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Editorial   |    
Issues for DSM-V: Clarifying the Diagnostic Criteria for Anabolic-Androgenic Steroid Dependence
Gen Kanayama, M.D., Ph.D.; Kirk J. Brower, M.D.; Ruth I. Wood, Ph.D.; James I. Hudson, M.D., Sc.D.; Harrison G. Pope, Jr., M.D.
Am J Psychiatry 2009;166:642-645. doi:10.1176/appi.ajp.2009.08111699

Illicit anabolic-androgenic steroid (AAS) use represents a growing worldwide public health problem (1, 2). Some AAS users consume only a few courses of these drugs in a lifetime, but others progress to a maladaptive pattern of almost continuous use, despite adverse medical, psychological, and social effects (3, 4). In the last 20 years, accumulating animal and human studies have documented and characterized this syndrome of AAS dependence. For example, rats and mice will select AAS in conditioned place preference models (5), and hamsters will self-administer testosterone even to the point of death (6). Unlike rodents, humans may initially develop a pattern of AAS dependence as a result of “muscle dysmorphia”—a form of body dysmorphic disorder characterized by preoccupation with the idea that one does not look adequately muscular (7). In later stages, however, AAS dependence comes to resemble classical drug dependence, with a well-defined withdrawal syndrome mediated both by neuroendocrine factors and by a variety of cortical neurotransmitter systems, especially the opioidergic system (5, 8). Dependence on AAS may be associated with substantial medical morbidity, including hypertension, dyslipidemia, cardiomyopathy, and persistent hypogonadism, together with psychoactive effects, such as manic or hypomanic episodes during AAS use (sometimes associated with aggression and violence), major depressive episodes during AAS withdrawal (with occasional reported suicides), and progression to other forms of substance abuse and dependence, especially opioid dependence (2). The full magnitude of these risks is still unknown, because widespread AAS abuse did not spread from the athletic world to the general population until the 1980s (2), and only now are many AAS users becoming old enough to have developed a dependence pattern with an increased risk for these adverse outcomes. Although AAS users historically have been reluctant to seek treatment (1, 9), these adverse outcomes may now bring increasing numbers to clinical attention.

An important difference between classical drugs of abuse and AAS is that the latter are not ingested to achieve an immediate “high” of acute intoxication but, instead, are consumed over a preplanned course of many weeks to achieve a delayed reward of increased muscularity. Therefore, the existing DSM-IV criteria for substance dependence, which were designed primarily for acutely intoxicating drugs, do not apply precisely to AAS. For example, criteria such as “the substance is often taken in larger amounts...than was intended” and “important social, occupational, or recreational activities are given up or reduced because of substance use” apply more easily to alcohol or cocaine than to AAS. But these considerations should not obscure the fact that AAS have definite psychoactive effects, including a potential for addiction, which is likely underestimated because attention has focused on the drugs’ muscle-building properties (1).

On the basis of the available literature (2–4, 10) and clinical experience with AAS-dependent individuals, we suggest that the existing DSM criteria be adapted for diagnosing AAS dependence with only small interpretive changes (Figure 1). Presently, AAS are the only major class of drugs scheduled by the Drug Enforcement Administration for which DSM-IV does not explicitly recognize a dependence syndrome (11); this omission could be rectified in DSM-V by offering these proposed interpretations for AAS dependence in the substance dependence section. Alternatively, DSM-V could initially propose these criteria only for research purposes, pending further evidence of their reliability and validity. In either case, clarified criteria for AAS dependence will likely improve recognition of this diagnosis among clinicians and researchers encountering the syndrome, and they should stimulate increased attention to this emerging public health problem.

1.Pope HG, Brower KJ: Anabolic-androgenic steroid-related disorders, in Comprehensive Textbook of Psychiatry, 9th ed. Edited by Sadock B, Sadock V. Philadelphia, Lippincott Williams & Wilkins, 2009, pp 1419–1431
 
2.Kanayama G, Hudson JI, Pope HG Jr: Long-term psychiatric and medical consequences of anabolic-androgenic steroid abuse: a looming public health concern? Drug Alcohol Depend 2008; 98:1–12
 
3.Brower KJ: Anabolic steroid abuse and dependence. Curr Psychiatry Rep 2002; 4:377–387
 
4.Perry PJ, Lund BC, Deninger MJ, Kutscher EC, Schneider J: Anabolic steroid use in weightlifters and bodybuilders: an Internet survey of drug utilization. Clin J Sport Med 2005; 15:326–330
 
5.Wood RI: Anabolic-androgenic steroid dependence? insights from animals and humans. Front Neuroendocrinol 2008; 29:490–506
 
6.Peters KD, Wood RI: Androgen dependence in hamsters: overdose, tolerance, and potential opioidergic mechanisms. Neuroscience 2005; 130:971–981
 
7.Kanayama G, Barry S, Hudson JI, Pope HG Jr: Body image and attitudes toward male roles in anabolic-androgenic steroid users. Am J Psychiatry 2006; 163:697–703
 
8.Kashkin KB, Kleber HD: Hooked on hormones? an anabolic steroid addiction hypothesis. JAMA 1989; 262:3166–3170
 
9.Pope HG, Kanayama G, Ionescu-Pioggia M, Hudson JI: Anabolic steroid users’ attitudes towards physicians. Addiction 2004; 99:1189–1194
 
10.Copeland J, Peters R, Dillon P: A study of 100 anabolic-androgenic steroid users. Med J Aust 1998; 168:311–312
 
11.United States Code Title 21; Controlled Substances Act; Section 812: Schedules of Controlled Substances. http://www.usdoj.gov/dea/pubs/csa/812.htm
 

Address correspondence and reprint requests to Dr. Pope, Biological Psychiatry Laboratory, McLean Hospital, 115 Mill St., Belmont, MA 02178; hpope@mclean.harvard.edu (e-mail).

Editorial accepted for publication January 2009 (doi: 10.1176/appi.ajp.2009.08111699).

The authors all report having no competing interests.

Supported in part by National Institute on Drug Abuse (NIDA) grant DA-016744 (to Drs. Pope, Kanayama, and Hudson) and NIDA grant DA-12843 (to Dr. Wood).

Editorials discussing other DSM-V issues can be submitted to the Journal at http://mc.manusriptcentral.com/appi-ajp. Submissions should not exceed 500 words.

 
Figure 1. DSM-IV Substance Dependence Criteria, Interpreted for Diagnosing Anabolic-Androgenic Steroid Dependence

Figure 1. DSM-IV Substance Dependence Criteria, Interpreted for Diagnosing Anabolic-Androgenic Steroid Dependence
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References

1.Pope HG, Brower KJ: Anabolic-androgenic steroid-related disorders, in Comprehensive Textbook of Psychiatry, 9th ed. Edited by Sadock B, Sadock V. Philadelphia, Lippincott Williams & Wilkins, 2009, pp 1419–1431
 
2.Kanayama G, Hudson JI, Pope HG Jr: Long-term psychiatric and medical consequences of anabolic-androgenic steroid abuse: a looming public health concern? Drug Alcohol Depend 2008; 98:1–12
 
3.Brower KJ: Anabolic steroid abuse and dependence. Curr Psychiatry Rep 2002; 4:377–387
 
4.Perry PJ, Lund BC, Deninger MJ, Kutscher EC, Schneider J: Anabolic steroid use in weightlifters and bodybuilders: an Internet survey of drug utilization. Clin J Sport Med 2005; 15:326–330
 
5.Wood RI: Anabolic-androgenic steroid dependence? insights from animals and humans. Front Neuroendocrinol 2008; 29:490–506
 
6.Peters KD, Wood RI: Androgen dependence in hamsters: overdose, tolerance, and potential opioidergic mechanisms. Neuroscience 2005; 130:971–981
 
7.Kanayama G, Barry S, Hudson JI, Pope HG Jr: Body image and attitudes toward male roles in anabolic-androgenic steroid users. Am J Psychiatry 2006; 163:697–703
 
8.Kashkin KB, Kleber HD: Hooked on hormones? an anabolic steroid addiction hypothesis. JAMA 1989; 262:3166–3170
 
9.Pope HG, Kanayama G, Ionescu-Pioggia M, Hudson JI: Anabolic steroid users’ attitudes towards physicians. Addiction 2004; 99:1189–1194
 
10.Copeland J, Peters R, Dillon P: A study of 100 anabolic-androgenic steroid users. Med J Aust 1998; 168:311–312
 
11.United States Code Title 21; Controlled Substances Act; Section 812: Schedules of Controlled Substances. http://www.usdoj.gov/dea/pubs/csa/812.htm
 
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