Intended for healthcare professionals

Career Focus

Tackling the midlife crisis

BMJ 1997; 315 doi: (Published 20 December 1997) Cite this as: BMJ 1997;315:S2-7123
  1. Carl Gray, consultant histopathologist
  1. Harrogate General Hospital,HG2 7ND

Re-invent yourself out of middle aged angst: ageing juvenile Carl Gray (42) contemplates the first day of the rest of his life.

So, we'll go no more a roving

So late into the night,

Though the heart be still as loving,

And the moon be still as bright.

Lord Byron wrote this at 29 and was dead 10 years later, having had his crisis early in a big girl's blouse. Nowadays you're old young: youth gives way to “middle youth” at 30 and middle age covers the awful bit between fuddy and duddy. The prospect is not encouraging: illness, decline, death, and bereavement; the loss of parents, uncles, aunts. Middle age brings inklings of society's ageism and hatred of the old. Even prosperous middle age may not appeal, with its organised

holidays - anoraks and sensible insurance - jewelled wedding anniversaries, the cruise…. Spending more time with the family may not be welcome to you or them. Medical careers reach a long plateau after training and doctors seem more susceptible than others to the midlife crisis. Students and trainees unconsciously learn that illness and ageing are for others: the people in the beds. After a hitherto blameless career doing all the right things, doctors may feel real distress and surprise as the fury strikes: “This can't be happening to me!” Middle age brings misery with maturity but hope mixed with the horror.

The components

You have left behind the upward view; onward is downwards now. You have got there and made it with several T-shirts. But … is this it? Better to travel than to arrive; to do is more fun than to complete. Every success is followed by anticlimax. Where has all the fun gone? It is a shock when deterioration is recognised in the all too soft tissues and skeleton. Spreading non-lean body mass leads to men growing breasts and women growing chins. Doctors and their corporations are less limber, sports and leisure are neglected or abandoned. Osteoarthrosis fortifies the bad back and knees. You become fair game for blood pressure, diabetes, gout, renal stones, cholesterol and presby-everything-else. A visit to the GP becomes interesting to you both: “Good heavens, there's sugar in this urine!” The well person's clinic seems gloomier to the departing unwell person who has failed the MOT test and can't find any reading glasses. Exhaustion joins increased fatiguability to make you really dog tired by 9 pm.

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Aphasia for names and faces now afflicts the memories which once could tabulate spinal nerve roots. How we envy those with the power of recall! The neuro- degenerative deal brings increased connections - improved parallel processing power - but rather less randomly accessible memory. The cerebral Sainsbury's becomes smaller: less on the shelves, and a lazy stacker. You lose your trolley and it feels silly to start making gaffes at your age.

Relationships adapt and change. Teenage children grow and leave and come back with your grandchildren. Sexual performance changes, discussed in well illustrated books in the health sections of bookshops.

Naturally, experience brings judgment and perspective on life. You have already rehearsed the consequences of many situations and served your punishment. You are adept at the selective application of attention: either the house is on fire or the partner has a new hairstyle, but not both. Despite failing faculties, intellectual optimism is well founded: the brain is needed less for use and you've long since passed your exams.

In the second adolescence, however, certainties dissolve and tastes undergo drift. Established pleasures no longer satisfy: “Not bloody La Bohme again!” Firm radicals entertain conservative thoughts and vice versa; surely the government has the evidence on its side? Reading travels on to The Telegraph and back to The Beano. Policemen and prime ministers - whose names we can remember - seem very young. Lifelong ideals weaken into dis- illusion and become uncharitable (“Bugger the whale!”) and indeed the environment seems worse, there is more cruelty and no less poverty in the world 30 years on.

The stout party should have a well padded wallet tucked safely into the beige windcheater but finance has to serve for fun now, capital projects, and the future. It may be running out and underprovision is commonplace.

We all know where we're going and sometimes who's going with us, but do you have a view of the next 10 years or your retirement?


The crisis is an emotional state with worry focused on the contributory factors; a time of anxiety and dread of difficult decisions. Traditionally one awakes with a jaundiced view on the 40th birthday morning - I have the photographs - but even without an actual crisis, the issues listed in the box are the bogeymen jumping out of all our wardrobes. Any two or more will count: broad and shallow or narrow and deep. If they add up to emotional preoccupation you have achieved crisis. I exclude specific disorders and the endocrine climacteric as these are better discussed by people who know.


Maladaptive responses include comfort eating, retail therapy, alcoholism and sex mania. Partners and children will report bad temper, uncharacteristic laziness and a recrudescence of toddler negativity. Many attempt to retain a desperately young image: women become fashion victims or the oldest teenager in a short skirt; men try to out-bloke the new lads in withit gear riding fast cars and younger women.

Differential diagnosis includes mental illness, and, of course, symptoms overlap with the cardinal features of depression. Suicides peak in men in their middle years so watch out! You can and should tackle middle age yourself; your doctor has to treat depression.


Despite the woes of middle age there are advantages (see box). Fortified by these, reduce each of the component problems below the threshold of anxiety using focused attention and the deliberate actions outlined in the box.

You can re-establish control over the organisational situation. An inch of gold will not buy an inch of time and it is your time to spend. There is a loaded diary in that briefcase: you know what to do.

Necessary mental adjustments include accepting all of your limitations and for once, finding your own excuses entirely satisfactory. You are not perfect and will not now achieve perfection. Go quietly in the world as your attitudes adjust to the person you have lately become. Deploy your valuable attention carefully. (By the way, is the house on fire? Was that in fact a new hairstyle?) Intellectual development is progressing; enjoy new ideas and views in the coming weeks.

Fashionable folk are at last striving towards a healthier lifestyle. Look in all these new gyms: half the members are bronzed and lean gods; the others are middle aged. Screening may show up some conditions to be solved so you can die healthy; feeling better. Your income portfolio has to match your aspirations; otherwise the result is misery. Your pension, insurance, and capital arrangements must support your last 30 years. See Mr Micawber - your finance adviser - and get it sorted out.

New professional or recreational destinations are exciting: admit it, you are attracted to the nice bits of South America, white water rafting in Zimbabwe, or even bungee jumping (blood pressure). Out of the doldrums you will see some peaks and troughs still to come. Risks and opportunities are there to be taken and more than just washing the car or putting in some new autumn bulbs. Are you the cat that would eat fish, and not wet her paws? You can discover the retiree you wanna be and start meeting him or her.

Retirement should be the happiest time given that the fundamentals are met. Now visualise your prospects on the basis of experience and try out bits of new life without embarrassment. Partial retirement portfolios lend themselves to multiple branches and trials. Despite being conservative and risk averse, middle age brings real opportunities and increasing freedoms from constraint. There is time again to take up childish things or leap recklessly into controlled adventure.

View this table:

Partners, especially ageing ones, need more cherishing. Your midlife crisis is already contributing to their anxiety in middle age. Try some nice surprises and presents; spend some time; take some notice and give permission for them to change too. Despite the new telecommunications, social circles tend to contract owing to divorces, deaths, and us all being so busy these days. Only positive action can reverse this trend. You can re-invent yourself in a designer image: the designer is you. Re-establish active leisure, do some work on happiness1 and take up some scholastic, artistic, or civic effort. Forget other people's view of you: which bits do you like? In conversation and les actualitŽs (in English?) you will become more interesting to everybody, including yourself.


Absurdists often said that life begins at forty and, whatever the strengths of Phyllosan (a proprietary vitamin preparation of historical interest only-Ed.), life has you in its grip and will inevitably put you through your natural history. Crises confront reason and emotion. In the tranquillity after the storm, rational decisions and judgments will come to feel not only right to you but justifiable to friends, who will be envious of your renewed health, vitality, and outlook. Your crisis will have seemed comic to your juniors - “It'll never happen to us!” - alarming to contemporaries - “What is the matter with Douglas?” - and passŽ to seniors: “Stuff and nonsense!” Lady Macbeth challenged her husband, asking [would he] “live a coward in [his] own esteem, Letting ‘I dare not' wait upon ‘I would'”? Of course he went slightly wrong later. Dylan Thomas also died young and during a florid crisis, but he wrote to his father: “Do not go gentle into that good night. Rage, rage against the dying of the light.” Has anyone seen my reading glasses?


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