or adolescence (Kessler et al., 2005; Schneier, Luterek, Heimberg, & Leonardo, 2004) and typically follows an enduring course without treatment. Moreover, compared to healthy individuals, individuals with SAD have a greater risk of developing comorbid disorders
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