Normal Equilibrium State and Stressors

Under normal circumstances, a person has a sense of internal psychological equilibrium and environmental support that generally permits activities of daily living (ADLs), working, and experiencing pleasure. A delicate balance among the person's internal wishes and fears, skills and capacities, and values and ideals determines psychological equilibrium. Environmental equilibrium refers to a stable balance among basic needs for food, water, shelter, physical comfort, and the integrity of community and social supports for job, family, religion, and society.

A patient in crisis enters an emotional storm after a stressor disturbs the normal equilibrium. Environmental precipitants typically seen in a family physician's office include IPV, sickness, and the stress of coping with death, divorce, marital separation, job loss, a financial crisis, and so forth. Disasters are acute environmental crises during which all concerned are focused on basic survival, acute medical care, and provisions of basic human needs. Psychological stressors may be related to events such as witnessing a trauma, surviving a disaster, loss of self-esteem, loss of love, a disturbing dream, sexual dysfunction, or sudden overwhelming fear, panic, or rage. Developmental crises such as latency, puberty, adolescence, marriage, birth of a child, midlife crisis, chronic medical illness, and retirement are common factors precipitating a crisis or may be comorbid factors.

Hobson and associates (1998) revised the Holmes and Rahe (1967) social readjustment scale. This newer scale lists 51 external life stressors that precipitate significant stress in most people. The top 20 items in this scale were in five separate domains: death and dying, health care issues, stress related to crime and criminal justice system, financial and economic issues, and family stresses. This scale includes events that range in severity from the most stressful being death of a spouse (rated as 1), divorce (7), experiencing domestic violence or sexual abuse (11), and surviving a disaster (16). It also includes events that many would consider positive yet stressful, such as getting married (32), experiencing a large monetary gain (42), and retirement (rated as 49). This list of stressors represents the most common precipitants causing a crisis. It is these types of stressors, and the internally disturbing feelings attached to the event, that produce emotional turmoil and a transient inability to adapt during the early stages of a crisis.

Most patients seeking treatment are surprised to discover that a major, unrecognized life stressor may have occurred on the same day or several days before the onset of the crisis. Less often, the stressor occurred sometime in the previous 6 weeks. Generally, events that occurred more than 6 weeks earlier are not acute stressors. Instead, these important past events may represent a previous crisis that was incompletely resolved and may be linked to the current crisis, as illustrated in Case Study 1.

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