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Contents:
Psychological Aspects of Steroid Use
L.J. Maile, Ph.D. and Mark Rodacker, M.D., PhD.
(copyright Maile/Rodacker, 2002)
Part 2
In Part 1 of this discussion, the formal psychiatric effects, and related psychological mechanisms were discussed. In the following section, issues of dependence will be discussed, as will some of the distortions of thought that support use of these dangerous drugs and allow the use of them to persist in individuals who "ought to know better."
Dependence:
To understand the dependencies that can develop with regard to substances, in general, and which these authors would argue, occur with use of anabolic steroids, we must start with a definition. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association defines substance dependence, generally, as "a maladaptive pattern of substance use, leading to clinically significant impairment or distress" (APA, 1994, p. 108, Diagnostic Criteria.) To make a formal diagnosis, three of the following characteristic must be present:
· Tolerance
· Withdrawal
· Increasing amounts used
· Desire or efforts (usually unsuccessful) to decrease use
· Significant time spent in obtaining the substance, using it, or recovering from the effects
· Social, occupational, or recreational activities are given up as a result of use of the substance
· Continuing use despite persistent or recurrent physical or psychological problems as a result of the use.
Let's examine each of these phenomena in some depth to establish whether or not an actual dependency exists when discussing use of steroids. Interestingly, this issue is unexamined in the professional literature of either of the author's professions (psychology, medicine).
Habituation and Tolerance:
Habituation is the physical phenomenon wherein increasing greater quantities of a given substance are required to achieve the same effect, and is strongly related to tolerance. When discussing such substances as stimulants, adaptations may be in the systems responsible for processing the substance, i.e., liver and kidneys, or at the neurochemical level. At the organ level, ongoing damage reduces the efficiency of the body to process the substance, so that less is biologically available. While intake may be greater, the amount that reaches the bloodstream decreases with continued, heavy use. Changes also occur at the level of the brain, specifically in the person's neurotransmitter systems such that a greater amount of the substance is needed to have the same chemical response on the individual brain cells (neurons). Over time, these two effects aggregate to make a worsening pattern of use wherein the user intakes greater and greater quantities of substances to achieve the same effect. The related phenomenon of tolerance also occurs in a manner often seen as directly proportional to habituation. Tolerance is increased when a person can use ever increasing amounts of a given substance without the negative effects, one of which is overdose, that would be seen in a naïve user. An alcoholic can drink volumes of alcohol that would result in poisoning in a non-drinker. Tolerance is seen in virtually all substances of abuse.
The question may then be examined as to whether a person habituates, or develops tolerance to anabolic steroids. These authors would say, "yes, definitely." Let's look at the mechanisms involved in habituation and tolerance and see if any parallels exist between abuse of anabolic steroids and other drugs of abuse. Perhaps the first question to answer is whether a mechanism exists that suggests a need for the user to increase doses for equivalent effect. Such a mechanism does, in fact, exist. As described in the related article on physiological effects of steroid use, our hormone system is a feedback loop. A simple summary is as follows: our bodies maintain a physiologically normal level of testosterone (and other essential hormones). The level defended varies for each person, and over the life span, but is fairly stable over a several year period. Should the testosterone level drop, it is detected, and the increases in the hormones that stimulate, or increase production of the male hormone. Should the level increase, the reverse occurs. That is, the body decreases production of hormones which stimulate testosterone production, and, in turn, lowers testosterone level. Anabolic steroids are recognized by the body as similar to testosterone. When an athlete supplements their natural hormone level, the body responds by dropping its production of endogenous, or internally-produced testosterone. As time passes with ongoing use, greater doses are required to compensate for the decrease in the body's testosterone production. Should the body's natural level of testosterone be depressed for a sufficient period of time, even decreasing or discontinuing external hormone supplementation will not result in a return to normal testosterone levels. In our related article, decreased sperm counts and testosterone level, and impotence were cited as persistent side effects of long-term steroid use. In simple terms, these are the mechanisms for these negative effects.
While the issue of the existence of tolerance is less clear, some mechanisms have been identified, mentioned briefly above, which suggest that this may exist as well. As discussed in the related articles on physiological effects of use of anabolics, specifically with regard to breakdown and elimination of androgens, the liver, and most specifically, a specific enzyme subsystem is responsible for breakdown of anabolic steroids into component metabolites, and these metabolites are excreted via the kidneys. As with any toxic element introduced into the body, anabolic steroids and extrinsic hormones are broken down, and removed. This is done with a cost to the body, however, in damage to the systems responsible. The longer the time these systems are exposed, and the greater the level of toxicity, either by the nature of the substance, itself, or via elevated doses, the greater the damage that results. One of the end effects of this damage is lower processing capacity, and therefore, less bioavailability and a greater percentage of the original substance excreted unchanged via the kidneys. In short, the more you take, the less useable it is. To achieve the same physiological effect, greater doses are used. It should be pointed out that there are no reported cases of overdose of anabolic steroids. Rather, users are willing to tolerate greater levels of side effects for the desired effect.
Withdrawal:
In substances such as alcohol, withdrawal reactions which may be directly life threatening, i.e., delirium tremens, may be experienced. Such responses are unreported in discontinuing anabolic steroids. However, measurable physical changes are evident, such as changes in liver enzymes, hormonal effects (discussed above, and elsewhere), changes in body mass and fat distribution, and psychological changes, which include mood symptoms, cravings, and changes in sexual and immune functioning. These are experienced as negative and undesired by those experiencing them, and when combined with psychological and emotional factors, mitigate in an across-the-board withdrawal reaction. This is often so severe as to result in the abuser resuming the use of the drug(s).
Increasing usage:
In both anecdotal reports, and in systematic investigations of usage of anabolic steroids, dosages used are routinely above those recommended for these substances by the manufacturers. Usage patterns such as stacking and pyramiding are aimed at maximizing the desired effects through using sometime massive doses of these drugs. Tracing the patterns of use over time in heavy users indicates that most started with relatively low doses during initial cycles, or periods of use, and progressed to higher doses and a wider variety of substances used. Reports of users reflect their efforts to increase effects: ever increasing strength, faster strength and mass gains, and shorter recovery time.
Desire or efforts to decrease use:
While many users see anabolics as an essential part of heavy training, all of those known to these authors who are willing to discuss their use have expressed a desire to cut down, or to "go clean." When faced with the possibility of serious side effects, most, if not all consider whether they want to continue using. Unfortunately, most abusers are unable to tolerate the loss of strength, decreasing gains, and changes in motivation and aggressiveness that results from such decreases. It is a clear, and unarguable medical fact, at least now, that steroids work. And that effectiveness often cuts short efforts to decrease or discontinue use.
Time spent in obtaining, using, or recovering:
While "hangover" effects have not been identified with use of steroids, recovery time following a cycle has been. For those who cycle on and off, a significant period is required for the body to normalize, and for the individual to experience a decrease in side effects related to discontinuing. In this way, recovery time from use of anabolics is similar to that seen in the "dry out" period in alcoholics and drug addicts in periods of sobriety. Interestingly, with permanent physiological changes which accompany long term, or heavy steroid use, this recovery time may well reflect a permanent physical readjustment or adaptation, rather than a shorter period in which the body "rebounds to normal."
Heavy use of anabolics often involves complex regimens of various drugs, taken at different times of the day, and over the weeks, and differing modes of use (i.e., oral, injectable, etc.) This has been referred to as the "ritual of abuse" in other drugs, and appears alive and well in the use of anabolics as well.
Finally, users are well known to go to great lengths to acquire, and secure a stable supply of anabolics. One only need consult the internet to find forums devoted to assistance with dosing, outlets for purchase, and discussions of positive and negative effects. While likely representing only the "tip of the iceberg," travel to Mexico to purchase legal steroids, available at most pharmacies is well known. Arrests for possession of drugs that are illegal in this country when entering the U.S. are probably the most common apprehensions of anabolics abusers and traffickers.
Time spent involved in use:
Comments in this section are likely redundant, but a brief overview yields the following obvious conclusion: if a person spends a significant amount of time buying, using, and recovering, and a great deal of money purchasing anabolics, as well as time training while using and recovery after stopping, it only stands to reason that use of steroids constitutes a significant theme in the life of the user. Those heavily involved must sacrifice friends, financial security, health, to do so.
Persistence in the face of serious side effects:
Prior articles well described the negative and unwanted physical effects of use of steroids. These are noticeable to the user, and to those around them. Loss of feminine attributes, and/or development of (exaggerated) male characteristics, as well as loss of physical health do not seem to deter those using from doing so. Denial mechanisms, social support, and focus on the positive effects render the negatives unnoticed by many users, or unimportant, at least until the competitive career of the athlete is over. Unfortunately, by then many of the effects are irreversible. The first author is acquainted with lifters who have continued use of drugs in the face of impending liver failure, developing cardiac problems, and loss of friends, family, and job. Many have ended their careers with little to show for the damage they have done to themselves and to those they care about.
Conclusions with regard to dependency:
It is our conclusion that dependency on anabolic steroids, while unreported in the literature, can be clearly established. The patterns of use parallel those of other drugs of abuse, such as alcohol, stimulants, and narcotics. While physical withdrawal mechanisms cannot be unequivocally defined, negative physical changes and psychological dependency constitute a full-blown and diagnosable clinical entity. Steroids are addictive. Their use has harmful physical, social, and emotional consequences that are often lifelong. These drugs are as addictive as many illicit, recreational drugs.
Cognitive distortions or "thinking errors":
Those who use anabolics in the face of information that they are both harmful and not allowed engage in a number of cognitive strategies which defend their use, or reduce psychological discomfort. Psychological theory posits the power of thought in driving behavior, reducing emotional consequences of uncomfortable actions, and in defining moral action. In short, we can "think away" guilt, and our morals and standards follow the thoughts we rehearse. Because of this, users of substances are able to persist in using in the face of condemnation by the public and those close to them, and will engage in behavior including lying and stealing (and other illegal actions) to continue or to justify using. Some of the "thoughts" or thinking strategies are discussed below. Examination of them may be helpful in understanding why organizations which test for banned substances are faced with continuing efforts on the part of some athletes to "beat the test," rather than just follow the rules spelled out by with regard to doping control.
"Everybody's doing it":
Many users, as reflected in interviews of those who have failed drug tests and received suspensions in USA Powerlifting, appear to believe that, or at least state that "everyone uses drugs." The logic is that their use is justified because of this. This belief is supported by a number of subsidiary distortions, including, "if they can beat me, they must be using," and, "no one can be that strong without drugs." Perhaps this springs for essential self-centeredness, as in, "I am the best."
A related distortion is that all foreign lifters use drugs, and that their use is supported by the government. Subsidiary distortions include that belief on the part of the athlete that "we have to do it if they are." In some twisted way, drug use is justified on a patriotic basis.
"They really don't mean it":
This distortion is invoked when an individual makes a declaration as to their drug free status which is a lie (no point in sugarcoating it). When the signator convinces themselves that "it is just for show," or that "it only applies to local (national, elite, take your pick) athletes," it is possible to disregard what is being asked. This distortion may be supported by the subsidiary thinking error, "I didn't fail in this organization, so it doesn't count."
"I am only using a little":
This is fairly straightforward, but bears a quick note of explanation. Each athletic body testing operationalizes drug use as no use. Some athletes commit thinking errors through mental manipulation of the concept of "clean". As organizations, it is a black and white issue, with no gray areas. These authors have known athletes who considered themselves "clean" when they reduced to minimal doses or single drugs, or when they convert to over-the-counter products that are "legal."
"It doesn't' matter to anyone but me whether I use":
Some lifters consciously ignore the consequences of their use on fellow competitors. If a lifter wins who should not be eligible, those who did honor the rules lose a place, and the rewards that go with the relatively better performance. This distortion may be supported by thinking errors such as, " it's my body and nobody's business what I put in it."
"I've been treated unfairly by (fill in the blank), so it's O.K. if I try to beat the test":
The thinking error involved in this cognitive distortion is that "the system" or the organization is responsible for any perceived wrongs that individual has experiences. In powerlifting, it may involve getting a bad call, getting overlooked for a world team, missing a qualifier, etc. However it is spun off, a perceived wrong is used to justify setting aside the rules or ignoring the consequences of drug use.
"I need (fill in a drug), for (e.g., health, medical reasons, etc.), so it is O.K. to use it":
One of the circumstances that frequently occurs in drug tested athletics is when an athlete is prescribed a medication which is not allowed under current drug testing rules. It is not uncommon for athletes, some of whom have legitimate physical disorders, to justify their entry into drug tested competition on the basis of having received the substance in question from a physician. However, the rules as to which substances are allowed are very clear, and some are not allowed under any circumstances, including while under a doctor's care. The cognitive distortions involved in circumstances such as these are, " my doctor knows better (which may be true)." However, the issue involved has no gray area; some medications may not be used. As unfortunate as it is, this restricts some athletes from competition. In many circumstances, alternative medications may be substituted. This is not likely to happen, however, if the athlete thinks they are entitled to use any medication their physician prescribes.
Conclusions:
Athletes engage in a number of strategies to justify setting aside rules on drug testing, and ignoring or minimizing the effects of their use of anabolics. Those discussed above only represent a small fraction of the thinking errors seen when this specific behavior is being justified. Drug testing, and the perspective of USA Powerlifting is very clear, and not open to interpretation. When signing the membership contract, an athlete is swearing on his or her honor that they have not used banned substances. One must conclude, in the case of some who attempt to "beat the test" that a deficiency of honor is at the root of the problems in thinking.
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