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Psychiatry (Edgmont). Dec 2009; 6(12): 16–18.
Published online Dec 2009.
PMCID: PMC2811139

Over-the-Counter Bulking Supplements and Panic Attacks

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 al1 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,911 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 anxiety15,16 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 suspiciousness15,16 —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.

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, M.D
Civilian family medicine physician; Medical Director of the Primary Care Clinic, Wright-Patterson Air Force Base, Dayton, Ohio

Contributor Information

Randy A. Sansone, 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, Civilian family medicine physician; Medical Director of the Primary Care Clinic, Wright-Patterson Air Force Base, Dayton, Ohio.

References

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