119 Summary and General Discussion Social avoidance tendencies: a behavioral marker of testosterone enhanced exposure? In line with predictions from chapter 2: testosterone can alleviate avoidance in individuals with SAD (Enter, Spinhoven, et al., 2016; Enter, Terburg, et al., 2016), we tested whether avoidance tendencies toward social stimuli moderate the efficacy of testosterone-enhanced exposure in chapter 5. The results of this study showed that individuals with SAD who showed relatively high pre-treatment social avoidance tendencies, showed larger fear decline during testosterone-enhanced exposure than individuals with relatively low avoidance. Unfortunately, our study was not optimized to test subtle changes in avoidance behavior during exposure. In order to do so we would need specific measures, for example body posture-, eye movement- or voice-trackers. Therefore, we can only speculate about the effects of testosterone on avoidance behaviors. However, the fact that testosterone facilitated in-session exposure-effects in high avoidant participants could be taken to suggest that it reduces avoidance and enables an individual with SAD to engage in exposure therapy. The moderating effect of baseline avoidance was present in the testosterone-enhanced group only and not in the placebo group. This suggests that avoidance tendencies could be a useful marker for personalizing testosterone-enhanced treatment for SAD. It is also worth discussing some observations related to the avoidance marker itself. In regard to the specificity of avoidance tendencies observed in our study, we found faster avoidance (versus approach) of social stimuli (faces) versus non-social stimuli (checkerboards). It is interesting to discuss these effects in relation to the literature. Previous work has shown mixed effects regarding the types of facial expressions for which individuals with SAD show avoidance tendencies. Relative stronger avoidance versus approach has been typically found for angry faces and to a lesser extent for happy and neutral faces (Heuer et al., 2007; Kuckertz et al., 2017; Loijen et al., 2020; Roelofs, Putman, et al., 2010; Roelofs, van Peer, et al., 2009b). In our study we found an avoidance tendency for all facial expressions (see chapter 5). In line with others, we explain this by the fact that all types of faces could signal threat for socially anxious individuals (Heuer et al., 2007). It is important to address that there is no firm tradition yet regarding how reaction times in Approach Avoidance tasks should be analyzed and interpreted. Consequently, there are differences between the procedures in the above-mentioned studies. For example, push/pull trials have been analyzed separately (Kuckertz et al., 2017), as a differences score (Rinck et al., 2009) or with response direction as a within subjects factor (Heuer et al., 2007). Also, different control stimuli or conditions have been used, which could be an alternative explanation why mixed results are found. With regard to our own study, we followed recommendations of Rinck and Becker (2007) and used a relative differ6
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