People with social anxiety disorder (SAD) have a pretty shoddy prognosis. Onset is early; about 50 percent of Americans diagnosed with SAD experience tension in social settings by age 11, and 80 percent show symptoms by age 20. Between 30 and 40 percent of people with social anxiety don't make any significant gains with treatment, either pharmaceutical or psychological.
The diagnosis often correlates with other psychological disorders, due in part to the way in which it blocks normal social-psychological development. “People with social anxiety are at high risk of developing depression and turning to drinking to cope,” says Heather Grigo, a psychiatrist formerly employed by the US Department of Veterans Affairs.
Research, however, has previously shown that at least one form of hormone therapy could help: When people with SAD took testosterone in a 2016 study, it helped them normalize eye contact, a key measure of social comfort and nonverbal synchronization. Eye contact is an important form of nonverbal, non-conscious social engagement and it hampers people with SAD, Terburg says. “Like other primates, [humans] often use eye contact in a ‘staring contest’ manner,” he says.
He notes that males in primate groups use stare-downs as both a lead up to violence and a way to prevent it. (If one looks away, the fight is avoided.) In more complex organisms, he says, eye contact can be used to emphasize something we want someone else to agree with. People with social anxiety, however, tend to rapidly break eye contact when confronted.
Testosterone is essential in the development of primary sexual characteristics (like the testis and prostate) and secondary ones (like body hair and muscle mass) during puberty. It also continues to be a driver of aggression and sexual arousal in adulthood and regulates mood and sexuality in women.
David Terburg, an assistant professor at Utrecht University in the Netherlands, has amassed a body of research assessing testosterone’s effects on mood and behavior, testing the hormone’s influence on everything from memory retention to playing poker.
“Testosterone serves to promote the motivation to be dominant over others in males as well as females,” Terburg says. But in more complex systems of social interaction, testosterone can boost any behavior that will help a person benefit, he adds. “In situations where cooperation gives more status, testosterone will for instance boost cooperation,” he says. “As such, testosterone affects behavior always in a context-specific manner.”
Brain scans have shown that testosterone is active across the organ, reaching regions involved in several aspects of mood and cognition. A meta-analysis of studies found it was particularly important to brain areas that respond to perceived social threats and emotional facial stimuli in others.
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So what does this mean for people with social anxiety disorder? In one study from Radboud University, of which Terburg was a coauthor, testosterone was shown to make people with social anxiety less likely to avoid the gaze of others. A group of 18 medication-free female participants with SAD looked at photos of people with angry, happy, or neutral facial expressions several times over the course of a few days. Before they did, they were given either 0.5 milligrams of testosterone or a placebo. Their gaze was recorded each time they looked at the pictures. Testosterone increased the likelihood of making ordinary eye contact with the photo when compared to the placebo. Terburg says it “normalized” their response, meaning the other women broke eye contact more readily.
The study also included a control group of women without SAD who went through the same process: taking testosterone or a placebo, followed by monitored exposure to photographs of facial expressions. This aspect of the research showed that the eye contact-maintaining benefits of testosterone were greater among those with SAD. Terburg says there is also research showing that testosterone has a similar effect on the threat perception of men with social anxiety, such as in business interactions and work dealings.
As a psychiatrist, Grigo says such findings give her hope. “We know that testosterone is a regulator of socio-emotional behavior … and that it can have implications for social anxiety disorder, but we don’t quite understand how it works yet.”
Terburg says he can’t yet recommend testosterone supplements as a therapy for social anxiety, but hopes that further research will lead to a more targeted use for it. “The idea,” he says, “is that testosterone makes one temporarily more prone to be dominant, which can boost the goals of behavioral treatment resulting in stronger and possibly longer lasting effects.”
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