1 Critical Literature Review Considering anabolic androgenic steroid use in relation to non ...

226 Pages·2014·2.05 MB·English

Critical Literature Review

Considering anabolic androgenic steroid use in relation to non-substance related
diagnostic categories with special emphasis on eating disorders. A review

Qualitative Research Project
What is the role of shame for male anabolic androgenic steroid users?

Service Evaluation
Clinicians’ views about diagnosing and treating anabolic androgenic steroid users in
three different settings

Critical Appraisal

Portfolio submitted for the Degree of
Doctorate in Applied Psychology (PsyD)
at the University of Leicester

by

Hercules Eli Joubert MA
Department of Psychology,
University of Leicester

2014

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The average man “feels like Clark Kent but longs to be like Superman”.1

1 Roberto Olivardia (2001) cited by Frederick et al 2007.
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Acknowledgements

It’s with a sigh of relief that I write these acknowledgements as I come to the
end of this project. It the interest of friends and colleagues which have carried me when
this project became demanding.
In particular, I would like to thank Dr Steve Melluish who has provided
guidance and supervision in a manner that was helpful, kind and accommodating. This
project would not have been possible without it. Thank you.
I was helped and supported by several people who I would like to thank;
Joeseph Kean for recruiting participants, Mo Bickers for transcribing all the interviews,
Lynn Ormond for help with the layout of graphs and Dr Benjamin Boecking and Clint
Steenveldt for proof-reading different sections of this portfolio.
Most importantly, I would like to thank the six men who were willing to
participate in this study. Your openness in sharing your own experiences made this
possible and will hopefully be of benefit to others.
This PsyD was partly funded by South London and Maudsley NHS Foundation
Trust’s Psychological Medicine Clinical Academic Group.

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Declaration

This thesis is a presentation of my original research work. Wherever contributions of
others are involved, every effort has been made to indicate this clearly, with due
reference to the literature, and acknowledgement of collaborative research and
discussions.

This project was completed under the guidance and supervision of Dr Stephen Melluish,
Department of Psychology, University of Leicester.

Hercules Eli Joubert:

Date:

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Table of Contents
List of Tables ................................................................................................................... 7
Abbreviations .................................................................................................................. 8
Portfolio Abstract ........................................................................................................... 9
Section 1: Systematic Literature Review .................................................................... 11
Abstract .......................................................................................................................... 12
Introduction ................................................................................................................... 13
Aims ................................................................................................................................ 19
Methodology .................................................................................................................. 19
Results ............................................................................................................................ 21
Discussion ...................................................................................................................... 34
Conclusion ..................................................................................................................... 38
References ...................................................................................................................... 39
Appendices .................................................................................................................... 43
Section 2: Qualitative Research Project ..................................................................... 56
Abstract .......................................................................................................................... 57
Preface ............................................................................................................................ 58
Background ................................................................................................................... 58
Aims and Objectives ..................................................................................................... 72
Methodology .................................................................................................................. 73
Results ............................................................................................................................ 79
Discussion and Conclusion ........................................................................................... 99
References .................................................................................................................... 103
Appendices ................................................................................................................... 111
Section 3: Service Evaluation ..................................................................................... 166
Executive Summary .................................................................................................... 167
Introduction ................................................................................................................. 169
Methodology ................................................................................................................ 171
Ethical considerations ................................................................................................. 174
Results .......................................................................................................................... 174
Discussion .................................................................................................................... 188
Conclusion ................................................................................................................... 192
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Clinical Implications and Recommendations ........................................................... 193
References .................................................................................................................... 194
Appendices ................................................................................................................... 196
Section 4: Critical Appraisal ...................................................................................... 217
Introduction ................................................................................................................. 218
Background and origin of current research ............................................................. 219
Planning ....................................................................................................................... 220
Ethics and Approval ................................................................................................... 220
Literature review ........................................................................................................ 221
Research Project ......................................................................................................... 221
Recruitment ................................................................................................................. 221
Analysis ........................................................................................................................ 222
Personal Reflections .................................................................................................... 223
The Role of Supervision ............................................................................................. 223
Learning Outcomes ..................................................................................................... 224
Final Reflection ........................................................................................................... 225

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List of Tables
Section One: Systematic Literature Review
Table 1. Search Results. ....................................................................................................... 22
Table 2. Features of AAS user subgroups. ........................................................................... 24
Table 3. Lifetime prevalence of psychiatric and substance use disorders in study groups
(Kanayama, 2009) ................................................................................................................. 26
Section Two: Qualitative Research Project
Table 1. Gilbert (1994) explanation of experiences of shame. ............................................ 64
Table 2. Research Participants. ............................................................................................ 75
Table 3. Themes and Sub-themes. ....................................................................................... 80
Section Three: Service Evaluation
Table 1. Services respondents worked in ........................................................................... 174
Table 2. Years of clinical experience of staff working with AAS use ............................... 174
Table 3. Breakdown of professions responding to survey ................................................. 175
Table 4. Clinicians’ level of familiarity with patients who use AAS ................................ 175
Table 5. Different services and their level of comfort in working with men presenting
with AAS use difficulties .................................................................................................... 176
Table 6. Views on how AAS use is understood by different clinical services .................. 177
Table 7. The views of different clinical services on AAS being used, such as in the
way a person with AN may use laxatives ........................................................................... 179
Table 8. The views of different clinical services on similarities between AN & AAS use180
Table 9. The views of different services on AAS use as a specific type of OCD .............. 181
Table 10. The views of different services on AAS use as part of an eating disorder
(similar to laxative abuse in AN) ........................................................................................ 182
Table 11. The views of different services on whether AN is a specific type of OCD. ...... 183
Table 12. The views of different services on whether men who use AAS might have a
form of reverse AN ............................................................................................................. 184
Table 13. The views of different services on whether men who use AAS might have a
specific type of OCD. ......................................................................................................... 185
Table 14. Different approaches to possible interventions for AAS use. ............................ 186
Table 15. Participants who selected more than one option ................................................ 191

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Abbreviations
AAS Anabolic Androgenic Steroids
AN Anorexia Nervosa
BDD Body Dysmorphic Disorder
DSM Diagnostic and Statistical Manual
EDU Eating Disorder Unit
IPA Interpretative Phenomenological Analysis
MD Muscle Dysmorphia
OCD Obsessive Compulsive Disorder
SPSS Statistical Package for Social Sciences

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Portfolio Abstract
Anabolic androgenic steroids (AAS) are synthetically produced drugs which
mimic the effects of naturally occurring testosterone (Wright, 2000; Kanayama, 2009)
including both anabolic/tissue building and androgenic/masculinising properties. Pope
(2000) suggests that pressure is being placed on men to have slender but muscular
bodies in Western societies mainly through media images promoting larger muscularity,
paralleled by a growth in the use of AAS (Wright & Grogan, 2000) with motivations for
such use including enhanced confidence. Body Dysmorphic Disorder (DSM-5) criteria
allow for muscle dysmorphia; however neither the diagnostic criteria nor the specifier
explicitly mention AAS. The systematic literature review resulted in 14 papers
considering whether AAS may be better understood as part of an eating disorder rather
than a simple substance-related disorder with similarities to laxative abuse in Anorexia
Nervosa (Murray, 2010, 2012; Pope, 1993, 1997). Results reflect a multi-factorial
understanding of AAS, although a more simplistic addiction model prevails. However,
there is ongoing academic debate encouraging alternative diagnostic conceptualisation
of AAS use, perhaps as an eating disorder or specific type of OCD. The IPA research
project, involving six male AAS users, considers the role of shame in AAS use from
psychoanalytic understandings of shame which describe it as a failure to ‘measure up’
(Piers & Singer, 1953). Participants felt that they had to prove themselves and gain
and/or maintain a desired reputation due to finding themselves lacking with feelings of
vulnerability underlying such shame. ASS use seems to be part of a defence strategy
aimed at avoiding shame, which seems to both motivate and maintain AAS use. The
service evaluation results show that AAS use is largely conceptualised as a substance
abuse difficulty by most participants from all three clinical groups with some
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willingness to consider it within other diagnostic categories. This is somewhat
problematic in that it does not reflect current debate or diagnostic positioning within the
DSM 5 and may limit clinical services available for AAS users.

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Word Count
Body of Text Appendix Total
Systematic Literature Review 5907 2909 8816
Research Project 11 481 9997 21 478
Service Evaluation 5431 3373 8804
Critical Appraisal 2108 2106
Total 24 925 16 279 41 204

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