PSYCH 091: Anabolic-Androgenic Steroid-Related Disorders

A famous bodybuilder walks into Medlock Holmes’ consulting room.

He is physically magnificent.

Broad shoulders. Sculpted chest. Powerful arms.

Yet Holmes notices something else.

The man cannot stop looking at his reflection.

Every polished surface becomes another mirror.

Every missed gym session feels catastrophic.

Every slight reduction in muscle size feels like losing part of himself.

Holmes quickly realises that this is not simply a story about muscles.

It is a story about identity.

Most people think anabolic-androgenic steroids (AAS) are drugs used by elite athletes chasing Olympic medals.

Holmes discovers the opposite.

Today, most users are ordinary men seeking a more muscular appearance rather than sporting success. The average age of first use is approximately 23 years, much later than most other illicit substances, and use is overwhelmingly confined to males.

Holmes begins by separating two commonly confused substances.

The drugs used by bodybuilders are anabolic-androgenic steroids, synthetic derivatives of testosterone designed to increase muscle growth while also producing masculinising effects.

These are entirely different from corticosteroids such as prednisolone, which reduce inflammation and have virtually no muscle-building properties. Confusing these two families of steroids remains remarkably common among both patients and clinicians.

The detective then asks a more interesting question.

If testosterone is a natural hormone, why does it become dangerous?

The answer lies in dosage.

Medical testosterone replacement simply restores normal physiological levels.

Illicit users often consume 10 to 100 times therapeutic doses, frequently combining several different steroids simultaneously (”stacking”) to achieve enormous supraphysiological androgen concentrations.

The result is extraordinary muscle growth.

But Holmes knows that biology never grants gifts without demanding payment.

As the investigation progresses, Holmes uncovers a fascinating paradox.

The body becomes stronger.

The brain becomes less stable.

Most users experience little psychiatric disturbance.

However, a vulnerable minority develop profound psychological changes.

Some become unusually energetic.

Need less sleep.

Feel invincible.

Become impulsive.

Spend recklessly.

Display intense irritability.

Others develop frank mania or even psychosis with grandiose or paranoid delusions. The risk increases substantially with higher steroid doses, particularly above the equivalent of 1,000 mg of testosterone per week.

Then comes the opposite problem.

When the steroids stop, testosterone production collapses.

The hypothalamic-pituitary-testicular (HPT) axis has been suppressed by months of external hormones.

Instead of euphoria comes exhaustion.

Instead of confidence comes depression.

Instead of libido comes sexual dysfunction.

Some men become severely depressed during withdrawal, and a minority require antidepressants-or even electroconvulsive therapy-for prolonged episodes.

Holmes soon encounters the most surprising diagnosis of all.

Muscle dysmorphia.

Unlike anorexia nervosa, where individuals see themselves as larger than they are, these men see themselves as too small, even when objectively extremely muscular.

Every mirror lies.

Every comparison hurts.

Every kilogram of lost muscle feels like personal failure.

This distorted body image becomes one of the strongest drivers of continued steroid use.

Holmes realises the steroids are no longer building muscle.

They are medicating fear.

The detective next investigates dependence.

Unlike cocaine or heroin, anabolic steroids produce relatively little acute intoxication.

Yet dependence still develops.

The textbook describes three interacting pathways.

First, body-image anxiety drives repeated use because individuals fear losing muscularity.

Second, endocrine withdrawal causes hypogonadism, depression, fatigue, reduced libido, and erectile dysfunction, encouraging users to restart steroids simply to feel normal again.

Third, steroids themselves possess rewarding properties through actions involving dopamine, GABA, and opioid systems, producing feelings of confidence, power, and occasionally euphoria.

Dependence therefore becomes far more complex than simple drug reward.

It is simultaneously psychological, hormonal, and neurobiological.

Holmes then turns his attention to the body.

The muscles tell only half the story.

Years of steroid exposure may produce:

• Dilated cardiomyopathy

• Accelerated coronary artery disease

• Hypertension

• Dyslipidaemia (↑ LDL, ↓ HDL)

• Polycythaemia

• Persistent hypogonadism

• Infertility

• Tendon rupture

• Liver injury (particularly with oral 17-α-alkylated steroids)

• Possible cognitive impairment associated with long-term exposure

Ironically, muscles often become stronger than the tendons attached to them.

Holmes notes that some tendon ruptures occur not during heavy lifting-but during ordinary daily activities.

Finally, Holmes asks the question that truly matters.

How do you treat someone whose identity has become chemically reinforced?

The answer is not simply to stop the steroids.

Recovery requires rebuilding three different systems.

The distorted body image requires cognitive behavioural therapy and sometimes serotonergic antidepressants.

The suppressed endocrine system often requires careful management by an endocrinologist using physiological testosterone replacement, clomiphene, human chorionic gonadotropin (HCG), and gradual restoration of the HPT axis.

The dependence itself may require addiction-focused psychological treatments similar to those used in other substance use disorders.

Holmes closes the case with one final observation.

Muscles can be measured.

Strength can be tested.

But insecurity has no visible weight.

Sometimes the heaviest burden carried by the strongest-looking person in the room is the belief that they are still not enough.

Key Takeaways

• Anabolic-androgenic steroids (AAS) are synthetic derivatives of testosterone used primarily to increase muscle mass and physical appearance.

• Most users are non-athletes seeking improved body image rather than sporting performance.

• Typical onset of use occurs around 23 years of age, much later than most illicit substances.

• AAS are distinct from corticosteroids such as prednisone.

• Illicit users commonly take 10–100 times therapeutic testosterone doses through “stacking” multiple preparations.

• Most users experience few psychiatric effects, but some develop hypomania, mania, psychosis, aggression, or severe irritability.

• Withdrawal commonly produces hypogonadism, fatigue, depression, reduced libido, and erectile dysfunction.

• Muscle dysmorphia is a major psychological driver of persistent steroid use.

• Dependence develops through interacting body-image, endocrine, and reward-system mechanisms.

• Long-term complications include cardiomyopathy, premature coronary artery disease, infertility, dyslipidaemia, tendon rupture, hepatic injury, and possible neurocognitive impairment.

• Management requires psychological therapy, endocrine treatment, and addiction-focused interventions rather than simple detoxification.

• Clinicians should actively enquire about AAS use in muscular men presenting with mood disorders, infertility, cardiovascular disease, or unexplained aggression.