Anabolic androgenic steroids and violence : a medicolegal and experimental study

Abstract: Non-medical use of anabolic androgenic steroids (AAS) has been linked to various psychological and behavioural complications in case and survey reports. Judging from these reports, the symptoms most consistently associated with AAS use are extreme irritability, increased aggressiveness and mood swings. There are also a limited number of reports connecting AAS-associated aggressivity with violent acts including homicide, while reports of self-injurious behaviour associated with use of AAS are extremely rare. With the objective to evaluate the possible role of AAS-related behavioural changes for outwardly or self-directed violence, violent acts committed by AAS users and premature death among users of AAS, were studied by reviewing autopsy and police reports, court records, forensic psychiatric evaluations and medical records. In a subset of AAS-using suicide victims further information was gained by means of psychological autopsy, i.e. semi-structured interviews with survivors. Hypotheses regarding the effects of AAS on mental processes brought out by observations in the medicolegal studies were tested in experimental animal studies. Different patterns of violence were associated with different phases of AAS use that in turn were associated with specific patterns of psychological changes. Mood swings, impulsive aggression with violent outbursts resulting in violence towards other persons - including homicide - or damage of property were associated with current use of AAS in subjects with a history of prolonged AAS use. The same phase of AAS use was also associated with homicidal death, impulsive suicide and death from impulsive intake of high amounts of analgesics in combination with benzodiazepines and/or alcohol without a clear suicidal intent. A mental state dominated by depressive symptoms, suicide with high suicidal intent and execution-like homicides in response to perceived humiliation were associated with AAS abstinence. Hypomania-like symptoms and planned criminal activity were associated with short-time intake of AAS. In most but not all cases in which a detailed background history was obtained, pre-existing psychopathology and/or abuse of other psychotropic drugs was reported. Acute influence of pharmaceuticals/illicit drugs and/or alcohol was also prevalent. In eight cases a mixed substance abuse was established after the use of AAS commenced. Administration of AAS at low doses resulted in a reduction of vigilance and fear in rats. High-dose treatment of AAS resulted in alterations in dopaminergic, serotonergic and cholinergic systems suggestive of increased neuronal activity in brain areas regulating mood, emotion and motivation. The observations in the present study indicate that long-term use of AAS may aggravate pre-existing and possibly may precipitate new psychiatric symptoms to a degree of severe outwardly directed violence, completed suicide or lethal mixed substance abuse. The sporadic use of AAS by criminals suggests that early effects of AAS on mental processes may involve reduction of anxiety and/or enhancement of antagonism. The observations of early central stimulatory effects of AAS gain support from the experimental studies showing a reduction of vigilance and fear and increased dopaminergic and serotonergic activity in limbic structures in AAS-treated rats. The observed shift from early hypomania-like symptoms in early AAS career towards symptoms characterised by impulsive aggression, mood swings, and depression in later career, together with the experimentally demonstrated effects on neurotransmission, suggests that stimulatory effects of AAS may later fatigue central systems regulating mood, emotion and motivation.