Steroid addiction – real disorder or media fiction?

Steroid addiction – real disorder or media fiction?

1. A word of introduction

Are anabolic-androgenic steroids addictive? When I first heard this question I had a big problem not to take it as sarcasm. In all the time I’ve been involved with figure sports, I’ve never met a person who would raise the issue of steroid addiction with me. And believe me, over the years people have told me really crazy stories in confidence. But no one has ever admitted that they have lost control of their lives because of these drugs. Nevertheless, some people are starting to ask this very question.
Nowadays, many psychiatrists believe that steroid addiction (SAA) is not a fiction and are trying to define the phenomenon. Before we take a closer look at it, let’s review some basic information about steroids and addiction to see if we can better understand whether the problem actually exists.

1.Steroids are drugs of abuse

To begin with, we must acknowledge that anabolic steroids are among the drugs of abuse. This simply means that people often continue to use these substances despite the appearance of side effects (health, financial or social). We all know that steroids help to build muscle, but there are potential health risks in doing so. Steroids can raise total cholesterol, lower HDL (good) cholesterol and induce other changes in the cardiovascular system that are capable of increasing the risk of heart disease over time. Many oral steroids are also highly toxic to the liver, and in very rare cases cause damage to this organ.
These drugs are generally safe if not abused. This means that (social and financial issues aside) classifying steroids as drugs of abuse makes sense. They are often taken even though it is not possible to completely eliminate the risks associated with them.

2 Are they at the same time addictive?

But we are not talking about simple abuse here. We’re talking about addiction, and that’s a whole other issue. To sound more sensational: we are talking about the dreaded ‘anabolic steroid addiction’. This means that these drugs are not only abused, but also directly impair the user’s ability to control their use. In other words, SAAs cause an internal need to use them constantly (abuse). According to this theory, it is possible to become addicted to steroids and have problems withdrawing from them. People have been debating for a long time whether anabolic steroids fit the definition of addictive drugs. Proponents of this theory do not even agree on the nature of the phenomenon (whether it is a psychological addiction, a physical addiction or perhaps both at the same time).

So is there any evidence that SAAs can cause addiction? The answer is yes. But there is too little of it and it is easily refuted. For example, experiments have shown that if mice and hamsters are allowed to take anabolic-androgenic steroids, they do so repeatedly. Of course, this is not because the animals felt a change in their physical appearance. They are unable to comprehend that the subsequent changes in their musculature are a result of the drug. This suggests that some internal impulse pushes them to keep taking it.
We also know that testosterone affects the mesolimbic dopamine pathway, which often plays a role in other types of addiction. Some studies suggest that they may (at some level) affect the sensitivity of the pleasure centre in the brain. Steroid abusers often report that when they are on a cycle, they have a better mood, more vitality and confidence. Is this the result of some weak psychotropic effect specific to these drugs? We really can’t be sure about this.
What we do know is that anabolic-androgenic steroids are not drugs that induce a state of intoxication. This fact alone makes them radically different from all other addictive drugs. Unlike drugs, which are used to induce a subjective feeling of ‘getting high’, the main motive behind steroid use is their positive effects on muscle and athletic performance.
Indeed, many people abuse these drugs, sometimes even a lot. But what is the reason for
this? Do steroids themselves cause some strong feelings of hunger? Or is it simply that it is their beneficial effects on musculature, strength and performance that cause them to be abused? In some cases, there are psychological issues against the backdrop of feelings of inadequate size and poor perception of one’s own body (‘muscular dysmorphia’) that push people to abuse SAAs. But are steroids responsible for this, or is their abuse a symptom of an illness?

3 The current view of the problem

This is where we stand. We know that anabolic steroids are widely abused. This is a fact that cannot be denied. We also know that they are often abused by people suffering from muscle dysmorphia. What we do not understand is the nature of either these relationships or steroid abuse itself. We do not even know whether steroids are mildly psychotropic substances at all. What we do have is some evidence that if animals are allowed to take these drugs, they do so, which suggests that there is a stimulus behind them. But we are not able to say anything more concrete.
If we try to fit steroids within the official definition of ‘addictive drugs’ created by the American Psychiatric Association, they do not fit there. According to the current recommendations, found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 3 or more of the following criteria must be met to be diagnosed as a psychotropic drug. Note that these have been paraphrased to avoid repetition later in the article.

1.The substance is taken in large doses or for longer than intended.
2.Willing or unsuccessful attempt to lower the dose or take control of substance use.
3.Too much time spent getting, using or getting out from under the influence of the substance.
4.Substance abuse results in the cessation of important activities.
5.Continued substance use despite negative psychological or physical effects.
6.Tolerance to higher doses or the desire to take more to achieve desired effects.
7.Symptoms of substance withdrawal.
We can try to present SAAs in such a light that they fit some of the DSM-IV criteria. For example, people often take larger doses or longer than they anticipated at the start (criterion 1.). Many abusers feel the need to lower their dose of medication, but fear of losing size, strength or performance prevents them from making this decision (criterion 2). Some continue to abuse steroids despite the emergence of negative health effects (criterion 5.).
Steroid abuse is also associated with a weaker body response and increasing dosage (criterion 6.). Finally, steroid withdrawal is associated with symptoms that we can call ‘coming down’ (criterion 7.), including: decreased sex drive, fatigue, depression, insomnia, dissatisfaction with one’s appearance and the desire to take more steroids. Despite this, many of these conscious decisions are driven by changes in appearance/attitude rather than a loss of control over one’s actions. It seems that in trying to fit steroids into many of these criteria, we have to make various concessions.

4 Official status

Officially, the DSM-IV does not recognise the existence of anabolic steroid addiction. Faced with the fact that the current guidelines simply do not cover steroids and the dilemma with diagnosing and treating what some in the medical community consider to be a real problem, a new set of criteria has been proposed for the next DSM-IV that would officially allow a diagnosis of anabolic steroid addiction. The old 7 criteria, which have been used for years to diagnose addiction to psychotropic drugs, are still in place.

5 Existing concepts

I’m a little concerned about the way the DSM-IV might describe steroid addiction. If we look at these new additions, it looks like they attribute a lot of non-drug behaviours to steroid use in order to ‘fit’ the criteria. For example, steroid users do not spend excessive amounts of time seeking and using SAAs. The DSM would then also include excessive training in this criterion, as it supports steroid use. Although many SAA users spend a lot of time eating, training and thinking about their musculature, many people who do not use them also do so. So we cannot claim that this behaviour is caused by the drugs in question. A link between post-cycle hormonal imbalance and stimulant withdrawal symptoms is also included in the new guidelines. Many people (including myself) disagree with this positioning. The DSM-IV also erroneously suggests that increasing doses are necessary to maintain muscle mass at the same level. In fact, increasing doses are necessary to maintain growth, not sustain it.
The APA article Issues for DSM-IV: Clarifying the Diagnostic Criteria for Anabolic-Androgenic Steroid Dependence, which describes the proposed criteria, also draws a worrying conclusion about presumed steroid dependence. The authors suggest that it may be associated with “(…) progression to other forms of substance abuse and addiction, particularly opioid dependence”. The authors evidently suggest that steroid use can cause you to become addicted to narcotic painkillers (reminiscent of heroin) and perhaps even heroin. This is, of course, referring to the infamous ‘gateway drug‘
theory – is that controversial assumption constantly cited to sustain the prohibition of cannabis (a drug that is less addictive in nature than caffeine). It seems that steroids are another means of opening the ‘gateway‘ to harder drugs. I don’t even know how to start a discussion on this topic (I hope it is redundant for most readers).

6 To sum up…

The proposed new DSM guidelines recognise the fact that steroids are fundamentally different from traditional addictive drugs, which in the past have always belonged to the group of psychotropic substances that cause ‘withdrawal’. This may now change. The proposed criteria will extend the framework of the existing addiction guidelines so broadly as to include drugs that primarily affect physical appearance. However, there appears to be too little medical information to support such a decision – there is only a sincere desire to address the issue.
While I am
very supportive of any effort to better understand SAAs, I believe we are still a long way from stating the fact that steroids are addictive. Perhaps more worrying is that instead of acknowledging that muscle dysmorphia can be confused with steroid addiction, the APA is attempting to link the condition to steroid abuse and lump it into a common bag called ‘addiction’. Muscular dysmorphia is a serious skewed perception of one’s body that should be treated directly. Based on the new guidelines, many psychiatrists can now, unfortunately, make the wrong diagnosis and conclude that their patients are addicted to drugs.