NASP Communiqué, Vol. 34, #7
Pediatric School Psychology
Steroids in Adolescence: The Cost of Achieving a Physical Ideal
By Sarita Gober, Malky Klein, Tzippy Berger, Cristina Vindigni & Paul C. McCabe, NCSP
Media accounts of young athletes committing suicide have recently captured the national spotlight (e.g., Wilson, 2005). What appeared unique about these adolescents and young adults is that they were also using steroids to enhance performance and increase body mass prior to their deaths. Their deaths were attributed to steroid use by their families and physicians, as they committed suicide shortly after discontinuing their use. Many questions followed, including Congressional hearings on March 17, 2005, to investigate the prevalence of steroid use in adolescents as well as possible links to suicidal ideation and/or intent (Government Reform Minority Office, 2005). It has been argued by many medical experts and researchers that adolescents are susceptible to negative effects from steroid withdrawal as they are particularly vulnerable to hormonal swings (Wilson, 2005). This article will review the neurobiological mechanisms of steroid effects, the possible relationship with psychological states such as mood, cognition, and suicidal behavior, and implications for school psychologists.
Overview of Steroids
Anabolic-androgenic steroids (AAS) are man-made substances related to male sex hormones. Anabolic refers to muscle-building, and androgenic refers to increased masculine characteristics. Steroids are legally available only by prescription to treat conditions that occur when the body produces abnormally low amounts of testosterone, such as delayed puberty and some types of impotence. They are also used to treat body wasting in patients with AIDS and other diseases that result in loss of lean muscle mass (National Institute of Drug Abuse, 2005).
There are more than 100 different anabolic steroids that have been developed (NIDA, 2005). Most steroids that are used illegally are smuggled in from other countries, illegally diverted from U.S. pharmacies, or synthesized in clandestine laboratories (NIDA, 2005). The most commonly encountered anabolic steroids on the illicit market include testosterone, nandrolone, methenolone, stanozolol, and methandrostenolone (Sharma, 2005). When used in combination with exercise, training, and high protein diets, anabolic steroids can promote increased size and strength of muscles, improve endurance, and decrease recovery time between workouts (Sharma, 2005).
Anabolic steroids are synthetic androgens that have been modified to maximize their anabolic properties while minimizing their androgenic properties. Androgens are defined as any molecules that are converted to testosterone in the body. Testosterone is a sex hormone that is essential to maturation and sex differentiation. When derived from the ingestion of steroids, however, testosterone contributes to the building of lean muscle mass (Millman & Ross, 2003). Steroid use causes the body to retain nitrogen that is ordinarily lost via urinary excretions. This retention, when combined with exercise, leads to muscle growth through the formation of new fibrils (Ward, 1973). Anabolic steroids occupy corticosteroid receptors in muscle cells, stimulating the production of tissue-building proteins and mediating the enzyme systems that metabolize such proteins (Millman & Ross, 2003).
Steroid hormones are derived from cholesterol lipids. Lipid solubility eases their crossing of cell membranes, allowing binding with intracellular receptor proteins. Steroids affect the surface of cells and ion permeability, as well as neurotransmitter, neuropeptide, and hormone release. The receptors to which steroids bind have common amino acid sequences with one another (Beato, 1989; Evans & Arriza, 1989). Corticosteroid receptors form part of this family and have been implicated in neurotransmitter action related to mood, behavior, and cognition (Gonzalez, McLachlan, & Keaney, 2001).
Side Effects of Steroid Usage
According to the National Institute on Drug Abuse (NIDA), anabolic steroids, particularly those in high doses, increase irritability and aggression. Some steroid abusers report that they have committed property crimes, such as stealing from a store, damaging or destroying others’ property, or breaking into a house or a building. Abusers who have committed aggressive acts or property crimes generally report that they engage in these behaviors more often when they are actively taking steroids (NIDA, 2005). Anabolic steroids have also been reported to cause other behavioral effects, including euphoria, increased energy, sexual arousal, mood swings, distractibility, forgetfulness, and confusion. Some studies of steroid usage have reported that a minority of their subjects develop behavioral symptoms that were so extreme that they disrupted their ability to function at work or in social settings. In a few cases, the subjects’ behaviors presented a threat to themselves and others (NIDA, 2005). Other symptoms described among AAS users included increased risk-taking behavior, extreme egocentrism, cognitive rigidity, altered physical identity, increased feelings of superiority, and extreme mood changes (Gonzalez, McLachlan, & Keaney, 2001).
Among men, heightened levels of testosterone lead to decreased luteinizing hormone (LH) and follicle stimulating hormone (FSH), both of which are required for spermatogenesis. The results are decreased sperm count, atrophied testicles, and impotence. Although sperm counts usually return to normal after cessation of drug use, testicular atrophy often is irreversible. When excess testosterone from steroids is converted to estrogens, male users may suffer from gynecomastia, in which breast-like tissue develops (Millman & Ross, 2003). In the female body, anabolic steroids cause masculine effects, such as hirsutism (abnormal hair growth), deepening of voice, clitoral hypertrophy, and male pattern baldness, and are irreversible (NIDA, 2005). Acne, increased libido, and menstrual irregularities also may be observed (Millman & Ross, 2003).
Steroids may affect growth and maturation. Rising levels of testosterone and other sex hormones normally trigger the growth spurt that occurs during adolescence. When these hormones reach certain levels, they signal the bones to stop growing. When a child or adolescent takes anabolic steroids, the artificially increased level of sex hormones can signal the bones to stop growing prematurely (NIDA, 2005).
Steroid abuse is associated with cardiovascular disease, including heart attack and strokes, even in athletes younger than 30 (NIDA, 2005). Continued use may lead to elevation in certain liver enzymes, which in turn can bring about cholestatic jaundice, a serious and potentially fatal condition (Millman & Ross, 2003). Steroids are also associated with liver tumors and a rare condition called peliosis hepatis, in which blood-filled cysts form in the liver. Both the tumors and the cysts sometimes rupture, causing internal bleeding (NIDA, 2005).
Adolescents and Steroids
According to NIDA, more teenagers are actively using steroid drugs while fewer are worrying about the dangers. In 2005, there was an increase among 10th grade boys from 2% to 2.7% (WebMD Medical News). According to NIDA Director Dr. Alan Leshner, steroid use has increased 50% in 8th graders and 10th graders since 1991. The period of risk of AAS dependence starts during secondary school. Approximately 6.6% of male high school seniors had used AAS during the pervious year (Gonzalez, McLachlan, & Keaney, 2001). NIDA estimates that 500,000 young Americans are currently using steroids.
As reported by the NIDA, national surveys indicate that girls account for about one-third of the high school students who abuse steroids. Many girls who take steroids have eating disorders, and those taking steroids are usually engaged in athletic activities. The primary reason offered by girls who use steroids is to lose fat and gain lean muscle. However, most research has focused on the male prototype and only recently have studies begun to examine females who take steroids.
Adolescents become increasingly aware of their bodies and others’ reactions to them. They often struggle with accepting their own appearance and strive for approval from others (Stout & Wiggins Frame, 2004). The media, peer pressure, and self-perception often serve as important factors influencing their decisions. Research suggests that these factors may also play a role in an adolescent’s decision to use steroids (Smolak, et al., 2005).
Pressure from media and parents. The media’s depiction of the ideal physique includes well-defined muscles and low body fat. Researchers studied popular men’s magazines and found that over the past few decades there has been an increase in numbers of articles focusing on strengthening and building muscles (Morrison, et al., 2004). Studies show that people assign positive characteristics such as assertiveness, confidence, and popularity to images of muscular men. Negative descriptors, such as lonely and depressed, are used to describe those who do not posses the physical attributes idealized by the media (Morrison, et al., 2004). Adolescent boys, who are in the midst of deciding who they want to be as adults, may internalize these messages and strive to attain the appearance that is positively portrayed (Stout & Wiggins Frame, 2004; Smolak, et al., 2005). Parental pressure in the form of negative comments and a focus on physical appearance was also correlated with motivation of adolescents to build muscles and take steroids (Irving, et al., 2002; Smolak, et al., 2005). Internalization of these media and cultural biases lead to greater body dissatisfaction and is associated with steroid abuse (Smolak, et al., 2005).
Disturbance in body image. Body image can be defined as a construct by which to view how a person understands, feels and behaves in regard to their physical characteristics. The construct can be further understood in terms of body image evaluation and investment. The former describes how a person perceives their physical appearance while the latter refers to the effort a person invests into changing their appearance (Morrison, et al., 2004). To date, little research is available on body image in males (Stout & Wiggins Frame, 2004). Body builders are at greater risk for disturbances in their body image (Kindlundh, et al., 2001). The muscular physiques featured in the media are very difficult to achieve through healthy means, and may be a result of anabolic steroid usage, dehydration, and other unhealthy practices (Stotu & Wiggins Frame, 2004). Researchers describe a body image disorder called muscle dysmorphia (MD), which is an extreme preoccupation with one’s body, poor insight into actual body size or weight, and rigid dietary practices. In addition, the disorder may contribute to impairments in social or occupational functioning. MD has been described in both males and female who weight train, as well as individuals who abuse anabolic steroids (Volkow, 2005). MD is becoming more common among adolescents, and studies have shown that MD in adolescence can affect one’s body image well into adulthood (Stout & Wiggins Frame, 2004). The disorder is associated with greater body dissatisfaction, depression, and perfectionism, and is characterlogically similar to women with eating disorders (Stout & Wiggins Frame, 2004). In addition, researchers have linked the presence of average to low self-esteem and poor school achievement with steroid usage (Kindlundh, et al., 2001).
Psychological Side Effects of Steroid Use
Although the adverse physical effects of steroid use have been widely reported, fewer studies have examined the psychological effects of steroid use. Recently media attention and congressional hearings have raised the question of a possible link between steroid use and suicide. Although suicide causality has not been verified, a number of studies have established that steroid use can result in harmful psychological effects.
Aggression is frequently cited as one consequence of steroid use (Burnett & Kleiman, 1994). High doses of steroids can increase aggression, and have been implicated in numerous instances of violence and aggression by athletes and body builders (Trenton & Currier, 2005). While there is usually a weak link found between aggression and anabolic steroids, very high doses, such as those taken by body builders and athletes, have been shown to trigger aggressive and violent behavior. While steroids can trigger negative reactions in any age group, it is during the teenage years that aggressive inhibitors are being developed. Steroids, such as testosterone, can interfere with brain development and may alter long-term capacity for aggressive inhibition (Benson, 2002).
Other studies examining the psychiatric effects of anabolic steroids have found them to cause or intensify psychiatric symptoms. Pope and Katz (1988) found significantly more frequent affective and psychotic symptoms during steroid exposure. Twenty-two percent of 41 body builders and football players presented with a full affective syndrome during periods of steroid use while 12% met DSM-III-R criteria for psychotic symptoms, such as auditory hallucinations and paranoid delusions. Examples of psychotic features included a subject who developed the paranoid delusion that his friends were stealing from him while another developed the grandiose delusion that he could pick up a car and tip it over. Impulsive and manic behaviors were also evident, such as a 23-year-old man who purchased a $17,000 sports car while using steroids—upon stopping to take the drug, he realized he could not afford the car and sold it, only to buy a $20,000 sports car the following year during another cycle of steroid use.
In their review of published literature regarding steroid use and its ramifications, Trenton and Currier (2005) found several adverse psychological effects associated with steroid use. One study found that mood changes occurred within days of initiating anabolic steroids, and other studies reported that their subjects experienced mania in association with steroid use. Another study compared athletes who were steroid users to those that were not steroid users. They found that 23% of the athletes using anabolic steroids experienced one or more manic episodes, hypomanic episodes or major mood syndromes, such as major depression (Pope and Katz, 1994).
Often, the cessation of steroid use can also result in adverse psychological effects. Depression is a common consequence of steroid withdrawal (Trenton & Currier, 2005). Pope and Katz (1988) found that 12% of their subjects developed major depression upon withdrawal from steroids. Similarly, severe depression can occur during withdrawal and, if not treated properly, can result in suicide (NIDA, 2005). Although suicide has been associated with steroid use, the direct relationship is not yet clear. Often suicides completed while the individual was actively using steroids occurred in conjunction with manic behavior and were more impulsive in nature. However, suicide completed during withdrawal was often premeditated and in association with severe depression. In either circumstance, anabolic steroids may have been one of the factors contributing to the completion of suicide (Trenton & Currier, 2005).
Although causality has not yet been established (Trenton & Currier, 2005), there may be certain psychological characteristics that influence the use of steroids by adolescents. Ricciardelli and McCabe (2003) found that low self esteem predicted body dissatisfaction among adolescent boys and girls, a trait which has been correlated with steroid use. Burnett and Kleiman (1994) were unable to find unique personality characteristics that differentiated athletic adolescents who used and did not use steroids. There is no definitive evidence as to whether a particular personality characteristic predisposes an adolescent to steroid use or whether negative psychological symptoms emerge as a result of steroid use.
Limitations of Literature
There is a paucity of studies of the psychological effects of steroid use. One reason is that most studies utilizing experimental trials do not use the high dose of steroids that may cause harmful psychological side effects, as it would be unethical and potentially lethal to do so. The common doses that are used by steroid abusers are 10 to 100 times higher than the amounts used in research (Pope, Phillips, & Olivardia, 2000). In addition, the common practice of “stacking”— where users combine several different types of steroids to maximize their effectiveness—can be a large contributor to these psychological symptoms. However, stacking is not used in the controlled research setting (Pope & Katz, 1988). For this reason researchers have suggested that steroid use should not be studied in laboratory or clinical settings but rather in a natural setting where the actual doses and combinations can be noted and their effects can be identified (Pope & Katz, 1988; Pope et al., 2000). In addition, many athletes do not reveal the amount of steroids that they are taking to their physicians, or even whether they are using steroids at all. Therefore, doctors rarely associate psychiatric and psychological affects with steroids (Pope et al, 2000).
Implications for School Psychologists
Awareness of the detrimental effects that steroids can have on individuals, particularly adolescents, is a key knowledge set for school psychologists. Given the growing popularity of steroid use among adolescents, school psychologists need to be able to identify students who may already be taking steroids or those who may be at risk for taking them. A profile for students that may be taking steroids may include those who are athletes and those who report a poor body image.
One of the main problems concerning adolescents and steroid use is that adolescents are unaware of the many negative side effects (Johnson, Jay, Shoup, & Rickert, 1989). According to a study by Johnson et al. (1989) some adolescents even have false information about what steroids can do to their body, such as increasing their height and aerobic performance. In addition, many adolescents begin taking steroids because they want to improve their physical appearance—they are often unaware that in order to increase their muscle size and strength, they must perform exercise in addition to using steroids. The first step for school psychologists is to increase the awareness of these effects among adolescents.
There are several strategies recommended for school psychologists in addressing individuals who have concerns related to their body image (Stout & Wiggins Frame, 2004). Individual counseling with a cognitive behavioral approach is often recommended and Ellis’ rational emotional behavior therapy in particular has been suggested. Another recommended approach is group counseling within the school, as peer groups can have positive effects on adolescent behavior change (Johnson et al., 1989). It can be particularly valuable for boys to learn about peers who feel the same way within an atmosphere of support. Peer counseling may also be effective, because peers are a major source of information concerning steroids (Johnson et al., 1989). In addition, healthcare providers need to play a larger role as an information source to adolescents regarding the adverse effects of steroids.
Parents also play a significant role in the life of their teenager. School psychologists can organize informational and support groups to raise awareness about the seriousness of body image disorders and steroid use among parents (Stout & Wiggins Frame, 2004). Pope and others (2000) outline interventions for parents if they suspect their child may be suffering from a body image disorder. Some of these interventions include talking to their children about the unrealistic body images in society, refraining from criticizing their appearance, and helping them look for other sources of self-esteem instead of their bodies. In addition, teachers and coaches also play a significant role in the lives of adolescents. School psychologists can help ensure that teachers and coaches have the appropriate outlook on body image and that they set appropriate goals encouraging their students (Stout & Wiggins Frame, 2004). Coaches need to establish a no-tolerance policy for steroid use, no matter how competitive the sport may be, or how pressured the coaches feel to produce a winning season.
Other programs have been successful in thwarting current and future steroid use. One Swedish study focused on improving appearance and self-confidence in males as a way to prevent steroid use (Nilsson, Allebeck, Marklund, Baigi & Fridlund, 2004). A NIDA-funded drug abuse prevention program called ATLAS has been implemented in a number of schools and is reported to have reduced steroid use among more than 1,500 football players from 31 high schools in the Portland area (Goldberg et al., 1996). The program educates student athletes about the harmful effects of anabolic steroids and provides nutrition and weight-training alternatives to steroid use. The weight-training component includes seven hands-on sessions that teach the students proper weight training techniques. These sessions are designed to help student athletes build the muscular strength needed to achieve their athletic goals without using steroids.
School psychologists can assess the needs in their school and modify the type of program that is appropriate for their student body. Given the dangers of anabolic steroids, as well as the growing number of adolescents who use them, it is crucial that school psychologists be vigilant regarding students who are at-risk or are using steroids and implement appropriate interventions.
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© 2006, National Association of School Psychologists. Sarita Gober, Malky Klein, Tzippy Berger, and Cristina Vindigni are graduate students in Graduate Program in School Psychology at BrooklynCollege – CUNY. Paul McCabe, PhD, NCSP, is an Associate Professor in the Graduate Program in School Psychology at BrooklynCollege – CUNY, Brooklyn, NY, and a Contributing Editor to the Communiqué.