91 Social Avoidance and Testosterone Enhanced Exposure Efficacy in Women with Social Anxiety Disorder Introduction Social anxiety disorder (SAD) is the most common of all anxiety disorders with a lifetime prevalence of 13% (Bandelow & Michaelis, 2015; Bruce et al., 2005; Hendriks et al., 2016). Social avoidance is a major factor that prevents fear to extinguish in individuals with SAD (Arnaudova et al., 2017) and is therefore a main target in exposure therapy (Clark & Wells, 1995). Based on the well-established social approach-promoting and avoidance-reducing effects of testosterone (Enter, Spinhoven, et al., 2016; Hermans & Van Honk, 2006; Maner et al., 2008), researchers have started to study the use of testosterone interventions to boost the effects of exposure therapy in SAD (Hutschemaekers et al., 2020; Hutschemaekers, de Kleine, Hendriks, Kampman, & Roelofs, 2021). Although initial findings are promising, it remains unclear whether social avoidance tendencies in individuals with SAD influence the efficacy of testosterone-enhanced exposure interventions. Identification of social avoidance tendencies as a behavioral marker for the efficacy of these interventions is relevant for the optimization of (personalized) treatments. In the present study, we tested social avoidance tendencies before and after an exposure-based treatment intervention in SAD. In half of the participants the exposure was augmented with testosterone, offering the unique opportunity to explore whether pretreatment social avoidance tendencies would moderate testosterone augmentation effects. Cognitive models of SAD imply that attentional processes and social avoidance behaviors play an important role in the etiology and maintenance of SAD (Clark & Wells, 1995). In addition to more overt avoidance behaviors such as avoiding social situations or eye contact, individuals with SAD also show more implicit automatic avoidance (biased action tendencies). Those automatic social avoidance tendencies can be measured using Approach Avoidance Tasks (AAT: Rinck & Becker, 2007), which instruct participants to respond to visual stimuli by pushing or pulling a joystick. Socially anxious individuals typically show automatic avoidance of social stimuli - i.e., stronger avoidance tendencies compared to approach tendencies toward angry, but also happy faces (Heuer et al., 2007; Loijen et al., 2020; Roelofs, Putman, et al., 2010; Roelofs, van Peer, et al., 2009a) and even neutral faces, compared to non-social stimuli and healthy controls (Kuckertz et al., 2017). Cross-sectional studies show that these avoidance tendencies toward social threat relate to higher SAD symptom levels (Enter, Spinhoven, et al., 2016), and to the onset and chronic course of social anxiety symptoms (Struijs et al., 2018). Although not all evidence points to such predictive value of symptom development (Kampmann, Emmelkamp, & Morina, 2018b; Struijs et al., 2017), the observation of relative avoidance tendencies to threathening cues on AAT-tasks is robust in individuals with SAD (for review see Loijen et al., 2020). 5
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