9 General introduction Imagine giving a speech in front of a large audience. While standing there looking at all those faces in front of you, your heart rate will likely rise, you may feel a bit warm and think “my cheeks may turn red” or “I hope they will like my talk.” These are normal reactions to a socially challenging event. However, for some people those feelings turn into a dominating fear, far more challenging and burdensome: Meet Rose. Rose is a 21-year-old bachelor student. Despite the fact that she has good grades and enjoys studying, she experiences problems in completing her bachelor. She did not pass her exam as she is terrified of giving a speech in front of a public. She worries she will tremble, blush and stutter. The thought of a complete blackout and people laughing at her may not reflect a realistic scenario, but feels very real and provokes anxiety. To prevent this scenario from happening, she avoids giving speeches entirely for a few years now. Her fear of public speaking started during secondary school where she had to give a plenary presentation. Although she prepared it very well, she saw some of her classmates laughing which she attributed to her behavior. The thought of doing something stupid made her nervous which in turn made it hard to find the right words. After this experience, she avoided future presentations and became increasingly scared of public performances. Recently, she started to avoid other social situations as well, such as parties, even of good friends. In these situations, she also noticed anxiety symptoms, feeling scared not knowing what to say and being disliked. Rose symptoms meet the diagnostic criteria of Social Anxiety Disorder. As her anxiety symptoms are more and more hindering here social and academic functioning, she seeks treatment to deal with her anxiety. Like Rose, many other individuals are suffering from Social Anxiety Disorder (SAD). This impairing mental disorder is characterized by persistent fear and avoidance of social and performance situations. SAD is one of the most common mental health disorders and it persists when untreated with high levels of impairment in social or occupational function (Aderka et al., 2012; Bruce et al., 2005; Kessler et al., 2005). It can be treated effectively with cognitive behavioral therapy. However, around 45-55% of the individuals with SAD do not profit sufficiently from treatment (Carpenter et al., 2018; Loerinc et al., 2015). Therefore, various (pharmacological) enhancement strategies have been examined to boost therapy outcomes for SAD (Guastella, Howard, Dadds, Mitchell, & Carson, 2009; Hofmann, Fang, & Gutner, 2014; Smits, Rosenfield, et al., 2013a). Based on pre-clinical research, the steroid hormone testosterone might specifically yield promise to enhance exposure therapy effects for those suffering from SAD. This hormone is an important regulator of social behavior both in males and females (Hermans & Van Honk, 2006). Relatively low levels of testosterone have been linked to social fear and avoidance 1
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