The Psychological Effects of Anabolic Steroids (Part 2)

Introduction

Do AAS cause psychological disturbance? By and large, empirical and experimental results differ. This month we will explore one possible reason for this discrepancy. Because aggression is the most controversial, widely researched, and highlighted psychological effect associated with AAS use, it will serve to exemplify the processes whereby pre-existing psychological factors might influence the behaviors associated with AAS use.

The Person: Where Behavior Begins

The behavior (e.g., AAS use) to outcome (e.g., aggression) relationship varies due to many factors. It may exist in the presence of a certain characteristic, but not in its absence. To understand the behavior-outcome association, such characteristics must be considered because they affect the relationship – serving as “switches” to turn it on. Consider the association between endogenous testosterone, aggression, and (social) withdrawal in young males (Chance, Brown, Dabbs, & Casey, 2000). Results indicated that, “The relation of testosterone to both aggression and withdrawal was moderated (italics added) by intelligence. When correlations were examined separately for children above or below the median for IQ, only among those with the lower IQ scores was testosterone significantly correlated with aggression and withdrawal (p. 443).” In the presence of lower IQ (the moderator or “switch”), the T/aggression association was reliable; otherwise, it was not. If IQ was not included in the analyses, this finding might have been overlooked.

How could such factors affect AAS/aggression research? Experimental studies randomly assign participants to treatments – equally spreading characteristics across treatments. Hence, a “switch” that might turn on aggression is no more likely in one group than another. A lack of pre-treatment group differences on these variables suggests effective random assignment (e.g., Bhasin et al., 1996; Bjorkvist, Nygren, Bjorklund, & Bjorkqvist, 1994; Pope, Kouri, & Hudson, 2000). Aggression is a less consistent outcome in experiments than in empirical studies (e.g., Bhasin et al., 1996 v. Pope et al., 2000), aggression is typically an infrequent outcome when it does occur, and is often difficult to attribute solely to AAS, based on hormonal measures. Su et al., (1993) administered varying doses of methyltestosterone and placebo, and noted that, although some subtle increases in aggressive responding were seen, “Symptomatic differences did not, however, reflect differences in plasma anabolic steroid levels (p. 2763).”

In naturalistic studies of AAS users and non-users, it is likely that such switches will differ, because the groups are not created randomly. These characteristics that differentiate the groups may be antecedents, concomitants, or unrelated to AAS use. Differences in aggression between real world users vs. experimental subjects may result from controlling these factors through random assignment. Those receiving AAS in experiments might never have used them otherwise and are frequently selected based on having never used. Those who choose to use AAS will differ from non-users in ways unrelated to use. For instance, Choi, Parrott, & Cowan (1990) found that AAS users were more aggressive than non-users, whether they were currently using or not. Lastly, in studies where differences are found, typically a small minority of users shows increased aggression and not all studies, even naturalistic ones, find differences between current users and non-users (e.g., Malone, Dimeff, Lombardo, & Sample, 1995). There are also reliability and validity issues in the assessment and measurement of aggression that are not being discussed here (e.g., Archer, 1994).

Individual Characteristics in the AAS/Aggression Relationship

Many psychological characteristics have been reported in AAS users, but examinations beginning prior to first AAS use are largely non-existent. Some individual case studies or retrospective evaluations (e.g., Thiblin, I., Kristiansson, M., & Rajs, J., 1997) and retrospective reports of personality either prior to first use or during off periods by users or their family members (Pope, & Katz, 1994; Thiblin, Lindquist, & Rajs, 2000) exist. All of the above suffer problems with hindsight and other memory biases.

To explore the role pre-existing characteristics in real-world AAS use and subsequent aggression, users must be studied over the time period wherein initiation of use occurs. But such studies are difficult, requiring the identification of naïve individuals with a high likelihood of future AAS use. Regardless of what you might have heard, predicting such changes in behavior over time is difficult. Many possible users would need to be followed for long periods to isolate even a small number who ultimately use.

In lieu of this, alternative methods are employed. Data is collected from users and non-users and differences between them are assumed to reflect risk. For instance, Yates, Perry, & Anderson (1990) compared steroid users, alcoholics, non-using weightlifters, and controls and reported that the antisocial traits of AAS users were similar to those in alcoholics (Alcohol has also been implicated in aggression; see Gustafson, 1994). Note – no random assignment – individuals’ behavior determines group membership. Thus group differences could result from, predate, or be unrelated to AAS use. Antisocial traits are a risk factor for substance use in general, including AAS use. However, such traits are also linked to aggressive behavior, whether substance-related or not. Given these factors, no one interpretation seems more supportable than any other would.

Potential risk might also be based on other factors. Brower, Blow, & Hill (1994) studied weightlifters who were using, not using, or “contemplating using” AAS. Increased competitive bodybuilding, trying performance enhancers, and knowing users were risk factors for potential steroid use (associated with contemplation). But is “thinking about using” risk? We cannot say if we do not know what percentage of lifters consider use at some time and how many of them ultimately use AAS. Contemplation does not equal intent. Do the above factors increase risk or does contemplation lead to “pseudo use” behavior? Differences between established groups at one point in time cannot answer these questions.

Perhaps the psychological effects of AAS use are precursors of use or switches that, when present, turn on the AAS use/aggression connection. Sapolsky (1997) suggested that AAS have a permissive effect on aggression – given pre-existing tendencies, it does not cause but enhances or permits such behavior, making it more likely. For instance, mood disorder (Pope & Katz, 1994) or self-reported aggressive traits (Galligani, Renck, & Hansen, 1996; Perry, Anderson, & Yates, 1990; Yates, Perry, & Murray, 1992) reportedly characterize AAS users. Alternatively, and consistent with other substance use research, they may predispose one to AAS use – and aggression. This might be true for a range of “abnormal” personality traits (Cooper, Noakes, Dunne, Lambert, & Rochford, 1996) or the aggressive mood (Bond, Choi, & Pope, 1995) reported in the literature. Behavioral science has long recognized that the best predictor of specific future behavior is similar past behavior. Hence, certain behaviors in some AAS users might predate AAS use, motivate AAS use, and/or switch on aggression in the permissive atmosphere provided by AAS. If such factors or behaviors occur more frequently in users, it could be a result of AAS use or that a larger number of AAS users begin with these characteristics. Such an interpretation is consistent with the literature on other substance use (e.g., Sher, Trull, Bartholow, & Vieth, 1999).

Aggression: Who, When, Where, and What

In certain professions, aggression is expected and valued (e.g., Neyer, 2000). However, the social problems of many leading sports personalities (Benedict, 1997) suggest that individuals with such tendencies who are “successful” in one sphere can suffer problems in others. Such incidents offer another example from which hints regarding AAS/aggression can be drawn.

What characteristics lead to excellence in contact sports? Small and/or passive individuals are unlikely drafts into the NFL, except as place kickers. Certain factors probably both draw individuals to such activities and support their potential excellence. Unfortunately, in different contexts (e.g., domestic relationships), such characteristics and behaviors (aggression/dominance) are less valued and negative consequences often result.

How might such factors affect the choice to use AAS in some users? In spite of early studies that asserted otherwise, AAS do, in a dose-response fashion, increase size and strength (e.g., Bhasin et al., 1996, Forbes, 1985). Hence, factors that relate to a desire for such improvements might predict the AAS/aggression relationship. For instance, muscle dysmorphia, wherein strong and/or unusually large individuals continue to view themselves as small and weak (Olivardia, Pope, & Hudson, 2000; Pope, Katz, & Hudson, 1993; Pope, Phillips, & Olivardia, 2000; Wroblewska, 1997) has been suggested as a motivation for AAS use. Other research suggests that AAS users have lower levels of social physique anxiety (concern over their physique in social situations) than non-users (Schwerin et al., 1996), potentially as a result of use. Social physique anxiety prior to use and the presence of such anxiety at a given level may moderate the AAS/aggression relationship as a function of decreased anxiety and increased confidence and dominance, especially in the case of heightened concern with physical size. Upper body strength, esteem, and body dissatisfaction also reliably predicted AAS use (Schwerin et al., 1997). This may be one answer to the question, “Why get bigger or stronger?” Certain factors may predispose some individuals to a desire for increased physical size or strength.

Body size is related to aggressiveness independent of AAS use. Larger children are more aggressive, but also more looked up to by their peers. It seems obvious that larger body size garners respect (or fear) and awe (or incredulity) in our society (Would Arnold be a famous actor otherwise?) and especially within specific subcultures. The knowledge that respect and admiration accompany larger body size is likely to motivate a desire for such a physique. Given that AAS increase muscle mass, it takes little extrapolation to relate these factors to decisions to use and potential subsequent behavior.

This also suggests that dominance related characteristics might switch on AAS related aggression. In fact, social status or dominance rank appears to switch on or off the relationship between AAS and aggression in non-human primates (Dixson & Herbert, 1977; Rejeski, Brubaker, Herb, & Kaplan, 1988). When administered AAS, existing social groups of monkeys show increased overall aggressive behavior. However, the increased aggression occurs primarily in dominant (within the social hierarchy) members. Lower ranking members exhibit increased submissive behavior after AAS administration. AAS apparently enhanced or permitted the expression of existing behavioral tendencies (dominance and aggression) and if dominance rank had not been included, an erroneous conclusion might have been reached. Animal models of complex behavior often lack applicability to humans, but these studies suggest the potential for temperament and circumstance to “switch on” the AAS/aggression relationship.

In humans, a positive feedback system has been suggested to explain the T and aggression relationship (Drigotas & Udry, 1993; Halpern, Udry, Campbell, & Suchindran, 1993). Individuals with higher levels of T may be more likely to be aggressive and experience frequent successes in dominance interactions. Given the reciprocal relationship between T and dominance (e.g., Suay et al., 1999), increased T results and further aggression becomes more probable. Now add exogenous T to this equation. The primate models suggest that dominance (which may reflect greater endogenous T) moderates AAS associated aggression. The feedback model suggests a self-perpetuating cycle. Should a dominant human add AAS to the equation, the likelihood of aggression may increase even further, especially in view of the fact that human dominance hierarchies are much more intricate than are those in captive monkey colonies.

Conclusion

Aggression, while a potentially serious effect of AAS use, appears to be relatively rare. Currently there seems little reason to suspect that aggression in AAS users is an inevitable outcome, regardless of dose, although at higher doses it may become more probable in certain individuals (dose and behavior are likely confounded). One potential explanation for the variability in the AAS/aggression relationship, that might also explain some inconsistencies in the literature, is the potential moderation (switching) of the relationship. Some factors (e.g., dominance, antisocial tendencies) might increase the likelihood of use and aggressive behavior during use. The infrequent occurrence of aggression when random assignment is used and discovery of higher levels of aggression in users, whether using or not, support such a hypothesis.

Part 3: The Role of Expectancy in Steroid-Related Aggression

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