39 Neuroendocrinological aspects of social anxiety and aggression related disorders be noted that there is still much unclear about the working mechanisms of testosterone and of pharmacological add-ons in exposure therapy. Testosterone could have beneficial effects on dopamine transmission and glucocorticoid mechanisms, but its effects on the GABA system might, apart from being anxiolytic, also potentially interfere with extinction learning, which should be elucidated in future research (Singewald, Schmuckermair, Whittle, Holmes, & Ressler, 2015). The anxiolytic effects of oxytocin administration have prompted research on its suitability for SAD treatment (Kirsch, 2015). It should be noted that there is still controversy around the effects of intranasal oxytocin, and that there is likely a publication bias (Lane, Luminet, Nave, & Mikolajczak, 2016; Leng & Ludwig, 2016). Intranasal oxytocin administration improved self-evaluation of performance during exposure therapy sessions, and thus was able to counteract the typical exaggerated negative mental representations after social performance in SAD; however, no long-term effects could be established, which warrants further research (Guastella, Howard, Dadds, Mitchell, & Carson, 2009, n = 25). In addition, intranasal oxytocin administration seemed to reduce “physical discomfort” in patients with SAD during a Trier Social Stress Test (Heinrichs et al., 2006). The ability of oxytocin to make social interactions more rewarding might be beneficial for certain subtypes of SAD patients who lack the motivation to engage in social interaction (Van Honk, Bos, Terburg, Heany, & Stein, 2015). Finally, an initial study with cortisol administration to promote extinction learning during exposure sessions in 40 patients with SAD led to reduced heart rate and self-reported anxiety during the sessions (Soravia et al., 2006). However, long-term effects of cortisol on persistent avoidance tendencies in SAD have not been investigated. Another interesting approach would be to explore whether the automatic avoidance tendencies in SAD and psychopathy could be diminished by approach–avoidance training on the AAT. Research on this topic across various disciplines has shown positive results (Eberl, Wiers, Becker, Lindenmeyer, & Rinck, 2011; for a review see Woud & Becker, 2014). Two studies featuring socially anxious participants showed that, after being required to approach positive social stimuli on the AAT (e.g., smiling faces), they subsequently showed more approach behavior during social interactions, elicited more positive reactions by their interaction partners (Taylor & Amir, 2012, n = 47, large effect sizes), and reported better mood and less anxiety after a social challenge (Rinck et al., 2013, n = 40, medium to large effect sizes). A study featuring approach–avoidance training in alcoholism (20 alcohol dependents versus 17 healthy controls) showed that amygdala activity reduced in response to alcohol-related stimuli (Wiers et al., 2014). This finding suggests that the affective evaluation of the stimulus was altered by the training; however, the mechanisms behind approach–avoidance training are not clear to date. It is 2
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