24th November 2023

Adulthood and Old Age Development

Development of Ego Identity in Adolescence and Adulthood

Erikson’s stages of human development

Erikson is one of the most important and influential theorist in the area of ego development, which can be understood as ‘a sense of wholeness involving the exploration of one’s abilities and interests, resulting in a crystallised identity in various domains such as personal, religious and occupational’ (Encyclopedia of Adolescence, 2011).

Jane Loevinger’s 9 stages of ego and personal identity development 

Loevinger, who worked with Erikson at an early stage in her career, proposed the following stages in ego development, which she saw as a process which emerges based on the encounters of the individual with the world and people in it. 

• Personal – In the infancy phase, the person has no individual identity and is at the mercy of the world around them.
• Impulsive – As a child grows older, it is driven initially by emotions and is focused only on the present. Understands the world in binary terms of ‘good’ and ‘bad’. 
• Self protective – As the child develops some sense of their own identity, they develop more sense of self control. Views the world in terms of punishment and reward.
• Conformist – With age, there is a growing awareness of the need to fit in with the ideas of the group or face suspicion.
• Self aware – Loevinger felt this stage was the model for most adult behaviour. Not generally reached before age 25. Increasing self criticism and awareness of the difference between the externally projected ‘self’ and the internal sense of self.
• Conscientious – At this stage, an individual has internalised the ideals of societal norms. However, there is more awareness of nuance and a sense of responsibility for the decisions and actions taken by the self. More able to assess others in terms of their inner motivations and their external actions. 
• Individualistic – The individual at this stage has more tolerance for individual differences and awareness of the complexities of the inner experience and how these might be expressed (or not) outwardly in others and self.
• Anonymous – Focus shifts to greater self acceptance and achieving a sense of self fulfilment. 
• Integrated – Can be compared to ‘self actualisation’ as perceived by Maslow in his hierarchy of needs. Whereby the individual has achieved inner wisdom and empathy for others along with self acceptance. As with Maslow, Loevinger felt that very few achieve this stage.

Other theories of identity development

Vaillant

Emphasised ‘resilience’ as a modification to Erikson and introduced ‘career consolidation’ and ‘keeper of the meaning’ as new substages in adulthood. This latter stage, Vaillant proposed, is motivated mostly by altruism and the drive to improve the individual’s wellbeing.

Jeffrey Arnett

Coined the term ‘emerging adulthood’ to encompass the ‘new transitional developmental period’ between ages 17-22 and proposed that key transition points can produce psychological distress.

Neugarten – Social clock theory 

Proposed that the timing of life events is ‘entrenched’ and based on ‘age graded expectations of life events,’ i.e., social norms are the driving force rather than biological age. Deviation from this can lead to stress.

Havighurst, Neugarten et al. – Continuity theory 

Proposes that personality influences the roles we choose and is well developed by the time we reach old age:

• Integrated personality – Adjusted well to ageing, evidenced by activity engagement.
• Disintegrated or unintegrated – Failure to cope with ageing leads to struggle.
• Armoured or defended – Continue with activities and roles held in middle age.
• Passive-dependent – Either highly dependent or not interested in the external world.

Gould – Inevitable turmoil theory

Proposes that an adult must ‘give up various illusions of childhood’ to develop as an adult.

Identified certain age related changes:

• 16-22 years – Leaving parents.
• 22- 28 years – Getting into the world.
• 28-34 years – Questioning life.
• 35-45 – Midlife.
• Reconciliation.
• Acceptance.

Identity stability

Marcia – Identities in adult life

Identified 2 elements in identity formation:

• ‘Crises’ which is a ‘period of self evaluation’ followed then by:
• ‘Commitment’ to a ‘new value, role, goal or ideology’ through which identity status emerges. 

Marcia identified 4 identity statuses:

• Achievement – The individual has explored alternatives and commits to a particular identity.
• Diffusion – An individual has yet to explore different identities or invest in one in particular.
• Foreclosure – An individual commits to an identity without exploring others. There is a link between this identity status and authoritative parenting.
• Moratorium – An individual is in the midst of exploring alternatives without a clear sense of commitment to any identity in particular. Seen particularly in the adolescent mind (identity versus role confusion – Erikson’s stage). 

Levinson – Seasons of life 

• Levinson identified 4 stable periods and 3 transition periods:
  • Stable periods
    • Childhood and adolescence.
    • Early adulthood.
    • Middle adulthood.
    • Late adulthood.
  • Transition periods
    • Early adult.
    • Midlife.
    • Late adult.
• Stable periods – Last around 20 years.
• Transition periods – Settled periods are disturbed by significant new challenges.

Levinson proposed that after each transition period follows a new stable period and the formation of a new life structure. A life structure encompasses ‘all of the roles the individual occupies, all his relationships and the conflicts and balances that exist among them’. 

Midlife crisis

The term ‘midlife crisis’ was coined by psychoanalyst and social scientist Eliot Jaques in 1965 and reinforced by Levinson. Links with Erikson’s stages of development (generativity versus stagnation). 

According to Jaques, this period, which occurs around the age of 35, is characterised by an adjustment to an individual’s set of circumstances (work, family, children growing older) and managing associated stressors, in combination with the ageing process, provokes ‘awareness of the reality of death’. Psychological immaturity provokes the key features of a ‘mid life crisis’ such as a sense of disillusionment with life, infidelity and detachment from family life, and a determination to ‘thwart advancing years’, e.g. through relationships with a younger person, are evidence of this. 

Jaques wrote: ‘The compulsive attempts […] to remain young, the hypochondriacal concern over health and appearance, the emergence of sexual promiscuity in order to prove youth and potency, the hollowness and lack of genuine enjoyment of life […] are familiar patterns. They are attempts at a race against time’. 

Characteristics of ‘midlife crisis’:

• Questioning.
• Appraisal. 
• Loss of dreams leading to disillusionment, suffering, loss.

Evidence for the presence of a ‘midlife crisis’ has been suggested in increased rates of depression and anxiety relating to key life events at this time.

Adaptations in Adult Life

Pairing

Pairing is defined as ‘a selective association that exists between two adults of the same species’. By incorporating attachment theory, we can also understand pairing (or the development of a pair bond) as including an affective component whereby there is a preference for a particular partner, a sense of loss with separation, emotional and psychological bonding and buffering of one another from life’s stressors. 

Key theories

• Eshelman 1985 – Homogamous mate selection
  • Proposes that partners tend to be similar in terms of culture, socioeconomic factors and religion.
  • Upheld by Byrne et al. 1966: ‘People choose partners of similar economic status’.
• Berscheid and Walster 1974 – Equity theory
  • Proposed people tend to pair with those perceived to have ‘a similar level of physical attractiveness’ as a means by which to reduce the risk of rejection.
• Newcomb 1956 – Reinforcement theory
  • Proposes that people tend to be ‘attracted by those who reinforce the attraction with rewards’ such as pleasure, self esteem, belonging and consistency.
• Homans 1961 – Social exchange theory
  • Pairing involves a ‘consideration of cost-benefit ratio’ and relationship aims to maximise benefits and minimise costs. It will involve a comparison with other alternatives.

Illness

According to the WHO, health is defined as ‘a state of complete, physical, mental and social well being, not merely the absence of disease or infirmity’. RS Downie argues that this is ‘overambitious’, especially considering its subjective nature. However, it is a widely accepted definition of health and makes good progress towards understanding this concept.

Definitions of illness and disease have varied over time. One suggested by Professor Marshall Marinker is as follows:

‘Disease … is a pathological process, most often physical as in throat infection […]. The quality which identifies disease is some deviation from a biological norm. There is an objectivity about disease that doctors are able to see, touch, measure, and smell. Diseases are valued as the central facts in the medical view…’

‘Illness … is a feeling, an experience of unhealth which is entirely personal, interior to the person of the patient. It often accompanies disease, but it may be undeclared, as in the early stages of cancer […] or diabetes. Sometimes, illness exists where no disease can be found. Traditional medical education has made the deafening silence of illness-in-the-absence-of-disease unbearable to the clinician. The patient can offer the doctor nothing to satisfy his senses…’

‘Sickness … is the external and public mode of unhealth. Sickness is a social role, a status, a negotiated position in the world, a bargain struck between the person henceforward called ‘sick’ and a society which is prepared to recognise and sustain him. The security of this role depends on several factors, not least the possession of that much treasured gift, the disease. Sickness based on illness alone is a most uncertain status. But even the possession of disease does not guarantee equity in sickness. Those with a chronic disease are much less secure than those with an acute one; those with a psychiatric disease than those with a surgical one … . Best is an acute physical disease in a young man quickly determined by recovery or death—either will do, both are equally regarded.’

Theories relating to ‘illness’ and the ‘sick role’

In 1991, Talcott Parsons coined the term ‘sick role’, which identified 4 main expectations:

• An exemption from normal social responsibilities for those who assume the sick role.
• The individual in the sick role cannot be expected to get well by decision or will.
• The individual has to demonstrate wanting to get well.
• There is an obligation to get well, seek appropriate help and cooperate with the treatment offered.

In 1986, Mechanic described ‘illness behaviour’ as ‘how people respond to bodily indications and the conditions under which they come to view them as abnormal’ and suggested that ‘illness behaviour thus involves how individuals monitor their bodies, define and interpret their symptoms, take remedial action and utilise sources of help, as well as the more formal healthcare system’. This is a ‘dynamic process’ shaped by the individual’s personal context and can involve a variety of others, including family members and formal medical services. 

Pilowsky proposed ideas about abnormal illness behaviour, which can be understood as ‘outside the range of that usually accepted in the society in which the person lives’. As such, this is highly contextual and requires observation by another for the behaviour to ‘act as a communication’ and can be used strategically.

Bereavement and stages of grief

According to dictionary.com, bereavement is defined as ‘a period of mourning or state of intense grief especially following the death of a loved one’. A person can also feel a sense of bereavement after a divorce or significant loss in their life and the resultant stress accompanying this.

According to Stroebe et al. (2018), Mourning includes ‘a range of behaviours that express to the outside world the internally experienced sorrow or sense of loss’. This process is influenced by family, cultural and religious contexts. 

Grief can be understood as ‘the anguish experienced after loss’ and is generally an internal psychological experience. There is an important distinction to be made between the normal process of grief and that of clinical depression. 

According to Freud (1917), mourning is a healthy and normal process which is necessary for recovery from a loss. Melancholia (which we may understand to mean depression) is an ‘abnormal pathology’.

Grief and adaptation 

John Bowlby and Colin Murray Parkes proposed a 3 stage model of grief characterised by the following:

• Shock and numbness.
• Yearning and searching.
• Despair and disorganisation.

A fourth stage was added by Parkes, which focused on ‘reorganisation and recovery’, during which the bereaved person is rebuilding their life and can have a more optimistic view of life.

In 2005, Kubler Ross suggested the following stages of grief:

• Denial.
• Anger.
• Bargaining.
• Depression.
• Acceptance.

Pregnancy and Childbirth

Physiological changes associated with pregnancy and childbirth

Physiological changes in pregnancy affect all bodily systems and are linked with changes in production of hormones, including progesterone, oestrogen and prolactin. As well as observable changes to the body, such as an increase in weight, oedema and changes in posture, there are significant adaptations made by the renal, cardiovascular and endocrine systems to accommodate the growing foetus. These include:

• Increase in plasma volume.
• Increase in cardiac output.
• Increased ventilation.
• Reduced gut motility.
• Changes in skin pigmentation.

Psychological changes associated with pregnancy and childbirth

The psychological impact of pregnancy can be felt through each stage of the trimester. It can vary from anxiety relating to the health and wellbeing of the foetus to mood swings and irritability. As well as possible bereavement in the event of miscarriage or stillbirth. Further, underlying mental health issues can be provoked during pregnancy for a number of reasons, including medication changes, stress and hormonal shifts. Psychological symptoms can be exacerbated when combined with physiological changes, which can make adaptation more stressful for the individual. 

Specific psychological changes associated with childbirth

• Postnatal blues – Occur shortly after delivery and generally resolve after a brief period. Characterised by tearfulness, emotional lability, worries about the health of the baby, difficulty with sleep and concentration
  • According to the Royal College of Midwives, postnatal blues occur in roughly 50% of women. They may be linked to a reduction in progesterone after delivery, relationship difficulties with a partner and difficulties with adjusting to the new role of motherhood. 
• Postnatal depression – Risk between 7-15% during pregnancy, increasing to 50% if there is a pre-existing episode of antenatal depression. Associated with the younger age of the mother, poor relationship with partner and poor social support.
• Puerperal psychosis – Seen within a few days to 2 weeks of birth. Incidence c.0.1%; however this is a serious mental illness requiring prompt treatment by professionals, which can include medication and admission to a specialist mother and baby unit (MBU) if possible. Symptoms include confusion and emotional lability, including mania, hallucinations and delusions. The risk is increased if there is a positive family history and background of previous affective disorder. 

Normal Ageing and its Impact 

The normal ageing process can be understood to impact each of the following components:

• Psychological, specifically:
  • Memory.
  • Attention.
• Physiological.
• Socio-economic. 

According to Cavanaugh et al., ageing is not a single process but rather 3 states:

1. Primary ageing – Defined as ‘normal disease free development during adulthood’.
2. Secondary ageing – Whereby developmental changes relating to disease, lifestyle and other environmentally induced changes occur which are ‘not inevitable’.
3. Tertiary ageing – The rapid losses occurring shortly before death.

Biological theories of ageing

Overall, it is understood that ageing is likely to comprise a combination of all of the themes set out by Woodford below:

• Hayflick’s limit – Supposes that cells have a finite number of divisions, which is determined by telomeres. The shortening of these non functioning areas of DNA at the end of chromosomes results in cells being capable of dividing a certain number of times (c.50) before this stops. Once they have reached the number of divisions possible, the ageing process commences.
• Free radical theory – Proposes that free radical production from aerobic cellular respiration produces damage to DNA, which, over time, accumulates in the process of ageing. 
• Genetic variation – The interaction of genes and environment is likely to account for a significant portion of the variation in ageing between individuals.
• Hormonal decline – Linked with a decline in growth and sex hormone production with age.
• Disposable soma theory – Proposes that humans have finite resources to be used for the process of repair or reproduction.

Physiological changes in ageing

Important anatomical and physiological changes identified as humans age include:

• • 20% brain weight reduction (Nichols and Wilson, 2012).
  • 66% >65 years old have cerebral white matter changes noted on MRI (Woodford, 2010).
  • Increase in visual problems – 13% of over 75s are visually impaired.
  • Presbycusis (age related hearing loss) – noted to develop in 25% older adults.
  • Reduced sense of taste and smell.
  • eGFR reduction in the decade after age 40.
  • Slower gut motility leading to increased risk of constipation.
  • Reduced hepatic mass and blood flow.

Psychological impact of ageing

It is worth noting that cerebral white matter changes can occur in the absence of identified cognitive deficits. However, there are noted changes to memory, specifically working memory and processing speed, associated with advancing age.

• Reduced attention, especially in the context of divided attention.
• Reduced episodic memory.
• Increased prevalence of depression; more commonly, older adults express somatic symptoms in comparison to younger adults and can have implications for diagnosis.
  • This is noted despite evidence from ONS (2013), which reported that, on average, those of retirement age were more satisfied with life than younger adults aged 24-64. 

As a consequence of the decline in attention and slowing of cognitive processing, older adults may struggle to process information immediately and may need the information to be given more slowly or repeated to better facilitate the processing. 

Glisky (2007) proposed a ‘frontal lobe hypothesis’ of ageing, supposing that the decline in executive function seen in older adults is a key driver in cognitive decline. Evidence for this hypothesis is the noted reduction in volume and function of the frontal lobe seen in imaging studies with age

Social changes with age

Loss

Individuals may experience many different types of loss, including loss of their health, their wealth (especially in the period of time after retirement), and loss of loved ones or bereavement. There may also be a (real or felt) loss of a role or status in society.

The socioeconomic impact of ageing may be felt differently depending on a person’s culture and community. Loss of contact with friends, family and/or social standing can lead to isolation and loneliness and links with poorer health.

Psychological theories of role change

Three main theories were identified:

• Social disengagement theory – Based on the theory that there is a mutual disengagement between the individual as they age and society, which benefits both.
• Activity theory – Suggested as an alternative to social disengagement theory by Robert J Havinghurst, who argued that older people who are more active are more satisfied with their lives.
• Continuity theory – Proposed by Havinghurst, Neugarten et al., who argue that personality influences the roles chosen by an individual, and this is well established by old age. Linked with activity theory – an integrated personality adjusts well to ageing, which is evidenced by activity engagement.

Phases of retirement

According to Robert Atchley, there are a number of stages a person has to work through when faced with retirement. He based his ideas on ‘continuity theory’, which proposes that, rather than being a period of crisis, retirement is a period of adaptation.

Atchley identified 7 phases of retirement:

• Pre-retirement.
• Honeymoon.
• Disenchantment.
• Reorientation.
• Stability.
• Termination.

References

• John C Cavanaugh and Fredda Blanchard Fields: Adult Development and Ageing, (Cengage, 8th Edition, 2019).
• Stephen De Souza, Normal Ageing, Trainees Online (TRoN), available online at: https://www.rcpsych.ac.uk/training [Accessed May 2023]
• Henry Woodford, Essential Geriatrics, (Radcliff, Oxford, 2010), as quoted by Dr De Souza as above.
• Kapila Sachdev – Adaptations in Adult Life, Trainees online (TRoN), available online at: https://www.rcpsych.ac.uk/training [Accessed April 2023]
• Erik Erikson’s 8 Stages of Psychosocial Development. Available online at: https://simplypsychology.org/Erik-Erikson.html#trust [Accessed April 2023]
• Ego Identity – an overview. Sciencedirect topics. Available online at: ‘https://www.sciencedirect.com/topics/immunology-and-microbiology/ego-identity’ [Accessed Feb 2023]
• Thomas Armstrong, ‘The Stages of Ego Development According to Jane Loevinger’, American Institute for Learning and Development, (Jan 2020). Available online at https://www.institute4learning.com/2020/01/31/the-stages-of-ego-development-according-to-jane-loevinger/ [Accessed April 2023]
• Elliot Jaques, Death and the Midlife Crisis, (1965) quoted in Mark Jackson: ‘Life Begins at 40: the demographic and cultural roots of the midlife crisis’, 2019 Wilkins – Bernal- Medawar Lecture, (25th March 2020, https://royalsocietypublishing.org/doi/10.1098/rsnr.2020.0008)
• Bales et al., ‘What is a Pair Bond’, Hormones and Behaviour, vol 136, Nov 2021. 
• Constitution of the World Health Organization. WHO. Available online at: https://www.who.int/about/governance/constitution [Accessed March 2023]
• Sree Prathap Mohana Murthy, SPMM Smart Revise, Revision Notes for Paper A
• Marinker M. Why make people patients? Journal of Medical Ethics 1975:I:81–4. quoted in Kenneth M Boyd, ‘Disease, Illness, sickness, health, healing and wholeness: exploring some illusive concepts’, Medical Humanities, (2000, 2:6, pp. 9-17) found at: https://mh.bmj.com/content/26/1/9.info
• Collier et al, Oxford Handbook of Clinical Specialities, 9th edition, (2013).