Stress was originally an engineering term referring to the pressure of an external force against a resisting body. Stories about social stress now far outnumber reports about surface wind stress. The causes of social stress, although they vary depending on a person’s age, financial resources, and friends, are all cultural and social—and they can be as powerful as a natural force like the wind.1
By the mid-1950s, medical sociologists and health psychologists were routinely calling attention to the pressures men experienced: at work and as breadwinners, as husbands and fathers, and when facing retirement. The researchers first recognized that stress affects heart health, and now we know that chronic psychological stress or even an accumulation of negative and positive life disruptions weakens the immune system,2 depresses mood,3 elevates cortisol, and causes early-onset hypertension and cardiovascular disease.4
To begin, let’s think of stress in three distinct ways. One, some degree of stress keeps us engaged and challenged. It increases arousal and alertness, enhances performance, and can lead to physiological toughness.5 Similar to the way aerobic exercise toughens our body, seeking challenges and coping effectively with social stress are psychologically toughening and result in better health. Some positive life events (e.g., a promotion, the end of paying college tuitions) and even some unpleasant experiences (e.g., having a dentist repair a cracked tooth, preparing for your second colonoscopy) may be stressful but do not cause harm. By contrast, it is when our stress piles up that the fulcrum tips and stress becomes dangerous. Whenever the number of stressors or amount of pressure exceeds our personal thresholds and defies our coping capacity, the level of arousal exhausts the body’s ability to recover and clouds thinking (see stress response chart). Too much stress becomes damaging. In this sense, stress isn’t an abstract concept or merely a restless state of mind. It is something real, measurable, and often dangerous—killing brain cells and challenging our heart’s functional ability to the point of death.
Figure 5.1. The stress response curve. From P. G. Nixon (1976). The human function curve. With special reference to cardiovascular disorders: Part I. Practitioner, 217, 765–770. P. G. Nixon (1976). The human function curve. With special reference to cardiovascular disorders: Part II. Practitioner, 217, 935–944.
Two, external stress needs to be distinguished from internal distress. External stressors (the events) include economic downturns, workplace demands, a grumpy neighbor, an empty marriage, arguments, a driveway full of snow, noise levels, or in-law troubles. By contrast, internal distress (our own particular response) is the effect the stressors have on us personally. It is the perceptible feeling of tension, frustration, or anxiety. External stress is as influential to our overall physiological and psychological health as our genetics.6
Three, stress is an individual experience. We all feel it and have to deal with it in our own way. Two men will cope with the same stress differently. In addition, what can be stressful for someone at one time may not be stressful for the same person at another time. Stress exists when we (even unconsciously) appraise a situation as taxing, a threat, and exceeding our coping resources.7 Most men are not able to always recognize when stressors affect their lives—as men, we are encouraged to normalize the innumerable demands and inevitable setbacks, worries, and pressures regularly bearing down on us. It is what men do. However, these nearly ignored stresses can quietly chip away at the integrity of our body and our emotional resiliency. This chapter examines the physiology of stress, the known effects of stress on men’s physical health and personal well-being, and strategies that best contribute to our ability to manage stress.
Most American men share a “masculine consciousness.” Whatever our ethnic/racial heritage, social class, or politics, as men, we commonly live with the cultural expectations that define what a “man” should be. This imagined “man” has qualities such as toughness, independence, personal control, physical and sexual competence, assertiveness, being successful at all costs, and not being anything like the “ladies.” Although the image of what a man is supposed to be will not be identical for a roomful of men, we all make judgments about ourselves and others based on a masculinity ideology.
Tension is who you think you should be. Relaxation is who you are.
—A Chinese proverb
Stress often arises when you believe that you are not living up to masculinity standards, or whenever a situation is interpreted as requiring “unmanly” behavior.8
I asked the woman desk clerk who was in her mid-50s to find the hotel manager, and this perky little thing came up who was barely 30. I explained again that the room they assigned me wasn’t what I asked for. I reserved a non-smoking room. The manager testily commented that there was no other available room; the hotel was full. It was nearly 11 p.m. and I didn’t have the energy to go find another hotel. So, I bit my tongue, accepted my fate, knowing that I was going to have to pay for a smelly room for the night. As I walked back to the elevator, I could feel my blood pressure pounding in my neck! (Dave, 59-year-old man)
Stress was experienced because Dave confronted conflicting expectations and because “the man” in Dave’s consciousness whispered “you wimp.” He was caught between separate stressors—to fight a battle at 11 p.m. for his pride versus to stay the night in the unwanted room and not argue with the night-shift clerk.
Every one of us knows that we will fall short of the flawless manhood standard, and almost every day we find ourselves faced with contradictory expectations similar to what Dave faced. Unlike the ideal man who never experiences losses in independence, power, sexuality, and self-reliance, real men do. We are also oftentimes without a “wing man” and live with the risk of a loss of social contacts and the backing they provide.
Men’s hormonal reactions to stress, especially our secretion of testosterone while under stress and our lesser amounts of oxytocin, which boosts sociability, team up to sustain our festering distress for longer periods of time.9 Fortunately, aging seems to defuse some of our physiological reaction: as we get older, we secrete less testosterone, engage in fewer “fight-or-flight” hormonal responses, and have a greater desire to tend and befriend than argue.10
Life Events and Their Stress Rating
100 Death of a spouse or partner
73 Divorce
63 Death of close family member
53 Personal injury or illness
47 Fired at work
45 Retirement
44 Change in family member’s health
39 Sexual difficulties
38 Change in financial status
37 Death of a close friend
35 Change in number of arguments with spouse
29 Son or daughter leaving home
26 Spouse stops work
20 Change in residence
18 Change in social activities
16 Change in sleeping habits
Source: Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research, 11, 213–218.
But middle-aged and older men face distinct forms of social stress because of our age and gender. As we get older, we live with more life changes, and change—both good and bad—is stressful. Too many changes in a short period of time can overtax someone’s ability to cope or adapt, leaving him more vulnerable to infection, injury, or disease.11
As we get older, we encounter stresses more common to later life, such as leaving the workplace, living on a retirement income, the death of friends, or living with our aging body and medically related limitations. We can become overwhelmed by the “pileup” of these life changes. In the mid-1960s, a team of stress researchers identified a series of life events that are regarded as most stressful (see chart),12 and it’s not surprising that the more grave stressors are what men (and women) run up against as we get older. For example, the “readjustment” necessary when we face a “life event” such as a wife’s or partner’s serious illness is more likely to occur as we are aging and might occur about the time men are experiencing what it means to retire. Depending on how you interpret retirement (e.g., an end of a career, or escape from drudgery to choice), this “life event” and facing a personal illness can add up to be almost as stressful as bereavement, which is recognized as one of life’s most heartbreaking, stressful experiences (see chart). Those life events that are negative and out of your control are much more predictive of distress than are positive, controllable life changes.13
Middle-aged and older men also face a whole new set of stresses caused by the ageism in our society. We are misperceived as healthier than same-age women, even though men take more sick days than women and die earlier.14 The misperception is especially dangerous when it comes to our psychological health. It is said that men’s psychological well-being isn’t as challenged as women’s when our bodies age. All of these misperceptions become expectations that urge every man to continue to hide behind a mask of “I’m okay” and not admit to having fears and worries about getting older. They discourage others from asking, “How do you feel?”
Your new neighbor moves in with two barking dogs. Your daughter who lives alone and out of state calls to tell you she is headed to the ER because she is experiencing severe chest pain. Which ER? What’s going on? These distinct stressors share one simple fact—stress is an attention getter, even if you are not consciously aware that stress is affecting you. Stress is greater when you are uncertain and do not understand what is going on. Stress is based on our (sometimes unconscious) appraisal of the situation as outside our control and as threatening. Cumulatively, stressors can become a slow poison that undermines our physical and psychological health.
How is stress poisonous? External stressors do not directly cause ill health, as might be the case when a deer tick bites and infects someone with Lyme disease. Rather, much as coastal winds affect the posture of some trees more than others, stress brings about bodily adaptations that prove to be more corrosive for some men than others. It all begins in our location on the social gradient and in the central nervous system and brain.
The social gradient reveals the social inequalities within our nation, or people’s access to resources such as employment, health insurance, retirement income, housing, and diet quality.15 Men who are lower on the totem pole and have fewer opportunities and resources to lessen the day-to-day psychological strain are at higher risk of stress-related health problems. Men with greater resources more often feel in control and are more able to defend themselves from stress.
Men who experience racial discrimination, for instance, live with more stress and have poor psychological well-being.16 Men with more wealth have more resources for managing their (lesser) daily stresses. This stands to reason. Being white, having better employment opportunities, and earning higher incomes buffer many stressors. Even animal studies have found that the risk of stress is related to a social hierarchy—the “bottom tier” males in baboon troops are much less relaxed than the dominant males, largely because they are repeatedly challenged by the dominant males. Their stress hormones are not able to return to normal levels, and they are more likely to suffer from cardiovascular disorders such as atherosclerosis and hypertension.17 People who feel that they cannot control their fate are much more likely to live with the ill effects of stress.18
Two neuroendocrine systems are specific to the stress-health connection. About the time of the Great Depression and thus only a generation after Darwin’s theory of evolution, a Harvard physiologist (Walter Cannon) persuasively argued that the human organism is, similar to all other organisms, continuously adapting to its environment—whether the environmental “demands” are forces like the weather or what people perceive as personal challenges.19 He theorized that the body seeks balance, or homeostasis. Using his analogy, when the weather is hot, the body sweats to allow evaporation to help cool the skin. When we have an infection, antibodies are produced to fight the germs. And when we encounter an external threat, our bodies engage in a fight-or-flight (or stress) response that mobilizes us for the perceived emergency.
The Stress Response
Almost any stress—from a physical wound to an argument—triggers the stress response. When the brain perceives stress, the hypothalamus engages the sympathetic nervous system (SNS) to release the hormone “corticotropin-releasing factor” (CRF), which tells the pituitary gland to release adrenocorticotropin (ACTH).
The flooding of ACTH into the bloodstream, along with direct signals from the brain sent through the autonomic nervous system, stimulates the adrenal glands to secrete the stress hormones cortisol and epinephrine (adrenaline) into the bloodstream.
Cortisol and epinephrine help provide more energy and oxygen. They stimulate the heart, the brain, and other muscles and organs to amplify the body’s response.
When the brain perceives that the stress has ended, hormones are returned to their baseline.
Physiology of stress response
The fight-or-flight response is defensive and self-protective. It is a biochemical reflex, just as antibodies are a defensive response to an infection. Imagine that you are trudging uphill in the dark in late November to the parking lot where your car is parked, and as you are climbing the walkway you hear the rattling of dog tags. Though it may seem like you heard the tags rattling barely milliseconds earlier and then envisioned milliseconds later the likelihood of a dog rapidly running at you, in fact when we experience a perceived threat the brain and body interact well before we are consciously aware. The perceived threat of a rushing dog triggers the immune, nervous, and neuroendocrine systems to prepare the body for the possible attack. What occurs, according to Hans Selye,20 is that the brain and the endocrine system synchronize, immediately setting about a host of physiological responses—the hypothalamus at the base of the brain triggers the secretion of an array of hormones into the blood, including adrenaline and cortisol; glucose, simple proteins, and fats pour out of fat cells and muscles for a rapid mobilization of energy; heart rate increases to speed the transportation of nutrients and oxygen; and both the brain and the pituitary release endorphins and enkephalins, which are opiate-like hormones designed to limit the impending pain. All of this occurs in order to ensure our survival. It’s primitive, instinctive. While these amazing physiological processes worked well for our prehistoric ancestors who came face to face with predators, they’re not as useful in our postmodern world. Very rarely in our normal lives do we need to respond in prehistoric programmed ways to every perceived challenge, as if every stress required an immediate, intense physical effort to survive.
Yet that is what our bodies do, day after day. Put on a heart monitor with a digital readout and watch your heart rate climb multiple times as you slug your way through the accordion of highway speedups and brake slamming during rush hour. When you awake from a claustrophobic dream with a shortness of breath or grit your teeth when a telemarketer interrupts dinner, your neuroendocrine systems have secreted hormones, taken control of heart activity, and regulated many other body functions to weather the challenge.
The problem is that, with the way that it is hardwired, the brain doesn’t distinguish one threat from another: a (perceived) threat is simply a threat, and the fight-or-flight reflex is activated. When any threat is presented, the brain signals the alert and the body mobilizes defensive reactions. The health-related problem isn’t complicated—the human body has a finite reserve of adaptive energy. When you live with the chronic stress that usually involves too many demands and too little personal control, or when you face a prolonged accumulation of many disruptions (your car is towed because the “Do not park here on game day” sign is posted 10 feet higher than other signs, the impound yard is closed and you must rent a hotel room to wait it out, your briefcase is locked in the trunk, you end up late for work on Monday, etc.), your brain keeps the body in full-scale mobilization. This “survival” response actually ends up with the body at war with itself. The stress response becomes more damaging than the original stressors.
Here’s the good news: initially in animal studies and later in human studies, researchers have demonstrated that when we are repeatedly exposed to certain stressors, we can become a bit immune to these stressors. We develop stress tolerance. As we learn to distinguish among challenges (e.g., a baby crying versus screaming), our brain is conditioned to recognize these stressors as ordinary.21 The intense arousal isn’t required. Similarly, whenever we encounter a challenging task in situations where we have high levels of personal control,22 these “manageable” stress situations do not require energy-demanding responses. In both cases, only some of the stress hormones are released—the catecholamines (epinephrine, norepinephrine, and dopamine) are released and your heart rate and blood pressure increase, but cortisol levels are not elevated.
Stress Consequences
Stress has become a major factor affecting men’s health. The tension and emotional strain of day-to-day living have been linked to heart disease, high blood pressure, migraine headaches, diabetes, cancer, and a weakened immune response to disease.
A word of caution: even though stress tolerance can be acquired and is desirable, learning to appraise stressors and manage stressful situations does not mean that our body’s responsiveness to even normal stress is devoid of long-term ill effects. Recall the times you came home from an ordinary day at work and found yourself unexpectedly napping; your body was trying to recover from the pileup of the many ordinary, challenging, and stressful workday demands. Even when managing little stressors, the brain repeatedly triggers our primitive neurophysiological stress response. The brain is only conditioned not to overreact. The body does not work as hard with these normal stressors, compared to what occurs when we face novel threatening situations. In addition, as we become older, our epinephrine (also known as adrenaline) and norepinephrine (also known as noradrenaline) levels are greater in a normal “resting state”; in other words, when older men encounter a stressful situation, hormone levels rise higher than they did in middle age and younger, and it takes older men longer to physiologically recover from the stress response.
Some of the hormones associated with the stress response, notably epinephrine and cortisol, purposively raise blood pressure and cholesterol levels to help us physiologically survive immediate threats, but they end up putting us at much greater risk for everything from colds to an accelerated rate of cancer cell growth.
The stress-related mind-body response is most malevolent to our heart and cardiovascular system, increasing our risk of hypertension, myocardial infarction, and stroke. The hormone epinephrine that is flooded into the bloodstream causes fatty nutrients to form, and the long-term result is a thickening of the artery walls and narrowing of the blood vessels, or “hardening of the arteries.” The secretion of epinephrine and norepinephrine also contributes to elevated blood lipid levels and increased blood clotting. Think in terms of the primitive stress response as cardiovascular reactivity: the frequent and large increases in blood pressure and heart rate strain the muscle integrity of blood vessels and the heart.
The relaxed heart rate for a middle-aged man is around 60–70 beats per minute. Moderate stress can raise the pulse rate to 100, and when we are facing more severe stress, the pulse rate can rise to 160–200 beats per minute. The work situation of air traffic controllers sharply increases their blood pressure, and a 20-year follow-up study revealed that these men had a long-term risk of hypertension (where the systolic blood pressure regularly exceeds 160).23 Many other workplaces silently contribute to men’s health problems and earlier death.24 The effect of prolonged stress is compounded when we are unable to get the amount of sleep we need and/or when there is a paucity of supportive friends to help us diminish the ill effects of stressful situations. Fortunately, as we get older, we have had more experience with managing most stressful situations and do not experience the same degree of physiological reactivity.
Biomedical research supports the warning that the pileup of stress increases our susceptibility to infections. The immune system produces two types of white blood cells (lymphocytes) to promote immunities, the T-cell and B-cell. T-cells are created by the thymus gland to fight bacterial and some viral infections. Every time the stress hormone cortisol suppresses immune function, it depresses T-cell functioning and can promote long-term, persistent inflammation. Stress shuts down digestion (you might notice dry mouth and a lack of saliva) at the same time it impairs immune function, giving the Helicobacter pylori bacteria that contribute to ulcers an opportunity to flourish.25 These physiological responses also prove advantageous for some kinds of cancer.26
Prolonged exposure to stress also seems to increase our risk of diabetes and memory problems. Health researchers find that when you’re stressed out, there is a risk of weight gain because elevated cortisol levels slow metabolism.27 Diabetes is a metabolic disorder linked to the metabolic syndrome28 and its cluster of risk factors (e.g., abdominal obesity, low concentrations of high-density lipoproteins [HDLs], or “good” cholesterol). The stress hormone cortisol is an insulin antagonist that elevates blood glucose levels, severely challenging the well-being of men who live with undiagnosed diabetes. In addition, when cortisol continually enters the brain, it seems to damage hippocampal formation and our memory.29 Ever experienced momentary forgetfulness when distressed? That is a symptom of the stress–(ill) health connection. In sum, stress is like a poison that can affect our immune, cardiovascular, digestive, and neurological systems. It is a real killer.
Physical Signs and Symptoms of Stress for Men
• Clenched jaws and grinding teeth
• Shallow breathing; shortness of breath
• Increased perspiration
• High blood pressure
• Chest pain
• Overeating and/or frequent snacking
• Diminished (sometimes, increased) sex drive
• Erectile difficulties
• Muscle tightening, back and neck pain
• Fatigue and exhaustion
• Headaches
• Nausea, maybe dizziness
• Tight, dry, or a feeling of a lump in your throat
• Digestive disturbances; indigestion, constipation, and/or diarrhea
When stress is unchecked, it can erode our psychological health and quality of life. For instance, you might think that more frequent raiding of the refrigerator and a modest uptake in calories is quite benign, if not harmless. You might also think that nagging shoulder muscle tightness is just a sign of a lack of good sleep or your occasional circadian-type low-energy dip. Each of these experiences is surely related to your energy level and sleep, but they are also warnings of the buildup of psychological distress that you may be ignoring.
If you are like most men, you probably pay little attention to your emotional health. This is partly because men do not have an “emotional pulse.” Unlike women, we’ve been encouraged to ignore feelings, and men learn to distract themselves from their moods by engaging in physical and task-oriented activities. Men usually respond to emotional distress by not thinking about it, whereas women are more likely to mull over the problem. What’s more, we learn to interpret negative feelings in somatic terms. We end up bottling up and squirreling away the psychological stress in our muscles, arteries, and gut. This is called somaticizing the stress: converting distress into headaches, muscle tension in the neck and shoulders, digestive disturbances, or an abdominal gut-wrenching pain. Behind the mask of being in control often lurks grumpiness and anger, and since we are not often penalized for it, we express our distress in a manner that Hollywood depicts as “manly,” such as uncorking into a “Mel Gibson rant,” slinging cutting remarks and in the process wounding people you live or work with. Stress-related psychological difficulties can escalate into burnout, one of many clinical anxiety disorders, or posttraumatic stress.
Psychological Signs and Symptoms of Stress
• Mood swings
• Irritability, anger
• Restless anxiety, inability to relax
• Anxious, racing thoughts
• Feeling overwhelmed
• Inability to concentrate
• Insomnia or fitful sleep
• Worry
• Lack of confidence
• Loss of interest in sex
• Dissatisfaction with work, friends
• Sense of loneliness and isolation
• Depression
• Sadness
• Preference for solitude rather than being with others
Prolonged stress can result in stress exhaustion or burnout. In burnout our emotions are blunted, whereas when stressed our emotions are heightened and reactive. Should the unremitting stress of daily hassles at work or at home have you feeling overextended and completely worn out, as if the tank is empty, you may be burnt out. When this happens, the littlest everyday problems seem insurmountable, and it’s difficult to rally enough energy to really care—let alone do something. Your emotional resources are depleted. You feel demoralized.
Burnout differs from depression in that burnout typically involves stresses linked to a particular situation, such as your work and workplace or your home life, whereas depression globally affects a person’s life. Burnout is defined by three dimensions: overwhelming exhaustion, feelings of cynicism, and a sense of ineffectiveness. It can occur when men are the 24/7 caregivers for an ill wife; when there are unrealistic expectations at work and you must always be “on,” and the workplace is ripe with the politics and power struggles that make it hard to get excited about your work; or when the distinction between being at work and time away from work becomes very blurred because you are required to make yourself available, perhaps always carrying a beeper.
Burnout isn’t just a state of mind. There is an excess of circulating glucose in the bloodstream triggered by chronic stress, and this blocks insulin production and inhibits the body from converting fats into needed energy. Chronic stress literally drains you. The feeling of being overloaded and physical exhaustion become a double-barrel assault on your health. Your immune system suffers, making you increasingly susceptible to viruses. We all have run up against stress exhaustion at one time or another—we crash. But the men who regularly suffer stress exhaustion are also aware of the unrelenting demands and unsupportive environment around them. It’s not uncommon to experience appetite disruption, sleep problems, restless anxiety, and irritability.
Contrary to common sense, burnout is not a recognized clinical psychological disorder. Despite being similar to both depression and anxiety disorders, burnout is much more common—there are estimates that suggest that half of all physicians, teachers and professors, police officers, technical personnel in hospital settings, and ministers have experienced burnout.30 A common denominator to the types of work that result in greater burnout is “people work” and the expectation to either display or suppress emotions on the job;31 for example, ER physicians and nurses can become blunted and unable to be emotionally empathic.
Signs and Symptoms of Burnout
• Emotionally worn down
• Exhaustion, headaches, and trouble sleeping
• Negativity—being more cynical, irritable, impatient
• You lack the energy to be productive
• Self-doubt, and feeling unappreciated
• Lack of any positive feelings
• Feeling overwhelmed, foggy thinking
• Feeling disillusioned about work, life
• You drink to feel better, or just not feel
• Feelings of incompetence
• Lack of achievement
Men facing burnout immediately benefit by becoming more physically active, seeking better sleep, and reevaluating their nutrition in order to eat well. Sounds simple, but men often find it difficult to enact all of these positive changes. It is important to try to alter the daily schedule, reward yourself once completing a task with a well-earned coffee break, and take mini-vacations to escape the rituals. You need to give yourself the “Attaboy” congratulations you deserve. Soaking in a hot tub, having a massage, and/or getting acupuncture to relieve nagging muscle tension caused by stress, as well as taking up one of the strategies of meditation (see below in treatment for anxiety), are all invaluable ways to manage burnout, once it’s noticed.
Anxiety is a normal reaction, and it is not the same thing as fear. As a mood or feeling, anxiety refers to the apprehensiveness, nervousness, restlessness, and tension we experience when faced with stressful situations. Anxiety is situational and related to a lack of mastery—ever hesitate to jump off a high diving board? Anxiety symptoms are similar to the signs of fear and may include trembling, headaches, sweating, elevated blood pressure, and changes in heart rate. But the ill ease of anxiety is when we do not feel in control of a situation. Anxiety can also arise from social changes that we do not control yet experience, such as an economic recession, and a poor diet, particularly low levels of vitamin B12.
All of us worry and feel anxious at times about our health, money, or family problems. It is when you are preoccupied about things, when you continue to ruminate, and when you feel a lack of confidence to manage the challenge that your anxiety level is no longer “normal.” Anxiety disorders have the same physical and emotional symptoms as commonplace anxieties, but the symptoms are more severe, debilitating, and/or intrusive. Regrettably, anxiety disorders are understudied conditions in older adults. From what we know, about 10 percent of adult men meet the criteria for an anxiety disorder in any one year.32 Adult men with a generalized anxiety disorder (GAD) experience almost constant, exaggerated worry and apprehension, even when there is little to provoke the feelings. Most people who experience the hyperarousal that distinguishes an anxiety disorder began dealing with the symptoms long before becoming middle-aged adults.
Adult men may experience a disturbing event, such as a terrible flight during a violent thunderstorm or witnessing a car hit a motorcycle and hurl the rider, and then begin to live with anxiety symptoms whenever there is a forecast for a pending thunderstorm or they see a driver tailgating. These “new-onset” anxiety problems are not uncommon among middle-aged and older men, but they are rarely treated. For instance, men who have been recently told that they have a heart condition may start to worry and fret, much more than their physician expected. They overcompensate and become “cardiac invalids.” Their anxiety percolates, and it can become debilitating. Anxiety disorders are observed among men approaching retirement or just after retirement, or when their own sexual functioning declines. The clinical reality is that most cases of anxiety disorder in later life remain undetected and untreated.33
Signs and Symptoms of Anxiety
• Twitching or trembling
• Muscle tension, headaches
• Restlessness or feeling keyed up or on edge
• Dry mouth, trouble swallowing
• Rapid breathing; rapid or irregular heart rate
• Emotional flipping (marked mood swings)
• Emotional numbness
• Irritability, loss of temper
• Sleeping difficulties, weird dreams
• Decreased concentration
• Nausea, lack of appetite
• Avoidance behavior
There isn’t one treatment that’s best. There are many strategies to treat anxiety, and not all of them will be proper for you. In fact, what might be effective treatment for some men won’t be for others. You will need to think about yourself and your willingness to manage your anxiety and, with the advice of others, decide what options can work for you. Unlike depending on pharmaceuticals, holistic approaches to treating anxiety combine several effective methods, starting with changes in your diet and lifestyle. Typically, you take up regular exercise, find time every day for relaxation, use herbal-based or prescription medicine, and, often, undergo psychological therapy for anxiety to help you reprogram your mind and stress reaction.
Regular exercise. The recommendation for staying healthy in mind and body is 30 minutes of regular exercise every day. The way exercise affects the mind and body is detailed in chapter 3, but for right now the message is simple: regular exercise releases the stress stored in our muscles, floods the brain with “good feeling” hormones, and encourages less fitful sleep; as a result, fewer symptoms of anxiety will occur. Exercise is vital in every treatment plan.
Relaxation exercise. Some men can benefit from a number of very good relaxation exercises. These mind-body treatments teach you breathing strategies and movements to help relax your body and balance your body chemistry. Many of the exercises are Asian in origin, such as qigong, which could involve meditative training and visualization on specific ideas, sounds, images, concepts, or breathing patterns, and Tai Chi, which involves dynamic training, including special movements. Yoga combines physical postures, breathing exercises, and meditation and is one of the top relaxation practices.
Psychological treatment. Perhaps the most common, well-established, and highly effective anxiety therapy is cognitive behavioral therapy (CBT). It focuses on identifying, understanding, and changing your thinking and behavior. More often than not, benefits are seen quickly, sometimes within a month, other times within 12–16 weeks. In CBT, you are actively involved in your healing and have a sense of mastery. CBT can be used with or without drugs. But it is our belief, based on research, that CBT is better than turning to pharmaceuticals.
Medication. Treating anxiety with medication is generally safe and effective, though medication will not cure an anxiety disorder. It can keep the anxiety under control. Use of antianxiety and antidepressant medication necessitates a physician visit and a prescription for the medication. You will need to talk with your doctor about what’s going on in order to receive the right medication and correct dosage and to minimize the danger of unwanted side effects. High-potency benzodiazepines (such as clonazepam and alprazolam) are successful in combating anxiety and have few side effects (other than drowsiness). At times, selective serotonin reuptake inhibitors (SSRIs—citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) are prescribed because they relieve symptoms by blocking the reabsorption of serotonin within brain cells. This leaves more serotonin available, which improves positive mood. There are also serotonin-norepinephrine reuptake inhibitors (SNRIs—venlafaxine and duloxetine) to increase levels of the neurotransmitters serotonin and norepinephrine.
Exposure to trauma is not a rare event, and it is estimated that more than half of all American men have been exposed to at least one traumatic event in the course of their lives.34 Exposure can lead to depression and posttraumatic stress symptoms well after the event. Unlike most stress-related disorders, posttraumatic distress does not feature anxiety as a primary presenting symptom. Four types of symptoms are characteristic: reexperiencing, avoidance, numbing, and hyperarousal. Originally a diagnostic category for only war trauma, our understanding of posttraumatic stress disorder (PTSD) has improved since 1980, when it was first introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Most men experiencing a traumatic event recover within a reasonable amount of time and do not develop posttraumatic stress. Traumatic events typically involve several stimuli, including sights, sounds, and smells. An awful car accident, for instance, is etched in slow-motion visual memory, the wrenching sounds of the crash, the rusty to metallic smell of blood, and the oddly, near-rational rhythm of EMTs taking over and transporting the injured person to medical care. Combat-related trauma is similarly coded in memory with all its chaos of voices, explosions, weather, smells, and visual images.
Posttraumatic stress and PTSD are now applied to men who suffer from a wide variety of noncombat-related traumas. Each involves a threat to the integrity of the self. A terrifying, triggering event buried in our biographies may involve a physical assault, living through a life-threatening myocardial infarction or a natural disaster such as a flash flood, a major injury arising from a motor vehicle accident, or witnessing a violent death.
Brief History of PTSD
The definition of PTSD has broadened since psychologists began treating Vietnam War veterans. Combat-related PTSD is thought to be a present-day version of “battle fatigue” and “shell shock,” which is psychological breakdown found to occur during the stresses of war. As early as the Civil War, some men were described as having the condition “nostalgia” and were reassigned to less stressful duties. During World War I, soldiers were thought to suffer from the proximity of exploding shells, hence the “shell shock” label. Their posttraumatic stress was thought to be organic, related to the concussion of the exploding shells. By World War II, clinical experts now assumed that trauma wasn’t organic and any soldier could break down under the trauma of war. “Battle-fatigued” men were temporarily reassigned to rest, and by the Korean War, the men were removed from the front line and given their R & R in Japan. The post-Vietnam era began to recognize the longevity of the symptoms of war trauma, even if the men (and women) had been asymptomatic for years.
Source: Karner, T. X. (2008). Post-traumatic stress disorder and older men: If only time healed all wounds. Generations, 32 (1), 82–87.
Whenever painful symptoms fundamentally undercut ordinary life, recovering from the trauma may take considerable time. In some cases there occurs an extended “latency” period where the man is asymptomatic for months or years. Men who do not psychologically recuperate will repeatedly relive their trauma and can progressively become more distressed. These men are living with a PTSD, which researchers estimate affects 5 percent of American men.35
For men with PTSD, the traumatic event remains vivid and disabling, sometimes for decades or a lifetime. It is a dominating experience and retains its power to call to mind the terror, dread, or grief through daytime intrusive memories and nightmares. The intrusive thoughts and memories seem to be responsible for why men with PTSD continue to be owned by the trauma well after it occurred. Some men will relive the triggering event with all its disturbing visual and auditory recollections. Other men may experience sleep problems, depression, feeling numb and empty, or being easily startled. It is not uncommon for men with PTSD to lose interest in being with people they used to enjoy or have trouble feeling affectionate. Their “psychic numbing” is a coping strategy to try to obliterate the trauma-based memories and feelings. They may lose interest in most things.
Symptoms of PTSD
Reexperiencing Symptoms
• Frequent memories or upsetting thoughts
• Having recurring nightmares
• Flashbacks; feeling the event recur
• Feeling strong distress when reminded of the event
• Experiencing a surge in heart rate or sweating
Avoidance Symptoms
• Making effort to avoid discussion of the event
• Avoiding places and people you associate with the event
• Trouble remembering details of the event
• Losing interest in important activities
• Not having positive feelings, such as happiness
Hyperarousal Symptoms
• Disrupted sleep or trouble falling asleep
• Feeling more irritable and angry
• Having difficulty concentrating
• Feeling constantly on guard
• Jumpy, easily startled
Source: Blake, D. D., Weathers, F. W., Nagy, L. M., et al. (1990). A clinician rating scale for assessing current and lifetime PTSD: The CAPS-I. Behavior Therapist, 13, 187–188.
Do you think you have PTSD? Use the following four questions as an assessment: have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you
1. have had nightmares about it or thought about it when you did not want to?
2. tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. were constantly on guard, watchful, or easily startled?
4. felt numb or detached from others, activities, or your surroundings?
If you answer “yes” to any three items, you should think about seeing a professional.36 Talk to a physician or mental health professional or religious leader. If you are a veteran, contact your local VA hospital or vet center. Do not hesitate to tell a close friend and family member that you think you have PTSD. The treatments currently available for men with PTSD are CBT, bright light therapy, individual and group dynamic psychotherapy, and medication.
Distress varies by our availability of friends and social support and the comparisons we make between ourselves and other men. The way we compare ourselves to others affects our level of distress. In terms of the social comparisons we make, imagine a ladder and you standing on one of the rungs. Men who routinely look upward and compare themselves to others above them often feel distressed and “trapped,” rather than confident and hopeful. A fairly wealthy white man may be dissatisfied and distressed with his station in life, if he perceives those around him as more successful. Thinking that someone else is better off than you provides two pieces of negative information: you are not as well off as many others, and it is possible for you to get worse.37 This man’s cortisol level would lessen if he used a comparison group similar to his own “station” in life. For example, an older Latino who earns a modest income and judges the adequacy of his financial health by comparing himself to his friends, neighbors, and close relatives is likely to feel satisfied with life. Even though his financial health is ranked lower on the totem pole than many other men, his comparisons were his equals. Furthermore, when we see others as less fortunate and genuinely feel compassion or reach out to volunteer support, we interact with other supportive people and receive validation, which leads to more stress resilience.38
The coping strategies men often draw on backfire and fuel rather than mitigate stress. When a “typical guy” has a bad day, he doesn’t want to talk about it. He is not interested in reaching out to friends for support. Rather than dealing with stress by “tending and befriending,”39 the typical guy internalizes the stress. He may decide to be by himself or brood. At the end of a stressful day, have you been brooding about things and then gotten frustrated with little things, like water from the sink splashing on your shirt or the phone ringing a third time in a row and interrupting your rest? Brooding and choosing to “shut down” are corrosive.
What protects us, however, are friends and lovers. Men’s go-to stress absorber is support from a woman.40 When men reach out to another man for support, our distress is not often reduced enough. Perhaps the reason is the way men communicate with one another—trading stories about our stressed-out days. It can be difficult for heterosexual or gay men to diffuse their pent-up stress if one-upmanship conversations keep the stress hormones elevated. But getting together with other men is most often a relaxing time-out and helps avoid the brooding. Stressed out? Go “hang out” with friends. Friends reduce the damaging effects of the stress hormone cortisol by distracting us, often making us laugh, and keeping us active. Don’t stop returning e-mails, calling your buddies, or going out with your group when you are feeling stressed. Friend therapy is protective. If you want to expand your friend group, take a class, join a gym or club, attend a church or temple, or volunteer.
Men with good emotional health have an ability to bounce back from stress and misfortune. This ability is called resilience. They remain flexible and positive in bad times as well as good. The good news is that there are many steps you can take to build your resilience and your overall emotional health. But you are going to have to overcome some of the beliefs and practices we acquire as a result of growing up as men. For example, men tend to distract themselves from their mood by engaging in physical or instrumental activities; while these activities are stress reducing, they are “downstream” strategies for dealing with stress after the body and mind are knarred.
Upstream management strategies are best, and there are four essential ways of managing stress. First, keep your body healthy so that the stress you experience doesn’t take an added toll on your heart and brain. Exercising regularly not only improves your physical health but also floods the body with endorphins (your body’s “feel good” chemicals) and reduces the stress hormone cortisol.
Second, try to prevent the unnecessary buildup of the stresses. Here are a pair of examples: prioritize things and unplug yourself. If you’re like other men, your life is overscheduled and demanding. Your objective is to learn to prioritize what you have to do and to have reasonable expectations that better assure achievable goals. It’s not reasonable to always be the go-to guy and do everything others might expect. Become someone who understands triage—determine the most important of the tasks on your plate and methodically complete those first, and then move on to the next tier of tasks that are not as vital. The last tier is what you decide to ignore. Because we have become way too accessible as a result of e-mail and cell phones, we too often forget that these devices can become others’ leashes to dictate our time. You need to build into your day some quiet time. Frankly, it’s okay not to answer your phone every time it rings or to wait to respond to an e-mail. Set aside a block of time each day to return phone calls and answer e-mails, rather than being on a leash that anyone can tug.
Third, do things that help you relax. You might set aside a half hour during the day—whether it is your lunch time or a break you’ve built into your work schedule—for quiet time; this half-hour window is yours to meditate, play solitaire, read a chapter in a novel, or take a 20-minute nap. As “girly” as it might first feel, try to meditate. In fact, take a health-related course on how to use 15–20 minutes a day for quiet contemplation, breathing, and clearing your mind. This promotes less stress and better sleep. Most employers’ health care benefit packages include “wellness programs” and a range of non-pharmaceutical strategies to help you relax which you can take advantage of for minimal cost.
Fourth, stay connected. The goal is to keep in touch with the people who make up your support network—family, friends, neighbors, coworkers—and especially stay connected with anyone who makes you feel relaxed and happy. For some men, it is their faith that is nourishing and provides a sense of coherence. For other men, their friendships and activities with other guys are what’s nourishing: nickel-and-dime poker nights, a regular Tuesday night dinner with a few friends (which you had to initiate and get established), or breakfast one morning a week with neighborhood friends before everybody breaks away for their separate days. Set up regular time with your friends and family. When life gets hectic, it’s too easy to let these relationships go unattended. Avoid the downside of “letting things go” and becoming solitary.