A Brief Overview and Prefatory Comments
This article briefly introduces and comments on issues relevant to an appreciation of the psychological effects of anabolic/androgenic steroids (AAS). Few scientific references are included, although a more detailed discussion is planned, so you don’t get off that easily. This article should not be seen as suggesting that AAS do not potentially have harmful psychological effects. Indeed, there are surely individuals for whom such effects are both likely and dangerous. However, I do assert that the relationship is more complex than is often suggested.
[Note: Male specific references may appear at points in this article. This reflects the fact that steroid use has largely been studied in males and viewed as a male phenomenon (although this is changing, e.g., Gruber & Pope, 2000; Fish, 1998)].
Strange Bedfellows: The Media and Research
A number of negative psychological effects, including “’roid rage” (unprovoked aggression), have been observed in some users of AAS. Aggression, in particular, has frequently been highlighted (e.g., Fultz, 1991; Taber, 1999). (Note, however, that within many athletic endeavors, not all of these effects are unanimously viewed negatively.) These effects are often cited as justification for the demonization of AAS use and, by extension, the intention to ban currently legal testosterone and nortestosterone precursors. Even though findings of negative psychological effects of AAS are inconsistent, they draw a great deal of attention from the media, government, and public. Perhaps there is justifiable concern with the image of a 250-pound madman on a rampage for no apparent reason. Certainly this possibility is more disconcerting than the possibility that AAS users might lose their hair or suffer reductions in endogenous androgens. This often makes the psychological effects of AAS the central focus of “scare tactic” approaches, which garner attention because, intrinsically, people are primarily concerned with danger to themselves, and then the danger to users. Scare tactics aimed at users tend to focus on those effects that “hit close to home” such as testicular shrinkage for young male users. It is not surprising that, in a society frightened by increasing instances of apparently random and senseless acts of violence, the image of an aggressive AAS user engenders fear regarding the epidemic use of AAS and tends to increase support for expanding bans to other currently legal substances.
- Most research indicates that the above does not describe the “typical” AAS user. Still it is a headline that is frequently used to draw the attention of the public by researchers who should be more critical and careful when they present conclusions. Perhaps their concerns regarding the AAS “epidemic” lead them to believe they have good reason and justification to focus on these issues. Comments regarding the probability or subtlety of such effects are often relegated to discussion sections of manuscripts, as opposed to the abstract, which is often the only section read by casual consumers. Scientists might believe that the public is incapable of handling the details. Whether true or not, that does not justify presenting partial and potentially misleading information. Sometimes the dearth of details is the cost paid to present results in bits small enough to be presented before the viewer’s attention wavers. Of course, it may also be that an idea is being sold, hence packaged to catch the public’s eye.
- Often the impetus for such presentations emerges from tragic tales of steroid use and negative outcomes (e.g., Pasquarelli, 1992; Purdy, 1991). There is, however, a lack of interest in stories of AAS users with no marked or clinically relevant personality change or psychopathology, apparently because AAS use, in and of itself, is viewed negatively by non-users (Van Raalte, Cusimano, Brewer, & Matheson, 1993). Nonetheless, such cases could be helpful in understanding the negative psychological effects seen in other AAS users. Examining cases in which effects do not occur can also be very instructive in understanding the processes involved. But just like tales of sober driving and safe sex, such tales do not make headlines. There seems a strong juxtaposition between science and entertainment – the research on the psychological effects of AAS use is rarely presented to the public in a thoughtful or critical manner.
Although the amount of research on AAS use and psychological factors has grown over the years, it has too often been ignored, misrepresented, or misused to create one-line summaries. Even accomplished researchers fall prey to such lapses, ignoring much of what is known about psychological processes in substance use and its outcomes. Presenting research to the public is never easy, however, and I should note that, as a researcher, there a few things scarier than seeing a study that took years to plan, run, analyze, and publish summarized in 30 seconds on the evening news. Believe me, I always end up mumbling, “But, that’s not what I said!”
Methods of Research on the Psychological Effects of AAS
- The majority of the research on AAS’ psychological effects has described the psychological characteristics of users, compared them to non-users, and sometimes compared them to prior users who are not currently using. Some studies use non-using resistance trainers (generic term for people who train with weights) to control for training’s effects on psychological factors. Of course, such a broad classification is controversial – weight lifters, power lifters, and body builders are likely different in ways that relate to AAS use patterns and outcomes. There are also a number of potential differences between users and nonusers that, while not directly related to AAS use, potentially influence behavior, yet are not accounted for in designs using pre-existing groups.
Experimental designs control for such factors by randomly assigning non-using participants to receive AAS or placebo. They frequently also prescribe a training regimen. Thus differences intrinsic to users and non-users, as well as characteristics such as endogenous T levels, are evenly represented across the groups. However, as will be noted below, the cost of this control is typically a reduced ability to mirror real world patterns of AAS use.
Overview: The Psychological Characteristics of AAS Users
- Research generally suggests that AAS users are more hostile, aggressive, irritable, manic, and depressed than former users or non-users. They are often reported as more likely to abuse other drugs, as well. Empirical studies (described above, typically self-reported “observations”) and anecdotal reports (case studies and gym lore, basically self-reported) agree that some AAS users show increased emotional instability, impulsivity, and aggression. However, to interpret these reports means considering the prevalence of these characteristics. In what percent of users studied do clinically relevant levels of psychopathology occur? Do users and nonusers differ in this prevalence? Do these levels differ depending on where in a cycle the user is assessed? To get beyond generalizations, 30-second sound bites, and brief headlines about the psychological effects of AAS, these details are crucial. And these are only a few of the issues that need to be addressed to understand the relationship between negative psychological outcomes and AAS use reported in empirical studies.
- In spite of the apparent consistency of these reports, there is really little evidence of a direct link between AAS and negative psychological effects. Certainly, some AAS users show these effects, but there is no inevitable one-to-one relationship. And this leads to more questions. What individual characteristics predict the increased probability of psychopathology in some AAS users? Do certain individual characteristics predict the probabilities of use and subsequent aberrant behavior? What psychological processes predict such behavior in AAS users? How might pre-existing characteristics and current psychological processes interact to influence behavior in some AAS users?
Dose and the Psychological Effects of AAS
- Two major differences between studies of real world AAS users and experiments that administer AAS are the doses and variety of drugs involved. The problem for experimental investigations is obvious – it is clearly impossible, when bound by protocols for the ethical treatment of human participants, to administer experimental volunteers the large array of drugs and astronomical doses used by some AAS users in the real world. As a result, the high-end dose used in experiments is 600 mg. weekly (Bhasin et al., 1996; Pope, Kouri, & Hudson, 2000; Tricker et al., 1996). However even at that dose, the results of the cited studies are not consistent.
AAS exhibit a dose-response relationship. In general, higher doses mean greater effects both for anabolic response (Forbes, 1985) and psychological effects (Pope & Katz, 1994), as well as for desirable and undesirable effects. Although mood disorder symptoms appeared to increase as self-reported dose increased, even at the highest doses reported in empirical studies (e.g., > 1000 mg. per week in Pope & Katz, 1994) there is a wide variability in psychological symptoms – < 50% of the users exhibited disordered mood. In addition, in an AAS administration study, Su et al. (1993), noted that “Symptomatic differences did not, however, reflect differences in plasma anabolic steroid levels (p. 2763).” Dose is only one factor in the equation and drug administration, more than injection or ingestion, is also a behavioral event.
Pre-existing characteristics and current psychological factors might influence not only decisions to use, and at high doses, but subsequent behavior and mood. Differences in dose cannot fully explain the complex psychological effects/AAS relationship. Selected dose may be confounded with several predisposing variables. Hence, another set of questions. Do certain individual characteristics presage AAS use, especially in supra-physiological doses, and the presence of psychological problems while using? For instance, do differences between empirical and experimental findings suggest that the individual characteristics that predate AAS use and expectations of drug effects must be accounted for? Such characteristics motivate the use of AAS or other performance enhancing substances, underlie the choice of substance and amount, and interact with those choices to produce the resulting behavior.
Interaction with Endogenous Testosterone
- Another individual characteristic that may influence the psychological effects of AAS is the level of endogenous testosterone (T). Research finds a relatively consistent but variable relationship between endogenous T and dominant and aggressive behavior. These levels both influence and are influenced by behavior. Endogenous T might predict aggression, but successful aggression apparently also predicts increased endogenous T. Given this, the effects of adding exogenous T (AAS) to this equation must be considered. How might endogenous T and AAS interact to produce behavior and how might behavior subsequent to AAS use influence endogenous T and further behavior?
Defining Psychological Outcomes
- The final issue I will mention involves how the various psychological effects of AAS are defined and assessed. The relevant psychological factors listed above are assessed using a variety of psychometric instruments [e.g., the Buss-Durke Hostility Inventory (Choi, Parrott, & Cowan, 1990); Multi-Dimensional Anger Inventory (Lefavi, Reeve, & Newland, 1990); Multidimensional Personality Questionnaire (e.g., Moss, Panzak, & Tarter, 1992); or Personality Diagnostic Questionnaire (e.g., Yates, Perry, & Anderson, 1990)]. Some studies use behavioral analogues [e.g., the Point Subtraction Aggression Paradigm, (Kouri, Lukas, Pope, & Oliva, 1995)]. Experimental studies often add interviews with significant individuals in users’ lives. Behavior is most often assessed not by observation of overt behavior, but by self-reported aggressive behavior (verbal and physical). How do these measures relate to each other and how accurately do they reflect real world behavior?
I have briefly highlighted some of the important issues in any discussion of the psychological effects of AAS. In short, the evidence relating negative psychological outcomes to AAS varies based on a number of factors, most notably research method and design, and at this point, may not fully justify the level of certainty often seen in short sensational headlines – “AAS use causes Psychological Disorder.” Next time we will look more closely at the research to determine whether there are any answers currently available to the questions posed.
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