Historical Considerations

Key Points

Thomas Salmon (1917), a British military physician during World War I, was asked to evaluate severe “shell shock” (traumatic neurosis), which was producing psychological paralysis in Allied soldiers. In this first medical description of the psychological effects of war, Salmon noted that French soldiers suffered fewer psychological casualties than British soldiers. Three factors seemed to account for the French advantage: (1) French soldiers were told that they could expect to recover from their psychological traumas; (2) soldiers received immediate psychological treatment, close to the battlefront; and (3) soldiers were returned to battle as quickly as possible. These principles became the cornerstone of modern crisis theory and disaster management strategies. Patients entering crisis treatment can expect to be treated immediately, in their natural environments, with an expectation that they will recover from the crisis or disaster. Efforts should be made to return patients to their normal life and community as soon as possible.

Eric Lindemann (1944) applied and expanded Salmon’s theories. He studied the acute grief reactions of persons who lost family members in the Coconut Grove fire in Boston, which claimed 500 lives. Lindemann discovered that normal people surviving such a horrific experience would develop an emotional crisis of pain, confusion, anxiety, and temporary difficulty in daily functioning. Also, he discovered that the psychological trauma caused by the crisis had little relation to preexisting psychopathology, and that only a small group of the victims declined to a lower level of functioning. Generally, the outcome of the crisis was most closely related to the severity of the stressor, personal reaction to the trauma, effect of trauma on the person’s family and friends, and degree of community disruption. Lindemann found that most crisis survivors recovered spontaneously within 6 weeks.

Erik Erikson (1959), a sociologist, introduced the idea of a life cycle composed of developmental stages and developmental crises. His eight stages were seen as normative processes during which age-specific psychological tasks, transitions, and crises were routinely encountered. A difficulty or inability to negotiate a stage successfully affects the ability to progress to the next stage. For example, an adolescent seeks an adult identity and redefines social roles that emphasize peer relationships and increasing autonomy from parents. Those who do not successfully traverse adolescence develop a childlike dependence on parental figures and often have difficulty developing a career, getting married, or developing autonomous social relations.

Other crisis practitioners have expanded Erikson’s basic concept of eight developmental crises to include other crises such as leaving home for the first time, the midlife crisis, and parents’ experience of the “empty nest syndrome.” For many patients, a transition from one life phase to the next, such as marriage, divorce, retirement, or an illness, may bring the potential for a new developmental crisis.

Gerald Caplan (1961, 1964) synthesized many of these earlier ideas into modern crisis theory and treatment. He defined the crisis state as a brief, personal, psychological upheaval precipitated by a stressor, or “hazard.” A precipitant produces emotional turmoil so that the person is temporarily unable to cope, adapt, or function in daily activities. Caplan demonstrated that a crisis implies the potential for danger and an opportunity for growth. Although subscribing to Lindemann’s theories of acute precipitants, Caplan believed that a person’s preexisting psychiatric condition could influence the development, evolution, and resolution of a crisis. A crisis may be based on the failure of a person’s individual coping style and ability to adapt. Caplan confirmed that most acute crises resolve in about 6 weeks, with four possible outcomes: improved functioning, functioning restored to precrisis levels, incompletely restored functioning with a susceptibility to the development of future crises, or a severely impaired but stable level of lower functioning. He corroborated Lindemann’s findings that some people cope with a crisis by spontaneously and flexibly developing new coping or problem-solving styles. Caplan developed a crisis treatment focus on development of better coping mechanisms and adaptations to life’s traumas.

Current Understanding of Crisis

Key Points

The current understanding of “crisis” has been used as one of several core strategies in the management and treatment of trauma. The frequency of traumatic experiences is defined by the type of events called “traumatic.” For example, early studies limited traumatic events to wars, natural disasters, and plane crashes, whereas more recent epidemiologic studies include intimate partner violence, car accidents, crime, or foreclosures. Estimates of lifetime trauma exposure vary with the definition of a “traumatic event,” so community studies of exposure to lifetime trauma also varies (25%-90%). According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM IV-TR), the lifetime rate of posttraumatic stress disorder (PTSD) ranges between 1% and 14%.

Natural disasters such as earthquakes, tsunamis, hurricanes, tornadoes, and volcanic eruptions can traumatize individuals, devastate whole communities, and disturb an entire population in a large geographic area. Man-made disasters, such as 9-11 (2001), Oklahoma City (1995), suicide bombings, plane crashes, and environmental accidents, are all byproducts of the 21st century and, unfortunately, have become a part of modern life.

The prevalence of exposure to mass trauma is difficult to estimate. In one study, 13% of the U.S. population reported a lifetime exposure to natural or human-generated disaster (Burkle, 1996). The U.S. National Comorbidity Survey estimated that 18.9% of men and 15.2% of women reported a lifetime experience of a natural disaster (Kessler et al., 1995). These are merely exposure rates to trauma. Fortunately, most victims recover from traumatic exposure over time, without long-term sequelae. However, some will go on to develop posttraumatic stress disorder (PTSD). According to the National Center for Posttraumatic Stress Disorder, the estimated lifetime prevalence of PTSD among adult Americans is approximately 8%, with women twice as likely as men to be affected at some time during their life (Stein et al., 2003). Women who are victims of intimate partner violence are almost four times more likely than nonabused women to develop PTSD (Campbell, 2002).

The most common traumatic events include witnessing an injury, murder, fire, flood, or natural disaster; life-threatening accident; and combat exposure. According to the World Health Organization (WHO), 1.2 million people are killed in motor vehicle crashes and 50 million injured annually (Mayou et al., 1993). Well-known man-made disasters include the U.S. atomic bombings of Hiroshima and Nagasaki (WWII, 1945), the Chernobyl nuclear power plant accident in Russia (1986), the domestic terrorist bombing of Murrah federal building in Oklahoma City (1995), and foreign terrorist destruction of the World Trade Center in New York (2001). In addition, violence and trauma in American society continues with shootings in schools, community centers, and businesses.

Intimate Partner Violence

Key Points

Intimate partner violence (IPV) is a specific type of crisis requiring some special consideration; we use this term throughout this chapter to account for diverse populations and types of abuse. The Family Violence Prevention Fund (FVPF, 2004) defines intimate partner violence as “a pattern of assaultive and coercive behaviors that may include inflicted physical injury, psychological abuse, sexual assault, progressive social isolation, stalking, deprivation, intimidation, and threats. These behaviors are perpetrated by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent, and are aimed at establishing control by one partner over the other.”

Worldwide, at least 10% to 50% of women have been physically or sexually abused in their lifetime (WHO, 2001). Annually, 2 to 4 million women and 835,000 men are assaulted by intimate partners in the United States (National Institute of Justice). Lifetime prevalence of physical or sexual abuse by an intimate partner of U.S. women is 20% to 30%, and for men, 7.5% (FVPF, 2004). From 22% to 46% of gays and lesbians have been victims of physical IPV (AAFP, 2000). Between 2000 and 4000 U.S. women die from these injuries each year. Up to one in six pregnant women is abused during pregnancy (AAFP, 2000). One study showed that IPV increased health care costs in affected women by 92% (Ramsay et al., 2009). Family violence leads to 39,000 physician visits and 73,000 hospitalizations annually (Kass-Bartelmes and Rutherford, 2004).

A common and costly problem, IPV is receiving increased attention. Several professional organizations and other groups have made policy statements and recommendations; some mandate screening. The majority of IVP research is about violence committed by men against women, although recent epidemiologic studies show that IPV remains a significant problem in male homosexual relationships and occurs in all types of relationships (FVPF, 2004). The previous statistics on IPV are even more striking when considering that IPV is almost universally underreported (Watts and Zimmerman, 2002). Many studies assess only physical violence, not accounting for the psychological, economic, and emotional abuse that may exist alone or with other forms of violence.

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.

Crisis State

The crisis state can be defined as a brief psychological upheaval, precipitated by a stressor, that produces an intense state of inner turmoil or disorganization that overwhelms a person’s ability to cope and adapt. As with Melinda, the crisis state can be experienced as panic, disbelief, fear, confusion, sudden awareness of vulnerability, initial elation at having survived, or beginning of a grief reaction. For some, the crisis state may be denied or experienced as psychological numbing.

Often, patients in a crisis or suffering from a trauma present to their family physician with a confusing array of physical complaints. Patients like Melinda, who seek help while in an acute crisis, are typically impaired in some aspect of their daily interpersonal, work, social, or family life. Patients may have obvious psychological symptoms, unconscious psychological distress and pain associated with substance abuse, or physical symptoms. Four clusters of symptoms are typically experienced by patients during a crisis or secondary to a trauma (Box 45-1).

Typically, a patient in crisis such as Seth cannot explain what is upsetting him, although he is certainly aware that something is wrong. Seth’s family physician asked, “Why now, at this point in time, are you depressed and feeling in crisis?” When asked, Seth felt distressed and confused. As he began to talk about his son and the birthday party, he realized that he was the same age as his son when his own mother died. He began to cry with the unresolved grief and the pride he imagined that she would have for him and her grandson.

Frequently, people in the crisis do not seek help by themselves and instead are brought in by concerned family members, lovers, friends, or perhaps the police or an ambulance. In these cases, it may take hours for the “Why now?” causes to be identified. Patients typically are not able to identify the specific cause of their crisis. Physician questioning and asking patients to retell their experience is typically how the “Why now?” of the crisis emerges. “Why now?” questioning is the first step in treating a crisis.

Acute Crisis Resolution and Adaptation to the Crisis (Within 6 Weeks)

For many patients, the acute nature of the crisis is often resolved within 6 weeks as the patient learns to cope or adapt to the acute stress. The DSM-IV-TR (APA, 2000) has classified the initial 1-month period of a crisis marked by impaired functioning as an “acute stress disorder.” DSM IV-TR specifies that the acute symptom picture must last more than 2 days and no more than 4 weeks and must cause significant distress or impairment in social or occupational functioning. The result of the acute stages of the crisis is one of four possible outcomes specified in Figure 45-1. Successful coping and adaptation to a crisis can lead to crisis resolution that ultimately promotes growth and can even lead to improved functioning. For most patients, however, crisis resolution means a return to a previous level of baseline functioning. Still other patients only partially resolve the crisis and instead “seal over” and deny the significance of their feelings or recent events, setting the stage for a future crisis. Those with the worst prognosis typically have poor adaptation skills and, at best, stabilize at a lower level of daily functioning. For example, a patient who swallowed many pills after being left by her boyfriend may in retrospect deny any suicidal intent and instead say, “I just had a headache.” This patient has sealed over her crisis. Denial of her suicidal intent and anger with her boyfriend will probably lead to poor adaptation and latent weakness, called a missed or unresolved crisis. The patient may continue to use unsuccessful coping strategies, such as drinking or repeated suicide gestures, as a way to deal with her feelings. Unresolved crises predispose the patient to future episodes that may be caused by even less stressful precipitants. For example, this same patient may once again become suicidal after a minor argument with a male friend. Fortunately, future crises can afford new opportunities to rework past unresolved crisis, with better adaptation and coping.