Chapter 17. Treatment of Anabolic-Androgenic Steroid–Related Disorders

Harrison G. Pope, M.D.; Kirk J. Brower, M.D.
DOI: 10.1176/appi.books.9781585623440.348286



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).

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

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.


American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000
Arvary D, Pope HG Jr: Anabolic steroids as a gateway to opioid dependence. N Engl J Med 342:1532, 2000
Babigian A, Silverman RT: Management of gynecomastia due to use of anabolic steroids in bodybuilders. Plast Reconstr Surg 107:240–242, 2001
Bahrke MS, Yesalis CE: Weight training. A potential confounding factor in examining the psychological and behavioural effects of anabolic-androgenic steroids. Sports Med 18:309–318, 1994
Bidwell M, Katz DL: Injecting new life into an old defense: anabolic steroid-induced psychosis as a paradigm of involuntary intoxication. University of Miami Entertainment Sports Law Review 7:1–63, 1989
Braseth NR, Allison EJ Jr, Gough JE: Exertional rhabdomyolysis in a body builder abusing anabolic androgenic steroids. Eur J Emerg Med 8:155–157, 2001
Brower KJ: Assessment and treatment of anabolic steroid abuse, dependence, and withdrawal, in Anabolic Steroids in Sport and Exercise, 2nd Edition. Edited by Yesalis CE. Champaign, IL, Human Kinetics, 2000, pp 305–332
Brower KJ: Anabolic steroid abuse and dependence. Curr Psychiatry Rep 4:377–387, 2002
Brower KJ, Rootenberg JH: Counseling for substance abuse problems, in Counseling in Sports Medicine. Edited by Ray R, Wiese-Bjornstal D. Champaign, IL, Human Kinetics, 1999, pp 179–204
Brower KJ, Blow FC, Hill EM: Risk factors for anabolic-androgenic steroid use in men. J Psychiatr Res 28:369–380, 1994
Brown JT: Anabolic steroids: what should the emergency physician know? Emerg Med Clin North Am 23:815–826, 2005
Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services: Youth risk behavior surveillance—United States, 2005. MMWR Morb Mortal Wkly Rep 55:SS–5, 2006. Data available online at: http://www.cdc.gov/HealthyYouth/yrbs/data/index.htm. Accessed November 22, 2007.
Cole JC, Smith R, Halford JC, et al: A preliminary investigation into the relationship between anabolic-androgenic steroid use and the symptoms of reverse anorexia in both current and ex-users. Psychopharmacology (Berl) 166:424–429, 2003
Dawson RT: Drugs in sport—the role of the physician. J Endocrinol 170:55–61, 2001
Duchaine D: Underground Steroid Handbook II. Venice, CA, HLR Technical Books, 1989
Gruber AJ, Pope HG Jr: Psychiatric and medical effects of anabolic-androgenic steroid use in women. Psychother Psychosom 69:19–26, 2000
Kanayama G, Pope HG Jr, Hudson JI: "Body image" drugs: a growing psychosomatic problem. Psychother Psychosom 70:61–65, 2001
Kanayama G, Cohane G, Weiss RD, et al: Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: an underrecognized problem? J Clin Psychiatry 64:156–160, 2003a
Kanayama G, Pope HG Jr, Cohane G, et al: Risk factors for anabolic-androgenic steroid use among weightlifters: a case-control study. Drug Alcohol Depend 71:77–86, 2003b
Kanayama G, Barry S, Hudson JI, et al: Body image, self-esteem, and attitudes towards male roles in anabolic-androgenic steroid users. Am J Psychiatry 163:697–703, 2006
Kanayama G, Boynes M, Hudson JI, et al: Anabolic steroid abuse among teenage girls: an illusory problem? Drug Alcohol Dep 88:156–162, 2007
Kashkin KB, Kleber HD: Hooked on hormones? An anabolic steroid addiction hypothesis. JAMA 262:3166–3170, 1989
Kindlundh AM, Rahman S, Lindblom J, et al: Increased dopamine transporter density in the male rat brain following chronic nandrolone decanoate administration. Neurosci Lett 356:131–134, 2004
Kouri E, Pope HG, Katz DL, et al: Fat-free mass index in users and non-users of anabolic-androgenic steroids. Clin J Sport Med 5:223–228, 1995
Kutscher EC, Lund BC, Perry PJ: Anabolic steroids: a review for the clinician. Sports Med 32:285–296, 2002
Malone DA Jr, Dimeff RJ: The use of fluoxetine in depression associated with anabolic steroid withdrawal: a case series. J Clin Psychiatry 53:130–132, 1992
Malone DA Jr, Dimeff R, Lombardo JA, et al: Psychiatric effects and psychoactive substance use in anabolic-androgenic steroid users. Clin J Sports Med 5:25–31, 1995
McBride AJ, Williamson K, Petersen T: Three cases of nalbuphine hydrochloride dependence associated with anabolic steroid abuse. Br J Sports Med 30:69–70, 1996
Menon DK: Successful treatment of anabolic steroid-induced azoospermia with human chorionic gonadotropin and human menopausal gonadotropin. Fertil Steril 79 (suppl 3):1659–1661, 2003
Midgley SJ, Heather N, Davies JB: Dependence producing potential of anabolic-androgenic steroids. Addiction Research 7:539–550, 1999
National Household Survey on Drug Abuse, 1994. Available at: http://www.icpsr.umich.edu/cocoon/ICPSR/DAS/06949.xml. Accessed November 22, 2007.
Neziroglu F, Khemlani-Patel S: A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectrums 7:464–471, 2002
Olivardia R, Pope HG Jr, Hudson JI: Muscle dysmorphia in male weightlifters: a case-control study. Am J Psychiatry 157:1291–1296, 2000
Parssinen M, Seppala T: Steroid use and long-term health risks in former athletes. Sports Med 32:83–94, 2002
Parssinen M, Kujala U, Vartiainen E: Increased premature mortality of competitive powerlifters suspected to have used anabolic agents. Int J Sports Med 21:225–227, 2000
Perry PJ, Lund BC, Deninger MJ, et al: Anabolic steroid use in weightlifters and bodybuilders: an internet survey of drug utilization. Clin J Sport Med 15:326–330, 2005
Pertusi R, Dickerman RD, McConathy WJ: Evaluation of aminotransferase elevations in a bodybuilder using anabolic steroids: hepatitis or rhabdomyolysis? J Am Osteopath Assoc 101:391–394, 2001
Peters KD, Wood RI: Androgen dependence in hamsters: overdose, tolerance, and potential opioidergic mechanisms. Neuroscience 130:971–981, 2005
Petersson A, Garle M, Granath F, et al: Morbidity and mortality in patients testing positively for the presence of anabolic androgenic steroids in connection with receiving medical care. A controlled retrospective cohort study. Drug Alcohol Depend 81:215–220, 2006
Phillips KA: Pharmacologic treatment of body dysmorphic disorder: a review of empirical data and a proposed treatment algorithm. Psychiatr Clin North Am 7:59–82, 2000
Phillips KA, O'Sullivan RL, Pope HG Jr: Muscle dysmorphia. J Clin Psychiatry 58:361, 1997
Pope HG, Katz DL: Affective and psychotic symptoms associated with anabolic steroid use. Am J Psychiatry 145:487–490, 1988
Pope HG, Katz DL: Psychiatric and medical effects of anabolic-androgenic steroid use. A controlled study of 160 athletes. Arch Gen Psychiatry 51:375–382, 1994
Pope HG Jr, Katz DL: Psychiatric effects of exogenous anabolic-androgenic steroids, in Psychoneuroendocrinology: The Scientific Basis of Clinical Practice. Edited by Wolkowitz OM, Rothschild AJ. Washington, DC, American Psychiatric Publishing, 2003, pp 331–358
Pope HG Jr, Brower KJ: Anabolic-androgenic steroid abuse, in Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th Edition. Edited by Sadock BJ, Sadock VA. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 1318–1328
Pope HG Jr, Kanayama G: Can you tell if your patient is using anabolic steroids? Current Psychiatry in Primary Care 2:28–34, 2005
Pope HG, Gruber AJ, Choi P: Muscle dysmorphia. An underrecognized form of body dysmorphic disorder. Psychosomatics 38:548–557, 1997
Pope HG, Olivardia R, Gruber A, et al: Evolving ideals of male body image as seen through action toys. Int J Eat Disord 26:65–72, 1999
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 57:133–140, 2000
Pope HG, Kanayama G, Ionescu-Pioggia M, et al: Anabolic steroid users' attitudes towards physicians. Addiction 99:1189–1194, 2004
Riem KE, Hursey KG: Using anabolic-androgenic steroids to enhance physique and performance: effects on moods and behavior. Clin Psychol Rev 15:235–256, 1995
Rubinow DR, Schmidt PJ: Androgens, brain, and behavior. Am J Psychiatry 153:974–984, 1996
Stanley A: Anabolic steroids—the drugs that give and take away manhood. A case with an unusual physical sign. Med Sci Law 34:82–83, 1994
Su TP, Pagliaro M, Schmidt PJ, et al: Neuropsychiatric effects of anabolic steroid in male normal volunteers. JAMA 269:2760–2764, 1993
Thiblin I, Lindquist O, Rajs J: Cause and manner of death among users of anabolic androgenic steroids. J Forensic Sci 45:16–23, 2000
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 68:1769–1774, 2001
Wines JD, Gruber AJ, Pope HG, et al: Nalbuphine hydrochloride dependence in anabolic steroid users. Am J Addictions 8:161–164, 1999
Wood RI: Reinforcing aspects of androgens. Physiol Behav 83: 279–289, 2004
Yates WR, Perry P, MacIndoe J, et al: Psychosexual effects of three doses of testosterone in cycling and normal men. Biol Psychiatry 45:254–260, 1999

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Anabolic-androgenic steroid (AAS) users will often use additional substances to either augment the effects of the AAS, to counteract AAS side effects, or to mask urine test results for AAS. Which of the following is used by AAS users to reduce AAS side effects?
Expected physical or laboratory findings on male AAS users include all of the following except
What is the typical finding on cholesterol levels with AAS users?
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