Advances in Psychiatric Treatment (2007), vol. 13, 203–211  doi: 10.1192/apt.bp.105.

000935

Anabolic androgenic steroids:

what the psychiatrist needs to know
Harry Rashid, Sara Ormerod & Ed Day

Abstract Anabolic androgenic steroids (commonly known as anabolic steroids) are synthetic derivatives of the
hormone testosterone. They are being increasingly used by professional and recreational athletes to
enhance performance, and by men and women to improve physical appearance. This article discusses
the characteristics of such steroid ‘misusers’ and the techniques of use. It highlights the psychiatric com­
plications associated with these steroids, including increased risk of aggression, personality disorders,
psychosis and mood disorders, particularly manic symptoms. Medical complications of steroid use are
common and frequently reversible. Use is associated with an increased risk of injury, cardiovascular
events, gastrointestinal complications, virilisation in women, and gynaecomastia and testicular atrophy
in men. Whether addiction to these steroids can occur is debatable, but there is evidence for dependence
and a withdrawal syndrome. Steroid use may be a ‘gateway’ to other addictions. Users are often reluctant
to seek treatment and the psychiatrist’s role in the recognition and management of use is presented.

Anabolic androgenic steroids are synthetic deriva­ public anabolic steroids are more commonly known
tives of the hormone testosterone and they are as drugs used by competing athletes as a performance-
characterised by a carbon skeleton with a four-ring enhancing (ergogenic) aid. However, the misuse and
cyclopentanoperhydro­phenanthrene structure. Testos­ harmful use of anabolic steroids is no longer the sole
terone is the primary hormone synthesised in the domain of elite professional athletes. In recent years
testes in males; in females the circulating levels are the recreational use of these drugs has increased
typically about 10% of those observed in males. It has significantly, usually for the cosmetic purpose of
both ‘anabolic’ (tissue-building) and ‘androgenic’ enhancing appearance (Johnston et al, 2003). Misuse
(masculinising) properties. During puberty its is also no longer limited to a predominately male
androgenic action is central to the development of population, as females are becoming increasingly
the male phenotype, and the hormone is responsible involved in using anabolic steroids.
for the secondary sexual characteristics observed in Unless otherwise stated, reference in this article
men. In addition, testosterone regulates muscle to steroid use in general indicates the taking of
protein metabolism, sexual and cognitive functions, steroids without prescription. In particular, ‘misuse’
erythropoiesis, plasma lipids and bone metabolism indicates that the drug is being taken in a way that
(Evans, 2004). The androgenic effect cannot be would not comply with medical recommendations
separated from the anabolic, but purely anabolic and ‘harmful use’ indicates a pattern of use that is
steroids have been synthesised in an attempt to causing damage to health but does not meet ICD–10
minimise the androgenic effects. criteria for dependence (Box 1).
Anabolic androgenic steroids (which for conciseness
we will call anabolic steroids hereafter) are prescribed
for the treatment of male hypogonadism, and there is Anabolic steroids and the law
evidence for their efficacy in the treatment of cachexia
associated with HIV, cancer, burns, renal and hepatic In the UK, anabolic steroids are prescription-only
failure, and anaemia associated with leukaemia and drugs under the Medicines Act 1968. They can be sold
hepatic failure (Basaria et al, 2001). To the general by a pharmacist only on the presentation of a doctor's

Harry Rashid is an innovative general practice registrar with an honorary contract with Birmingham Heartlands and Solihull NHS
Trust, having initially worked in general adult psychiatry for the Birmingham and Solihull Mental Health NHS Trust. He has a specialist
interest in sports medicine and anabolic steroid misuse. Sara Ormerod is a specialist registrar in old age psychiatry currently working
for Birmingham and Solihull Mental Health NHS Trust. Her clinical and research interests include the interface between physical and
psychiatric disorders. Ed Day is a senior lecturer in addiction psychiatry at the University of Birmingham (Department of Psychiatry,
Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2QZ UK. Email: e.j.day@bham.ac.uk), and an
honorary consultant psychiatrist with the Birmingham and Solihull Mental Health NHS Trust. His research interests include developing
innovative pharmacological and psychological treatments for alcohol and drug dependence.

203
Rashid et al

Medical Association Board of Science and Education,

Box 1  ICD–10 criteria for dependence 2002) found that as many as half of the members of
ICD–10 criteria include experience of at least dedicated bodybuilding gyms admitted to taking
three of the following during the past year: anabolic agents, and that steroid use ran as high as
13% even in some high-street fitness centres. A third
• a strong desire to take steroids
of all general practitioners were treating patients who
• difficulty in controlling use
took steroids, and needle-exchange programmes for
• withdrawal syndrome when use is reduced
heroin addicts were reporting increasing numbers of
• evidence of tolerance
steroid users among their clients.
• neglect of other interests and persistent use
An annual survey of adolescent drug use in the
despite harmful consequences USA in 2002 found a sharp increase in the lifetime
(World Health Organization, 1992) use of anabolic steroids, with lifetime prevalence in­
creased by 1.7% in 10th graders (15–16 years old) and
2.9% in 12th graders (17–18 years old) over a 10-year
prescription, and a small number of individuals are period (Johnston et al, 2003). Recent data from the UK
prescribed them for legitimate medical reasons (see suggest a large rise in anabolic steroid misuse over the
above). Anabolic steroids are also Controlled Drugs, past year by a group of people who are distinct from
class C (Schedule 4ii), under the Misuse of Drugs Act users of other illicit drugs (Druglink News, 2006).
1971 (Box 2). It is not an offence to possess anabolic
steroids for personal use, but it is an offence to supply
them. The penalty for unlawful supply of class C Who misuses steroids?
drugs is a maximum of 14 years in prison and an
unlimited fine. There are a number of reasons for the non-prescribed
In the USA, the Anabolic Steroid Control Act of use of anabolic steroids. Athletes use them to enhance
2004 was introduced in response to the growing use performance, driven by the potential financial and
of steroid precursors (pro-steroids) by professional other rewards that may come with sporting success.
athletes in particular, thus expanding the list of Although older research suggested that anabolic
substances available on prescription only. steroids were no more efficacious than placebo in
improving performance, such work suffered from a
number of methodological limitations that restricted
How common is steroid misuse? its usefulness. A key factor was that researchers did
not use the high ‘supraphysiological’ doses (see
There is a dearth of epidemiological data regarding below) necessary to achieve the muscle-building
anabolic steroid misuse in the UK. In a survey of 687 effect (Lukas, 2003). Anabolic steroids allow the
students at a British college the overall rate of current user to increase both the frequency and intensity of
or previous use was 2.8% (4.4% in males, 1.0% in workouts, in addition to increasing muscle capacity,
females) and, of these, 56% had first used anabolic reducing body fat, increasing strength and endurance,
steroids at the age of 15 or younger (Williamson, and hastening recovery from injury.
1993). Recreational users of anabolic steroids are the most
Over the past decade the harmful use of anabolic rapidly expanding group, and their aim is to enhance
steroids has increased both in the UK and in the their physical appearance in order to receive the
USA. This was highlighted in a report by the British admiration that Western societies give to a ‘perfectly
Medical Association in 2002, which classified steroid toned’ body. A much smaller proportion of those
misuse as a public health risk. The report (British who misuse steroids have experienced physical or
sexual abuse, and are trying to increase their muscle
size to protect themselves. A further group (possibly
Box 2  Controlled drugs in the UK between 5 and 10%) includes people who have a form
of body dysmorphic disorder (sometimes called
• A drug’s class (A–C) determines how dan­ ‘reverse anorexia nervosa’), in which they believe
gerous it is perceived to be and the penalties that they look small and weak, even if they are large
relating to its use. Drugs in class A are con­ and muscular (Brower et al, 1991).
sidered to be the most dangerous
• A drug’s schedule defines who may be in
possession of or supply the drug. Drugs in How are anabolic steroids used?
schedule 1 are under the greatest level of
control Anabolic steroids can be taken orally, injected intra­
muscularly and, less commonly, applied topically in

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 Anabolic androgenic steroids

Table 1 Commonly used androgenic anabolic steroids

Drug Effect Side-effects
Oral preparations
Methenolone acetate Limited muscle gain but relatively safe. Causes little water retention or liver
Relatively little androgenic potency damage
Methandrostenolone Moderate androgenic properties. Also reported Gynaecomastia, fluid retention and
to enhance feelings of well-being hypertension are commonly reported
Oxandrolone Relatively mild androgenic properties, so popu­ Gastrointestinal irritation, including
lar with women. Has a reputation for increasing pain and diarrhoea, is commonly
strength not size reported; liver toxicity is possible
Oxymetholone Widely recognised as one of the strongest oral Headaches and stomach pains re­
anabolic steroids available. Highly anabolic and ported; very toxic to the liver
highly androgenic
Stanozolol Modest anabolic and weak androgenic effects Has a reputation for causing
gastrointestinal discomfort after
prolonged use
Intramuscular preparations
Boldenone undecenoate Veterinary product commonly thought to be
effective in producing rapid increase in strength
and muscle mass
Methenolone acetate See above
Nandrolone decanoate Most commonly used injectable anabolic steroid Dose-dependent side-effects may in­
for performance enhancement. High anabolic clude hypertension, acne and sexual
and low androgenic properties and reproductive problems
Sustanon 250® Contains a combination of four esters of
testosterone. Considerable anabolic and
androgenic properties. Fast acting and long
lasting
Testosterone enantate Moderate androgenic properties; in an injectable
oil preparation. Short-lived effects
Testosterone cypionate Moderate anabolic and androgenic properties. Large doses have been associated
Oil based, so long acting with aggression; hypertension,
premature balding and acne
commonly reported
After Lukas (2003) and Lenehan et al (2004).

the form of creams and gels (Table 1). Amounts used towards the end of the cycle, in the hope of allowing
are supraphysiological, often 10–100 times greater the body’s hormonal system time to recuperate and
than therapeutic doses. There are three common maintain homoeostasis.
regimes practised by steroid misusers: ‘cycling’, Some people use anabolic steroids continuously for
‘stacking’ and ‘pyramiding’ (Lukas, 2003). years. Various additional drugs are taken to combat
During ‘cycling’ the user takes the steroid for 4– the side-effects of the steroids, and these include
12 weeks and then stops for a variable period, after human chorionic gonadotrophin, diuretics, thyroid
which use is resumed again. Users believe that this hormones, growth hormone and insulin (Table 2).
time-off period helps to minimise side-effects.
‘Stacking’ is the use of more than one steroid
at a time, to maximise increases in lean muscle Psychiatric complications
mass, weight gain and strength. The drugs may be
administered by different routes, for example as a Anabolic steroids have been associated with a range
combination of injectable and oral steroids. of psychiatric symptoms, although the limited
In ‘pyramiding’ the user follows a cycle of building research literature in this area does not yet prove a
up to a peak dose and then tapering back down causal link.

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Table 2  Other drugs commonly taken in association with anabolic androgenic steroids
Drug Effect Side-effects/comments
Human growth hormone Widely believed to increase muscle and tendon Major side-effects are bone over­
(HGH) strength, making rupture less likely growth, cardiomegaly and tendency
to develop diabetes
Insulin Promotes uptake of amino acids by cells and High risk of hypoglycaemia
increases protein synthesis. Often used after a
workout
Insulin-like growth Mediates metabolic effects of HGH. Increases Requires diet high in carbohydrate
factor 1 (IGF–1) protein synthesis and decreases protein break­ and containing sufficient protein for
down in muscle cellular reproduction
Clenbuterol Bronchodilator used to treat asthma. A beta-2
agonist with a potential role as a fat burner
Human chorionic Natural protein hormone that mimics luteinising
gonadotrophin (HCG) hormone’s effects in stimulating production of
testosterone. Used to counter negative feedback
effects of exogenous steroids
Tamoxifen Anti-oestrogenic agent prescribed for treatment
of oestrogen-dependent breast tumours. Used to
prevent or reduce gynaecomastia
Diuretics Used before competitions to remove excess sub­ Can induce electrolyte imbalance
cutaneous water
Cytomel® Synthetic thyroid hormone (T3) used to increase
basal metabolic rate by increasing synthesis of
protein, carbohydrates and fats
After Lenehan et al, 2004.

Aggression and violence girlfriends because of their intolerably aggressive

behaviour. Nearly all denied comparable behaviour
Empirical studies in both animals and humans have before steroid use. Other work has suggested that
shown an increase in aggression in both males and adolescents who abuse anabolic steroids have nearly
females exposed to anabolic steroids (Eisenberg & triple the incidence of violent behaviour (Dukarm et
Galloway, 2005), and self-reported aggression may be al, 1996).
the only sign of steroid misuse (Copeland et al, 2000).
Moderately high doses of testosterone cypionate have
been shown to increase aggressive responding in Psychosis
individuals who have not used steroids before (Kouri
et al, 1995), and increasing doses of methyltestosterone In earlier research, Pope & Katz (1988) studied 41
have been correlated with increasing irritability, individuals who used anabolic steroids. Of these, 
mood swings, violent feelings and hostility (Su et 5 (12.2%) had psychotic symptoms and 4 (10%) had
al, 1993). Misusers of anabolic steroids subjectively sub-threshold psychotic symptoms while taking
report significantly more fights, verbal aggression steroids: none had these symptoms when not taking
and violence towards their significant others during them. A subsequent larger study (Pope & Katz, 1994)
periods of use compared with periods of non-use found similar results, with psychotic symptoms
(Choi & Pope, 1994). There have been several case diagnosed in 3% of the 88 users ‘on-cycle’, but in
reports of what users call ‘roid rage’, frenzied violent none ‘off-cycle’. The risk of developing psychotic
behaviour during the high-dose cycles of steroid use symptoms may be related to high-dose testosterone
(Lukas, 2003). In 88 athletes who were using anabolic (Pope & Katz, 1994; Hall et al, 2005).
steroids Pope & Katz (1994) found that aggressive Clinical presentations include grandiose and
or violent behaviour often accompanied steroid- paranoid delusional states that often occur in the
associated manic or hypomanic episodes. Participants context of a psychotic or manic episode. Symptoms
admitted to a range of serious episodes, including usually resolve in a few weeks if steroid use is
property damage, assault, being involved in a murder discontinued, although may persist for as long as a
plot and beating a pet dog. Several of the sample month even if adequately treated with antipsychotics
had been expelled from home by parents, wives or (Hall et al, 2005).

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 Anabolic androgenic steroids

Personality disorders men, and one participant developed an acute manic

episode.
Self-report questionnaires and informant histories
There is also evidence that depression can be
have been used to retrospectively assess the personal­
associated with withdrawing from steroids: in
ity type of anabolic steroid misusers before their first
Pope & Katz’s original (1988) study 12.2% of those
use. Such work suggests that they start out with per­
using anabolic steroids developed DSM–III–R major
sonalities similar to those of non-using bodybuilders,
depression when they stopped taking the drugs.
but develop abnormal personality traits that could be
attributed to steroid misuse (Eisenberg & Galloway,
2005). Cooper et al (1996) identified a high rate of Medical complications
abnormal personality traits in a sample of 12 body­
builders who had used anabolic steroids compared The side-effects of anabolic steroids are well-
with a matched group who had not. The reported known (Box 3). Fortunately most of the serious, life-
personality traits of the steroid users before the onset threatening effects appear relatively infrequently, and
of use did not differ from those of the non-users, but may be more likely to occur with some of the oral
in the user group there were significant differences agents. The most common side-effects are less serious,
between the before and after traits. During steroid mostly cosmetic and usually reversible with cessation
use, individuals were more likely to score higher on (Brower, 1992). However, observational studies
paranoia, schizoid, antisocial, borderline, histrionic, suggest that the majority (88–96%) of anabolic steroid
narcissistic and passive aggressive personality pro­ users experience at least one minor objective side-
files. Other studies have suggested that antisocial effect, including acne (40–54%), testicular atrophy
personality disorder is slightly more likely among (40–51%), gynaecomastia (10–34%), cutaneous striae
anabolic steroid users than among non-users (Pope (34%) and injection-site pain (36%) (Evans, 2004).
& Katz, 1994). Steroid users have been shown to have
a higher prevalence of cluster B (histrionic, narcissis­
tic, antisocial and borderline) personality traits than Musculoskeletal
community controls (Yates et al, 1990).
It is widely believed that a large increase in muscle
mass associated with anabolic steroids can overwhelm
Mood and anxiety disorders the tendons and ligaments and lead to an increase
in musculoskeletal injuries among users (Liow &
Affective disorders have long been recognised as a
Tavares, 1995). Adolescents who misuse anabolic
complication of anabolic steroid use. Case reports
steroids risk premature closure of epiphyses, leading
describe both hypomania and mania, along with
to a reduction in final height.
irritability, elation, recklessness, racing thoughts
and feelings of power and invincibility that did not
meet the criteria for mania/hypomania (Eisenberg Cardiovascular
& Galloway, 2005). Of 53 bodybuilders who used
anabolic steroids, 27 (51%) reported unspecified There are numerous case reports of unexpected cardio­
mood disturbance (Lindstrom et al, 1990). vascular events in anabolic steroid users, and use
The above-mentioned study by Pope & Katz has been linked to the development of hypertension,
(1988) involving 41 steroid-using bodybuilders used left ventricular hypertrophy, impaired diastolic filling
structured interviews to measure affective symptoms and arrhythmia (Kutscher et al, 2002). The situation is
according to DSM–III–R criteria. They identified 5 further complicated by the effect of anabolic steroid
participants (12.2%) who met the criteria for a manic use on lipid profile (Box 3), and the use of diuretic
episode during steroid exposure; a further 8 (19.5%) drugs in combination with steroids (Table 2). The
only narrowly missed the diagnosis. Significantly effects of anabolic steroid use on thrombotic activity
more participants developed a full affective syndrome is also a risk factor, as platelet aggregation is increased
during periods of steroid exposure (22%) than non- in steroid users (Eisenberg & Galloway, 2005).
exposure (5%), and 10 were ‘stacking’ when they
experienced manic symptoms. Gastrointestinal
In a later prospective study, Pope and colleagues
(2000) gave placebo or 600 mg testos­terone to males Oral alkylated testosterone can cause primary biliary
aged 20–50 years with no history of steroid use or stenosis and cholestatic jaundice, and this may
past psychiatric illness. In the testosterone group, progress to hepatorenal syndrome. Anabolic steroid
6% of the men becoming mildly hypomanic and 4% use may cause a reversible rise in aminotransferase
becoming markedly hypomanic. levels, and may also increase the incidence of hepatic
Su et al (1993) administered methyltestosterone tumours in susceptible individuals (Eisenberg &
(40 or 240 mg/day) or placebo to 20-year-old healthy Galloway, 2005).

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Endocrine
Box 3  Physical signs of anabolic steroid use
Hyperandrogenism is associated with insulin resis­
Musculoskeletal system
tance, although trial results are equivocal and may
• Muscular hypertrophy
vary with the type of steroid used. For example,
• Increases in skeletal muscle enzymes detect­
a direct correlation between methyltestosterone
ed by routine serum chemistry
administration and insulin resistance has been
Cardiovascular system (often reversible after demonstrated in non-obese women (Diamond,
steroid use ceases) 1998), whereas other work has shown that neither
• Decreased high-density lipoprotein choles­ testosterone nor nandrolone adversely affected
terol and increased low-density lipoprotein insulin resistance in men (Hobbs et al, 1996).
cholesterol (known risk factor for coronary Aromatisation is the process by which steroid
artery disease) hormones are interconverted. Testosterone and other
• Increased blood pressure aromatisable anabolic steroids are metabolised in part
• Reported cases of myocardial infarction, left to oestradiol and other oestrogen agonists, and males
ventricular hypertrophy and stroke using high doses of anabolic steroids can have the
circulating oestrogen levels typical of women during a
Hepatic system normal menstrual cycle (Wilson, 1988). This can lead to
• Cholestatic jaundice
breast pain in men and gynaecomastia, which is one of
• Benign and malignant liver tumours
the most frequently described side-effects of anabolic
• Peliosis hepatis (blood-filled cysts)
steroid use. Gynaecomastia is often irreversible. The
Reproductive system effect of anabolic steroids on female breast tissue in
Males the long term is not well studied, although some
• Benign prostatic hypertrophy animal studies suggest that it may cause breast cell
• Testicular atrophy autolysis and necrosis (Blanco et al, 2002). Anabolic
• Sterility steroids suppress gonadotrophins, with variable
• Gynaecomastia effects on sexual interest, erectile function (causing
• Abnormalities of sperm count, motility and spontaneous erections), the prostate and fertility.
morphology Testicular atrophy has been documented in control
• Painful breast lumps trials, and oligospermia may follow anabolic steroid
• Anabolic steroid misuse by prepubertal use (Eisenberg & Galloway, 2005).
boys may lead to premature closure of bony Supraphysiological doses of anabolic steroids in
epiphyses and a consequent reduction in fi­ women lead to virilisation. Women taking steroids
nal height have reported voice instability (deepening of
Females both projected speaking voice and singing voice),
• Breast tissue may shrink
clitoral hypertrophy, shrinking breasts, menstrual
• Menstrual abnormalities
irregularities, nausea and hirsuitism. Many of
• Masculinisation, including clitoral hyper­
these side-effects are largely irreversible. Steroid
trophy, hirsuitism, deepened voice use can also lead to cutaneous striae, acne and
balding. There is a case report of secondary partial
Dermatological system empty sella syndrome, with pituitary atrophy from
• Male-pattern baldness negative feedback associated with the misuse of
• Acne steroids together with growth and thyroid hormones
• Oily skin (Dickerman & Jaikumar, 2001).
• Jaundice
• Needle marks
• Oedema due to water retention evident in Other complications
the hands and feet
Injecting is the predominant route of administration
Other systems of anabolic steroids (80% in one study), and so users
• Sleep apnoea are at risk of contracting blood-borne viruses includ­
• Exacerbation of tic disorders ing hepatitis B and C and HIV (Brower et al, 1991).
• Polycythaemia However, a study of 149 injectors of anabolic steroids
• Altered immunity in England enrolled between 1991 and 1996 showed
• Glucose intolerance that only 2% were hepatitis B core antibody positive,
• Non-hepatic neoplasias compared with 18% of intravenous heroin users and
(Brower, 1992) 12% of amphetamine users. None of the steroid users
tested positive for HIV (Crampin et al, 1998).

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 Anabolic androgenic steroids

Dependence effects of the steroids meets the diagnostic criterion

for dependence of spending large amounts of time
Reports of physical dependence on anabolic steroids on drug-related activities (Brower, 2002).
first appeared in the 1980s, usually in young male
weightlifters, who reported an inability to stop
Links to other substance misuse
taking them (Brower, 1992). Withdrawal symptoms
were prominent in these descriptions, but one case It has been suggested that anabolic steroid use may
suggested that moderate to severe dependence had serve as a gateway to opioid misuse. In a study of
resulted from taking anabolic steroids (Brower et al, lifetime drug use by 223 men admitted to a substance
1989). In a study of 49 male weightlifters (Brower misuse treatment unit primarily for treatment of
et al, 1991), 41 (84%) reported withdrawal effects, alcohol, cocaine and opioid dependence, 29 (13%)
with the most frequently described symptom being reported prior anabolic steroid use. Eighteen of
craving for more steroids. Those who reported being these men reported that anabolic steroids were the
dependent on anabolic steroids generally took higher first drugs that they had ever self-administered by
doses, completed more cycles of use, and reported injection, and seven men with opioid dependence
more aggressive symptoms than those who did not reported that they first learned about opioids from
report dependence. friends at the gym, and subsequently first obtained
Symptoms of steroid withdrawal include mood opioids from the same person who had sold them
disorders (with suicidal depression as the most life- anabolic steroids (Kanayama et al, 2003).
threatening complication), apathy, feelings of anxiety,
difficulty in concentrating, insomnia, anorexia,
decreased libido, fatigue, headache, and muscle Evaluation and treatment
and joint pain (Corrigan, 1996). It is often difficult
to distinguish symptoms that are due to neuronal It is rare for users of anabolic steroids to present to
rebound in withdrawal from those that can be said to medical services with a primary complaint of steroid
be psychological in origin. Observing oneself to lose use. Most do not view themselves as drug misusers, as
muscle mass, strength, performance and confidence steroid use is seen as a positive step towards bettering
after cessation of steroid use has a powerful negative themselves physically. Furthermore, users have little
effect on mood, and this may lead to a strong desire trust in doctors’ knowledge of anabolic steroids, and
to take steroids again. often do not disclose their steroid use in consultations.
Survey data have provided some evidence of In one study, 40% of users trusted information on
the development of a full dependence syndrome in anabolic steroids from their drug dealers at least as
anabolic steroid users. In the above-mentioned study much as information from any physician, and 56%
by Brower et al (1991), 28 (57%) met DSM–III–R criteria had never revealed their steroid use to a doctor (Pope
for dependence, based on responses to an anonymous et al, 2004). It is therefore important to consider the
self-administered questionnaire. Examination of possibility of steroid use, particularly in high-risk
the symptoms reported revealed features of both groups such as men who engage in weight training
physical and psychological dependence, with some or sports that require strength or power. Enquiries
users reporting up to six of the DSM–III–R features should be made about the perceived benefits of
of substance dependence. anabolic steroids and the side-effects experienced
(both physical and psychological). Denial of steroid
use obviously does not rule out harmful use of these
Mechanisms of dependence drugs. In an anonymous confidential questionnaire
Various mechanisms have been suggested to explain survey of 1004 male bodybuilders in London, more
the development of a dependence syndrome, than 10% reported ever injecting anabolic steroids.
including the effect of anabolic steroids on endogenous However, only 36% of these individuals said that they
opioids or monoamine systems in the brain, and admitted this to a physician. This highlights the need
dependence resulting from social reinforcement of to promote open communication with patients who
a muscular physical appearance. When enquiring may be reluctant to disclose potentially risky, illegal
about dependence, the psychiatrist must distinguish or embarrassing behaviours (Bolding et al, 1999).
between the effects of steroid use and those of weight
training, which may act as a confounding factor. For Physical examination
example, weight training, even in the absence of
steroid use, may have a noticeable impact on lifestyle, The combination of muscular hypertrophy with
as it can involve spending a lot of time in the gym testicular atrophy in males or virilisation in females is
and on a strict diet. However, only time actually strongly suggestive of anabolic steroid use. However,
spent on obtaining, using and recovering from the there is a wide normal variation in the habitus of the

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Rashid et al

population and the clinician must be aware of this low potential for overdose, adverse cardiac effects
in order to avoid an incorrect diagnosis of steroid and anticholinergic side-effects, all of which must
use. For example, a normal teenage pubertal male be taken into account when treating people who
may exhibit breast buds, small testes and cystic acne. have an increased risk for suicide, cardiotoxicity and
Similarly, endocrine disorders may mimic harmful prostatic hypertrophy. Antipsychotic drugs may be
use of anabolic steroids: polycystic ovary disease and needed to treat persistent and marked irritability,
idiopathic hirsutism are highly relevant and treatable aggressiveness or agitation.
examples of this. Muscular hypertrophy and thin
abdominal skin folds are among the most common
findings in anabolic steroid users. Unusual injuries Conclusions
such as ruptured tendons, ligaments or muscles
should also alert the clinician to possible steroid Anabolic steroid use has increased in prevalence in
use (Eisenberg & Galloway, 2005). Unexplained or many high-income countries over the past decade,
pronounced aggression may be the only obvious and it can lead to aggression, depression, mania and
symptom or sign (Copeland et al, 2000). The use of psychosis, in addition to a range of physical complica­
other illicit drugs should always be considered. tions. Psychiatrists should be aware of the possibility
of steroid use, particularly in young men. Knowl­
edge of the potential physical signs, combined with
Laboratory tests a detailed assessment of all drug use, will enable
Urine testing can confirm anabolic steroid use and the clinician to include anabolic steroid use in a dif­
be used as a measure of abstinence. Although these ferential diagnosis where relevant. Abstinence from
tests are common in competitive sports, they are not steroid use usually leads to a reversal of most physi­
usually available from hospital laboratories as part cal and psychological signs, although a withdrawal
of routine drug screenings in the clinical setting. In syndrome has been described. The symptoms of 
addition, their use as a screening method for evidence dependence on anabolic steroids are similar to those
of drug cessation is complicated by the fact that seen with other drugs of misuse, suggesting that some
many injectable steroids have long half-lives and are of the conventional drug misuse treatments may be
lipophilic, resulting in sequestration in adipose tissue effective with people dependent on steroids.
and potential detection in urine a number of months
after use. Alterations in liver transaminase levels, or Declaration of interest
an unsual low-/high-density lipoprotein cholesterol
profile may also suggest anabolic steroid use. None.

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Basaria, S., Wahlstrom, J. T. & Dobs, A. S. (2001) Anabolic
Very few anabolic steroid users enter treatment androgenic steroid therapy in the treatment of chronic diseases.
for dependence, and research evidence is limited. Journal of Clinical Endocrinology and Metabolism, 86, 5108–5117.
Treatment recommendations can be made on the basis Blanco, A., Moya, L., Flores, R., et al (2002) Effects of anabolic
implants of oestradiol alone or in combination with trenbolone
of the treatment of other substance misuse disorders, acetate on the ultrastructure of mammary glands in female
along the lines of abstinence, treatment of withdrawal lambs regarding their interference in prolactin secretion. Jour-
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5. b� reduced frequency of manic or hypomanic symptoms
Dukarm, C. P., Byrd, R. S., Auinger, P., et al (1996) Illicit substance c� increased risk of psychosis on- and off-cycle
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complications of anabolic steroid use. Psychosomatics, 46, 285. c� all types of anabolic steroids increase insulin
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in normal men. Journal of Clinical Endocrinology and Metabolism, if used by adolescents
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anabolic-androgenic steroid use among men admitted for b� antipsychotics have no role in treatment
substance abuse treatment: an underrecognized problem? c� psychological interventions need to focus purely on
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Medicine. c� can use needle exchanges as frequently as opiate users
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depression associated with anabolic steroid withdrawal. A case
d� can always be said to be dependent
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Pope, H. G., Kouri, E. M. & Hudson, J. I. (2000) Effects of supra­
physiologic doses of testosterone on mood and aggression in 1 2 3 4 5
normal men. A randomised controlled trial. Archives of General a F a F a F a F a F
Psychiatry, 52, 133–140.
Pope, H. G., Kanayama, G., Ionescu-Pioggia, M., et al (2004) b F b F b F b F b F
Anabolic steroid users' attitudes towards physicians. Addiction, c F c T c F c F c T
99, 1189–1194. d F d F d F d F d F
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