Middle age and adulthood

Jeff Clothier, M.D.

Objectives

1) The student will be able to describe the features of psychological development during the middle age phase of adulthood.

2) The student will be able to compare the developmental theories of Erikson, Benedek, Jacques, Vaillant, Levinson, and Gould.

3) The student will be able to describe features of the so called mid-life crisis or climacteric for both men and women.

4) The student will be able to describe the symptoms of menopause and the role of exogenous estrogen in the treatment of menopausal symptoms.

5) The student will be able to describe common medical conditions that present as psychiatric disorders during middle age life.

Introduction

Development during adulthood was ignored by Freudian analysts for decades. It was assumed that adult functioning was a static period that followed the dynamic period of adolescence. There are two major groups of theories regarding adult development. The first group describe psychologic development as a process that proceeds in stages. It is an extension of the life-cycle. These theories are called stage demand process theories. The second group of theories describes development as a process that proceeds in response to situations or specific stressors. This second group of theories are called situation demand process theories. In reality the best explanation for psychologic development during adulthood is a combination of both groups of theories. Age related stress and the accompanying physiologic changes that occur during adulthood produce major effects on the health of middle aged Americans. A practicing physician should have a framework of understanding these developmental issues when caring for adults. The chart above includes the major contributors and keywords to describe their theories.

 

Stage demand process theories

Several theoreticians have described major life-cycle /stage theories of adult development. The best known is that of Erik Erikson. Erikson's theory revolves around the concept of periods of crisis in which age and stage specific internal conflicts occur. Erikson suggested the crisis for middle age could be described as a conflict between generativity and stagnation. In short this describes the conflict between the drive to generate and the tendency to stagnate during middle age.

For many persons middle age is the time during which you reach your peak professionally. Either you have realized that your goals of youth are not yet attainable, or you have reached them. The result can be similar. The typical responses to the crisis of middle age are either self absorption or involvement with the next generation. Involvement with the next generation is seen as an attempt to leave a part of yourself for society. As such it is not necessarily procreative. The self absorption is often a response to the realization that your time is finite. A pressure to change occurs. This may result in a change in the guiding question of "what would my parents have me do?" to "what do I want to do?". It is a continuation of the separation-individuation process that began during childhood. In some ways this time is similar to adolescence. This has lead to the characterization of middle age as a second adolescence.

At times the pressure to change can be quite intense with the result of what has been termed the mid-life crisis(Jacques). Clearly this time has several physiological as well as psychosocial changes. The ability to adequately confront the crisis and stress of middle age is determined by the coping resources that were developed during earlier developmental struggles. As such simplistic explanations of behavior during this period are inadequate.

The stage demand process theories suggest that the stressors are intrinsic to the specific life-cycle stage. In reality it should be remembered that the middle aged adults of the 1950's and 1960's had similar situational demands. This cohort went through the great depression, WW II, Korean war, Vietnam era, and the generational shift of the 60's. The fact that these people had similar responses to middle age could be due to a cohort effect and not a product of a specific life stage.

Other than Erikson there are two major contributors to life cycle theories of middle age. Levinson and Gould developed theories that were probably remnants of their psychoanalytic training. Levinson emphasized that there were transitional periods that were separated by relatively stable periods of psychological functioning. The transitional periods yield to periods of stability following a consolidation of achievements internally and externally. Gould described a somewhat similar model but framed it in terms of the change between childhood and adulthood fantasies. During middle age Gould describes the progressive concerns with one's health, loss of loved ones and personal status, and ultimately death. In his model these concerns confronted childhood fantasies of safety and ultimate justice. Successful transition in Gould's model requires the development of internal controls based on an accurate assessment of reality and not childhood fantasies. A common criticism of these models is the degree of 'psycho-babble' used to describe common events. Generally, these theorists have said basically that there are characteristic stressors throughout adult life that challenge us to adapt. Successful adaptation increases your abilities and prepares you for the next stressor.

Situational demand process theories

Two theorists identified specific stressors as fundamentally important in middle age. Benedek studied the successful and unsuccessful adaptation of women to middle age. She identified menopause as a fundamental stressor. The way a woman handled menopause determined her middle age adjustment. Benedek identified two basic ways in which women adjusted. For some women, menopause resulted in a sense of a loss of femininity and loss of self esteem while in others it resulted in a greater sense of freedom and sexual expression that was accompanied by a greater drive towards generativity. The role of the physiologic changes has not been adequately studied.

The other specific stressor seen as fundamental to middle age development is the realization of death as imminent. The realization of a finite amount of time left usually appears as the person has to deal with the loss of friends and family and personal health. Jacques described the increased awareness of death and it's impact on a person as a mid-life crisis. Successful adaptation is a mellowing and change in personality that is accompanied by increased decisiveness in decision making. Such as with retirement planning etc. Attempts to deny the inevitability of death or being overwhelmed by the futility of life are seen as unsuccessful adaptations to the mid-life crisis.

Adaptation to life

Vaillant studied the question of why some persons adjust well to life and others do not. In a landmark study he followed 95 Harvard freshman into middle age and beyond. Vaillant attempted to divide the sample into groups according to successful life experiences at home, at work, in the world, and within the self. He administered a modified interview to subjects on a periodic basis. This was known as the Grant Study. The group of subjects were selected specifically as 'sound students'. Students with known medical or psychological infirmities were excluded as were any 'mediocre' students. In addition to a series of interviews with the subjects a family worker traveled to each student's home and interviewed the parents and any siblings, aunts, uncles, and grandparents available. Because of the interest in the 1930's in body habitus and psychopathology each student was also examined by a physical anthropologist to determine anthropometric dimensions. A series of physiologic measurements were done which included insulin tolerance, cardiac treadmill and respiratory functions. Psychologic testing was done and included the Rorschach, and elements of the WAIS and TAT. Demographic data has been collected throughout the study.


Vaillant described the antecedents of healthy adult adjustment as being related to the totality of childhood experience. Single episodes of childhood trauma did not predict poor adult adjustment. However, life in a disturbed home did predict poor adjustment. Good object relations during childhood predicted good adult adjustment. The best predictors of healthy adjustment were the type of defense mechanisms. Healthy defenses by age 18 predicted good adjustment. Vaillant described the hierarchy of defense mechanisms listed below. Vaillant also found that men who had difficulty adjusting to college had less health as adults. In fact, the mortality was almost 2x by age 47. The illnesses that commonly present during middle age are typically stress sensitive. Attention to coping styles of the patient can identify perpetuating factors that prevent optimal treatment response.

 


Menopause and the Climacteric

The physiologic changes that occur in middle age can be prominent. In general menopause relates to the syndrome of effects that occurs with a loss of gonadal hormone production in women. Whether this is a natural process or a state of estrogen deficiency is a matter of degree. For some women the transition is uneventful, for others it is difficult. The loss of ovarian function occurs by one of two processes in general. The first is a gradual loss of follicular production of estrogen. The second is by surgical removal of the ovaries. It is more difficult to adjust to the sudden loss of ovarian. The climacterium is commonly used to describe the period of adjustment of middle age. The climacterium is best described for women.

The symptoms of menopause are generally those associated with estrogen deficiency. At the early stages of ovarian failure menstrual bleeding becomes more irregular and ultimately ceases. The diagram below shows the changes in estrogen production over the lifetime.

Over 50% of women surveyed described menopause as an unpleasant period of their life. Common unpleasant symptoms include vasomotor instability (hot flushes), profuse sweating, headaches, dryness and thinning of the vaginal walls increased vaginal infections, sensation of cold in the hands and feet, pruritis of the sexual organs, constipation, arteriosclerosis, osteoporosis, loss of breast firmness, depression, irritability, insomnia, and dizziness. When a large group of middle aged women are surveyed, the only ones to be associated with menopause consistently are hot flushes, night sweats, osteoporosis, and thinning of the vaginal mucosa. These effects are also the ones most responsive to estrogen replacement. As with Vaillant's study of men, LaRocco found that pre-menopausal adjustment was predictive of post-menopausal adjustment. Depressive syndromes during menopause are found most often in women who had poor premenopausal adjustments.

The question of whether there are central effects of estrogens is intriguing. The limbic system and the hypothalamus have a high density of estrogen receptors. Estrogens act through cytosolic receptors and probably act to modulate the second messenger systems of specific neuron systems. The dopamine and norepinephrine systems seem to be preferentially effected. This might explain some of the symptoms associated with menopause such as vasomotor instability, profuse sweating, and insomnia. If research bears this out then this might help understand why some women describe behavioral symptoms with the various changes in estrogen function. Your textbook is surprisingly silent on this interesting topic.

Exogenous estrogens have been used widely since the 1960's for post menopausal symptoms. 20% of postmenopausal Swedish women are treated with exogenous estrogens. Over the last 20 years the incidence of fractures in post menopausal women has been reported to have decreased. Epidemiological studies have shown that this is related to estrogen use in the post menopausal period. Other findings include significant reductions in coronary artery disease and improved sexual adjustment in patients on exogenous estrogens. The hot flashes are also responsive to exogenous estrogen use. Risk associated with estrogen replacement include endometrial hyperplasia, uterine bleeding, uterine cancer, and breast cancer. Unopposed estrogen use may increase the risk of uterine cancer by as much as 4 fold. The addition of progestins in cyclic administration is believed to reduce this risk considerably perhaps to baseline. The available studies suggest that unopposed estrogens may increase risk of breast cancer by 25%. Thus, the risks are not minimal. The risk of not treating menopausal symptoms is not minimal either. For instance, the mortality in the year following a hip fracture is as much as 10% in patients in their 50's and may rise to as much as 35% in patients over 80. Also if coronary artery disease is reduced by treatment, the cost-benefit ratio may be considerable. At present it appears that targeted treatment to patients with high risk factors for hip fractures or CAD would make since. Close monitoring of the endometrium and breast tissue would be warranted.

There are three dosage forms available. The most commonly used is the oral form of conjugated estrogens with progestins given on a cyclic basis. There is also a cream available for vaginal atrophy. The estrogens are absorbed in significant amounts with this cream. The newest dosage form is a transdermal patch that lowers the exposure of the liver to the estrogens. This seems to reduce the side effects which can accompany oral estrogens. Side effects include increased incidence of gall bladder disease, thrombophlebitis, hypertension due to excess water retention, dysfunctional uterine bleeding, increased fibroma size, breast tenderness, nausea, bloating and cramps, headaches, migraines, and a variety of psychiatric complaints, reduced carbohydrate tolerance and a variety of other complaints. Estrogens should be avoided in patients with known breast cancer, uterine cancer, thrombophlebitis, in the setting of uncontrolled hyperlipidemia and heart disease, if they do not work for the patient, and if the patient is pregnant. Progestins are given for seven or more days during the cycle. Most of the side effects are related to dose and duration of therapy and for this reason the lowest dose necessary should be used.

In general it is believed that the vasomotor symptoms will eventually go away without treatment and that if treatment is stopped they will reappear. Other potential treatments for the vasomotor symptoms include adrenolytic agents such as clonidine or behavioral measures. Women should be encouraged to maintain a physically active life during early adulthood to increase bone mass. Calcium supplements are usually safe and may reduce bone loss with or without estrogen administration. Hot flashes are sensitive to the ambient temperature. A cool environment reduces the frequency and severity significantly. In addition, measures to reduce the level of stress such as progressive relaxation, are useful for many patients. Diet, exercise, and relaxation training may obviate the need for exogenous estrogens to treat the vasomotor instability. The decision to treat with estrogens will usually be made related to risk of osteoporosis and the danger of hip fracture in an individual patient. If significant dysphoria is present attention to life cycle issues should be given. This may require referral to a psychotherapist for some patients.

The male climacterium is controversial. In general there is a reduction in endogenous gonadal hormones in males. The principle findings suggest a reduction in frequency of sex an increase in endurance, and an increase in refractory period. The risk of exogenous testosterone is considerable and usually not warranted.

Medical illnesses in middle age

One of the challenges of middle age is the feeling of getting older. The realization of age is ushered in for many middle age men and women with the first serious or chronic medical illness. There are characteristic illnesses that present during middle age. The chart below list some of the illnesses that present with psychiatric or behavioral symptoms. Adjustment problems to mid-life may present as a result of these illnesses. The presumption that the psychological difficulties are primarily functional may result in a missed diagnosis of these illnesses. In addition the interaction of life cycle stress with illness can present problems in compliance and patient management.