120 Chapter 6 ence between push/pull scores by comparing the social stimuli with a control stimulus (checkerboards) and thereby we limited the influence of factors such as participants seating position. Our finding of relative avoidance of social vs non-social stimuli add to the rather robust findings that relative avoidance tendencies to threathening cues on AAT-tasks are found in social anxiety disorder (for review see Loijen et al., 2020). Moreover, they are in line with notions that automatic avoidance tendencies can play an important role in more complex instrumental types of avoidance (Arnaudova et al., 2017; Pittig, Treanor, LeBeau, & Craske, 2018). Specifically, during speech exposure facial expressions of the public are usually mixed (neutral, happy, angry) and therefore testing the value of avoidance tendencies toward different facial expressions as a behavioral marker of (testosterone) enhanced exposure is relevant. Pharmacological enhancement for SAD: effects on symptom severity It is interesting to discuss our findings on testosterone enhancement in light of other pharmacological exposure enhancement studies in SAD. Despite the promising effects of our endogenous testosterone-challenge on symptom severity in chapter 3. Single-session testosterone administration in chapter 4 only affected relevant fear-mechanisms during exposure, but it did not improve exposure efficacy more than placebo in terms of fear levels at the end of our second exposure session, neither in terms of social anxiety symptoms from baseline to follow-up. The fact that we did not find improvement at the level of symptom levels (our secondary outcome measure) contrasts our hypothesis and previous work with the pharmacological enhancer D-cycloserine (DCS). Rodebaugh and et al. (2013) found effects of a single dose of DCS on fear levels which showed transfer to social anxiety symptom levels in a sample of 34 individuals with SAD. Similarly, Hofmann et al., (2006) found reductions in symptom severity for SAD after 4 sessions DCS enhanced exposure for SAD. Another study found reductions in symptom severity after 5 sessions of DCS enhanced exposure, but not for tailored (administered after sessions marked by low fear) DCS administration (Smits et al., 2020). The scarce other pharmacological enhancement studies for SAD exposure showed mixed results regarding symptom levels. For Yohimbine (an α-2adrenoceptor antagonist) symptom level reduction was observed on self-report measures, but only for participants with low end fear (Smits, Rosenfield, Davis, et al., 2013) and for Oxytocin no effects were found for symptom severity (Guastella et al., 2009). An important factor that should be considered in this regard is that social anxiety disorder is a complex disorder in which an interplay of biological, environmental, cognitive, temperamental and cultural factors are involved (Spence & Rapee, 2016). As such, detecting reductions in a total score on a self-report measure of ‘social anxiety
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