54 Chapter 3 tween pre-treatment testosterone reactivity, approach behavior and exposure outcome, respectively, may guide the development of targeted augmentation strategies. Critical to this type of research is complementing the correlational approach with experimental research. In the parent trial (Davis et al., 2017), we attempted to engage testosterone reactivity using a simple behavioral strategy (i.e. power posing), but failed. Other work from our group suggests that testosterone administration to patients with SAD alleviates social avoidance and promotes prosocial behavior (Enter, Spinhoven, et al., 2016), as well as reduces automatic threat bias to angry faces (Enter, Terburg, et al., 2016; van Peer et al., 2017). Currently, our group is conducting a study testing whether administration of 0.5 mg of testosterone to females with SAD prior to an exposure session can improve exposure success by reducing avoidance behavior. The finding that exposure-anticipatory testosterone levels predicted reductions in social anxiety symptoms, but not in fear experienced during the exposures, is in line with previous work showing that anticipatory physiological anxiety responses to a speech exposure were associated with social anxiety symptoms but not to the in-session fear levels (Cornwell, Johnson, Berardi, & Grillon, 2006). It also supports theoretical models that frame SAD as a problem of threat anticipation in specific (Clark & Wells, 1995; Heimberg & Rapee, 1997). We extend these notions by providing an objective marker of testosterone reactivity in the anticipation of threat. Together these finding may also imply that, during exposure, the social motivational properties of testosterone are more relevant compared to its anxiolytic properties (e.g. promoting direct approach behavior rather than reducing fear). This interpretation is in line with the findings of a vast amount of testosterone administration studies (Enter, Spinhoven, et al., 2016; Enter, Terburg, et al., 2016; van Peer et al., 2017) showing that testosterone directly influenced approach behavior and reduced threat avoidance in patients with SAD. In turn, approach behavior during exposure treatment may be a more important predictor of exposure efficacy, whereas fear reductions during the exposure are not necessary for good exposure outcome. For example, studies testing predictions from Emotional Process Theory (Foa & Kozak, 1986; Foa, Huppert, & Cahill, 2005) have found no relation between reductions in subjective reported distress during an exposure session and exposure outcomes in different anxiety disorders (Baker et al., 2010; Hendriks, Kleine, Broekman, Hendriks, & Minnen, 2018; Kozak, Foa, & Steketee, 1988; Meuret, Seidel, Rosenfield, Hofmann, & Rosenfield, 2012; Van Minnen & Hagenaars, 2002). Thus, fear reductions during exposure sessions do not seem to be a reliable predictor of exposure outcomes (Craske et al., 2008, 2014). There are some limitations that deserve note. First, this study reports on correlations and therefore we cannot make inferences with respect to causality. Second, al-
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