Psychosomatics 46:285-290, August 2005
© 2005 The Academy of Psychosomatic Medicine
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Review
Psychiatric Complications of Anabolic Steroid Abuse
Ryan C.W. Hall, M.D., Richard C.W. Hall, M.D., and Marcia J. Chapman
Received March 9, 2004; revisions received June 29 and Aug. 19, 2004; accepted Sept. 27, 2004. From the Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, Baltimore; and the Department of Psychiatry, University of Florida, Gainesville. Address correspondence and reprint requests to Richard C.W. Hall, M.D., 100 East Sybelia Ave., Suite 210, Maitland, FL 32751.
ABSTRACT
TOP
ABSTRACT
INTRODUCTION
Psychiatric Syndromes and the...
Psychiatric Pathology of AAS...
Investigative Findings and...
Animal Studies of Neurochemical...
Characteristics of AAS Abusers
AAS Dependence
Usage Patterns, Including...
Polysubstance Abuse and AAS
Complications and Side Effects...
Summary
REFERENCES
The authors review the literature from human and animal studies on the neurochemical and pathological psychiatric effects of supraphysiological doses of anabolic-androgenic steroids (AAS) and discuss the AAS use and abuse patterns, additional drug use patterns, and personality and behavioral characteristics of AAS abusers.
INTRODUCTION
TOP
ABSTRACT
INTRODUCTION
Psychiatric Syndromes and the...
Psychiatric Pathology of AAS...
Investigative Findings and...
Animal Studies of Neurochemical...
Characteristics of AAS Abusers
AAS Dependence
Usage Patterns, Including...
Polysubstance Abuse and AAS
Complications and Side Effects...
Summary
REFERENCES
In 1889, physiologist Charles E. Brown-Sequard made the first public claims about the effects of anabolic-androgenic steroids (AAS). He announced that he had extracted a substance from dog and guinea pig testicles, which, when injected, had increased his strength, improved his intellect, provided relief from constipation, and increased the arc of his urine.1 Since then, an underground population of athletes, coaches, and recreational users has developed complicated AAS regimens to enhance their athletic performance and, in so doing, have unleashed a myriad of psychiatric complications such as addiction, depression, rage, and psychosis on themselves and the public at large.
Psychiatric Syndromes and the Issue of Violence
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ABSTRACT
INTRODUCTION
Psychiatric Syndromes and the...
Psychiatric Pathology of AAS...
Investigative Findings and...
Animal Studies of Neurochemical...
Characteristics of AAS Abusers
AAS Dependence
Usage Patterns, Including...
Polysubstance Abuse and AAS
Complications and Side Effects...
Summary
REFERENCES
Historically, low doses of AAS have been used to treat depression and melancholia, either as primary agents or as adjuncts to standard treatment.1 Misuse of these agents has added a new term to the drug lexicon, "roids rage."2 Studies comparing steroid abusers with non-steroid-using athletes have shown steroid abusers to have a higher incidence and prevalence of psychiatric symptoms.3–5 The most prominent psychiatric features associated with AAS abuse are manic-like presentations defined by irritability, aggressiveness, euphoria, grandiose beliefs, hyperactivity, and reckless or dangerous behavior. Other psychiatric presentations include the development of acute psychoses, exacerbation of tics and depression, and the development of acute confusional/delirious states.2,6–8 Extreme variability of symptom presentation exists because of differences in the dose consumed, agent used, duration of use, personality type of the abuser, and current or previous use of other recreational drugs.2,9–11
Studies in which steroid abusers have been used as their own comparison subjects, in the attempt to eliminate the variable of personality disorder, have shown differences in the degree of hostility, aggression, and severity of manic-like symptoms during periods of use and nonuse.4–8 Pope and Katz,6,12 in their reviews of the literature, reported that studies in which steroid use is quantified and categorized on the basis of total weekly dosing have found that psychiatric symptoms become more common and severe as the dose increases. Studies that have used Pope and Katz’s categories of medium steroid use (between 300 and 1000 mg/week of any AAS) and high use (more than 1000 mg/week of any AAS)6 have demonstrated that 23% of subjects using these doses of steroids met the DSM-III-R criteria for a major mood syndrome (mania, hypomania, and major depression) and that 3.4%–12% developed psychotic symptoms.6,8
It is hard to determine whether the unexplained violent rages that occur with AAS abuse might be better understood as part of a paranoid psychotic state or as instances of unprovoked rage unassociated with other psychiatric findings (i.e., as a psychiatric or cognitive disorder or as an impulse control problem). Psychotic symptoms associated with the use of anabolic steroids generally occur among individuals consuming more than 1,000 mg of testosterone weekly.6 Classic presentations include grandiose and paranoid delusional states that often occur in the context of a frank psychotic or manic episode. The symptoms usually resolve within a few weeks after the individual has discontinued steroid use, although they may persist for as long as 1 month, even if adequately treated with antipsychotic medication. Reactions tend to be more agitated, violent, and coordinated than the agitation that occurs as an adverse reaction to corticosteroids, which can also produce idiosyncratic manic and psychotic symptoms.9,10
Psychiatric Pathology of AAS Abuse
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ABSTRACT
INTRODUCTION
Psychiatric Syndromes and the...
Psychiatric Pathology of AAS...
Investigative Findings and...
Animal Studies of Neurochemical...
Characteristics of AAS Abusers
AAS Dependence
Usage Patterns, Including...
Polysubstance Abuse and AAS
Complications and Side Effects...
Summary
REFERENCES
Pope and Katz13 interviewed 41 bodybuilders and football players who had used AAS. Applying DSM-III-R criteria, they found that 22% displayed a full affective syndrome and 12% developed psychotic symptoms in association with their steroid use, suggesting that major psychiatric symptoms are an adverse effect of the misuse of these drugs. In a subsequent study, Pope and Katz6 used the Structured Clinical Interview for DSM-III-R to compare 88 athletes who used steroids with 68 nonusers. They found that 23% of the AAS users reported major mood syndromes, including mania, hypomania, and major depression, in association with their steroid use. The steroid abusers experienced mood disorders significantly more frequently when using AAS than when they were steroid free.
Su et al.14 administered 40 mg/day and 240 mg/day of methyltestosterone in a 2-week, double-blind, fixed-order, placebo-controlled, crossover inpatient study of healthy male volunteers. The 20 men in the study were otherwise medication free and were free of any medical or psychiatric illness. The researchers noted higher symptom scores during high-dose methyltestosterone administration, compared with baseline. The changes were either mood-elevating effects, such as euphoria ("steroid rush"), increased energy, and increased sexual arousal and drive, or mood-dysphoric effects, such as irritability, mood swings, increasingly violent feelings, and increased hostility. The researchers also noted cognitive impairment, including distractibility, forgetfulness, and confusion, in subjects taking the higher dose of steroids. Baseline characteristics, including family history and history of previous drug abuse, did not predict the development or the nature of psychiatric symptoms.
In a randomized, placebo-controlled crossover trial, Pope et al.15 administered testosterone cypionate for 6 weeks in doses ranging to 600 mg/week, followed by 6 weeks of no treatment and then placebo for 6 weeks to 56 men ages 20–50 years. A variety of outcome measures were used to assess mania, aggression, and depression. The results showed that testosterone significantly increased mania, elevating scores on multiple instruments; that the drug was liked and sought after; and that aggression increased. The investigators noted that the response to the drug, however, was highly variable. Eighty-four percent of the subjects exhibited minimal to no psychiatric effects, 12% became mildly hypomanic, and 4% became markedly hypomanic. The investigators were not able to differentiate the manic responders from the nonresponders on the basis of demographic characteristics or baseline psychological, laboratory, or physiological measures.
Yates et al.16 examined the psychosocial effects of low-dose steroids in men as a possible form of birth control and found minimal risk of adverse psychosexual effects in the majority of men receiving less than 500 mg/week of testosterone cypionate. At a dose of 500 mg/week, however, a minority of subjects began to experience significant adverse psychological effects, such as dysphoria, irritability, and hypomania.
Hall et al.9–11 and Wyszynski and Wyszynski17 suggested that the adverse effects of testosterone may be similar to those of prednisone and other corticosteroids. Studies by Hall et al.9–11 and the Boston Collaborative Program18 have shown that adverse psychiatric effects increase with increasing dosages of corticosteroids, a finding similar to that of Pope et al.15 for AAS.
Investigative Findings and Anecdotal Reports on Aggression
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ABSTRACT
INTRODUCTION
Psychiatric Syndromes and the...
Psychiatric Pathology of AAS...
Investigative Findings and...
Animal Studies of Neurochemical...
Characteristics of AAS Abusers
AAS Dependence
Usage Patterns, Including...
Polysubstance Abuse and AAS
Complications and Side Effects...
Summary
REFERENCES
Choi and Pope19 noted that increased aggression was associated with the illicit use of AAS by athletes and that the wives and girlfriends of these athletes often become the victims of physical abuse. In a controlled study, they interviewed 23 AAS-using strength athletes and 14 non-AAS using athletes. The AAS users reported significantly more fights, verbal aggression, and violence toward their significant other and had significantly higher scores on two of three indicators of violence during periods when they were taking AAS, compared to periods when they were not taking AAS. When they were not taking AAS, the AAS users were not distinguishable from nonusers on the aggression scales.
Bond et al.20 investigated the effects of AAS on attentional bias to aggressive cues in 46 male strength athletes. The researchers found no difference in attentional bias between AAS users and nonusers but noted that AAS users who were currently taking AAS had subtle mood changes and slowed cognitive performance, compared to users who were not actively taking AAS.
Anecdotal case reports published by Pope and Katz21 highlighted both the psychological and physical dangers of abusing AAS. They described three men with benign premorbid psychiatric histories and no evidence of antisocial personality disorder or violence who impulsively committed violent crimes, including murder, while taking AAS. Pope and Katz suggested that the steroids played a necessary, if not primary, role in the etiology of these violent behaviors. They concluded that steroid-induced violence poses a little-recognized public health threat.
We have seen six cases of AAS-induced criminal behavior—three homicides and three violent assaults. Two of the three lethal assaults were senseless, nonpremeditated, and occurred during a psychotic episode. In three of the six cases, there was evidence of significant antisocial behavior, violence, or criminal behavior before the steroid-related episode. The AAS psychosis in each case was remarkably similar to that in the others, as well as to AAS psychoses described in the literature, and included stereotypic qualities of irritability, aggressiveness, and grandiosity. In each case, an irrational thought of the patient or a minor deed of an unknown individual prompted a violent attack. The mental status of all six perpetrators cleared within weeks to 2 months, and they had specific memory of the act and of their delusional thinking at the time the act was committed.
Other studies have tried to measure aggression and psychiatric disturbances in AAS abusers by looking at how they died. An investigational study of 34 deceased male AAS abusers found that nine were the victims of homicide, 11 had committed suicide, and 12 died of accidental causes.22 The authors concluded that AAS abusers are at a higher risk of dying violently because of impulsive/aggressive behavior and/or depression.
Animal Studies of Neurochemical Changes
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ABSTRACT
INTRODUCTION
Psychiatric Syndromes and the...
Psychiatric Pathology of AAS...
Investigative Findings and...
Animal Studies of Neurochemical...
Characteristics of AAS Abusers
AAS Dependence
Usage Patterns, Including...
Polysubstance Abuse and AAS
Complications and Side Effects...
Summary
REFERENCES
Studies examining neurochemical changes in sexually maturing/adolescent animal brains exposed to supraphysiological doses of AAS have found complex changes in multiple neurochemical communication pathways long associated with depression, anger, and sexual behavior in humans. Studies of neurohormonal receptors in adolescent rodent brains found that AAS exposure was associated with a decrease in the inhibitory receptors for -aminobutyric acid in the medial amygdala, medial preoptic area, and ventromedial nucleus of the hypothalamus.23,24 Studies in nandrolone-treated guinea pigs showed a significantly greater density of c-Fos and Fos-related antigen-positive neurons in the central nucleus of the amygdala and of Fos-related antigen-positive neurons in the frontal cortex, the shell of the nucleus accumbens, and the supraoptic nucleus.25 These areas have been shown to correlate with human brain areas that are involved in stress, behavioral, and reward responses. Animal studies have also shown that AAS have effects on serotonin receptors, specifically a significant down-regulation of 5-HT1B receptor density in the hippocampus CA1 region and the medial globus pallidus and a significant up-regulation of 5-HT2 receptor density in the nucleus accumbens shell.26 Alterations in receptor density were also observed in the lateral globus pallidus, ventromedial hypothalamus, amygdala, and intermediate layers of various cortical regions. In studies of the anterior hypothalamic-arginine vasopressin (AH-AVP) neural system in animals treated with anabolic steroids, the treated animals had biting tendencies and less time to provocation to bite, compared with control animals; these effects could be reduced or reversed by using AH-AVP antagonists.27
Characteristics of AAS Abusers
TOP
ABSTRACT
INTRODUCTION
Psychiatric Syndromes and the...
Psychiatric Pathology of AAS...
Investigative Findings and...
Animal Studies of Neurochemical...
Characteristics of AAS Abusers
AAS Dependence
Usage Patterns, Including...
Polysubstance Abuse and AAS
Complications and Side Effects...
Summary
REFERENCES
