Number Six, March 2002    -    MONTHLY FEATURES
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     This issue of Powerlines is focusing in on the dangers of performance enhancing drug use.

Below find an article on the Psychological aspects of drug use, and also check out a very comprehensive article on the Physiological Aspects, by Mark Rodacker.  

Psychological Aspects of Steroid Use
L.J. Maile, Ph.D.
Mark Rodacker, M.D., PhD.

Part 1

Abuse of anabolic steroids is seen to have many of the same characteristics as are seen in patterns of abuse of other substances. When considering the overall impact of steroid use, the effects are seen in all areas of functioning: physical, interpersonal, social, and legal. Physical and medical disease as part of the syndrome seen in abusers of anabolics are a separate, and significant topic area in and of themselves, and will be addressed in a series of articles starting in this issue of Powerlines, and continuing in following issues. Non-medical aspects of use of steroids will be addressed below.

Psychological effects and impacts:

Male hormone supplementation in believed to have originated in China more than 2000 years ago. Texts describe physicians collecting urine, "boiling" it down, purifying it (one would hope), and forming the residue into pills. Recent recreations of these ancient methods show that biologically active testosterone was produced (Kochakian, 1990). The original texts also describe the effects of these compounds on those taking them. In addition to increased strength and virility, patients were also observed to have an increased sense of wellbeing and increased aggression. It has, of course, been widely rumored that military combatants have used steroids and hormones for just these side effects. These rumors are unproven in published literature, but the possibility exists that such an effect could be achieved.

Use of anabolic steroids has been linked to increases in incidence of formal psychiatric disorders. While it can be argued that those who develop psychiatric problems secondary to steroid use are more prone to development of these symptoms, it is difficult to rule out the causal effect of these substances as triggers to decompensation in those who might otherwise "mature" into formal mental illness.

One of the best described pattern of symptoms, in both the psychiatric literature (e.g., Pope, 1994), and in gym lore is the increase in symptoms of depression following discontinuation of use of anabolic hormones and steroids. Perhaps this is so because of the subjective distress the user experiences and the likelihood that they will seek professional help and discuss their feelings with others. Development of other symptoms appear to be less likely shared with others. Symptoms of depression, by virtue of receiving widespread media attention, are also less stigmatizing than other psychiatric disorders, and are seen as more treatable. In any case, depressive symptoms are easily recognizable and very common when discontinuing use of anabolics. This is compounded by loss of hard earned muscle mass, strength, etc. This combination of factors leads many steroid users to "go back on." Suicide is also one of the major risks of steroid use and withdrawal. Thiblien, Linduist, and Rajs (2000) identified homicide and suicide as the cause of death in, respectively, 9 and 11 users of anabolic steroids of 38 decedents. This is 23.7 and 28.9% for these two causes of death. While this study stands out as reflecting the highest figures for both homicide and suicide, other studies also indicate those using steroids or hormones are at greater risk for both of these problems (e.g. Parssiaen, Hkijola, Vartiainen, Sarna, & Seppala, 2000).

Use of anabolic steroids, alone, have also been seen to increase the probability of development of psychotic symptoms, auditory hallucinations, delusional thinking (including paranoia), and significant elevation in mood (as seen in bipolar disorder or manic depression). This is compounded by concurrent use of stimulants, also commonly abused by strength athletes to increase endurance. While these symptoms may improve, or disappear with discontinuation of use, they may persist, requiring formal psychiatric diagnosis and treatment. Such treatment generally includes antipsychotic and/or mood stabilizing medication. While effective, and certainly necessary, these medications are not without side effects of their own. Those who develop formal psychiatric disorders secondary to steroid abuse may suffer from these conditions for the remainder of their lives.

One of the benefits of steroid use, in addition to the muscle and strength building factors is decreased recovery time. With increased capacity to recover often comes increased energy. The unfortunate flip side of increased energy is excessive restlessness (up to and including hyperactivity), decreased ability to concentrate, and impulsiveness. In the formal psychiatric literature, these symptoms are associated with poor decisions resulting in domestic difficulties, legal problems, and financial misfortune. Each of these problems has been identified in those who abuse steroids.

"Roid rage" is almost a legend among athletes. Increases in domestic violence have been identified among users of anabolic steroids (Schulte, Hate, Boyer, 1993). These are several well known cases of homicide of domestic partners of users. There have even been several well publicized cases of steroid side effects in legal defenses of those accused of violent acts, or as mitigators at sentencing (Moss, 1988). While there hasn't been a rush to claim steroid related insanity, at least in this writer's forensic evaluation practice, these arguments are based on well identified phenomena. Excusing criminal responsibility based on voluntary use, or abuse of anabolic compounds seems like a stretch, and hopefully, the Courts will continue to view such efforts as such.

Examination of steroid users in Great Britain suggests that those who use anabolics are likely to use other substances as well (Evans, 1997, and consensually among medical professionals). Steroid abuse appears to follow a pattern that is similar to that seen in abuse of other substances, e.g. alcohol and recreational drugs. Many of the cognitive mechanisms, and distortions that perpetuate other substance abuse operate among steroid abusers as well. Perhaps chief among these is denial.

It never ceases to amaze this author the frank falsehoods which surround use of steroids. That is to say, very few users will admit to using. Even when found positive for these drugs repeatedly, it is very rare for the athlete to just "own up to it." This is a very similar pattern to that seen in alcoholics and other drug abusers. The statement, "I only had two beers" is legendary among police officers and in Court. While some of this denial can be explained by the ever increasing penalties among sports organizations, and legally as well, for possession or sale of steroids. This phenomena seems to go beyond that.

The process of denial is also active in terms of the side effects and health problems attributable to use of anabolics. A number of strength athletes who started training during this author's career have either succumbed to the disorders related to their use of drugs, or are currently experiencing significant health problems as a result of that use. Conversations with these former athletes suggests that a high percentage, perhaps more than 50% have some residual effects from their past use of steroids. Those who are deceased died as a direct result of heart or liver disease, or malignancies. It is difficult to conceive that these phenomena are local or specific to athletes I have known personally. Denial mechanisms are reflected in these athletes statements that while they were using that they would not experience problems later, or in their denying or minimizing their past use. The older they get the less they used and the less important that use is in predicting their current health problems.

Denial, in a limited and well identified community, has been shown to break down with better information that details the cause of the problems, and that openly discusses the problems that have been experienced by public figures. This has clearly occurred among celebrities, some of whom have been open about their use of recreational drugs and alcohol, but is surprisingly lacking among strength athletes who have used anabolic steroids. Scientifically sound information is reported with increasing frequency, but powerlifters have not tied this to the experiences of people they know or know of. Until powerlifting "celebrities" start talking about their own bad experiences, little understanding will be found among grassroots lifters of the seriousness of using anabolic steroids, and the negative health and psychological effects that accrue.

Part 2: Cognitive distortions and dependence on steroids
(to follow)