Erikson spoke of middle age as characterized by a conflict between generativity and stagnation.6 This stage is often attended by consolidation of one’s social and occupational roles. The uncertainty and testing of the young adult stage has passed. Many are firmly fixed in their careers, sometimes disproportionately so. Children are growing up and leaving home. For many, it is a time of relative economic stability and intellectual accomplishments. The question often arises concerning the appropriate goals in life, often termed the “mid-life crisis.”
An important adaptational response to this stage is the development of new challenges to replace those already met (Table 2.7). For some, it means changing jobs or duties within a job. Some take on added responsibilities or managerial roles. Others increase their involvement in church and community affairs or exercise programs. Whatever the method, such endeavors are probably preferable to gaining all of one’s sense of accomplishment through other people’s activities, such as from one’s spouse or children.
Much has been written about the “empty nest” phenomenon. Traditionally, it refers to a sense of loss and emptiness, especially in women, after the children leave home. Research has been unable to document such a negative experience. Rather, it seems that the prime determinant of the parent’s response to the children leaving is their own feelings of self-worth.
Levinson described several stages in men’s lives during this period7: early (17-45 years), middle (40-65 years), and late (> 60 years). Each stage is separated by a transition period of 4 to 5 years. Within the stages are specific patterns and developmental experiences. These researchers found remarkable similarities in the experiences of men from varied backgrounds and occupations. This type of research lends further evidence to the continual process of growth and development throughout the life-span.
Women during this stage have special transitions as well.8 Traditionally, menopause was viewed as something fraught with problems: hot flashes, depression, loss of femininity. Research has failed to bear out these ominous outcomes (see Chapter 104). Sexual activity may even increase when the couple is freed from the concerns of childbearing. Women may begin to fill the useful role of a grandmother, assisting in raising and teaching the grandchildren. Some women embark on new careers or educational endeavors.
Table 2.6. Issues of Young Adulthood
- Forming meaningful and lasting relationships
- Adjusting to the partner’s life style and expectations
- Deciding on whether or when to have children
- Adapting to the families of origin of each member
- Career choices
Table 2.7. Concerns of Middle Age
- Development of new career challenges
- Adjustment to children leaving home
- Impact of age-related physical changes
On the other hand, divorce in this stage of life can be particularly troublesome for women. Income falls precipitously; and if children are still home, the demands of parenting are usually carried out alone. Women tend to remarry less often than men and may not have had a viable source of independent income before the divorce.
As one enters the forties and fifties, there is a growing awareness of the inevitable changes in one’s body in response to aging. Aging becomes a physical reality, rather than just an intellectual concern. Weight gain is common, and many report difficulty reducing even with increased exercise. Illnesses, particularly in men, begin to rise in prevalence. Often there is a new-found desire to exercise to recover one’s “lost youth.”
One of the most important interventions by the family physician is to communicate the normality of these experiences. Some persons are particularly upset that they are dissatisfied with their lives at a time when they have accomplished so much. Health maintenance and disease screening interventions become more important. The patient needs to be taught that it is never too late to make positive changes in health status.