Anabolic-androgenic steroids (AAS) are mainly used to treat androgen deficiency syndromes and, more recently, catabolic states such as AIDS-associated wasting. There is no evidence in the reviewed literature that AAS abuse or dependence develops from the therapeutic use of AAS. Conversely, 165 instances of AAS dependence have been reported among weightlifters and bodybuilders who, as part of their weight training regimens, chronically administered supraphysiologic doses, often including combinations of injected and oral AAS as well as other drugs of abuse. A new model is proposed in which both the "myoactive" and psychoactive effects of AAS contribute to the development of AAS dependence. The adverse consequences of AAS are reviewed, as well as their assessment by means of a history and physical, mental status examination, and laboratory testing. When patients with AAS use disorders are compared with patients with other substance use disorders, both similarities and differences become apparent and have implications for treatment.
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References and Recommended Reading
Conway AJ, Handelsman DJ, Lording DW, et al.: Use, misuse and abuse of androgens. The Endocrine Society of Australia consensus guidelines for androgen prescribing. Med J Aust 2000, 172:220–224.
Shahidi NT: A review of the chemistry, biological action, and clinical applications of anabolic-androgenic steroids. Clin Ther 2001, 23:1355–1390.
Basaria S, Wahlstrom JT, Dobs AS: Clinical review 138: Anabolic-androgenic steroid therapy in the treatment of chronic diseases. J Clin Endocrinol Metab 2001, 86:5108–5017.
Polsky B, Kotler D, Steinhart C: HIV-associated wasting in the HAART era: guidelines for assessment, diagnosis, and treatment. AIDS Patient Care STDS 2001, 15:411–423.
Langer CJ, Hoffman JP, Ottery FD: Clinical significance of weight loss in cancer patients: rationale for the use of anabolic agents in the treatment of cancer-related cachexia. Nutrition 2001, 17(suppl):S1-S20.
Morton R, Gleason O, Yates W: Psychiatric effects of anabolic steroids after burn injuries. Psychosomatics 2000, 41:66–68.
Hart DW, Wolf SE, Ramzy PI, et al.: Anabolic effects of oxandrolone after severe burn. Ann Surg 2001, 233:556–564.
Ferreira I, Brooks D, Lacasse Y, Goldstein R: Nutritional intervention in COPD: a systematic overview. Chest 2001, 119:353–363.
Morley JE: Testosterone replacement in older men and women. J Gend Specif Med 2001, 4:49–53.
Midgley SJ, Heather N, Davies JB: Dependence-producing potential of anabolic-androgenic steroids. Addict Res 1999, 7:539–550.
Brower KJ: Anabolic steroids: potential for physical and psychological dependence. In Anabolic Steroids in Sport and Exercise, edn 2. Edited by Yesalis CE. Champaign: Human Kinetics; 2000:280–304. A detailed and comprehensive review of the literature on AAS dependence, including evidence, course, predictors, and mechanisms.
Copeland J, Peters R, Dillon P: Anabolic-androgenic steroid use disorders among a sample of Australian competitive and recreational users. Drug Alcohol Depend 2000, 60:91–96.
Midgley SJ, Heather N, Best D, et al.: Risk behaviors for HIV and hepatitis infection among anabolic-androgenic steroid users. AIDS Care 2000, 12:163–170.
Gruber AJ, Pope HG Jr: Psychiatric and medical effects of anabolic-androgenic steroid use in women. Psychother Psychosom 2000, 69:19–26.
O’Sullivan AJ, Kennedy MC, Casey JH, et al.: Anabolic-androgenic steroids: medical assessment of present, past and potential users. Med J Aust 2000, 173:323–327.
Nilsson S, Baigi A, Marklund B, Fridlund B: Trends in the misuse of androgenic anabolic steroids among boys 16–17 years old in a primary health care area in Sweden. Scand J Prim Health Care 2001, 19:181–182.
Irving LM, Wall M, Neumark-Sztainer D, Story M: Steroid use among adolescents: findings from Project EAT. J Adolesc Health 2002, 30:243–252.
Wichstrom L, Pedersen W: Use of anabolic-androgenic steroids in adolescence: winning, looking good or being bad? J Stud Alcohol 2001, 62:5–13.
Kindlundh AM, Hagekull B, Isacson DG, Nyberg F: Adolescent use of anabolic-androgenic steroids and relations to self-reports of social, personality and health aspects. Eur J Public Health 2001, 11:322–328.
Johansson P, Lindqvist A, Nyberg F, Fahlke C: Anabolic androgenic steroids affects alcohol intake, defensive behaviors and brain opioid peptides in the rat. Pharmacol Biochem Behav 2000, 67:271–279.
Arvary D, Pope HG Jr: Anabolic-androgenic steroids as a gateway to opioid dependence. N Engl J Med 2000, 342:1532.
Thiblin I, Lindquist O, Rajs J: Cause and manner of death among users of anabolic androgenic steroids. J Forensic Sci 2000, 45:16–23. This article well documents the influence of psychiatric factors on premature mortality in AAS users. Suicide, homicide, reckless driving, and mixed drug abuse accounted for all 34 cases described.
Clark AS, Lindenfeld RC, Gibbons CH: Anabolic-androgenic steroids and brain reward. Pharmacol Biochem Behav 1996, 53:741–745.
Manoharan G, Campbell NP, O’Brien CJ: Syncopal episodes in a young amateur body builder. Br J Sports Med 2002, 36:67–68.
Long SF, Wilson MC, Davis WM: The effects of nandrolone decanoate on cocaine-induced kindling in male rats. Neuropharmacology 2000, 39:2442–2447.
Phillis BD, Irvine RJ, Kennedy JA: Combined cardiac effects of cocaine and the anabolic steroid, nandrolone, in the rat. Eur J Pharmacol 2000, 398:263–272.
Kutscher EC, Lund BC, Perry PJ: Anabolic steroids: a review for the clinician. Sports Med 2002, 32:285–296. An up to-date overview of the topic for practicing physicians.
Yesalis CE: Anabolic Steroids in Sport and Exercise, edn 2. Champaign: Human Kinetics; 2000. An excellent compilation of well-referenced chapters that cover the full spectrum of AAS-related topics including history, epidemiology, effects on performance, medical and psychiatric consequences, drug testing, prevention, assessment and treatment, and legal aspects. Another chapter is devoted to the use and effects of AAS in women.
Pope HG Jr, Brower KJ: Anabolic-androgenic steroid abuse. In Comprehensive Textbook of Psychiatry, edn 7. Edited by Sadock BJ, Sadock VA. Philadelphia: Lippincott Williams & Wilkins; 2000:1085–1095.
Parssinen M, Seppala T: Steroid use and long-term health risks in former athletes. Sports Med 2002, 32:83–94. Details information that is useful for informing and counseling potential and current users of AAS.
Torres-Calleja J, Gonzalez-Unzaga M, DeCelis-Carrillo R, et al.: Effect of androgenic anabolic steroids on sperm quality and serum hormone levels in adult male bodybuilders. Life Sci 2001, 68:1769–1774.
Babigian A, Silverman RT: Management of gynecomastia due to use of anabolic steroids in bodybuilders. Plast Reconstr Surg 2001, 107:240–242.
Zaugg M, Jamali NZ, Lucchinetti E, et al.: Anabolic-androgenic steroids induce apoptotic cell death in adult rat ventricular myocytes. J Cell Physiol 2001, 187:90–95.
Haupt HA: Upper extremity injuries associated with strength training. Clin Sports Med 2001, 20:481–490.
Parssinen M, Kujala U, Vartiainen E, et al.: Increased premature mortality of competitive powerlifters suspected to have used anabolic agents. Int J Sports Med 2000, 21:225–227.
Bahrke MS: Psychological effects of endogenous testosterone and anabolic-androgenic steroids. In Anabolic Steroids in Sport and Exercise, edn 2. Edited by Yesalis CE. Champaign: Human Kinetics; 2000:247–278.
Pope HG Jr, Kouri EM, Hudson JI: Effects of supraphysiologic doses of testosterone on mood and aggression in normal men: a randomized controlled trial. Arch Gen Psychiatry 2000, 57:133–140. One of few controlled studies investigating the psychiatric effects of high-dose AAS. The authors go on to estimate the prevalence of mania and hypomania among AAS users, and argue why their estimate is the lower limit.
Midgley SJ, Heather N, Davies JB: Levels of aggression among a group of anabolic-androgenic steroid users. Med Sci Law 2001, 41:309–314.
Rabkin JG, Wagner GJ, Rabkin R: A double-blind, placebocontrolled trial of testosterone therapy for HIV-positive men with hypogonadal symptoms. Arch Gen Psychiatry 2000, 57:141–147.
Yates WR: Testosterone in psychiatry: risks and benefits. Arch Gen Psychiatry 2000, 57:155–156.
Dean CE: Prasterone (DHEA) and mania. Ann Pharmacother 2000, 34:1419–1422.
Bahrke MS, Yesalis CE: Weight training: a potential confounding factor in examining the psychological and behavioral effects of anabolic-androgenic steroids. Sports Med 1994, 18:309–318.
Daly RC, Su TP, Schmidt PJ, et al.: Cerebrospinal fluid and behavioral changes after methyltestosterone administration: preliminary findings. Arch Gen Psychiatry 2001, 58:172–177. One of the first studies to make a correlation between AAS-induced neurochemical effects and behavioral changes in humans.
Aitken C, Delalande C, Stanton K: Pumping iron, risking infection? Exposure to hepatitis C, hepatitis B and HIV among anabolic-androgenic steroid injectors in Victoria, Australia. Drug Alcohol Depend 2002, 65:303–308.
Hallberg M, Johansson P, Kindlundh AM, Nyberg F: Anabolicandrogenic steroids affect the content of substance P and substance P(1-7) in the rat brain. Peptides 2000, 21:845–852.
Harrison RJ, Connor DF, Nowak C, et al.: Chronic anabolicandrogenic steroid treatment during adolescence increases anterior hypothalamic vasopressin and aggression in intact hamsters. Psychoneuroendocrinology 2000, 25:317–338.
Schlussman SD, Zhou Y, Johansson P, et al.: Effects of the androgenic anabolic steroid, nandrolone decanoate, on adrenocorticotropin hormone, corticosterone and proopiomelanocortin, corticotropin releasing factor (CRF) and CRF receptor1 mRNA levels in the hypothalamus, pituitary and amygdala of the rat. Neurosci Lett 2000, 284:190–194.
Brower KJ: Withdrawal from anabolic steroids. Curr Ther Endocrinol Metab 1997, 6:338–343.
Tennant F, Black DL, Voy RO: Anabolic steroid dependence with opioid-type features. N Engl J Med 1988, 319:578.
Negus SS, Pope HG Jr, Kanayama G, et al.: Lack of evidence for opioid tolerance or dependence in rhesus monkeys following high-dose anabolic-androgenic steroid administration. Psychoneuroendocrinology 2001, 26:789–796.
Johansson P, Hallberg M, Kindlundh A, Nyberg F: The effect on opioid peptides in the rat brain, after chronic treatment with the anabolic androgenic steroid, nandrolone decanoate. Brain Res Bull 2000, 51:413–418.
Harlan RE, Brown HE, Lynch CS, et al.: Androgenic-anabolic steroids blunt morphine-induced c-fos expression in the rat striatum: possible role of beta-endorphin. Brain Res 2000, 853:99–104.
Yesalis CE, Bahrke MS: Doping among adolescent athletes. Baillieres Best Pract Res Clin Endocrinol Metab 2000, 14:25–35.
Fingerhood MI, Sullivan JT, Testa M, Jasinski DR: Abuse liability of testosterone. J Psychopharmacol 1997, 11:59–63.
Brower KJ: Assessment and treatment of anabolic steroid abuse, dependence, and withdrawal. In Anabolic Steroids in Sport and Exercise, edn 2. Edited by Yesalis CE. Champaign: Human Kinetics; 2000:305–332. This book chapter contains the authors’ most comprehensive review of clinical assessment and treatment issues, and served as the guide to relevant sections of the current article.
Arnedo MT, Salvador A, Martinez-Sanchis S, Gonzalez-Bono E: Rewarding properties of testosterone in intact male mice: a pilot study. Pharmacol Biochem Behav 2000, 65:327–332.
Johnson LR, Wood RI: Oral testosterone self-administration in male hamsters. Neuroendocrinology 2001, 73:285–292.
Rosellini RA, Svare BB, Rhodes ME, Frye CA: The testosterone metabolite and neurosteroid 3alpha-androstanediol may mediate the effects of testosterone on conditioned place preference. Brain Res Brain Res Rev 2001, 37:162–171.
Frye CA, Park D, Tanaka M, et al.: The testosterone metabolite and neurosteroid 3alpha-androstanediol may mediate the effects of testosterone on conditioned place preference. Psychoneuroendocrinology 2001, 26:731–750.
Kindlundh AM, Lindblom J, Bergstrom L, et al.: The anabolicandrogenic steroid nandrolone decanoate affects the density of dopamine receptors in the male rat brain. Eur J Neurosci 2001, 13:291–296.
Johansson P, Ray A, Zhou Q, Huang W, et al.: Anabolic androgenic steroids increase beta-endorphin levels in the ventral tegmental area in the male rat brain. Neurosci Res 1997, 27:185–189.
Brower KJ, Blow FC, Hill EM: Risk factors for anabolicandrogenic steroid use in men. J Psychiatr Res 1994, 28:369–380.
Pertusi R, Dickerman RD, McConathy WJ: Evaluation of aminotransferase elevations in a bodybuilder using anabolic steroids: hepatitis or rhabdomyolysis? J Am Osteopath Assoc 2001, 101:391–394.
Braseth NR, Allison EJ Jr, Gough JE: Exertional rhabdomyolysis in a body builder abusing anabolic androgenic steroids. Eur J Emerg Med 2001, 8:155–157.
Olivardia R, Pope HG Jr, Hudson JI: Muscle dysmorphia in male weightlifters: a case-control study. Am J Psychiatry 2000, 157:1291–1296. This article from the authors who coined the term, "muscle dysmorphia," examines a variant of body dysmorphic disorder characterized by preoccupation with the perception that one’s musculature is too small. Previously labeled "reverse anorexia nervosa" by the same investigators, muscle dysmorphia may possibly underlie many cases of Stage I dependence on AAS.
Phillips KA, Albertini RS, Rasmussen SA: A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry 2002, 59:381–388.
Brower KJ, Rootenberg JH: Counseling for substance abuse problems. In Counseling in Sports Medicine. Edited by Ray R, Wiese-Bjornstal D. Champaign: Human Kinetics; 1999:179–204.
Ahrendt DM: Ergogenic aids: counseling the athlete. Am Fam Physician 2001, 63:913–922.
Kanayama G, Gruber AJ, Pope HG Jr, et al.: Over-the-counter drug use in gymnasiums: an underrecognized substance abuse problem? Psychother Psychosom 2001, 70:137–140.
Stephens MB, Olsen C: Ergogenic supplements and health risk behaviors. J Fam Pract 2001, 50:696–699.
Brower KJ, Blow FC, Beresford TP, Fuelling C: Anabolic-androgenic steroid dependence. J Clin Psychiatry 1989, 50:31–33.
Brower KJ, Eliopulos GA, Blow FC, et al.: Evidence for physical and psychological dependence on anabolic androgenic steroids in eight weight lifters. Am J Psychiatry 1990, 147:510–512.
Hays LR, Littleton S, Stillner V: Anabolic steroid dependence. Am J Psychiatry 1990, 147:122.
Copeland J, Peters R, Dillon P: Anabolic-androgenic steroid dependence in a woman. Aust N Z J Psychiatry 1998, 32:589.
Brower KJ, Blow FC, Young JP, Hill EM: Symptoms and correlates of anabolic-androgenic steroid dependence. Br J Addict 1991, 86:759–768.
Gridley DW, Hanrahan SJ: Anabolic-androgenic steroid use among male gymnasium participants: dependence, knowledge, and motives. Sport Health 1994, 12:11–14.
Pope HG Jr, Katz DL: Psychiatric and medical effects of anabolic-androgenic steroid use: a controlled study of 160 athletes. Arch Gen Psychiatry 1994, 51:375–382.
Malone DA Jr, Dimeff RJ, Lombardo JA, Sample RH: Psychiatric effects and psychoactive substance use in anabolic-androgenic steroid users. Clin J Sport Med 1995, 5:25–31.
Clancy GP, Yates WR: Anabolic steroid use among substance abusers in treatment. J Clin Psychiatry 1992, 53:97–100.
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Brower, K.J. Anabolic steroid abuse and dependence. Curr Psychiatry Rep 4, 377–387 (2002). https://doi.org/10.1007/s11920-002-0086-6