Chapter 17 Treatment of Anabolic-Androgenic Steroid–Related Disorders

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Chapter 17. Treatment of Anabolic-Androgenic Steroid–Related

Disorders

TREATMENT OF ANABOLIC-ANDROGENIC STEROID–RELATED DISORDERS:

INTRODUCTION

The anabolic-androgenic steroids (AAS) are a family of hormones that includes the natural male

hormone testosterone and more than 100 other synthetic relatives of testosterone (Pope and

Brower 2004). All AAS possess both anabolic (muscle-building) and androgenic (masculinizing)

properties. Data from the National Household Survey on Drug Abuse (1994) suggest that about 1

million American men have used these drugs at some time. Although AAS use was once confined

largely to elite athletes, increasing numbers of young men have now begun to use these drugs to

gain muscle and lose fat, often simply for the sake of personal appearance (Kanayama et al. 2001).

The majority of these men are in their 20s or 30s, with a minority starting AAS use as teenagers

(Kanayama et al. 2007). Girls and women rarely use AAS because they are less likely to want to be

muscular and because AAS use makes women subject to their masculinizing effects, such as beard

growth, deepening voice, and masculinizing of sexual characteristics (Gruber and Pope 2000).

Although some recent anonymous surveys have suggested that substantial numbers of females

have used AAS (CDC, U.S. Department of Health and Human Services 2005), these surveys have

likely produced inflated estimates as a result of false positive responses on questionnaires; the true

number of female AAS users is likely very small (Kanayama et al. 2007). For these reasons, the

following discussion will focus primarily on treatment of male AAS users, although the general

principles expressed would presumably apply to the rare cases of female users as well (Gruber and

Pope 2000).

Although AAS pose important medical and psychiatric risks (described later in this chapter), AAS

users almost never seek treatment. Indeed, one recent study reported that 56% of illicit users had

never disclosed their AAS use to any physician at any time in their lives (Pope et al. 2004). There

are several reasons for this phenomenon. First, many users perceive their use of AAS to be a

positive and healthy activity when it is combined with intensive exercise and optimal diet as part of

a bodybuilding lifestyle. Commercial and societal forces are partly responsible for this

misperception of AAS (Kanayama et al. 2001): muscular male bodies are portrayed as an ideal in

advertising, magazines, television, and movies. Even children’s action toys, such as G.I. Joe, have

grown from ordinary-looking men in the 1960s and 1970s to muscle-bound specimens in the 1990s

(Pope et al. 1999). Makers of cars, electronics, and other products may promote their products as

“on steroids,” but they would never claim that their products were “on marijuana” or “on cocaine.”

Given this societal climate, it is not surprising that AAS users rarely perceive their drug use as a

psychiatric disorder requiring treatment.

Second, AAS are very different from conventional drugs of abuse. Most drugs of abuse described in

this volume deliver an immediate reward in the form of intoxication within minutes or hours of

ingestion. However, with body image drugs such as AAS, the immediate reward is negligible

(except perhaps in Stage 2 AAS dependence; see the section “AAS Dependence” later in this

chapter), and the user is seeking a long-term reward in the form of a more muscular body, athletic

success, or admiration from peers or potential sexual partners. Thus, conventional methods of

treating substance abuse are usually inappropriate unless modified specifically for AAS users

(Brower 2000; Kanayama et al. 2001).

Third, some AAS users have little respect for doctors. Underground guides and Internet sites for

illicit AAS users are replete with derogatory remarks about health professionals (Duchaine 1989);

AAS users may regard physicians as “geeks” or “pencil-necks” who have no understanding of thePrint: Chapter 17. Treatment of Anabolic-Androgenic Steroid-Related … http://www.psychiatryonline.com/popup.aspx?aID=348290&print=yes…

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bodybuilding world. For example, in one recent study, AAS users gave high marks to doctors on

knowledge of tobacco, alcohol, and ordinary drugs of abuse, but much lower marks on knowledge

of AAS. In the same study, 40% of AAS users reported that they trusted information about AAS

from their drug dealers at least as much as information from any physician that they had seen

(Pope et al. 2004). There is some basis for this distrust: for decades, many medical professionals

asserted that AAS were ineffective for gaining muscle mass. This claim, based on two decades of

seriously flawed studies, caused doctors to lose their credibility among many athletes (Pope and

Brower 2004). Now, most professionals finally concede that AAS are effective for gaining muscle

mass, but they still remain largely uninformed about the extent and nature of the AAS-using

subculture. Several recent papers have stressed that clinicians should attempt to become more

familiar with AAS and AAS-associated syndromes (Brown 2005; Dawson 2001; Kutscher et al. 2002;

Pope and Kanayama 2005).

Given the above considerations, it is understandable that AAS users almost never voluntarily

request treatment to stop using these drugs. Nevertheless, there are a number of specific

situations that bring AAS users to the attention of clinicians, at which point some attempt at

treatment may be initiated. These include 1) AAS dependence syndromes; 2) hypomanic and manic

syndromes during AAS exposure; 3) syndromes of depression and anxiety associated with AAS

withdrawal; 4) co-occurring substance use disorders, including progression from AAS use to opioid

abuse and dependence; 5) body image disorders associated with AAS use; and 6) forensic

situations, such as cases of AAS-induced violence or criminality. In the sections below, we begin

with a general discussion of the initial identification and assessment of AAS users and continue

with each of the six clinical issues enumerated above.

IDENTIFICATION AND ASSESSMENT

Identification

AAS use is one of the few types of substance use where a diagnosis is often suggested simply by

looking at the patient as he walks through the door (Pope and Kanayama 2005). As we have

described elsewhere (Kouri et al. 1995), there is a fairly sharp upper limit of muscularity that can

be achieved by a lean individual without the help of drugs. We have published a formula to

calculate muscularity, expressed as the fat-free mass index (FFMI), which clinicians can apply if

they know the height, weight, and approximate percentage of body fat of the patient (Kouri et al.

1995). Men who have low body fat and display an FFMI of greater than approximately 26 kg/m2 are

almost certainly using drugs that help them to achieve their size. We have published photographs

comparing bodybuilders who have used AAS with those who have not to aid the clinician in making

this distinction (Pope and Brower 2004). Clinicians who suspect AAS use in any patient should

follow several guidelines, described in the following section, to take a specific history.

History

The clinician may lead into the topic of AAS by asking about athletic or fitness-related activities.

Young men who lift weights regularly are at greatest risk to use AAS (Brower et al. 1994). Other

lead-in topics include the use of over-the-counter and mail-order dietary supplements such as

vitamins, minerals, amino acids, creatine, and dehydroepiandrosterone (DHEA), because the use of

such legal substances is commonly associated with AAS use. The clinician might also ask whether

the patient knows other people who use AAS—potential users often learn about AAS from other

users. Finally, the clinician could directly ask whether the patient has ever tried AAS or thought

about using them, and if so, why the patient is interested in using and what has prevented the

patient from using to date. Patients thinking about AAS use are good candidates for prevention. In

addressing these questions, it is particularly critical for the clinician to be nonjudgmental, while

still discouraging use.

For patients who admit to having tried AAS, both the perceived benefits and any adverse

consequences of use are important to determine. The dates of first and last use, the names and

doses of AAS used, sources of drugs, and routes of administration should be ascertained. PatientsPrint: Chapter 17. Treatment of Anabolic-Androgenic Steroid-Related … http://www.psychiatryonline.com/popup.aspx?aID=348290&print=yes…

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who inject AAS should be asked about needle sharing. Sources of drugs include prescriptions,

diversion from the legal market (including the veterinary market), and the illicit market. Unlike

many other drugs of abuse such as heroin and cocaine, AAS are legally available without a

prescription in many countries outside of the United States. Thus, potential AAS users can easily

travel to nearby countries and also find Internet sites offering to sell AAS from overseas. Drugs

purchased through these sites and received through the mail are often not intercepted. Patients

and clinicians should remember that drugs obtained from the illicit domestic market and from

overseas sources are frequently adulterated, falsely labeled, and sometimes nonsterile. In short,

the user does not necessarily know what and how much he is taking.

Inquiry into the patterns of use is also important. Illicit AAS users typically combine, or “stack,”

multiple AAS, including both oral and injected intramuscular forms, in order to achieve doses that

are 10–100 times the amounts ordinarily prescribed for therapeutic indications (Perry et al. 2005;

Pope and Brower 2004). AAS are usually taken in courses, or “cycles,” of 4–16 weeks or more,

often characterized by taking small doses at the beginning, building to large doses and

combinations in the middle, and tapering doses at the end—a pattern referred to as a pyramid. The

clinician gains useful information when exploring the role of cycling with an individual AAS user.

Does the patient cycle off AAS to avoid testing positive on drug screening? Does the patient cycle

off AAS to give his body a rest, allowing his endogenous hormonal system a chance to regain

normal functioning? Does the patient experience depression or other withdrawal symptoms during

off periods? Dependent users may eliminate cycling altogether in favor of prolonged, continuous

use in order to avoid withdrawal symptoms.

Finally, a history of other drug abuse should be obtained. Users often combine other drugs with

AAS to augment their effects (e.g., human growth hormone, human chorionic gonadotropin,

clenbuterol), to reduce unpleasant side effects (e.g., clomiphene, tamoxifen), and to mask urine

testing (e.g., probenicid, diuretics). Also, in contradiction to the image of the healthy bodybuilding

lifestyle, a large portion of AAS users display a history of other forms of substance abuse or

dependence. For example, in one study, 25% of men hospitalized for opioid dependence were found

to report a history of AAS use (Kanayma et al. 2003a); in another study, 88% of AAS users reported

past use of other illicit drugs, and 44% met the DSM-IV-TR criteria for a history of abuse of or

dependence on alcohol and/or an illicit drug (American Psychiatric Association 2000; Kanayama et

1. 2003b).

Physical Examination

The physical examination is essential to detect the somatic consequences of using AAS. Generalized

muscle hypertrophy with a disproportionately large upper torso (neck, shoulders, arms, and chest)

is readily apparent. The skin is examined for acne (on the face, shoulders, and back) and needle

marks in large muscles (especially the gluteals, but sometimes the thigh and deltoids).

Gynecomastia, caused by metabolic conversion of excess testosterone to estrogen, may be

detectable by palpation or even simple observation in some men. Gynecomastia may occasionally

be sufficiently marked to require surgical intervention (Babigian and Silverman 2001). By contrast,

the testicles become atrophic as they shut down testosterone production when exogenous AAS are

administered in high doses; this may lead to azoospermia and sterility (Torres-Calleja et al. 2001).

Male pattern baldness, hirsutism, hypertension, hepatomegaly, right upper quadrant tenderness,

jaundice, and prostatic hypertrophy are also possible but are not reliably associated with AAS use.

In women, hirsutism, deepening of the voice, and clitoral hypertrophy may be detected.

Mental Status Examination

The clinician should assess the patient’s appearance for excessive muscularity as described above,

sometimes disguised by oversized clothes, especially in patients with muscle dysmorphia who

become preoccupied that they do not look big enough (Pope et al. 1997). The patient’s cooperation

may vary depending on his defensiveness or denial of AAS use. Speech and sensorium are generally

normal. However, if the patient is experiencing hypomanic or manic symptoms from current AAS

use, he may display irritability, agitation, and possibly grandiose beliefs. Patients experiencingPrint: Chapter 17. Treatment of Anabolic-Androgenic Steroid-Related … http://www.psychiatryonline.com/popup.aspx?aID=348290&print=yes…

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depression from AAS withdrawal may exhibit depressed mood, dysphoria, anxiety, psychomotor

retardation, and possible suicidal ideation.

Laboratory Examination

Laboratory abnormalities reported in AAS users are summarized in Table 17–1. Standard urine

screens for drugs of abuse do not include AAS, so urine testing for AAS must be performed at a

reference laboratory. Such testing can detect only recent AAS use; orally active AAS disappear from

the urine within weeks, and most intramuscular preparations disappear within a few months.

However, given the association between AAS use and other illicit drug use, standard urine screens

for illicit drugs should also be ordered.

TABLE 17–1. Laboratory abnormalities in anabolic-androgenic steroid users

Blood work

Muscle enzymes

ALT, AST, LDH and CK

Liver function tests

ALT, AST, LDH, GGT and total bilirubin

Cholesterol levels

HDL-C, LDL-C, or no change in total cholesterol and triglycerides

Hormone levels

Testosterone and estradiol (with use of testosterone esters); testosterone (without

use of testosterone esters or during withdrawal); LH and FSH

Complete blood

count

RBC count, hemoglobin and hematocrit

Urine testing

AAS Positive

Other drugs of

abuse

May be positive

Cardiac testing

Electrocardiogram Left ventricular hypertrophy (seen in intensive weight trainers also)

Echocardiogram Impaired diastolic function

Semen analysis

Sperm count and motility, abnormal morphology

Note. ALT = alanine aminotransferase, AST = aspartate aminotransferase, CK = creatine kinase, FSH =

follicle stimulating hormone, GGT = -glutamyltransferase, HDL-C = high-density lipoprotein cholesterol, LDH

= lactate dehydrogenase, LDL-C = low-density lipoprotein cholesterol, LH = luteinizing hormone, RBC = red

blood cell.

Important blood chemistries include skeletal muscle enzymes, but these can be elevated even in

non-AAS users after intensive weight training. AAS users may occasionally display extreme

elevations of creatine kinase from rhabdomyolysis (Braseth et al. 2001; Pertusi et al. 2001).

Standard liver function tests, such as transaminases and lactic dehydrogenase, are nonspecific,

because these enzymes are also present in muscle and may be elevated from weight training.

Elevation of chemistries specific to the liver, such as bilirubin and -glutamyltransferase, may

suggest true hepatic abnormalities, whereas elevated creatine kinase (an enzyme largely specific

to muscle) may suggest muscle damage (Braseth et al. 2001).

Blood testosterone concentrations may be grossly elevated in patients who are administering

exogenous testosterone, or they may be grossly depressed in patients who are administering other

types of AAS and thereby inhibiting their own endogenous testosterone production. Testosterone

levels may also remain depressed for weeks and sometimes months during AAS withdrawal.

General Considerations

Although many health consequences of using AAS are readily detectable by performing a

comprehensive history, physical examination, and laboratory tests, the long-term healthPrint: Chapter 17. Treatment of Anabolic-Androgenic Steroid-Related … http://www.psychiatryonline.com/popup.aspx?aID=348290&print=yes…

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consequences are poorly studied (Parssinen and Seppala 2002) despite the fact that evidence of

premature mortality among AAS users continues to accumulate (Parssinen et al. 2000; Petersson et

1. 2006; Thiblin et al. 2000). Therefore, the clinician should be alert to heretofore undocumented

sequelae of AAS use as the first generation of users advance in age. In the meantime, the following

syndromes resulting from long-term use are most likely to bring AAS users to the attention of

psychiatrists.

AAS dependence

Although the “anabolic steroid addiction hypothesis” (Kashkin and Kleber 1989) remains subject to

debate (Bahrke and Yesalis 1994; Midgley et al. 1999), AAS are included and discussed in

DSM-IV-TR under the category of “Other (or Unknown) Substance-Related Disorders,” and a recent

review of the medical literature has documented at least 165 AAS users who met DSM-III-R or

DSM-IV criteria (American Psychiatric Association 1987, 1994) for AAS dependence (Brower 2002).

We have hypothesized a two-stage model of dependence on AAS (Brower 2002; Pope and Brower

2004). During stage 1, users are primarily interested in developing muscle size and power to

improve their body image or athletic performance. Training and diet at this stage have a

compulsive quality to them that extends to using AAS. The AAS user may appear to meet

DSM-IV-TR criteria for substance dependence at this stage because of the compulsive nature of

drug taking. This stage of dependence, however, can be explained without invoking any

psychoactive properties of AAS because AAS are strongly “myoactive” and they do help users to

achieve their muscle-related goals when combined with proper training and diet.

Addiction-specialized treatment is not likely to be needed at this stage, although treatment for a

body image disorder, such as muscle dysmorphia, may be (Pope et al. 1997).

According to the model, some AAS users will eventually develop stage 2 dependence, perhaps due

in part to genetic vulnerability and in part to cumulative, high-dose exposure to AAS. Chronically

consumed high doses of AAS are postulated to stimulate brain reward systems in humans, as

suggested by the animal literature (Kindlundh et al. 2004; Peters and Wood 2005; Wood 2004), and

to result in neuroadaptations in other brain systems that manifest as withdrawal symptoms upon

discontinuation. Thus, users take AAS for both their psychoactive and myoactive effects at this

stage. Clinically, stage 2 dependence resembles dependence on traditional drugs of abuse, and it

meets formal DSM-IV-TR criteria for substance dependence. In addition, stage 2 dependent users

may have co-occurring dependence on other drugs of abuse, such as opioids, alcohol, and

stimulants.

Stage 2 users have difficulty stopping drug use on their own and are likely to require

addiction-specialized treatment. The first step in such treatment is to initiate and motivate the

patient for abstinence. As with other drugs of abuse, motivational techniques include providing

empathic feedback and encouraging self-efficacy as well as involving family and friends (Brower

and Rootenberg 1999). Feedback, given in a nonjudgmental manner, about findings from the

physical examination and laboratory abnormalities allows for engagement around bodily concerns.

Encouraging self-efficacy takes advantage of the patient’s need to see oneself as big, powerful, and

strong. Initiating abstinence also involves the treatment of withdrawal symptoms, which are

discussed in detail in the section “AAS Withdrawal Depression” later in this chapter.

After initiating abstinence, the principles of relapse prevention may be applied as with other

addicted individuals, but there are also unique therapeutic issues to address in AAS users. One is

the overreliance on physical attributes for self-esteem that resembles the dynamics of patients

with eating disorders and body dysmorphic disorder (Pope et al. 1997). Therefore, the diagnosis of

comorbid mental disorders not ordinarily observed in patients with substance dependence is

important. Another therapeutic issue concerns the psychological response to giving up AAS, which

have likely served the patient to achieve some measure of competitive success. The patient will

likely feel smaller and weaker, both literally and figuratively, without AAS. In helping the patient to

accept the loss of AAS, the clinician appreciates that 1) the patient’s goals were culturally

congruent (the bigger, better, stronger, winner) and 2) AAS are potently myoactive and really canPrint: Chapter 17. Treatment of Anabolic-Androgenic Steroid-Related … http://www.psychiatryonline.com/popup.aspx?aID=348290&print=yes…

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facilitate those goals.

AAS hypomania and mania

A substantial portion of the literature since the mid-1990s has demonstrated that AAS produce

hypomanic or manic syndromes in some individuals, which are sometimes accompanied by

aggressive or violent behavior and, very rarely, psychotic symptoms (Pope and Katz 2003). These

effects are rare in individuals taking the equivalent of 300 mg/week or less of testosterone, but

they appear to become progressively more common with higher dosages, especially above 1,000

mg/week (Pope and Katz 1994). These syndromes were initially noted in field studies of illicit AAS

users, and some investigators questioned whether the effects were actually due to AAS themselves,

as opposed to expectational factors, personality variables, or subcultural influences (Bahrke and

Yesalis 1994; Riem and Hursey 1995). Recently, however, several studies have demonstrated that

such syndromes can develop even in psychiatrically healthy volunteers taking supraphysiological

doses of AAS under placebo-controlled, double-blind laboratory conditions (Pope et al. 2000; Su et

1. 1993; Yates et al. 1999). Therefore, the mood-altering effects of AAS almost certainly have a

biological basis, even though they can undoubtedly be modified by contextual factors (Rubinow and

Schmidt 1996).

Little has been written about the treatment of manic or hypomanic episodes beyond anecdotal

reports (Pope and Katz 1988; Stanley 1994). Thus, the best treatment recommendations would

seem to include removal of the offending agent and temporary treatment, if necessary, with

neuroleptics or other anti-manic drugs. In general, it appears that manic or hypomanic episodes

will remit quickly when AAS are stopped and that clinicians should be alert for the onset of

depressive symptoms associated with abrupt AAS withdrawal. If a patient reports a history of mood

disorder prior to AAS use or continues to exhibit manic or psychotic symptoms for more than a

week or two after AAS are stopped, it would seem important to consider the possibility of an

underlying major mood disorder independent of AAS.

AAS withdrawal depression

The withdrawal syndrome from AAS is primarily depressive in nature and includes symptoms of

fatigue, restlessness, anorexia, insomnia, decreased libido, and a desire to take more AAS (craving)

in addition to depressed mood (Brower 2000). The syndrome typically lasts for several weeks and

usually does not require specific pharmacological treatment. However, some individuals may

develop severe or persistent depressive symptoms, sometimes accompanied by suicidal ideation. In

one study, 4% of AAS users reported that they had actually made a suicide attempt during AAS

withdrawal (Malone et al. 1995). Depression accompanying AAS withdrawal appears to respond

well to selective serotonin reuptake inhibitors such as fluoxetine (Malone and Dimeff 1992). These

drugs are also the agents of choice for treating muscle dysmorphia and other forms of body

dysmorphic disorder that may accompany AAS use (Phillips 2000).

The hypothalamic-pituitary-gonadal (HPG) axis can be depressed for many months during the

withdrawal period, resulting in sterility in some cases and contributing to depressive symptoms in

others. In men who continue to exhibit impaired sexual function or persistent depressive symptoms

despite pharmacotherapy, consultation with an endocrinologist should be considered. Endocrine

pharmacotherapy, including injected testosterone esters, human chorionic gonadotropin, and

anti-estrogens, may be indicated to restore functioning of the HPG axis in such cases (Brower

2000; Menon 2003).

Syndromes associated with AAS use

Recent years have seen the appearance of two important syndromes that appear associated with

AAS use. The first, termed muscle dysmorphia or reverse anorexia nervosa, is a form of body

dysmorphic disorder in which the individual perceives himself to be small and frail, even though he

is actually large and muscular (Cole et al. 2003; Kanayama et al. 2006; Olivardia et al. 2000; Pope

et al. 1997). Men with muscle dysmorphia will often engage in compulsive weightlifting and

bodybuilding, even to the exclusion of other activities that they enjoy. They frequently will avoidPrint: Chapter 17. Treatment of Anabolic-Androgenic Steroid-Related … http://www.psychiatryonline.com/popup.aspx?aID=348290&print=yes…

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situations in which their body will be seen by others, such as going to the beach or changing in a

locker room, for fear that they look too small. Not surprisingly, such individuals may use AAS to

“treat” their preoccupation, but paradoxically, many describe even more severe symptoms of

muscle dysmorphia following initiation of AAS use. There are no systematic studies of treatment of

muscle dysmorphia per se, but it seems reasonable to follow general principles of treatment of

other forms of body dysmorphic disorder, relying on cognitive-behavioral and pharmacological

interventions (Neziroglu ad Khemlani-Patel 2002; Phillips 2000; Phillips et al. 1997).

Another ominous syndrome associated with AAS use has been progression from AAS to opioid

abuse and dependence. Specifically, many AAS users learn about opioids from fellow bodybuilders

and often first purchase opioids from the same individual who sold them AAS (Arvary and Pope

2000; Kanayama et al. 2003a; McBride et al. 1996; Wines et al. 1999). AAS users often start by

experimenting with the opioid agonist-antagonist nalbuphine, followed by progression to pure

opioid agonists, including heroin. The authors are personally aware of many deaths among AAS

users who developed opioid abuse or dependence and then inadvertently overdosed on intravenous

opioids. Needless to say, opioid abuse or dependence in current or former AAS users should be

aggressively treated (see Chapters 18, 19, and 20 in this volume regarding opioid use and

treatment).

AAS IN FORENSIC SITUATIONS

AAS users may occasionally come to clinical attention through the courts as the result of violent or

criminal behavior. Specifically, numerous works have described individuals, often with no history of

psychiatric disorder, violence, or criminal behavior, who became uncharacteristically violent, and

sometimes committed murder, while intoxicated with AAS (see Pope and Katz 2003). In some such

cases, the relationship to AAS use may be missed because the possibility is never considered.

However, AAS use should be suspected in any unusually muscular man apprehended for violent

behavior, especially if it appears that this violence is not characteristic of his usual personality. The

clinician’s index of suspicion should be particularly raised when such a man rapidly develops

vegetative symptoms of depression after being incarcerated, but then improves a few weeks or

months later. This pattern may indicate AAS withdrawal, precipitated by the abrupt discontinuation

of AAS following incarceration, with a gradual remission of depressive symptoms as suppressed

HPG function gradually returns to normal. Of course, this pattern of biological depression must be

distinguished from the situational depression associated with incarceration itself.

In cases where AAS use is openly acknowledged by the defendant and appears to have been a clear

precipitant of criminal behavior, forensic clinicians may be asked to offer an opinion that the

defendant exhibited “involuntary intoxication” or “diminished capacity” from AAS. (The legal

aspects of this defense have been discussed in detail elsewhere [Bidwell and Katz 1989].) If an

individual is released and placed on probation after a crime believed to be associated with AAS, it

may be wise to require random, unannounced, observed urine tests for AAS to ensure that he does

not resume these drugs.

CONCLUSION

Of the various forms of substance abuse and dependence described in this volume, AAS abuse and

dependence may be the least likely to come to the attention of the average clinician. However, the

frequency of surreptitious AAS abuse and dependence, together with the various psychiatric

syndromes associated with it, is very likely underestimated, and many cases doubtless go

unrecognized. Greater awareness of this problem among clinicians may lead to the detection of

many more cases as well as a better understanding of how best to treat them.

KEY POINTS

The use of anabolic-androgenic steroid (AAS) must be approached differently from other forms of substance

abuse because AAS do not produce an immediate reward or “high” in the manner of conventional drugs of

abuse and are linked to body dysmorphic disorder.Print: Chapter 17. Treatment of Anabolic-Androgenic Steroid-Related … http://www.psychiatryonline.com/popup.aspx?aID=348290&print=yes…

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AAS users rarely see their drug use as pathological, rarely seek treatment, and may have contempt for

physicians.

AAS users often display a history of abuse of or dependence upon other drugs, especially opioids.

Some individuals experience hypomanic or manic symptoms during AAS exposure and depressive symptoms

during AAS withdrawal.

AAS may produce a well-documented dependence syndrome for which an animal model exists.

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