114 Chapter 6 relevant theory explaining the role of testosterone in social behavior is the social challenge hypothesis (Wingfield et al., 1990). According to this theory, testosterone levels rise in anticipation to a socially challenging situation, thereby stimulating approach behavior and simultaneously reducing fear. I deemed this theory as particularly relevant for the current dissertation aiming to work towards an intervention to alleviate avoidance during exposure therapy in SAD. Our literature review also indicated that individuals with SAD show (biased) action tendencies, that is, they show automatic avoidance toward socially threatening stimuli (for example angry but also happy faces). Interestingly, testosterone can reduce these tendencies. Based on these findings we presented a research agenda as a starting point for the translation of these well-established findings in the lab to a clinical application. Accordingly, in the following chapters I examined whether endogenous and exogenous testosterone challenges could improve exposure efficacy for individuals with SAD and whether the magnitude of social avoidance tendencies in SAD moderate efficacy of testosterone-enhanced exposure therapy. The aim of chapter 3 was to translate the social challenge hypothesis (Wingfield et al., 1990), which was described in chapter 2, to the clinical practice. Specifically, I tested whether pre-exposure endogenous testosterone levels were predictive of exposure outcome for individuals with SAD. A total of 73 participants (52 females) with SAD performed 3 speeches within one exposure session, as well as a fourth speech at a post-assessment one week later. We assessed pre-treatment testosterone levels before (baseline testosterone) and in response to a pre-exposure instruction (testosterone reactivity). Pre-treatment testosterone levels were not related to fear levels during exposure, but they were associated with reductions in social anxiety symptoms from pre-to post-exposure. Specifically, we found that the participants who displayed relatively high pre-exposure testosterone reactivity (e.g., rises in testosterone in anticipation of the exposure) showed larger reductions in social anxiety symptoms. This result suggest that the relative anticipatory reactivity of the HPG-axis contributes to the success of the exposure session that follows immediately after. This finding was specific for the relative reactivity (baseline-controlled testosterone increase to the pre-exposure instructions) and not the absolute reactivity (absolute increase in testosterone levels pre-exposure). This may imply that the relative reactivity of the HPG-axis may be particularly important for SAD-treatment efficacy, and perhaps more so than the absolute testosterone levels in the system during a pre-exposure instruction. In contrast to our hypotheses, low baseline testosterone was also related to larger symptom reduction. This finding might suggest there is more to gain in terms of testosterone rise in individuals with low baseline testosterone levels. Future research should replicate these findings in larger
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