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"Is Having a Crisis Normal at My Age?"

Yes, the midlife crisis is real.

As a medical student, I learned that major mental health issues often first emerge in a person’s teens and twenties. Later on, I began to appreciate another peak in onset among the elderly: As a psychiatric specialist in an academic hospital, I was often called in to consult on older medical and surgical patients. For many this was their first interaction with psychiatry; serious mental health concerns had never arisen in their lives before.

A few years ago I began to treat outpatients exclusively. Given my previous experience, I expected to see peaks in new cases among younger and older adults. So I was a bit surprised to observe yet another peak occurring at middle age. A significant portion of new patients walking into my office are between the ages of 45 and 55. For many, it’s the first time they’ve been to see a psychiatrist, and they’re often dumbfounded to find themselves sitting in front of me. Frequently, after fidgeting awkwardly for a few minutes while trying to explain what brought them in, they will stop suddenly and ask: “Umm… Is this normal?”

Why do some people first need to see a mental health professional in their 40s and 50s? Why are there age peaks in the onset of mental health issues at all? Why do more people consult a psychiatrist for the first time when they are around 20, 50, or 70—and not when they are 30 or 60?

As with all psychiatric questions, the answer to this one is neither purely biological nor psychological—it lies at the intersection of biology and psychology. To get an answer, let’s start by considering the peaks I mentioned in young adults and the elderly, and then we’ll get to middle age.

The usual biological explanation for why major psychiatric disorders first crop up in teenagers and twenty-somethings is that this is an age when rapid changes in brain organization occur. The brains of humans are in constant flux, but there are developmental stages when our brains undergo more sensitive adjustments than others. One such stage occurs at the transition from adolescence to adulthood. This is a time when the brain undergoes its final maturation into adult form, driven in part by a surge in sex hormones.1 These hormones, along with other developmental factors, drive the final maturation or elimination of some connections (synapses) between brain cells (neurons). They also drive refinements in the branching pattern (wiring diagram) of neurons, as well as completion of the myelination (insulation) of major brain tracts (the “cables” connecting different brain regions). One theory is that some of these biological events go awry in people who first become mentally ill at this stage of their lives. Another possibility is that these developmental events occur normally in these people, but uncover biological vulnerabilities left over from earlier developmental stages. It is likely that these two theories are both correct to varying degrees in different patients.

That said, refinements in synapses and brain wiring are not the only major events happening in the lives of young adults. While this invisible biology quietly runs its course deep inside their heads, teens and twenty-somethings are also engaged in a highly conspicuous psychological and social transformation. This is the age when humans explore their first romantic relationships, bond with an intimate partner (possibly for a lifetime), seek out and establish independence from their family of origin, consider starting their own new family, and explore and choose an initial career path.

Together, these events constitute not just a sea change but a veritable tsunami of life changes. Any life change is stressful psychologically, and mental illness (like all illness) is sensitive to psychological stress. It should, therefore, come as no surprise that the tsunami of psychological changes occurring at the transition from adolescence to adulthood is accompanied by a peak in onset of mental health issues. It is also no coincidence that this psychologically stressful life stage coincides closely with the biological brain changes discussed in the prior paragraph. Far from being a coincidence, the psychological and biological transformations of young adulthood are two sides of the same coin. Just as you cannot separate the heads side of a coin from the tails side, you cannot separate brain biology from the psychology that surrounds it. The biological, psychological (and by extension, social and situational) shifts that occur in young adults are each a cause and consequence of the other.

The same principle applies to the peak in mental health issues occurring among the elderly. Like it or not, we humans are physical creatures with an expiration date, and old age is accordingly marked by significant biological changes in brain organization. As we age, we lose neurons and synapses, and those we retain become less biologically flexible. We may first notice this as a reduction in our ability to learn; as we age the speed with which we can acquire new skills and incorporate new information deteriorates. We misplace our keys more frequently as our short-term memory begins to wear out. Socially, this life stage coincides with a wind-down in our work productivity that most often culminates in retirement. It also coincides with changes in our interpersonal relationships fueled by our own biology as well as that of important people in our lives: our partners, children, and friends are progressing through their life stages too. As Bette Davis famously observed: “Old age ain’t no place for sissies!”—inevitably, as people age, they must accept increasing physical limitations, infirmity, and ultimately mortality.

As with the young adult stage, the biological and psychological transformations of the elderly are two sides of the same coin. It is the complex interplay between these two sides that leads older patients to seek expert help from mental health professionals like myself.

And so now, as promised, we come to consider middle age:

Is the midlife crisis "real"?

….Well of course it’s real!

Significant biological transformations occur in the brains of humans at mid-lifespan. One reason we can be so sure of this is that a very conspicuous biological event occurs in at least half the population at this stage: menopause. In women undergoing menopause, levels of estrogen that had been cycling monthly since puberty—or were held steady by pregnancy or birth control—fall off for the last time. Prior to menopause, estrogen does a lot more than prepare a woman’s ovaries and uterus to make babies. Like other hormones, estrogen exerts powerful effects on every organ in the body. That includes the brain, where estrogen promotes complex synapse formation and increases surface area projections (the synaptic spine count) of neurons in brain regions such as the hippocampus, which is involved in memory.2 Estrogen also exerts myriad effects on neurons in other brain regions, including those involved in mood regulation. Some young women and their partners get a striking monthly reminder of this, called PMS (“Premenstrual Dysphoric Disorder” in DSM-5).

Another reminder of estrogen’s power on the brain can occur in new mothers: postpartum depression (or psychosis) is a serious psychiatric condition impacting some women when their estrogen levels plummet shortly after giving birth. Menopause is yet another example of the same phenomenon: The reduction in estrogen that occurs at and around menopause results in significant shifts in the brains of middle-aged women. This includes permanent reductions in certain subtypes of synapses and synaptic spines in some brain regions, associated with a small reduction in overall brain volume.3

As for middle-aged men, although the biological basis for “male menopause” is far less well-characterized, significant changes to male brain structure do occur at this same life stage. This includes an even more significant decrease in the volume of certain brain areas in middle-aged men compared to menopausal women. These changes in brain structure correlate with reductions in circulating levels of the male sex hormone testosterone. But in both men and women, midlife brain changes are also driven by other biological factors, including the normal pace of several innate biological clocks,4 as well as “wear and tear” in other parts of the body, such as decreases in overall vascular fitness.5

Paul Vasarhelyi/Shutterstock
Some things change, others stay the same
Source: Paul Vasarhelyi/Shutterstock

Psychologically, midlife is a time when many people reach a plateau in both their personal and professional lives. Many middle-aged people have long ago married and had kids; by midlife, they may have been with their partner for a decade (or two or three), while their kids have grown less dependent and are preparing to leave the nest, if they haven’t left already. On the flipside, middle-aged people have parents who may be in the process of becoming more dependent on them; parents who eventually fall ill and pass away. In their careers, regardless of whether they have attained the level of success they once dreamt about, people at midlife are likely to be facing the prospect of what lies beyond for them professionally. To summarize, middle-aged people are confronted (consciously or not) by inevitable questions: “Given that I’ve learned from my youthful mistakes, what can I accomplish during the second half of my life?” “Given that I’m not going to live forever, what do I want to do with my remaining time before it’s too late?”

Although what I’ve written above is based on my own clinical observations, I am by no means the first to notice it. Four centuries ago, drawing upon contemporary and classical sources, William Shakespeare soliloquized about the seven ages of man.6

Closer to modern times, psychologist Erik Erikson (1902-1994) identified eight life crises, including three in adults roughly corresponding to what I’ve discussed here.7 As a psychiatrist with a strong background in developmental neuroscience, I find it interesting that changes in brain biology play as big a role in these adult life crises as the psychological issues that Erikson focused on. But once again, this is because the biological and psychological are two sides of the same coin. The separation we humans like to make between brain biology and psychology is an artifact. Ironically, that apparent separation is a product of our brain itself—which has an ingenious ability to shroud its biological inner workings within an ephemeral cloak we refer to as "consciousness," "mind," "psyche," or even "soul" or "spirit."

So to finally answer my middle-aged patients’ achingly awkward question: “…Is this normal?”

Yes, the personal crisis you are experiencing is perfectly normal. It is normal biologically, psychologically, socially, and situationally—but it’s all tangled together in a big knot you can’t pull apart. It’s also normal for you to be confused and frustrated—after all, this is a situation you’ve never faced before. So please make yourself comfortable and let’s talk it over. I may not be able to untie the knot for you, I may not be able to cut it in two—but I do have lots of experience helping people cope with these sorts of knotty problems. Between me and my prescription pad, I may be able to loosen it up a bit for you.

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1. Ariam et al. (2013) Neuropsychiatr Dis Treat 9:449-461; PMID 23579318

2. Hara, Y et al. (2015) Physiol Rev. 95:785-807. PMID: 26109339

3. Guo, J et al. (2016) Neurosci Let. 615:107-112. PMID: 26777626

4. Belsky D et al. (2018) Am J Epidemiol. 187:1220-1230. PMID: 29149257

5. Barnes, J. (2015) Adv Physiol Educ. 39:55-62. PMID: 26031719

6. As You Like It 2.7.142-165

7. Erikson, E. (1994) Identity and the Life Cycle. New York: W.W. Norton & Company