Testerone-Related Disorders


March 21, 2003

(With apologies to the Work Group to Revise DSM-IV)

Subcommittee on


Gordon H. Nagai, Ph.Ynq, Chair

Ghengis Khan Tamerlane
Adolph Hitler Ronald Reagan
Rambo Richard Nixon
Arnold Schwarzenager Napoleon Bonapart
George W. Bush (the Elder) George W. Bush (the Junior)


The Substance-Related Disorders include disorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin exposure. The substances discussed in this section are grouped into 11 classes: alcohol; amphetamines or similarly acting sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiods; phencyclidine (PCP) or similarly acting arylcyclohexylamines; and sedatives, hypnotics, or axiolytics. Little known but thoroughly documented evidence has identified a twelfth class, that of Testosterone, which is included in this discussion.

Testosterone-Related Disorders

292.xy1 Testosterone Intoxication

Diagnostic Features

The essential feature of Testosterone Intoxication is the development of a sometimes non-reversible substance-specific syndrome due to the recent ingestion (or exposure to) this substance (Criterion A). The clinically significant maladaptive behavioral or psychological changes associated with Testosterone Intoxication (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning, and an irritating obnoxiousness) are due to the direct physiological effects of the substance on the central nervous system, and develop during or shortly after use of the substance (Criterion B). The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder (Criterion C). Evidence for recent intake of Testosterone can be obtained from the history, physical exam (e.g., smell of hard liquor and stale cigars on the breath, and bruises on the back of the knuckles), or toxicological analysis of body fluids (e.g., excessive drooling).

The most common changes involve disturbance of perception, wakefulness, attention, thinking, judgment, psychomotor behavior , and interpersonal behavior. Short-term or "acute" testosterone intoxication's may have different signs and symptoms from sustained or "chronic" intoxication. For example, moderate testosterone doses may initially produce gregariousness, but social withdrawal with associated antisocial ideation may develop if doses are frequently repeated over days or weeks. "Head-in-the-Sand Syndrome" may predominate overall cognitive functioning. However, differential diagnosis should distinguish this from "Head-up-the-Ass Syndrome."

Speed of onset. Rapidly acting substances are more likely than slower-acting substances to produce immediate intoxication and lead to Dependence or Abuse. Testosterone is in the hyper-accelerating class of substances.

Duration of effects. The duration of effects associated with testosterone is also important in determining the time course of Intoxication and whether use of the substance will lead to Dependence or Abuse.

Route of administration. The route of administration of testosterone is an important factor in determining its effect (including the time course of developing Intoxication, the probability that its use will produce physiological changes associated with Withdrawal, the likelihood that use would lead to Dependence or Abuse, and whether consumption patterns will be characterized by periodic binges or daily use). Routes of administration that produce more rapid and efficient absorption into the bloodstream (e.g., marathon viewing of the entire "Rambo" or "Die Hard" DVD series) tend to result in a more intense intoxication and an increased likelihood of an escalating pattern of substance use leading to Dependence.

Associated mental disorders. Substance use is often a component of the presentation of symptoms of mental disorders. When the symptoms are judged to be the direct physiological consequence of a substance, a Substance-Induced Disorder is diagnosed. Substance-Related Disorders are also commonly co-morbid with, and complicate the course and treatment of, many mental disorders (e.g., Conduct Disorder in adolescence; Antisocial and Borderline Personality Disorders; Schizophrenia; Mood Disorders; Stupidity and Arrogance).

Diagnostic Criteria for 292.xy1 Testosterone Intoxication:
  1. Recent use of testosterone, or testosterone-inducing behavior such as viewing of excessive amounts of "Rambo-style" and "Die Hard" macho-videos.
  2. Clinically significant maladaptive behavior or psychological change (e.g., euphoria or affective blunting; changes in sociability observed primarily in development of "trash-mouth"; hypervigilance often associated with paranoid-like thought processes; interpersonal insensitivity; anxiety, tension or anger, often expressed in tantrums specifically the result of not getting one's way; stereotyped or stereotyping behaviors; impaired judgment; or impaired social or occupational functioning) that developed during, or shortly after, use of testosterone.
  3. Six (or more) of the following, developing during, or shortly after, testosterone use:
    1. Tachycardia or bradycardia; in severe cases the "Tinman Syndrome."
    2. Pupillary constriction with associated loss of "vision," as observed in the "Ostrich Syndrome."
    3. .
    4. Elevated or lowered blood pressure; in extreme exacerbation the blood turns cold.
    5. Disturbance in cognitive centers of the brain, as observed in the "Cry Wolf Syndrome."
    6. Perspiration or chills the result of fears of exposure of social or occupational malfunctioning.
    7. Constriction of the mind, with the concomitant intent to restrict the minds of others for their own good because "I know best"
    8. Evidence of insight loss reflective of regression to childhood developmental levels.
    9. Psychomotor agitation, or the "Chicken-Little Syndrome"
    10. Confusion, seizures, dyskinesias, dystonias, or coma - especially coma.
    11. Disturbed and delusional ideation, as in "Napoleon Complex."
    12. Loss of moral bearing.
    13. Behaviors that present a danger to self or others.
  4. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

292.xy2 Testosterone Withdrawal

Diagnostic Features

The essential feature of Testosterone Withdrawal is the development of a substance-specific maladaptive behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged testosterone use (Criterion A). The substance-specific syndrome causes clinically significant distress or impairment in social, occupation, or other important areas of functioning (Criterion B). The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder (Criterion C). Withdrawal is usually, but not always, associated with Substance Dependence. Most (perhaps all) individuals with withdrawal have a craving to readminister the substance to reduce the symptoms, commonly leading to the condition known as the "Texas Cowboy Syndrome."

Duration of effects. The half-life of testosterone parallels aspects of Withdrawal: the longer the duration of immersion in "Rambo" or "Die Hard" DVDs, the longer the time between cessation and the onset of withdrawal symptoms and the longer the withdrawal is likely to last.

Diagnostic Criteria for 292.xy2 Testosterone Withdrawal
  1. Cessation of (or reduction in) testosterone use that has been heavy and prolonged.
  2. Dysphoric mood and four (or more) of the following physiological changes, developing within a few hours to several days after Criterion A:
    1. Fatigue, as manifested especially in temper tantrums of impatience, and increasingly, intolerance.
    2. Vivid, unpleasant dreams, manifested in nightmares based on the Devil and the "Axis of Evil."
    3. Insomnia or hypersomnia, and in severe cases, sleepwalking in a world of danger.
    4. Increased appetite for aggression and war-mongering, with the concomitant of "dissing" of former colleagues or allies.
    5. Psychomotor agitation associated with anticipation of "kicking ass," with accompanying breast-beating and excessive flag waving.
    6. Xenophobic ideation, associated with misguided and misinformed patriotism.
    7. Paranoia around the release of information pertaining to the functioning of one's office and close colleagues.
    8. Constriction of the mind, with especial focus on the restricting of personal freedoms the close colleagues believe is in the best interests of the people.
  3. The symptoms of Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Differential Diagnosis

Diagnostic criteria for 292.xy3 Testosterone-Induced Psychotic Disorder

Testosterone-Induced Disorders may be characterized by symptoms (e.g., depressed mood) that resemble primary mental disorders (e/g., Major Depressive Disorder versus Testosterone-Induced Mood Disorder, With Depressive feature, With Onset During Withdrawal). The marked mental disturbances that can result from the effects of testosterone should be distinguished from the symptoms of Schizophrenia, Paranoid Type, Bipolar and Other Mood Disorders, Generalized Anxiety Disorder and Panic Disorder, Stupidity and Arrogance. As symptoms of the latter are often coexistent with those of Testosterone-Induced Psychotic Disorder, additional care should be taken to identify proper classification.