Use of anabolic-androgenic steroids (AAS) has increased over the last several decades, and has developed into a significant public health concern. AAS have been shown to lead to numerous adverse health effects, impacting both somatic and mental health. Approximately 30% of people who use AAS develop dependence, and have an increased risk for adverse effects. AAS dependence is characterized by symptoms including withdrawal and continuing to use AAS despite the negative impacts on mental and physical health. People with AAS dependence experience symptoms of both psychological and physiological dependence, which makes ceasing AAS use extremely difficult. However, the psychological and cognitive mechanisms underlying AAS dependence are not well understood, and the majority of existing knowledge is based on samples of males in the weightlifting and bodybuilding communities. This thesis aims to illuminate these mechanisms in diverse populations and improve the current understanding of AAS dependence in order to improve prevention and treatment.
Paper I investigates the relationships between executive function and personality traits and severity of AAS dependence in substance use disorder (SUD) patients in Norway. Three classes of AAS dependence were identified: low, moderate and high symptoms. Moderate and high AAS dependence symptoms were associated with poorer self-monitoring, and increased antagonism, disinhibition, and rigid perfectionism. People who reported using AAS but had low or no dependence symptoms had higher capacities for emotional control and cognitive flexibility and less negative affectivity compared to non-AAS using SUD patients. Poor emotional control, reduced empathy and impulsivity were the strongest indicators of severe AAS dependence in this population. These findings indicate that several cognitive and psychological features which are often associated with SUD are further elevated among SUD patients with more severe AAS dependence.
Paper II explores the relationships among AAS dependence and muscle dysmorphia symptoms in a sample of male weightlifters. Using network analysis, the most central symptoms of AAS dependence appeared to be continuing use despite physical and mental side effects, using longer than planned, tolerance, and work/life interference, while time spent appeared less influential in the network. Exercise dependence was the most central muscle dysmorphia symptom among men who used AAS, while size/symmetry concerns were most central among men who did not use AAS. In a network of both AAS dependence and muscle dysmorphia symptoms, no significant connections were identified. These findings suggest that somatic and psychological symptoms of AAS dependence are closely linked, and targeting both is critical for treatment. Muscle dysmorphia symptoms related to actions such as strict diet, exercise, and supplement use appear more closely connected for men using AAS compared to controls, which may be indicative of extremely rigid practices in this population. While muscle dysmorphia is elevated among men who use AAS compared to controls, symptoms of muscle dysmorphia may not constitute a risk factor for AAS dependence.
Paper III assesses the relationship between social cognitive capacities, assessed by facial emotion recognition, and AAS use and dependence. The potential mediating role of circulating androgen levels was assessed. Men currently using AAS had lower recognition accuracy for both anger and disgust compared to never-using controls, however this relationship was not mediated by free testosterone levels. Compared to non-dependents, men with AAS dependence had lower recognition of fear and sadness, however this finding was not significant after corrections for multiple testing. These findings indicate impaired facial emotion recognition among men currently but not previously using AAS, which suggests some acute effect. In addition, current AAS use appears to impair the recognition of different emotions than AAS dependence, suggesting that acute AAS use and lifetime dependence may be associated with different aspects of social cognition.
Paper IV assesses symptoms of AAS dependence in a female population, and connections with aggression and other psychological characteristics. Half of the women in this study met clinical criteria for AAS dependence, but reported less withdrawal symptoms than men. Women who used AAS reported higher levels of aggressive traits and behavioral and psychiatric problems including attention problems, internalizing and externalizing pathology compared to controls. Several dependence symptoms were correlated with these psychological traits. Tolerance was correlated with aggressive behavior, withdrawal was correlated with attention problems, and being unable to quit was correlated with internalizing problems. These findings demonstrate the high levels of psychological distress among women who use AAS, and the burden of comorbidity in this population is important to take into account in treatment.
Taken together, these findings demonstrate the complex nature of AAS dependence and the importance of understanding how cognitive and psychological mechanisms in different populations may contribute to its development. While these findings are based on cross-sectional data and cannot determine causality, there are clear associations between cognitive factors including impulsivity and impaired emotion recognition, as well as challenges with attention and AAS dependence. Across all populations examined in this thesis, AAS dependence is associated with a higher burden of psychological distress in addition to somatic challenges, indicating that ceasing use among those with dependence will require psychiatric, psychosocial and somatic treatment.