There tends to be alot of info missing in an absract. Here is the rest of the article if anyone wants to read it.
[Anabolic androgenic steroids (AAS) have attracted much attention in the sporting and medical communities over the past decades, as their use by amateur, professional, and body-building athletes has become widespread [1] and [2]. AAS are derived by chemical manipulation of the 19-carbon testosterone molecule, thus exhibiting (in different degrees) all the anabolic and androgenic effects of the parental molecule [3], which is responsible for the production and maintenance of the male physical features, as well as the recognizable male psychological and behavioral attributes [4].
AAS are only legally available with a prescription, and are used to treat body wasting, or conditions when the body produces abnormally low amounts of testosterone [5]. Illegally, AAS are easily acquired “over the counter” or in the black market and are being used by professional and amateur athletes [6] to increase muscle size, reduce body fat tissue and/or enhance athletic performance [7]. AAS have been shown to produce adverse medical [8] and psychiatric/psychological effects [9] and [10]. AAS are expected to produce some degree of psychological change [11] after they have been administered for some time [12]. Aggression [13] and [14] and extreme mood swings can occur, as well as, marked increase in libido, irritability, anger [15], and agitation, paranoid jealousy, delusions, impaired judgment, and feelings of invincibility [16].
The purpose of the study was to investigate the presence of psychopathological side effects (including the increase of aggression and hostility) by monitoring the AAS abuse patterns in the monozygotic twin users, in comparison with their twin brothers who were not using the drugs.
2. Methodology
We conducted an observational case report study involving two pairs of monozygotic twins: two healthy males 24 years old (pair A) and two healthy males 31 years old (pair B). Monozygosity for both pairs was determined by use of the restriction fragment length polymorphism (RFLP) DNA profiling method. Pair A twins, were raised in a provincial Hellenic town, with similar socioeconomic conditions. They had a common path during their educational years (12 years of basic education), had a common manual job at the family enterprise and married at approximately the same age. They were 24 years old, 182 cm high, user 1 weighted 79.6 kg with 12.4% body fat, while non-user 1 weighted 79.1 kg with 11.9% body fat. Pair B twins, were raised in a provincial town in Germany, under similar socioeconomic conditions, before moving back to Greece to study at the University at the age of 18. They followed a common path during their educational years (17 years of higher education) and became professional athletes. Non-user 2 twin was married. The twins were 31 years old, 177 cm height, user 2 weighted 87 kg with 14.2% body fat while non-user 2 weighted 86.8 kg with 13.9% body fat. Pair A is recreational non-competitive weight lifters, while pair B is professional athletes. In both pairs, one of the twins used anabolic steroids in order to enhance his physical appearance and strength [17], while the other refrained from any abuse, thus providing us with the opportunity to study the psychological side effects of anabolic steroids in persons exhibiting absolute genome and phenotype similarity.
We conducted an observational comparative study of this unique case report, which detailed the drug history of the twin AAS users, with their non-user twins acting as controls. The main feature of this study is the monitoring of a self-administration pattern of various AAS in a “cycle”, as it is commonly referred to and practiced in the modern athletic community, while examining the total impact of this abuse in the user's psychological profile.
The Institutional Review Board of the Medical Faculty of the University of Thessaly approved the research protocol. All participants were provided with an information manual stressing the adverse and dangerous for life side effects of AAS abuse. The twins who were not discouraged by our intervention gave a written informed consent prior to their inclusion in the research. The observed user twins were self-applying AAS in regimes that they had obtained by themselves and all AS used were also self-obtained.
An AAS “cycle” typically consists of a combination of multiple oral and/or injectable formulations of different agents, used in supra physiological doses for the span of numerous weeks (varying from 4 to 16) [19]. This modern type of usage is mainly based on anecdotal information and is supported by a strong belief that a combination of some of the most potent AAS with some milder ones, for a sufficient period of time, will effectively produce dramatic results in muscle mass, strength and overall physique improvement. Within a “cycle”, doses of each of the individual AAS used vary from a minimum to a maximum value. Initial modest doses are quickly followed by an escalation in the administered milligrams of each AAS agent which is usually reaching a climax (maximum dose) at least 2 weeks before the cycle's end. This maximum dose is then maintained for the rest of the cycle's duration. Frequent dosage administration and decrease of available injection sites due to the post-administration muscle soreness [20], forces users to incorporate in their “cycle” numerous different potent anabolic oral compounds and some strong injectable ones.
During a self-obtained common AAS “cycle” (Table 1) lasting 12 weeks, the athletes utilized three oral agents and three long-acting injectable products. Dosages of oral preparations tended to be similar to those utilized in efficacy studies, whereas dosages of the long-acting injectable agents were approximately 5–10 times greater than those utilized in controlled studies. Under this spectrum, we had the opportunity to study the psychological side effects of a combination of AAS, in accordance with recent data and drug administration.
Table 1.
AAS “cycle”. Generic names of specific AAS drugs used in the 12 weeks steroid cycle; doses and timing Oxymetholone 50 mg tablets Methandrostenolone 5 mg tablets Oxandrolone 2.5 mg tablets Nandrolone decanoate 100 mg/ml Testosterone propionate 50 mg/ml Stanozolol 50 mg/ml
Week 1 100 mg/day 10 mg/day 100 mg two times/week 50 mg one time/week 50 mg two times/week
Week 2 100 mg/day 15 mg/day 150 mg two times/week 50 mg one time/week 100 mg two times/week
Week 3 100 mg/day 20 mg/day 150 mg two times/week 50 mg one time/week 100 mg two times/week
Week 4 50 mg/day 30 mg/day 150 mg two times/week 50 mg one time/week 50 mg two times/week
Week 5 30 mg/day 10 mg/day 200 mg two times/week 50 mg two times/week 50 mg two times/week
Week 6 40 mg/day 10 mg/day 200 mg two times/week 50 mg two times/week 50 mg two times/week
Week 7 50 mg/day 10 mg/day 200 mg two times/week 50 mg two times/week 50 mg two times/week
Week 8 50 mg/day 10 mg/day 250 mg two times/week 50 mg two times/week 100 mg two times/week
Week 9 50 mg/day 10 mg/day 250 mg two times/week 50 mg two times/week 100 mg two times/week
Week 10 50 mg/day 10 mg/day 250 mg two times/week 50 mg two times/week 100 mg two times/week
Week 11 45 mg/day 10 mg/day 250 mg two times/week 50 mg two times/week 100 mg two times/week
Week 12 40 mg/day 10 mg/day 250 mg two times/week 50 mg two times/week 100 mg two times/week
According to our protocol, during the 12-week use period, all twins followed a common training and dietary regime, personalized on basis of their categorization according to body mass index (BMI) standards [21] and [22]. In order to ensure the validity of use, categorization and study accordance, we monitored drug levels; all used drugs were analyzed and validated by method of liquid chromatography test with identity confirmation by use of mass spectrometry [24], while all participants were subjected to two random and unexpected doping control tests [23].
The observational study lasted 6 months, from the 21st of July 2003, till the 20th of January 2004. In this time period, the users completed a sole AAS “cycle”, but not at the same time interval (user 1 started at the end of July, while user 2 at the end of October), thus explaining the length of the study. The psychometric instruments used were the Symptom Check List-90 (SCL-90) and the Hostility and Direction of Hostility Questionnaire (HDHQ).
The SCL-90 is a 90-item self-report system inventory, of multidimensional nature, developed in the 1980s by Derogatis et al. [25] and is designed to reflect the psychological symptom patterns of community, medical and psychiatric respondents. It is divided into 10 subscales, containing nine dimensions of psychiatric symptomatology: somatization, obsessive–compulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism and includes three symptomatic indexes: general symptomatic index (GSI), positive symptomatic total (PST) and positive symptomatic distress level (PSDL).
The HDHQ was developed by Caine et al. [26] in 1967, designed to monitor hostility and the extent to which a subject expresses it internally or externally. It is an attitudinal measure for a wide range of hostility manifestations, having little implication of aggressive behavior physically expressed. Two dimensions underline hostility as it is measured by the HDHQ: a readiness to respond with aggressive behavior and a tendency to evaluate persons, including the self, in negative terms. It consists of five subscales in 52 items. Three subscales, acting-out hostility, criticism of others and paranoid hostility are measures of extraverted hostility or extrapunitiveness. Two subscales, guilt and self-criticism are measures of introverted hostility or intrapunitiveness. Total hostility is the sum of the five subscales. The accepted score norms for total hostility in normal populations are between 12 and 14.
Both participants would be evaluated with the SCL-90 the day before the onset of the 12 weeks cycle. The results of this evaluation would act as our reference point of original psychological status. At the end of weeks 4 and 8, both pairs would be evaluated by use of the HDHQ, in order to ascertain the level of hostility in two different points in the steroid cycle. The selection of the two evaluation points was plotted in reference to the users' drug regime, so as to coincide with the end of the first increase in drug administration (week 4) and the end of the maximum administered doses (week 8). HDHQ was therefore used as a more selective psychometric instrument, in order to ascertain and explore the expected increase in hostility levels associated with the escalation in drug dosages at the specified time period. The general increase of hostility (from the baseline measurement to the final one) was nonetheless measured by the individualized subscale of the SCL-90. At the end of the 12 weeks cycle, both participants would be re-evaluated with the SCL-90, in order to infer about the appearance of psychological side effects in the user, the status of the control (non-user twin) and the comparison between the final evaluation and the reference evaluation.
3. Results
All participants were primarily studied at the beginning of the 12-week period with the SCL-90, to attain a reference point for our study. For pair A, this first evaluation (Table 2), revealed low distress levels in the interpersonal sensitivity, hostility and psychoticism subscales of the SCL-90 for both twins. This first evaluation revealed that though extremely low, the distress levels of the pair A twin willing to commence use of anabolic steroids, were higher than his twin brother's on the interpersonal sensitivity subscale. For pair B, the first evaluation (Table 2), revealed low distress levels in the somatization, depression, hostility subscales of the SCL-90 for both twins and low distress levels on the paranoid ideation subscale for the future AAS user twin. This first evaluation also revealed that though extremely low, the distress levels of the 31-year-old male twin willing to commence use of anabolic steroids, were higher than his twin brother's on the somatization and paranoid ideation subscales. The results of these primary evaluations were nominated as our reference point for final evaluation and comparison purposes. Factorized scores for the SCL-90 and symptomatic profiles for all twins are represented in Table 2.
Table 2.
SCL-90 first and second (final) evaluations for both pairs Pair A Pair B
User 1 N-user 1 User 2 N-user 2
SCL-90 subscales 1st Final 1st Final 1st Final 1st Final
Somatization 0 0 0 0 3 8 3 2
Obsessive compulsive 0 6 0 0 0 12 0 0
Interpersonal sensitivity 4 9 2 2 0 23 0 0
Depression 0 4 0 0 1 4 1 1
Anxiety 0 1 0 0 0 20 0 0
Hostility 2 20 2 2 2 23 2 2
Phobic anxiety 0 0 0 0 0 15 0 0
Paranoid ideation 0 15 0 0 1 17 1 0
Psychoticism 1 2 1 1 0 12 0 0
GSI 0.089 0.69 0.067 0.067 0.122 1.667 0.122 0.088
Positive symptom total 7 31 6 6 11 50 11 8
Positive symptom distress Level 1.14 2.0 1 1 1 3 1 1
At the end of weeks 4 and 8, the twins were studied by consecutive use of the HDHQ psychometric instrument. Users of both pairs reported much higher levels of hostility in all HDHQ subscales (Table 3). In the non-users, no substantial differences on HDHQ scores between the fourth and eighth week were detected (Table 3). It also noted that in the users of both pairs, the differences on HDHQ scores between the fourth and eighth week were very high in all subscales (Table 3).
Table 3.
HDHQ scoring for all twins, fourth week and eighth week Pair A Pair B
User 1 Non-user 1 User 2 Non-user 2
HDHQ subscales Fourth week Eighth week Fourth week Eighth week Fourth week Eighth week Fourth week Eighth week
Acting out hostility (AH) 11 13 1 1 2 13 2 2
Criticism of others (CO) 12 12 6 5 1 11 1 1
Paranoid hostility (PH) 2 7 0 0 5 8 5 5
Guilt (G) 2 5 2 2 1 6 1 1
Self criticism (SC) 6 8 5 5 1 10 1 1
Total extrapunitiveness (TE) 25 32 7 6 8 32 8 8
Total intrapunitiveness (TI) 8 13 7 7 2 16 2 2
Total hostility (TH) 33 45 14 13 10 48 10 10
At the end of the 12 weeks cycle, the twins were re-evaluated using SCL-90. In pair A, user 1's self-ratings were particularly high on the hostility and paranoid ideation subscales, while presenting moderate to low ratings on the interpersonal sensitivity, obsessive compulsiveness, depression, psychoticism and anxiety subscales (Table 2). In the same pair non-user 1 twin showed no deviation from the original reference point, retaining the extremely low distress levels on the interpersonal sensitivity, hostility and psychoticism subscales (Table 2 and Fig. 1). In pair B, user 2's self-ratings were particularly high on the obsessive compulsiveness, interpersonal sensitivity, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism subscales, with low levels on the somatization and depression subscales. The non-user 2 twin showed a slight deviation towards improvement from the original reference point, retaining the extremely low levels on the depression and hostility subscales, while the distress levels on the somatization and paranoid ideation subscales receded (Table 2 and Fig. 2).
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Fig. 1. SCL-90 final evaluation, symptomatic profiles for pair A.
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Fig. 2. SCL-90 final evaluation, symptomatic profiles for pair B.
The users reported elevated levels on multiple subscales of the SCL-90, with the emergence of symptoms not present at the first evaluation. Moreover, their non-user twins remained stable and unaffected, indicating that the only factor responsible for the user's psychological turmoil was the use of AAS. Fig. 3, shows that the use of AAS elevated various distress levels and particularly those associated with hostility and paranoid ideation. The use of AAS caused major elevations to various distress levels and particularly those associated with obsessive compulsiveness, interpersonal sensitivity, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism (Fig. 4). These findings, combined with the users' self-ratings on HDHQ subscales, provide evidence that this abuse pattern of AAS was responsible in the case of user 1 for the increase in hostility, paranoid ideation, depression, anxiety, obsessive compulsiveness subscales, and an enlivenment of “dormant” disorders represented by interpersonal sensitivity and psychoticism subscales scoring, as well as the dramatic increase in obsessive compulsiveness, interpersonal sensitivity, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism subscales and an enlivenment of “dormant” disorders represented by somatization, depression and paranoid ideation in the case of user 2.
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Fig. 3. Comparison of symptomatic profiles for user 1 (pair A).
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Fig. 4. Comparison of symptomatic profiles for user 2 (pair B).
4. Discussion
In recent years, professional athletic competition has intensified to the point that increasing numbers of athletes are striving to improve their performances with the desire to be recognized as the “top competitor”, so as to acquire all the vast economic and social benefits. However amateur athletes and sport's fans are taking up the challenge as well, in a meaningless effort to improve their physical appearance or enhance their strength [27]. Significant numbers of athletes are employing AAS “boosts” in their training programs [28] and [29]; despite the knowledge of the potentially serious adverse consequences of these agents [30].
The anabolic steroid using athletes of today prefer to self-administer a complex combination of AAS, gradually increasing doses while escalating the frequency of the administration. At this frail point, old efficacy studies fail to comply, as their data were based in an outdated method of use, extinct in the athletic community of today. All precedent clinical studies, concerning the psychological side effects of AAS abuse, have been conducted under the ethical scope of a controlled usage of a single AAS agent [18], while monitoring the impact of this selected drug on hostility and aggression. This single drug selection may be a methodological deficiency, as it causes an inconsistency in dosing strategies between clinical trials and real-world use, reducing the value of the clinical study. Moreover, past clinical studies solely focus on monitoring the elevation of hostility and aggression without examining the true range of psychopathological side effects of AS drugs. The current athletes that used AAS administered a complex combination of AAS, gradually increasing doses (ranging higher than the equivalent of 1000 mg of testosterone per week) while escalating the frequency of the administration.
Our research suggests that psychological alterations indicated by the significant elevation of distress scales for both users as well as the enlivenment of dormant disorders observed in the abusing twins during the study period, were induced by the “stacked” AAS agents, since exercise and nutritional regimens were comparable for all subjects. The complete range of these elevations were recorded by use of the SCL-90 while the use of HDHQ ensured a more specialized reading of the subjects' hostility and aggression that progressively increased (almost 10-fold) as the abuse pattern escalated. These readings are in accordance with anecdotal evidence in contemporary literature [31] concerning hostility and aggression. Moreover, our clinical observations are in harmony with current clinical literature describing the psychiatric behavioral effects [32] of AAS abuse, the contribution of this study being the observation of the complete range of psychological side effects (besides aggression and hostility) in a controlled specimen group of contemporary AAS abusers.
Our findings are supportive of previous anecdotal reports of violent crimes associated with AAS [33], making obvious the legal implications of the abuse of these agents. Escalation of the “stacked androgens” dosing is proportional to the elevation of psychotic as well as hostility and aggression distress levels, thus making the abuser capable of excess violence towards others and the community in general. The understanding and better exploration of the aforementioned implication, may lead to the prevention of violence and violent crimes committed by AAS users, as well as the formation of a more strict and functional legislation against abuse, commerce and trafficking of AAS, that is currently lacking or is insufficient in most European Union countries.
The small number of participants in this research is an obvious limitation to the study, but the genomic purity and similarity of these participants consists a strong point suggesting that the escalation of the AAS abuse pattern, coincides with a predictable progression (aggravation) of acute psychological symptoms measured by somatization, hostility, paranoid ideation, depression, anxiety, phobic anxiety, obsessive compulsiveness, interpersonal sensitivity and psychoticism subscales and by the dramatic increase in GSI, positive symptom total and positive symptom distress levels. Once a patient has been identified as an AAS abuser, the use of the proper psychometric instruments in the appropriate time periods (as suggested by this research) within an AAS cycle, along with a more focused clinical examination, can provide solid information easily evaluated by clinicians possibly averting future psychiatric decompensation. Proper consultation as well as a deeper understanding of the AAS abuse problem that causes a progressive deterioration of the abuser's psychological status, is the only means available in this effort. A study involving a bigger cohort is needed in order to support the aforementioned suggestions.
The real contribution of the investigation of this case report was the controlled observational study of an ideal study group with total genome similarity who self-administered a multiple combination of AAS. The psychological alteration induced by the use of AAS was characteristic of changes observed in both twins of both pairs. The variety of appearance and the impact of abuse on the user's psychological status are connected to the type, combinations, doses and duration of use of the drugs selected by the user, though a larger research is needed to proper investigate and strengthen the results.
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