Abstract
The Hypothalamus-Pituitary-Gonadal (HPG)-axis, and testosterone in particular, play an important role in social motivational behavior. Socially avoidant behavior, characteristic of social anxiety disorder (SAD), has been linked to low endogenous testosterone levels, and can be alleviated by testosterone administration in SAD. Although these beneficial effects of testosterone may translate to exposure therapy, it remains unknown whether testosterone increases prior to exposure improve therapy outcomes. In this proof-of-principle study, we tested whether pre-exposure (reactive and baseline) endogenous testosterone levels were predictive of exposure outcome in SAD. Seventy-three participants (52 females) with a principal SAD diagnosis performed four speech exposures: three during one standardized exposure therapy session and one at post-assessment one week later. Subjective fear levels were assessed before and after each speech exposure and social anxiety symptoms were assessed at pre- and post-treatment. Pre-treatment testosterone levels were assessed before (baseline) and in response to a pre-exposure instruction session (reactive). Pre-treatment testosterone levels were not related to fear levels during exposure therapy, but predicted pre- to post-treatment reductions in social anxiety symptom severity. Specifically, low baseline and high reactive pre-treatment testosterone levels were associated with larger reductions in social anxiety symptom severity. These findings support the role of HPG-axis in social fear reduction. Specifically, our finding that high reactive testosterone as well as low baseline testosterone predicted exposure outcome in SAD, suggests that good reactivity of the HPG-axis is a promising marker for the symptom-reducing effects of exposure therapy.
Highlights
Social anxiety disorder (SAD) is one of the most common anxiety disorders, with a lifetime prevalence rate of 13 % (Bandelow and Michaelis, 2015)
In order to test this further, we checked whether effects for reactive testosterone would disappear without controlling for the initial testosterone levels and found that this was the case (Estimate = −2.79(2.12), F(1,66) = 1.73, p = 0.19). This finding suggests that it is the relative and not the absolute reactivity of the HPAaxis system that positively relates to treatment outcome. In this proof-of-concept study, we demonstrated that reactivity of the HPG-axis constitutes a promising biomarker of response to exposure therapy in social anxiety disorder
We showed that those patients who displayed relatively high pre-exposure testosterone reactivity showed better outcomes following a standardized session of exposure therapy
Summary
Social anxiety disorder (SAD) is one of the most common anxiety disorders, with a lifetime prevalence rate of 13 % (Bandelow and Michaelis, 2015). The social challenge hypothesis (Wingfield et al, 1990), originally based on testosterone and aggression associations in monogamous birds (Wingfield et al, 2001) and later established in primates (Muller and Wrangham, 2004) and humans (Neave and Wolfson, 2003; Bateup et al, 2002) is the most predominant theory of testosterone reactivity It states that testosterone levels rise in preparation to a challenging encounter in which social status may be threatened, thereby initiating approach motivation and reducing fear (Archer, 2006; Bos et al, 2012).
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