19 General introduction 2016; Enter, Terburg, et al., 2016). Based on these fundamental and experimental findings on testosterone, we expect that testosterone reactivity (or administration) prior to an exposure session improves engagement and approach behavior within the exposure session, resulting in improved corrective learning, as assessed by retention of learning in the following exposure session(s) (see Figure 1.3 for an illustration). Figure 1.3 An illustration of the proposed mechanism of action for testosterone as an enhancer for exposure therapy. A. The upper part of the figure depicts subtle avoidance and safety behaviors during a speech exposure, such as holding notes, talking quietly, hiding face behind hair etc. According to Inhibitory Learning Theory this negatively affects inhibitory learning, thereby reducing the efficacy of exposure treatment. If anything, individual learns confirmation that absence of social rejection can be attributed to safety behaviors, leading to maintained fear for the next exposure session. B. The lower part of the picture illustrates our hypothesis that Testosterone reactivity or administration stimulates within-session approach behavior and engagement: no notes, talking at higher volume, open posture. We expect that reducing subtle avoidance and safety behaviors in individuals with SAD, results in more effective exposure and improved corrective learning. Note. The dotted lines reflect hypotheses rather than established findings. Aim of this dissertation To summarize, SAD is one of the most common anxiety disorders with detrimental consequences when left untreated. It is characterized by avoidance behavior, which is the core target of exposure therapy. Although efficacious, the therapy leaves ample room for improvement (response rates vary between 45–55%). Considering the anxiolytic, avoid1
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