103 Social Avoidance and Testosterone Enhanced Exposure Efficacy in Women with Social Anxiety Disorder on social anxiety symptoms either (Hutschemaekers et al., 2021). One possibility is that single-session enhancement is not sufficient to yield longer-term effects or changes in social anxiety symptom severity. These observations call for follow-up parametric studies. In line with previous work, individuals with SAD showed avoidance tendencies not only for angry but also neutral and (to a lesser extend) happy faces (Heuer et al., 2007; Kuckertz et al., 2017; Loijen et al., 2020; Roelofs, Putman, et al., 2010; Roelofs, van Peer, et al., 2009a). Angry faces explicitly communicate threat to the individual and may therefore automatically activate avoidance mechanisms, especially in socially anxious individuals (Heuer et al., 2007; Roelofs, Putman, et al., 2010). The same can be true for neutral faces. Indeed, neutral faces are ambiguous, activate negative bias, and have been labeled as threatening by socially anxious individuals (Heuer et al., 2007; Lange, Allart, Keijsers, Rinck, & Becker, 2012). Relative avoidance tendencies to happy faces (Heuer et al., 2007; Lange et al., 2012; Roelofs, Putman, et al., 2010) are also common, pointing perhaps to tendencies among individuals with SAD to avoid any potential social interaction partner (Roelofs, Putman, et al., 2010). We did not observe any changes in social avoidance tendencies over time with exposure therapy. It is possible that such changes require testing social avoidance tendencies during the testosterone treatment window (Enter et al., 2014; Enter, Spinhoven, et al., 2016). The fact that social avoidance tendencies did not change from pre to post exposure may in fact suggest that avoidance tendencies in individuals with SAD are stable over time. Interestingly, Kampmann et al. (2018a) found no change in social avoidance tendencies in individuals with SAD even after 10 sessions of (successful) exposure therapy. Collectively, these observations point to the possibility that targeting social avoidance tendencies during the course of established interventions for SAD as a way to boost their efficacy and reduce relapse may require more intensive (e.g., frequency, duration) treatment with testosterone or other augmentation strategies that can directly engage this therapeutic target. Several strengths and limitations of this study deserve comment. As far as the strengths, we only included individuals who met the diagnostic criteria of SAD (American Psychiatric Association, 2013) and we used well-established tasks and protocols. Second, the hypotheses were preregistered and were grounded in a long standing research line testing prosocial properties of testosterone and their boundary conditions in individuals with SAD (Enter, Spinhoven, et al., 2016; Enter, Terburg, et al., 2016; Hutschemaekers et al., 2021). As far as the limitations, first, the study was underpowered to detect small effects. Second, we only included females because the administration method we used has been validated only in females (Bos, van Honk, et al., 2012; Enter, Terburg, et al., 2016; Tuiten et al., 2000). Building upon recent single-dose testosterone administration studies in men 5
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