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Ask the Mental Health Expert Archives 2001-2004

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Midlife Crisis

Q. I was wondering if you had any information on the debate of midlife crisis being included in the DSM-IV. Is it a real disorder or a culturally induced myth? Can you please explain to me why or why not it should be a recognized mental illness? What mental illnesses are similar to this condition?

A. I am not aware that there was any real debate about including midlife crisis in the DSM-IV. Most likely, the DSM-IV would incorporate midlife crisis under the diagnostic heading of "Adjustment Disorder, Unspecified type", which is described as a maladaptive reaction to psychosocial stressors that does not fit one of the other adjustment disorder types (e.g., adjustment disorder with anxiety, adjustment disorder with depressed mood, etc.)

However, depending on how one defines crisis, I think many within the mental health community would regard this as a normal, developmental issue for many (though probably not most) middle-aged men and women. As S.C. Samuels notes in an article you may want to see, "Midlife may be associated with changes and losses, including declining health status, retirement, caregiving for aging parents, and unexpected responsibility for adult children or grandchildren." (Geriatrics, July 1997 52:55-6). There is also the loss of children from the home (empty nest syndrome) and, for women, the onset of menopause to cope with. (By the way, for most women, menopause per se is not a major psychiatric problem; rather, much depends on how active, creative, and socially engaged the woman feels).

To the extent that the middle-aged individual (man or woman) experiences sadness, worry, and uncertainty over these losses and changes, I'd argue that he or she is reacting normally, and would not want to label the person as having a mental illness. This is assuming that the individual is generally able to meet his or her social and vocational obligations without significant impairment. On the other hand, if the individual began to develop signs and symptoms of a major depressive episode (loss of appetite, impaired sleep, extreme sense of self-loathing, guilt, loss of pleasure, hopelessness, social withdrawal, inability to function at work, suicidal feelings, etc.), I would be very worried--particularly since suicide rates increase (generally speaking) with older age.

But in general, I tend to take an Eriksonian (after Erik Erikson) perspective on midlife; i.e., that this is normally a period in which the healthy individual struggles with "generativity versus stagnation" (see GE Vaillant, The Wisdom of the Ego, 1993). The issue of when a cluster of symptoms and signs becomes an illness, a disease, etc., is a very thorny problem in the history of medicine and philosophy--for details on this issue, you may want to see a piece I did many years ago, in the February 1979 issue of the Archives of General Psychiatry.

One key feature of disease, in my view, is the presence of suffering and incapacity. The DSM-IV lists "social or vocational impairment" as a criterion in nearly all the major mental illnesses, and with good reason--otherwise, every perturbation of the person's emotional life becomes an illness. In addition, clinicians look for a recognizable pattern of signs and symptoms; a familial or genetic predisposition; an expectable or predictable course; and, in some cases, a predictable response to treatment, as general features of what we would call a disease, illness or disorder. (All these terms have quite variable meanings in the history of medicine and philosophy).

Schizophrenia clearly fits the bill-but I am dubious that midlife crisis meets this standard. You may want to see the article by A. Kruger entitled, "The Midlife Transition: crisis or chimera?", in Psychol Rep December 1994, 75 (3 pt. 1): 1299-1305. Maybe the Chinese have summed it up best: the twin symbols for crisis in Chinese translate into English as danger and opportunity.

July 2001

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