Initial visit: Road rage or ‘roid’ rage?
Mr. A, 25, was arrested after police interrupted an altercation between him and a senior citizen at a stoplight. He had emerged from his car, walked over to the older driver in front of him, ripped open the car door, and pulled the man out of the car and onto the street. He was still yelling at the victim when a passing officer intervened.
Mr. A was charged with assault. After a plea bargain, he was sentenced to probation and fined. He had been seeing his probation officer every 2 weeks, but his parents were worried about his erratic and sometimes defiant behavior and insisted he see a psychiatrist. He reluctantly agreed to one consultation, largely because his parents threatened to withhold financial support if he failed to do so.
The first thing the psychiatrist noticed was Mr. A’s striking muscular appearance. He was approximately 5 feet, 7 inches tall, weighed at least 200 pounds, and had a 30-inch waist and less than 10% body fat.
Dr. Carter’s and Pope’s observations
Mr. A’s diagnosis should be suspected immediately upon his entering the office. Extensive anabolic steroid use produces body changes that can be diagnosed almost at a glance. It is virtually impossible to achieve a level of muscle mass comparable to what Mr. A exhibited without the use of anabolic steroids.1
Remarkably, however, most people—including Mr. A’s parents, law enforcement personnel, and even some members of the treatment team—failed to diagnose Mr. A’s steroid use. He somehow convinced them that his extreme muscularity was the result of hard work, dedication, and scrupulous attention to diet. This suggests that steroid abuse cases involving serious violence—such as that of Mr. A—frequently go unreported and undiagnosed and are probably more common than we suspect.
Epidemiologic data suggest that clinicians should become familiar with the presentation of patients who are using anabolic steroids (Box).
Evaluation: ‘Stacking’ up
Mr. A at first vehemently denied that he had ever used anabolic steroids. After a more detailed conversation, during which the clinician demonstrated some knowledge of this area, Mr. A eventually conceded that he was taking a substantial weekly dose of the drugs at the time of the assault.
A subsequent clinical evaluation revealed that Mr. A had taken several ‘cycles’ (courses) of anabolic steroids over the last 2 to 3 years. Each cycle lasted 10 to 16 weeks and had been characterized by simultaneous use of two or more steroids, a practice known as ‘stacking.’
Mr. A started his first cycle with a modest ‘stack’ of drugs: testosterone cypionate, 200 mg twice a week, and stanozolol, 10 mg/d. Taken together, these dosages represented roughly 470 mg of testosterone equivalent per week—about 10 times the weekly secretion of testosterone in a normal male. He noticed no change in mood during this initial cycle.
With subsequent cycles, however, Mr. A became increasingly obsessed with his body image and used higher dosages. When the assault occurred, he was taking testosterone cypionate, 800 mg a week, nandrolone decanoate, 400 mg a week, and oxymetholone, 50 mg/d. With this regimen—the weekly equivalent of 1,550 mg of testosterone—Mr. A noticed prominent mood changes that met DSM-IV criteria for a manic episode. He experienced euphoria, dramatic irritability, limitless self-confidence, decreased need for sleep, distractibility, extreme recklessness (driving too fast, spending too freely), and some mildly paranoid ideation (without frank delusions). He admitted that he had twice assaulted his girlfriend and that he invariably became enraged at even the slightest annoyance when driving in traffic. He revealed that although the altercation with the older driver had led to his first arrest for ‘road rage,’ it was his third such incident.
The clinician warned Mr. A that continued steroid use could worsen his behavior—and lead to more serious trouble later on. Mr. A, however, said he was more afraid of losing muscle mass and becoming ‘small again.’ When the clinician mentioned that use of anabolic steroids without a prescription is illegal, Mr. A retorted that several of his friends had used the drugs without legal consequences.
Mr. A left the office showing no inclination to return for further treatment. The clinician could only offer to be available in the future.
The National Household Survey on Drug Abuse, which last assessed anabolic steroid use in 1994, estimated that about 1 million Americans had used anabolic steroids at some point, with 30% of those reporting use within the previous year. Among subjects who reported use within the last 3 years, the ratio of males to females was about 13 to 1.2
Clearly, anabolic steroid abuse is no longer exclusive to professional football players and other elite male athletes. In fact, more people appear to be using anabolic steroids to improve their physiques, rather than to enhance athletic performance.3 Evidence points to increasing use by adolescents, with one survey reporting current or past use by 6.6% of male high school seniors.4