Dear Editor:
A number of over-the-counter (OTC) dietary, nutritional, and/or bulking supplements used by body builders and other types of athletes have been suspected of containing anabolic steroids. For example, Green et al[1] examined 12 OTC dietary supplements and found that eight contained anabolic steroids. In addition, in an empirical study, the United States Food and Drug Administration (FDA) uncovered 22 dietary supplements marketed on the internet that contained anabolic steroids.[2] In response to such ongoing and disturbing findings, two United States laws have been passed to classify anabolic steroids as controlled substances (the Anabolic Steroids Control Act of 1990; the Anabolic Steroids Act of 2004).[3] Yet, the development and emergence of new anabolic-steroid congeners is ongoing, resulting in a constant influx of novel and diverse compounds.[4]
Current data suggest that a number of psychiatric consequences, including aggressive behavior, are associated with the use of anabolic steroids. However, much less is known about their effects on anxiety.[5] Anabolic steroids are believed to modulate the activity of a number of receptors in the brain, which are involved with both mood and anxiety disorders (e.g., they have activating effects at inhibitory GABA-A receptors).[6,7] In terms of existing evidence, studies in rats indicate that anabolic steroids may increase,[8] decrease,[9–11] or have negligible effects on anxiety.[12,13] These divergences are evident in human studies,[14] as well, with some data indicating that anabolic steroids increase anxiety[15,16] and other data indicating otherwise.[17]
Beyond the association with general anxiety symptoms, we could locate no case reports or studies on relationships between anabolic steroids and panic disorder, in either the PubMed or PsycINFO databases. In this case report, we describe a temporal association between the use of an OTC bulking agent and the onset of panic attacks, with the continuation of panic symptoms after the discontinuation of the product.
Case Report. Mr. A., age 41, presented for psychiatric intervention for the treatment of panic attacks, which began approximately three years prior. During the first attack, the patient assumed that he was having a heart attack and was transported to an emergency room for treatment. Since their onset, Mr. A. has experienced multiple recurrent attacks. The attacks are consistently characterized by light-headedness, diaphoresis, tachycardia, dyspnea, dizziness, feeling flushed, truncated visual fields, intense anxiety, and the sensation that, “I’m having a heart attack.” Episodes last about three minutes. He denies tremulousness, nausea, agoraphobia, a family history of panic disorder, or a history of abnormal thyroid or cardiac studies (he had been fully evaluated by his family physician). The patient has no medical illnesses and was on no current medication, but had received successful surgery for sleep apnea sometime in the past. After several psychotherapy sessions, Mr. A. disclosed that he was previously an amateur weight lifter and had received several awards. During his late 30s, when the attacks initially began, he recalled taking a particular OTC metabolic supplement that was marketed to promote bulk, not weight loss. The product was manufactured by Legal Gear and he disclosed that it was eventually, “taken off the market because it contained steroids.” Prior to its removal from the market, the patient discontinued the product because of the suspected association with his symptoms. He never used any related products afterwards, but he has continued to experience episodic panic attacks. At present, symptoms are responding well to treatment with a selective serotonin reuptake inhibitor (SSRI).
We suspect that this bulking product, which contained an anabolic steroid congener, may have been a priming factor for this patient’s panic attacks. Indeed, in March 2006, Legal Gear was ordered by the FDA to cease distribution of a product that contained an unapproved synthetic steroid.[18] Unfortunately, in most cases, the genuine contents of these types of OTC products remain largely obscure. On a side note, a number of supplements and metabolic boosters contain caffeine or ephedra, but these are usually promoted for weight loss not as a bulking agent. Given that this product contained an anabolic steroid congener, this case illustrates another potential psychiatric consequence of OTC products containing steroid derivatives—panic attacks.
Because approximately 1.5 percent of high school students knowingly use anabolic steroids,[19,20] it behooves the clinician to be alert to related risk factors for anabolic steroid use, such as being male, an elite athlete or a body builder, and the associated symptoms of aggression, irritability, anxiety, and suspiciousness[15,16]—as well as possibly panic attacks. We are aware of no other case reports in the literature on the relationship between anabolic steroids and panic attacks.
References
1. Green GA, Catlin DH, Starcevic B. Analysis of over-the-counter dietary supplements. Clin J Sport Med. 2001;11:254–259.
2. Baker M. DEA identifies 22 dietary supplements containing anabolic steroids. Steroid Report. http://www.steroidreport.com/2008/05/dea-identifies-dietary-supplements-containing-anabolic-steroids. Accessed on 9/16/09.
3. Regulations.gov. Classification of three steroids as schedule III anabolic steroids under the controlled substances act. http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480532b92. Accessed on 9/16/09.
4. Thevis M, Thomas A, Kohler M, et al. Emerging drugs: mechanism of action, mass spectrometry and doping control analysis. J Mass Spectrom. 2009;44:442–460.
5. Clark AS, Henderson LP. Behavioral and physiological responses to anabolic-androgenic steroids. Neurosci Biobehav Rev. 2003;27:413–436.
6. MacKenzie EM, Baker GB, Le Melledo J-M. The role of neuroactive steroids in anxiety disorder. In: Ritsner MS, Weizman A (eds). Neuroactive Steriods in Brain Function, Behavior and Neuropsychiatric Disorders: Novel Strategies for Research and Treatment. New York: Springer;2008:435–447.
7. Hosie AM, Wilkeins ME, da Silva HM, Smart TG. Endogenous neurosteroids regulate GABAA receptors through two discrete transmembrane sites. Nature. 2006;444:486–489.
8. Rocha VM, Calil CM, Ferreira R, et al. Influence of anabolic steroid on anxiety levels in sedentary male rats. Stress. 2007;10:326–331.
9. Kouvelas D, Pourzitaki C, Papazisis G, et al. Nandrolone abuse decreases anxiety and impairs memory in rats via central androgenic receptors. Int J Neuropsychopharmacol. 2008;11:925–934.
10. Bitran D, Kellogg CK, Hilvers RJ. Treatment with an anabolic-androgenic steroid affects anxiety-related behavior and alters the sensitivity of cortical GABAA receptors in the rat. Horm Behav. 1993;27:568–583.
11. Agren G, Thiblin I, Tirassa P, et al. Behavioural anxiolytic effects of low-dose anabolic androgenic steroid treatment in rats. Physiol Behav. 1999;66:503–509.
12. Rojas-Ortiz YA, Rundle-Gonzalez V, Rivera-Ramos I, Jorge JC. Modulation of elevated plus maze behavior after chronic exposure to the anabolic steroid 17alpha-methyltestosterone in adult mice. Horm Behav. 2006;49:123–128.
13. Barreto-Estrada JL, Barreto J, Fortis-Santiago Y, et al. Modulation of affect after chronic exposure to the anabolic steroid 17alpha-methyltestosterone in adult mice. Behav Neurosci. 2004;118:1071–1079.
14. Bahrke MS. Psychological effects of endogenous testosterone and anabolic-androgenic steroids. In: Yesalis CE (ed.). Anabolic Steroids in Sport and Exercise. Champaign, IL: Human Kinetics;2000:247–278.
15. Parrott AC, Choi PY, Davies M. Anabolic steroid use by amateur athletes: effects upon psychological mood states. J Sports Med Phys Fitness. 1994;34:292–298.
16. Pagonis TA, Angelopoulos NV, Koukoulis GN, et al. Psychiatric and hostility factors related to use of anabolid steroids in monozygotic twins. Eur Psychiatry. 2006;21:563–569.
17. Galligani N, Renck A, Hansen S. Personality profile of men using anabolic androgenic steroids. Horm Behav. 1996;30:170–175.
18. Food and Drug Administration. Federal agents seize nearly $1.3 million of illegal dietary supplements—products alleged to be adulterated under the Federal Food, Drug, and Cosmetic Act. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm116876.htm. Accessed on 9/23/09.
19. Hoffman JR, Faigenbaum AD, Ratamess NA, et al. Nutritional supplementation and anabolic steroid use in adolescents. Med Sci Sports Exerc. 2008;40:15–24.
20. vandenBerg P, Neumark-Sztainer D, Cafri G, Wall M. Steroid use among adolescents: longitudinal findings from Project EAT. Pediatrics. 2007;119:476-486.
With regards,
Randy A. Sansone, MD
Professor, Departments of Psychiatry and Internal Medicine, Wright State University School of Medicine, Dayton, Ohio; Director, Psychiatry Education, Kettering Medical Center, Kettering, Ohio
Lori A. Sansone, MD
Civilian family medicine physician; Medical Director of the Primary Care Clinic, Wright-Patterson Air Force Base, Dayton, Ohio
Disclaimer:
The views and opinions expressed in this article are those of the authors and do not reflect the official policy or position of the US Air Force, Department of Defense, or US Government.
