Part One: Beliefs, Faith & Spirituality · Part Two: Forgiveness But Don’t Forget · Part Three: Life Purpose & Existential Angst. Coming: The Autonomic Balance.
There is a question I have started asking clients that sits outside the standard intake form, and that I rarely asked in the first twenty years of practice because I didn’t fully understand how much the answer mattered.
The question is simple. The answer is usually not.
What are you for?
Not what do you do for a living. Not what are your responsibilities. Not what keeps you busy. What are you for — in the sense of what gives your life a direction and a significance that would still be there even if the schedule were empty and the obligations temporarily lifted.
Some people answer immediately. They know. The answer has been with them long enough that it doesn’t require thought — it just needs to be named. Others sit with the question for a long time. Some find it uncomfortable. Some, particularly those in mid-life who have spent decades fulfilling roles and meeting obligations, discover that they genuinely don’t know — and that the not-knowing is, itself, the source of a particular kind of low-grade distress that has been present for years without a name.
That distress has a physiology. And the physiology has clinical consequences that show up on test panels in ways we can measure.
The biology of purposelessness
Viktor Frankl, writing from inside the Nazi concentration camps in what would become Man’s Search for Meaning, made an observation that has since accumulated a substantial body of empirical support: the people who survived were not always the physically strongest. They were disproportionately those who had something to survive for. A person to return to. A work to complete. A meaning that the experience could not extinguish.
Frankl was not making a motivational argument. He was making a biological one, though the biology to fully explain it wasn’t available to him at the time. What he observed, across extreme conditions that stripped away almost everything else, was that meaning functions as a physiological resource — that the presence or absence of it changes what the body is able to do under duress.
We now have a reasonable mechanistic account of why this is the case.
A strong sense of purpose appears to modulate HPA axis reactivity — people with clear purpose show blunted cortisol responses to psychosocial stressors, meaning the stress response activates but recovers more efficiently. Purpose also correlates with better autonomic regulation, higher heart rate variability, and reduced inflammatory tone. The immune system, which is highly sensitive to chronic stress signalling, functions differently in a body that knows what it is for.
Hill & Turiano (2014, Psychological Science) followed over 6,000 adults across fourteen years and found that a higher sense of purpose in life was associated with a significantly lower risk of all-cause mortality — an effect that held across age groups, including adults in their twenties and thirties, suggesting the benefit is not simply a feature of having a settled retirement. The effect size was substantial and independent of positive affect, suggesting that purpose operates through distinct mechanisms from simply feeling happy.
Zilioli et al. (2017) demonstrated that purpose in life was associated with lower and flatter diurnal cortisol output — specifically, lower waking cortisol and a more appropriate decline across the day — independent of depression, positive affect, and socioeconomic status. The cortisol pattern of purposeful living is measurably different from the cortisol pattern of purposeless drift.
Boyle et al. (2012, Archives of General Psychiatry) found that among older adults, a higher sense of purpose was associated with a 2.4-fold reduction in the risk of Alzheimer’s disease and a significantly reduced risk of mild cognitive impairment — effects that persisted after controlling for depressive symptoms, neuroticism, and social network size.
The Okinawan concept of ikigai — loosely translated as “reason for being,” the intersection of what you love, what you are good at, what the world needs, and what you can be rewarded for — has attracted significant research attention as a potential explanatory variable for the exceptional longevity observed in that population. The evidence is correlational and the cultural context is not straightforwardly transferable, but the direction of the finding is consistent with the broader literature: people who can articulate a reason to get up in the morning live longer and age better than those who cannot.
What existential angst actually is
Existential angst is not clinical depression, though it can precede it or accompany it. It is not anxiety in the conventional sense, though it produces a particular quality of unease that is sometimes mistaken for it. It is the experience of confronting the questions that Western culture is extraordinarily effective at helping people avoid — questions about mortality, about meaning, about whether the life being lived is the life that was intended, about what would remain if the roles and routines were stripped away.
These questions tend to surface at particular moments: mid-life, bereavement, serious illness, the departure of children from the home, retirement, the loss of a long-held role or identity. They also surface, more quietly, in the background hum of a life that is functionally successful but privately unsatisfying — the person who has everything the culture said would constitute a good life and finds, on reflection, that the word “good” doesn’t quite fit.
Clinically, I encounter this as a presenting pattern rather than a presenting complaint. The person doesn’t arrive saying “I have existential angst.” They arrive with fatigue, with gut symptoms, with sleep that doesn’t restore, with a vague sense that something is wrong that they can’t locate. The tests often show HPA dysregulation, elevated inflammatory markers, suboptimal cortisol curves. The interventions help, partially. And then there is a residual that doesn’t shift — and the residual, on deeper enquiry, has a name.
The absence of meaning is not a philosophical problem with no clinical relevance. It is a chronic stressor with measurable physiological consequences — and it responds to clinical attention in the same way that other chronic stressors do.
The mid-life inflection
There is a reason the existential questions cluster in mid-life. It is not simply that people have more time to think, or that the cultural narrative about mid-life crisis has primed them to experience it. It is that mid-life is, for many people, the first point at which the distance between the life being lived and the life that was intended becomes impossible to ignore.
In the first half of adult life, most of the energy goes into building: career, relationship, family, financial stability, social position. These are absorbing projects. They provide direction and a sense of progress that functions, in the short to medium term, as a substitute for deeper purpose. The question of what you are for doesn’t press very hard when you are busy enough with what you are doing.
In mid-life, for many people, the building phase reaches a kind of completion — not necessarily success, but completion. The career is established or has plateaued. The children are older or have left. The relationship has settled into a particular shape. The external structures that provided direction are still present but no longer generating the same forward momentum. And the question that was never quite answered because there was never quite enough space to ask it begins to make itself felt.
This is not pathology. It is a developmental challenge that every reflective adult eventually faces. What matters clinically is whether the person has the internal resources — and the external support — to engage with it rather than avoid it.
The avoidance strategies and their cost
The culture offers a remarkable range of purpose-avoidance strategies, most of them socially endorsed and some of them clinically concerning.
Busyness is the most common. The scheduling of every available hour so that the question never quite has room to surface. This works in the short term and is one of the primary drivers of the kind of chronic sympathetic activation that shows up as elevated evening cortisol, disrupted sleep onset, and the inability to genuinely rest even when the opportunity is present.
Consumption — of goods, of experiences, of stimulation — serves a similar function. The dopaminergic reward of acquisition and novelty temporarily displaces the background unease without addressing its source. The tolerance builds. The next acquisition needs to be larger to produce the same effect. The unease returns faster each time.
Achievement escalation — the pursuit of the next qualification, the next promotion, the next milestone — is particularly common in high-functioning people who have been rewarded throughout their lives for performance. It looks healthy from the outside. The cortisol pattern tells a different story.
None of these strategies are categorically wrong. Busyness serves legitimate purposes. Consumption can be genuinely enjoyable. Achievement is often intrinsically valuable. The clinical question is whether they are chosen freely or deployed defensively — whether they are additions to a life that has meaning, or substitutes for one that doesn’t.
Purpose is not found — it is constructed
One of the most unhelpful framings of the purpose question is the idea that purpose is something that exists out there, waiting to be discovered — that there is a specific calling or vocation that belongs to each person, and that the task is to find it. This framing produces a particular kind of paralysis in people who haven’t found it yet, and a particular kind of anxiety in people who thought they had found it and then lost it.
The evidence, and my clinical experience, points in a different direction. Purpose appears to be less a discovery than a construction — something built through engagement, reflection, and commitment rather than waiting to be revealed. It tends to emerge from the intersection of what you genuinely care about, what you are actually good at, and where those two things make contact with something beyond yourself.
That last part matters. The research consistently shows that purpose oriented outward — towards other people, towards a cause, towards something that will outlast the individual — produces stronger physiological benefits than purpose oriented primarily inward, towards personal achievement or self-improvement. This is not a moral claim. It appears to be a feature of how the nervous system responds to different kinds of engagement — something about the self-transcendent quality of outward purpose that downregulates the default mode network and reduces the kind of self-referential rumination that drives chronic stress activation.
When I encounter a client whose test results show persistent HPA dysregulation that is not fully explained by the identifiable stressors in their life, I now consider the purpose question as part of the differential. Not instead of the nutritional and lifestyle interventions — those remain essential — but alongside them.
The question I find most useful is not “do you have a sense of purpose?” — most people will say yes because the alternative feels shameful. The more useful questions are: “What would you do with your time if nothing was required of you?” and “What do you care about enough to be genuinely upset if it went badly?” The answers to those two questions tell you more about the actual state of the purpose architecture than any direct enquiry.
The retirement problem
I want to say something about retirement specifically, because it represents one of the clearest natural experiments in the relationship between purpose and health that exists in the epidemiological literature — and the findings are more alarming than the culture acknowledges.
Retirement, for people whose primary source of purpose and identity has been their work, is a significant physiological event. The research shows elevated mortality risk in the period immediately following retirement, particularly for men, particularly for those who retire into unstructured leisure rather than purposeful engagement. The effect is not explained by the loss of income, the loss of social contact, or the change in physical activity levels alone — there appears to be a specific contribution from the loss of directed purpose that these other variables do not fully account for.
The people who age well after retirement are disproportionately those who had constructed sources of purpose outside their work before they stopped working — who retire to something rather than from something. This is not an argument against retirement. It is an argument for beginning to answer the question “what are you for?” well before the external structures that have been answering it on your behalf are removed.
What to do with the question
I am not going to tell you what your purpose is or should be. That would be both presumptuous and clinically useless. What I can say is that the question deserves to be taken as seriously as the dietary protocol and the supplement stack — not instead of them, but alongside them, as part of a complete picture of what health actually requires.
The question is worth sitting with rather than rushing past. The discomfort it produces is information, not a problem to be solved. The angst that surfaces when you genuinely confront the possibility that the life you are living is not quite aligned with the life you intended — that is not pathology. That is a signal from the nervous system that something important needs attention.
In my experience, the people who engage with it — who sit with the discomfort long enough to let it become informative rather than just aversive — tend to make different choices. Not dramatic ones, necessarily. Sometimes the shift is small: a morning practice, a commitment redirected, a relationship given more of what it actually needs. But the physiological consequences of even modest movement towards a more purposeful life are measurable, and they compound over time.
The cortisol curve shifts. The sleep improves. The inflammatory markers come down. The body, it turns out, knows the difference between a life with direction and one without it — even when the person hasn’t quite admitted it yet.
The tests show the pattern. The conversation explains it.
HPA dysregulation that doesn’t fully resolve with nutritional intervention often has roots in the terrain that the tests can identify but not name. The clinical conversation is where the picture completes. Book a free discovery call to begin.
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