A piece by Michael Odell in today’s Times:
I still remember the cough. Furry, tickly and utterly unresponsive to intervention by all manner of syrups, linctuses, pastilles or lozenges. Then I saw the NHS posters. If you have a persistent cough, they warned, it may indicate something more serious. The accompanying photo was of a grey-skinned man apparently spluttering his way to the knacker’s yard. I went to the doctor fearing the worst. Within five minutes she had ruled out any physical ailment, but fortunately she was cannier than most GPs. She saw how anxious I was.
“You look worried,” she said, and after she walked me through a timeline of my ailment’s development I realised it had begun soon after I had proposed to my then-future wife. “Do you think the wedding preparations are getting on top of you?”
They were. We were blending two families and I was worried about how our respective children would get on.
I went home and, interrupting the jovial prenuptial mood, encouraged everyone to address these issues. Gradually, the cough went away.
The anxious cough illustrates a problem that mental-health practitioners are only now waking up to: anxiety can show itself very differently in men than it does in women. In the UK, statistics suggest that misreading symptoms may be leading to misdiagnosis or even no diagnosis. NHS figures show that one in five women suffers from anxiety or depression compared with one in eight men. And yet men are three times more likely to take their own lives, with suicide the biggest killer of males under the age of 49. They are also three times more likely to become alcohol-dependent or report frequent drug use.
“Male anxiety and depression present in a completely different way to women, and it’s a scandal how this means they are all but ignored,” says Martin Pollecoff, the chairman of the UK Council for Psychotherapy. “If you look at the Diagnostic and Statistical Manual of Mental Disorders, which is the bible for diagnosing mental-health conditions, there are 800 pages of symptoms women will readily recognise because they express feelings, but few for men, whose behaviours under stress can be quite displaced. It’s a terrible thing to say, but women feel and men act out. They slope off to the pub, smoke a joint, start a fight, see a prostitute. Anxious men tend to lose themselves. And then the awful thing is, their anxiety is not diagnosed and we end up in this terrible situation where the first time we know something is wrong is when they take their own lives.”
Dr Billy Boland, a consultant psychiatrist and the chairman of the faculty of general adult psychiatry at the Royal College of Psychiatrists in London, says that, despite some high-profile figures coaxing men to explore their feelings more openly, there is still a significant stigma attached to men’s anxiety.
“Men may admire celebrities like the [former] footballer Rio Ferdinand talking about his mental-health issues, but you have to remember that such figures are rarefied and more difficult to relate to than, say, male friends seen socially or at work. Men may take their cues from their immediate social circle, and broadly there remains a culture of shame around male anxiety. This can have a further effect; men go into denial and don’t even acknowledge their symptoms. It’s surprising how often men don’t even realise they are anxious and depressed, let alone that they can be helped.”
We all need a level of anxiety to function. It’s how children get delivered to school on time, jobs get done and bills get paid. One of the problems is deciding what is productive and what is destructive anxiety, Boland says.
“If I wasn’t slightly anxious about paying my mortgage then I might not bother getting out of bed and going to work. A certain level of anxiety is productive. But a man suffering headaches or muscular pain that doesn’t seem to have an obvious cause — that is possibly displaced anxiety in some way and it can be quite hard to diagnose the underlying problem. For me, the key to it all is conversation. Often it takes a friend or loved one to notice an ailment or perhaps increased risk-taking behaviour, such as drinking. It’s them who will say, ‘You know, you don’t seem quite yourself and I think we can do something to improve things.’ ”
Four years ago Henry Hobson, 44, a communications manager for a large retailer, thought he had developed a drink problem. He had almost convinced himself it was time to attend Alcoholics Anonymous. It was only after his wife suggested he see a therapist that he discovered that the truth was more nuanced.
“My dad had become very ill and died very quickly of cancer the summer before. I wouldn’t say I was particularly buttoned up. I took time off and felt I had grieved,” Hobson says. “But actually I really hadn’t got over it. Or, more to the point, my grief had evolved into a fear of me or my wife and kids dying. I was used to being in control and thinking life was something that would go on indefinitely, but the way my dad was taken away from us seemed so random. It really shook me. My world got smaller. I lost the lust for life I’d had before.
“Drinking was a way of taking the edge off my anxiety, but also driving my family away until I could come to terms with the randomness of my loss. But it was a huge relief to realise that I wasn’t an alcoholic. Anxiety is this sort of vague, gnawing monster and I don’t think men are very good at realising they are in its grip until things are bad. My wife used to say I was too proud to ask for directions when we were clearly lost driving on holiday. Well, I think that goes for getting lost in anxiety too.”
If men are prone to acting out their anxieties, which displacement activities should be seen as acceptable and which ones as diagnosable? One may argue that cashing in one’s pension to buy an Aston Martin, developing a taste for free-fall parachute jumping or wearing an ill-advised toupee are symptoms of male anxiety. Should they be challenged? While the trend is towards encouraging men to be more open and expressive about their feelings, Pollecoff thinks we should respect men’s means of self-expression. In the present cultural climate, he says, masculinity is already under siege.
“Frankly I am sick of hearing all this shit about ‘toxic masculinity’,” he says. “It’s about time we accepted that men, particularly white, working-class men, express themselves in a different way to other men and certainly to most women. Our mental-health diagnostic methods are not built to accommodate them. The fact is that men hate the idea of crying while nursey sits there with a tissue saying, ‘There there.’ If a depressed or anxious man is going to unburden himself, he is more likely to respond to humour.
“There is a great American website called mantherapy.org [the site is hosted by a blustering, fictitious therapist called Dr Rich Mahogany, although, as you click through, it does address serious issues such as addiction and suicide] and it captures exactly what men want. Yes, it’s a bit over the top, but men enjoy humour as a way into their feelings. Too often, because they do not emote in the same way as women, men are seen as the problem. I’m afraid these days we are not fashionable. In the pantheon of modern-day victimhood we don’t even make bronze.”
Improving sleep and taking exercise are standard recommendations for those suffering with anxiety and depression. And, of course psychotherapy, cognitive behavioural therapy (CBT) and mindfulness exercises have their place. One innovation that Boland believes may prove particularly attractive to men is cCBT (computerised CBT), in which patients self-refer and get treatment remotely on their computer or phone. As part of its Improving Access to Psychological Therapies programme the NHS has begun offering various therapies in this way through a service called Silvercloud.
“Men suffering with anxiety can be very private about their feelings,” Boland says. “And though that in itself can be very isolating, ironically some men find remote or computerised treatment less daunting.”
Chris, 37, a management consultant, tried a course of online CBT after a short romantic affair almost destroyed his marriage. When his wife discovered the affair she asked him to leave. Living in a friend’s spare room, he spent many hours working through his issues on a Silvercloud cCBT programme.
“My wife got pregnant. It was unplanned and not great timing for either of us. I already felt completely overwhelmed with the pressures of work and the demands of our two boys, who are 9 and 11 years old. And so what did I do? I got off with someone at a conference. It was such a stupid thing to do and I had plenty of time to think about what was going on in my head after she threw me out.
“Online CBT is fairly anonymous [a clinician checks in every week]. You self-refer, so there’s no embarrassing face-to-face interview and you can access all the tools 24 hours a day. I liked working alone and this thing called the ‘worry tree’ helped me to break down what I was really thinking. I worked out I was blowing everything up because, really, I couldn’t find a way of saying, ‘I really don’t think I can cope with another child.’ Being destructive was the only way I could get my message across. Men are not great at saying what they feel. I’m afraid we tend to lash out instead.”
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