Making a quick diagnosis in a hyperactive, inattentive child is often difficult. The National Institutes of Health concluded in a consensus statement that no independent diagnostic test for attention-deficit/hyperactivity disorder (ADHD) exists.¹ Furthermore, the American Academy of Child & Adolescent Psychiatry (AACAP) issued a treatment guideline classifying ADHD as a clinical diagnosis.

With the time constraints imposed by managed care organizations, questioning and history gathering must be precisely aimed to elicit specific information. Over the years, I have identified the following 5 red flags that help distinguish ADHD from mood problems,² anxiety, psychosis, obsessions, and other psychiatric disorders.

1. Moodiness is not part of ADHD. The DSM-IV criteria for ADHD do not include elevated mood. “Mood swings,” persistent clowning, or angry affect should prompt further questioning about similar features in relatives. Frequently we hear that “his father was never diagnosed with anything, but he was the class clown.”
2. ADHD is not an intermittent condition. By asking if the child has “good days and bad days,” we can obtain valuable information. ADHD has a biological basis and is present every day, like Parkinson’s disease or diabetes. Obviously, some days can be more challenging than others, but if a parent says, “Some days she is a perfect child,” the possibility of ADHD is small.
3. Symptoms are not present in kindergarten. The child with ADHD begins to show signs of this condition very early in life; parents are frequently informed of problems by preschool and kindergarten teachers. The usual complaints are inability to stay with a task and disrupting the class. Start of these symptoms as late as first or second grade is a red flag to question the ADHD diagnosis.
4. More than one diagnosis probably means “none of the above.” When a child has been diagnosed with conduct disorder (CD) and/or oppositional-defiant disorder (ODD) along with ADHD, chances are that we are missing the real diagnosis. I have seen cases of social anxiety disorder that had been diagnosed as ADHD/ODD because the child was inattentive secondary to nervousness. Incidentally, DSM-IV does not allow the diagnosis of ODD in the presence of CD.
5. Worsening of symptoms is not an expected outcome of stimulant medications for ADHD. Lack of response to psychostimulants or only mild improvement may occur in ADHD. Frequently, however, we see children with histories of getting worse after starting medication for presumed ADHD.

Making a quick diagnosis in a hyperactive, inattentive child is often difficult. The National Institutes of Health concluded in a consensus statement that no independent diagnostic test for attention-deficit/hyperactivity disorder (ADHD) exists.¹ Furthermore, the American Academy of Child & Adolescent Psychiatry (AACAP) issued a treatment guideline classifying ADHD as a clinical diagnosis.

With the time constraints imposed by managed care organizations, questioning and history gathering must be precisely aimed to elicit specific information. Over the years, I have identified the following 5 red flags that help distinguish ADHD from mood problems,² anxiety, psychosis, obsessions, and other psychiatric disorders.

1. Moodiness is not part of ADHD. The DSM-IV criteria for ADHD do not include elevated mood. “Mood swings,” persistent clowning, or angry affect should prompt further questioning about similar features in relatives. Frequently we hear that “his father was never diagnosed with anything, but he was the class clown.”
2. ADHD is not an intermittent condition. By asking if the child has “good days and bad days,” we can obtain valuable information. ADHD has a biological basis and is present every day, like Parkinson’s disease or diabetes. Obviously, some days can be more challenging than others, but if a parent says, “Some days she is a perfect child,” the possibility of ADHD is small.
3. Symptoms are not present in kindergarten. The child with ADHD begins to show signs of this condition very early in life; parents are frequently informed of problems by preschool and kindergarten teachers. The usual complaints are inability to stay with a task and disrupting the class. Start of these symptoms as late as first or second grade is a red flag to question the ADHD diagnosis.
4. More than one diagnosis probably means “none of the above.” When a child has been diagnosed with conduct disorder (CD) and/or oppositional-defiant disorder (ODD) along with ADHD, chances are that we are missing the real diagnosis. I have seen cases of social anxiety disorder that had been diagnosed as ADHD/ODD because the child was inattentive secondary to nervousness. Incidentally, DSM-IV does not allow the diagnosis of ODD in the presence of CD.
5. Worsening of symptoms is not an expected outcome of stimulant medications for ADHD. Lack of response to psychostimulants or only mild improvement may occur in ADHD. Frequently, however, we see children with histories of getting worse after starting medication for presumed ADHD.

Making a quick diagnosis in a hyperactive, inattentive child is often difficult. The National Institutes of Health concluded in a consensus statement that no independent diagnostic test for attention-deficit/hyperactivity disorder (ADHD) exists.¹ Furthermore, the American Academy of Child & Adolescent Psychiatry (AACAP) issued a treatment guideline classifying ADHD as a clinical diagnosis.

With the time constraints imposed by managed care organizations, questioning and history gathering must be precisely aimed to elicit specific information. Over the years, I have identified the following 5 red flags that help distinguish ADHD from mood problems,² anxiety, psychosis, obsessions, and other psychiatric disorders.

1. Moodiness is not part of ADHD. The DSM-IV criteria for ADHD do not include elevated mood. “Mood swings,” persistent clowning, or angry affect should prompt further questioning about similar features in relatives. Frequently we hear that “his father was never diagnosed with anything, but he was the class clown.”
2. ADHD is not an intermittent condition. By asking if the child has “good days and bad days,” we can obtain valuable information. ADHD has a biological basis and is present every day, like Parkinson’s disease or diabetes. Obviously, some days can be more challenging than others, but if a parent says, “Some days she is a perfect child,” the possibility of ADHD is small.
3. Symptoms are not present in kindergarten. The child with ADHD begins to show signs of this condition very early in life; parents are frequently informed of problems by preschool and kindergarten teachers. The usual complaints are inability to stay with a task and disrupting the class. Start of these symptoms as late as first or second grade is a red flag to question the ADHD diagnosis.
4. More than one diagnosis probably means “none of the above.” When a child has been diagnosed with conduct disorder (CD) and/or oppositional-defiant disorder (ODD) along with ADHD, chances are that we are missing the real diagnosis. I have seen cases of social anxiety disorder that had been diagnosed as ADHD/ODD because the child was inattentive secondary to nervousness. Incidentally, DSM-IV does not allow the diagnosis of ODD in the presence of CD.
5. Worsening of symptoms is not an expected outcome of stimulant medications for ADHD. Lack of response to psychostimulants or only mild improvement may occur in ADHD. Frequently, however, we see children with histories of getting worse after starting medication for presumed ADHD.

ABSTRACT

BACKGROUND: Symptoms resulting from early response to allergen exposure are histamine mediated, last a few minutes, and often cue patients to take medication. Hours later, the late response begins and typically leads to symptoms of congestion. The late-phase response is not histamine mediated; other studies have shown intranasal corticosteroids to inhibit the response. The researchers tested the hypothesis that intranasal steroids may be as beneficial as or superior to antihistamines for as-needed use because of their effect on the late response to environmental allergens.

POPULATION STUDIED: The 88 subjects, aged 18 to 48 years, had fall seasonal rhinitis for at least 2 ragweed seasons before enrollment and had a positive puncture skin test to ragweed antigen extract. The population was 52% male, 60% white and in general good health. Patients were excluded for nasal polyps, displaced septum, perennial rhinitis, and signs or symptoms of renal, hepatic, or cardiovascular disease. Patients were also excluded if they had received immunotherapy within 2 years before enrollment or had taken topical or systemic steroids, antihistamines, decongestants, or cromolyn sodium within 2 weeks before enrollment.

STUDY DESIGN AND VALIDITY: This is a randomized unblinded study. Patients were enrolled before or during the early part of the ragweed season. They were randomized to receive 100 μg/day fluticasone propionate per nostril or 10 mg loratadine once daily as needed for 4 weeks. Nasal lavage for eosinophil count and eosinophil cationic protein (ECP) and completion of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ, a validated instrument) were performed initially, at 2 weeks, and at 4 weeks. Patients were instructed to record medication usage and symptom severity in a diary twice daily. Itchy eyes and 3 symptoms for each nostril (rhinorrhea, nasal congestion, and sneezing) were rated on a scale of 0 to 3, ranging from 0 = no symptoms to 3 = severe symptoms.

OUTCOMES MEASURED: The RQLQ score was the primary outcome. The symptom diary scores were evaluated by symptom; a total symptom score was calculated. Other outcomes included nasal lavage eosinophil count and ECP levels.

RESULTS: Patients used medication an average of 17 of 28 days in the fluticasone group, similar to the average of 18 of 28 days in the loratadine group. The RQLQ scores were similar in the 2 groups initially. Significant improvement in the fluticasone group over the loratadine group was seen at the second and third visits in the overall score and activity, sleep, practical, and nasal domains of the RQLQ (P < .05). Symptom diaries showed a median score of 7.0 out of 21 for the loratadine-treated group and 4.0 out of 21 for the steroid-treated group (P = .005). Eosinophil count and ECP showed significant decreases in the steroid group.

ABSTRACT

BACKGROUND: Symptoms resulting from early response to allergen exposure are histamine mediated, last a few minutes, and often cue patients to take medication. Hours later, the late response begins and typically leads to symptoms of congestion. The late-phase response is not histamine mediated; other studies have shown intranasal corticosteroids to inhibit the response. The researchers tested the hypothesis that intranasal steroids may be as beneficial as or superior to antihistamines for as-needed use because of their effect on the late response to environmental allergens.

POPULATION STUDIED: The 88 subjects, aged 18 to 48 years, had fall seasonal rhinitis for at least 2 ragweed seasons before enrollment and had a positive puncture skin test to ragweed antigen extract. The population was 52% male, 60% white and in general good health. Patients were excluded for nasal polyps, displaced septum, perennial rhinitis, and signs or symptoms of renal, hepatic, or cardiovascular disease. Patients were also excluded if they had received immunotherapy within 2 years before enrollment or had taken topical or systemic steroids, antihistamines, decongestants, or cromolyn sodium within 2 weeks before enrollment.

STUDY DESIGN AND VALIDITY: This is a randomized unblinded study. Patients were enrolled before or during the early part of the ragweed season. They were randomized to receive 100 μg/day fluticasone propionate per nostril or 10 mg loratadine once daily as needed for 4 weeks. Nasal lavage for eosinophil count and eosinophil cationic protein (ECP) and completion of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ, a validated instrument) were performed initially, at 2 weeks, and at 4 weeks. Patients were instructed to record medication usage and symptom severity in a diary twice daily. Itchy eyes and 3 symptoms for each nostril (rhinorrhea, nasal congestion, and sneezing) were rated on a scale of 0 to 3, ranging from 0 = no symptoms to 3 = severe symptoms.

OUTCOMES MEASURED: The RQLQ score was the primary outcome. The symptom diary scores were evaluated by symptom; a total symptom score was calculated. Other outcomes included nasal lavage eosinophil count and ECP levels.

RESULTS: Patients used medication an average of 17 of 28 days in the fluticasone group, similar to the average of 18 of 28 days in the loratadine group. The RQLQ scores were similar in the 2 groups initially. Significant improvement in the fluticasone group over the loratadine group was seen at the second and third visits in the overall score and activity, sleep, practical, and nasal domains of the RQLQ (P < .05). Symptom diaries showed a median score of 7.0 out of 21 for the loratadine-treated group and 4.0 out of 21 for the steroid-treated group (P = .005). Eosinophil count and ECP showed significant decreases in the steroid group.

ABSTRACT

BACKGROUND: Symptoms resulting from early response to allergen exposure are histamine mediated, last a few minutes, and often cue patients to take medication. Hours later, the late response begins and typically leads to symptoms of congestion. The late-phase response is not histamine mediated; other studies have shown intranasal corticosteroids to inhibit the response. The researchers tested the hypothesis that intranasal steroids may be as beneficial as or superior to antihistamines for as-needed use because of their effect on the late response to environmental allergens.

POPULATION STUDIED: The 88 subjects, aged 18 to 48 years, had fall seasonal rhinitis for at least 2 ragweed seasons before enrollment and had a positive puncture skin test to ragweed antigen extract. The population was 52% male, 60% white and in general good health. Patients were excluded for nasal polyps, displaced septum, perennial rhinitis, and signs or symptoms of renal, hepatic, or cardiovascular disease. Patients were also excluded if they had received immunotherapy within 2 years before enrollment or had taken topical or systemic steroids, antihistamines, decongestants, or cromolyn sodium within 2 weeks before enrollment.

STUDY DESIGN AND VALIDITY: This is a randomized unblinded study. Patients were enrolled before or during the early part of the ragweed season. They were randomized to receive 100 μg/day fluticasone propionate per nostril or 10 mg loratadine once daily as needed for 4 weeks. Nasal lavage for eosinophil count and eosinophil cationic protein (ECP) and completion of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ, a validated instrument) were performed initially, at 2 weeks, and at 4 weeks. Patients were instructed to record medication usage and symptom severity in a diary twice daily. Itchy eyes and 3 symptoms for each nostril (rhinorrhea, nasal congestion, and sneezing) were rated on a scale of 0 to 3, ranging from 0 = no symptoms to 3 = severe symptoms.

OUTCOMES MEASURED: The RQLQ score was the primary outcome. The symptom diary scores were evaluated by symptom; a total symptom score was calculated. Other outcomes included nasal lavage eosinophil count and ECP levels.

RESULTS: Patients used medication an average of 17 of 28 days in the fluticasone group, similar to the average of 18 of 28 days in the loratadine group. The RQLQ scores were similar in the 2 groups initially. Significant improvement in the fluticasone group over the loratadine group was seen at the second and third visits in the overall score and activity, sleep, practical, and nasal domains of the RQLQ (P < .05). Symptom diaries showed a median score of 7.0 out of 21 for the loratadine-treated group and 4.0 out of 21 for the steroid-treated group (P = .005). Eosinophil count and ECP showed significant decreases in the steroid group.

ABSTRACT

BACKGROUND: Adding 2 to 3 doses of ipratropium bromide (Atrovent) to conventional therapy with inhaled β-agonists and systemic corticosteroids improves lung function and decreases hospital admissions when given in the emergency department (ED). This study evaluated whether ipratropium bromide administration improves outcomes in children who require subsequent hospitalization.

POPULATION STUDIED: The authors enrolled 80 children aged 1 to 18 years with a history of asthma admitted to the pediatric inpatient unit of a tertiary-care urban hospital. Children had to have moderate to severe symptoms upon admission, defined as requiring inhaled β₂-agonists at least every 2 hours, having a forced expiratory volume in 1 second (FEV₁) of 25% to 80% of predicted, or having a clinical asthma score of 3 to 9 out of a possible 10. The clinical asthma score is a total of 5 items—respiratory rate, wheezing, inspiratory–expiratory ratio, retracting, and observed dyspnea—scored on a 3-point scale. Excluded patients had coexisting cardiac, neurologic, immunosuppressive, or other chronic pulmonary disease, hypersensitivity to the study drugs, or known ocular abnormalities. Children were excluded if their asthma score was 10, if they needed airway intervention, or if more than 12 hours had elapsed between the first nebulizer treatment and admission.

STUDY DESIGN AND VALIDITY: This was a double-blind randomized controlled trial. Study patients received frequent nebulized albuterol at 0.15 mg/kg as well as either IV hydrocortisone at 4 to 6 mg/kg every 6 hours or oral prednisone 1 mg/kg once daily. Attending physicians determined nebulizer treatment frequency, ranging from 30 minutes to 4 hours. Subjects were randomized to receive either ipratropium bromide or normal saline, matched to the albuterol dosing interval. Participants were stratified by age (less than 5 years vs 5 years or more) and by the number of ipratropium bromide doses they received in the ED (3 or less vs more than 3). Investigators used an intention-to-treat analysis and allocation was concealed.

OUTCOMES MEASURED: The primary outcome was the clinical asthma score, measured at baseline and every 6 hours until discharge. The clinical score is reproducible, valid, and predictive. Secondary outcomes included oxygen saturation, FEV₁, length of stay, time to a 4-hour albuterol dosing interval, and readmission to the hospital or ED within 72 hours of discharge.

RESULTS: Of the 212 patients assessed for the trial, only 99 were eligible. Of these, 84 parents consented to enroll their children (4 children were later determined not to meet inclusion criteria and were excluded). The ipratropium and placebo groups were essentially the same. There was no difference in the asthma score between treatment and control groups in 3 of the 4 subgroups. In one subgroup—those who had fewer than 3 doses of ipratropium bromide in the ED—ipratropium provided a slight benefit. The difference in change in scores was 0.5 on the clinical asthma score, a statistically but not clinically important change. There were no differences in the secondary outcomes. The average heart rate was 6 to 10 beats per minute greater in the ipratropium group. The authors noted no transient anisocoria, a potential adverse effect of ipratropium bromide in children.

ABSTRACT

BACKGROUND: Adding 2 to 3 doses of ipratropium bromide (Atrovent) to conventional therapy with inhaled β-agonists and systemic corticosteroids improves lung function and decreases hospital admissions when given in the emergency department (ED). This study evaluated whether ipratropium bromide administration improves outcomes in children who require subsequent hospitalization.

POPULATION STUDIED: The authors enrolled 80 children aged 1 to 18 years with a history of asthma admitted to the pediatric inpatient unit of a tertiary-care urban hospital. Children had to have moderate to severe symptoms upon admission, defined as requiring inhaled β₂-agonists at least every 2 hours, having a forced expiratory volume in 1 second (FEV₁) of 25% to 80% of predicted, or having a clinical asthma score of 3 to 9 out of a possible 10. The clinical asthma score is a total of 5 items—respiratory rate, wheezing, inspiratory–expiratory ratio, retracting, and observed dyspnea—scored on a 3-point scale. Excluded patients had coexisting cardiac, neurologic, immunosuppressive, or other chronic pulmonary disease, hypersensitivity to the study drugs, or known ocular abnormalities. Children were excluded if their asthma score was 10, if they needed airway intervention, or if more than 12 hours had elapsed between the first nebulizer treatment and admission.

STUDY DESIGN AND VALIDITY: This was a double-blind randomized controlled trial. Study patients received frequent nebulized albuterol at 0.15 mg/kg as well as either IV hydrocortisone at 4 to 6 mg/kg every 6 hours or oral prednisone 1 mg/kg once daily. Attending physicians determined nebulizer treatment frequency, ranging from 30 minutes to 4 hours. Subjects were randomized to receive either ipratropium bromide or normal saline, matched to the albuterol dosing interval. Participants were stratified by age (less than 5 years vs 5 years or more) and by the number of ipratropium bromide doses they received in the ED (3 or less vs more than 3). Investigators used an intention-to-treat analysis and allocation was concealed.

OUTCOMES MEASURED: The primary outcome was the clinical asthma score, measured at baseline and every 6 hours until discharge. The clinical score is reproducible, valid, and predictive. Secondary outcomes included oxygen saturation, FEV₁, length of stay, time to a 4-hour albuterol dosing interval, and readmission to the hospital or ED within 72 hours of discharge.

RESULTS: Of the 212 patients assessed for the trial, only 99 were eligible. Of these, 84 parents consented to enroll their children (4 children were later determined not to meet inclusion criteria and were excluded). The ipratropium and placebo groups were essentially the same. There was no difference in the asthma score between treatment and control groups in 3 of the 4 subgroups. In one subgroup—those who had fewer than 3 doses of ipratropium bromide in the ED—ipratropium provided a slight benefit. The difference in change in scores was 0.5 on the clinical asthma score, a statistically but not clinically important change. There were no differences in the secondary outcomes. The average heart rate was 6 to 10 beats per minute greater in the ipratropium group. The authors noted no transient anisocoria, a potential adverse effect of ipratropium bromide in children.

ABSTRACT

BACKGROUND: Adding 2 to 3 doses of ipratropium bromide (Atrovent) to conventional therapy with inhaled β-agonists and systemic corticosteroids improves lung function and decreases hospital admissions when given in the emergency department (ED). This study evaluated whether ipratropium bromide administration improves outcomes in children who require subsequent hospitalization.

POPULATION STUDIED: The authors enrolled 80 children aged 1 to 18 years with a history of asthma admitted to the pediatric inpatient unit of a tertiary-care urban hospital. Children had to have moderate to severe symptoms upon admission, defined as requiring inhaled β₂-agonists at least every 2 hours, having a forced expiratory volume in 1 second (FEV₁) of 25% to 80% of predicted, or having a clinical asthma score of 3 to 9 out of a possible 10. The clinical asthma score is a total of 5 items—respiratory rate, wheezing, inspiratory–expiratory ratio, retracting, and observed dyspnea—scored on a 3-point scale. Excluded patients had coexisting cardiac, neurologic, immunosuppressive, or other chronic pulmonary disease, hypersensitivity to the study drugs, or known ocular abnormalities. Children were excluded if their asthma score was 10, if they needed airway intervention, or if more than 12 hours had elapsed between the first nebulizer treatment and admission.

STUDY DESIGN AND VALIDITY: This was a double-blind randomized controlled trial. Study patients received frequent nebulized albuterol at 0.15 mg/kg as well as either IV hydrocortisone at 4 to 6 mg/kg every 6 hours or oral prednisone 1 mg/kg once daily. Attending physicians determined nebulizer treatment frequency, ranging from 30 minutes to 4 hours. Subjects were randomized to receive either ipratropium bromide or normal saline, matched to the albuterol dosing interval. Participants were stratified by age (less than 5 years vs 5 years or more) and by the number of ipratropium bromide doses they received in the ED (3 or less vs more than 3). Investigators used an intention-to-treat analysis and allocation was concealed.

OUTCOMES MEASURED: The primary outcome was the clinical asthma score, measured at baseline and every 6 hours until discharge. The clinical score is reproducible, valid, and predictive. Secondary outcomes included oxygen saturation, FEV₁, length of stay, time to a 4-hour albuterol dosing interval, and readmission to the hospital or ED within 72 hours of discharge.

RESULTS: Of the 212 patients assessed for the trial, only 99 were eligible. Of these, 84 parents consented to enroll their children (4 children were later determined not to meet inclusion criteria and were excluded). The ipratropium and placebo groups were essentially the same. There was no difference in the asthma score between treatment and control groups in 3 of the 4 subgroups. In one subgroup—those who had fewer than 3 doses of ipratropium bromide in the ED—ipratropium provided a slight benefit. The difference in change in scores was 0.5 on the clinical asthma score, a statistically but not clinically important change. There were no differences in the secondary outcomes. The average heart rate was 6 to 10 beats per minute greater in the ipratropium group. The authors noted no transient anisocoria, a potential adverse effect of ipratropium bromide in children.

Evidence summary

While many sources state that extraesophageal symptoms (eg, cough, chest pain, asthma) are reported by patients with GERD, only one study reported the frequency of associated symptoms.¹ This population-based survey showed that symptoms of reflux and acid regurgitation are experienced by almost 60% of the population each year. The prevalence of frequent heartburn and acid reflux was approximately 20%. Bronchitis, defined as cough that occurs as often as 4 to 6 times per day on 4 or more days per week, was reported by more than 20% of those with frequent typical GERD symptoms (occurring at least weekly) and by 15% of those with infrequent GERD symptoms. Interestingly, bronchitis was reported by almost 11% of those without GERD. This study showed the association of cough with GERD but did not address whether the cough was the initial presenting complaint.

In as many as 40% of patients with cough, GERD is the underlying cause.^2-7 Chronic cough may be triggered by more than one condition (eg, GERD, postnasal drip, or asthma) in 18% to 93% of patients.⁸ Among patients with cough caused by GERD, 50% to 75% do not have classic symptoms of reflux or regurgitation.⁹ Finally, cough may initiate GERD and start a cough–reflux cycle.⁹ These studies were conducted in pulmonary clinics. Patients with cough whose underlying GERD was easily diagnosed and treated by their primary physician were probably not referred for evaluation in a pulmonary clinic.

Recommendations from others

The American College of Chest Physicians issued a consensus statement in 1999 regarding the management of cough.¹⁰ According to the statement, GERD should be strongly suspected in coughing patients with upper GI symptoms or in those without GI symptoms who have normal chest radiographs, do not smoke, and do not take angiotensin-converting enzyme inhibitors. The statement reports that asthma, postnasal drip syndrome (PNDS), and GERD are the causes of cough in nearly 100% of these patients. The recommendation for evaluation of GERD is a 24-hour pH monitor or an empiric trial of antireflux medication after ruling out asthma and PNDS.

Evidence summary

While many sources state that extraesophageal symptoms (eg, cough, chest pain, asthma) are reported by patients with GERD, only one study reported the frequency of associated symptoms.¹ This population-based survey showed that symptoms of reflux and acid regurgitation are experienced by almost 60% of the population each year. The prevalence of frequent heartburn and acid reflux was approximately 20%. Bronchitis, defined as cough that occurs as often as 4 to 6 times per day on 4 or more days per week, was reported by more than 20% of those with frequent typical GERD symptoms (occurring at least weekly) and by 15% of those with infrequent GERD symptoms. Interestingly, bronchitis was reported by almost 11% of those without GERD. This study showed the association of cough with GERD but did not address whether the cough was the initial presenting complaint.

In as many as 40% of patients with cough, GERD is the underlying cause.^2-7 Chronic cough may be triggered by more than one condition (eg, GERD, postnasal drip, or asthma) in 18% to 93% of patients.⁸ Among patients with cough caused by GERD, 50% to 75% do not have classic symptoms of reflux or regurgitation.⁹ Finally, cough may initiate GERD and start a cough–reflux cycle.⁹ These studies were conducted in pulmonary clinics. Patients with cough whose underlying GERD was easily diagnosed and treated by their primary physician were probably not referred for evaluation in a pulmonary clinic.

Recommendations from others

The American College of Chest Physicians issued a consensus statement in 1999 regarding the management of cough.¹⁰ According to the statement, GERD should be strongly suspected in coughing patients with upper GI symptoms or in those without GI symptoms who have normal chest radiographs, do not smoke, and do not take angiotensin-converting enzyme inhibitors. The statement reports that asthma, postnasal drip syndrome (PNDS), and GERD are the causes of cough in nearly 100% of these patients. The recommendation for evaluation of GERD is a 24-hour pH monitor or an empiric trial of antireflux medication after ruling out asthma and PNDS.

Evidence summary

While many sources state that extraesophageal symptoms (eg, cough, chest pain, asthma) are reported by patients with GERD, only one study reported the frequency of associated symptoms.¹ This population-based survey showed that symptoms of reflux and acid regurgitation are experienced by almost 60% of the population each year. The prevalence of frequent heartburn and acid reflux was approximately 20%. Bronchitis, defined as cough that occurs as often as 4 to 6 times per day on 4 or more days per week, was reported by more than 20% of those with frequent typical GERD symptoms (occurring at least weekly) and by 15% of those with infrequent GERD symptoms. Interestingly, bronchitis was reported by almost 11% of those without GERD. This study showed the association of cough with GERD but did not address whether the cough was the initial presenting complaint.

In as many as 40% of patients with cough, GERD is the underlying cause.^2-7 Chronic cough may be triggered by more than one condition (eg, GERD, postnasal drip, or asthma) in 18% to 93% of patients.⁸ Among patients with cough caused by GERD, 50% to 75% do not have classic symptoms of reflux or regurgitation.⁹ Finally, cough may initiate GERD and start a cough–reflux cycle.⁹ These studies were conducted in pulmonary clinics. Patients with cough whose underlying GERD was easily diagnosed and treated by their primary physician were probably not referred for evaluation in a pulmonary clinic.

Recommendations from others

The American College of Chest Physicians issued a consensus statement in 1999 regarding the management of cough.¹⁰ According to the statement, GERD should be strongly suspected in coughing patients with upper GI symptoms or in those without GI symptoms who have normal chest radiographs, do not smoke, and do not take angiotensin-converting enzyme inhibitors. The statement reports that asthma, postnasal drip syndrome (PNDS), and GERD are the causes of cough in nearly 100% of these patients. The recommendation for evaluation of GERD is a 24-hour pH monitor or an empiric trial of antireflux medication after ruling out asthma and PNDS.

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm

About 1.4 million people are stalked each year in the United States.¹ Chances are you or one of your patients have been among that statistic.

In the U.S., 8% to 12 % of adult women and 2% to 4% of adult men have been stalked at some point in their lives.² While celebrities and politicians tend to be high-profile targets, psychiatrists and other health-care professionals may find themselves subject to unwanted contact or obsessive pursuit; this may be because psychiatrists are perceived to be warm, caring, or nurturing. Also, mental health professionals regularly see patients who are particularly prone to engaging in stalking behaviors.

As a former forensic psychiatry fellow, I have studied the risks and patterns of stalking in an effort to help victims of stalkers protect themselves and use legal remedies when appropriate.

The objectives of this article are threefold:

1. To identify the unique problem of a patient stalking a psychiatrist and how to cope.
2. To address what every stalking victim (including a patient) can do to protect herself or himself.
3. To provide basic definitions of stalking and to outline the current, most widely accepted clinical classification of stalkers and its relevance in predicting the stalker’s response to legal and/or mental health interventions. All 50 states and the District of Columbia have passed laws specifically criminalizing stalking.³

When a psychiatrist is stalked

In her book, I Know You Really Love Me,⁴ psychiatrist Doreen Orion, MD, recounts her experience as a stalking victim. Her victimization began in 1989, when she was on night call for a psychiatric hospital in Arizona. One of the patients she admitted that night was Fran, who developed the erotomanic delusion that Dr. Orion loved her. Despite all evidence to the contrary, Fran pursued Dr. Orion for nearly 8 years, even following her to another state.

Dr. Orion’s book illustrates several issues of import, starting with a crucial failure to communicate. The following morning, Dr. Orion went to the psychiatric hospital to evaluate the patients she had admitted the night before. She contacted Fran’s treating psychiatrist, who angrily hung up on Dr. Orion because Fran had been admitted to the “wrong hospital.” He neglected to inform Dr. Orion that Fran had a history of same-sex stalking and erotomanic delusions. Had she been informed of Fran’s stalking patterns. Dr. Orion may have then simply transferred Fran’s care to a male colleague.

Ultimately, some of Dr. Orion’s colleagues viewed her as somehow inviting or being at fault for her stalking victimization. This classic “blaming the victim” aggravated a situation that was already maddening enough. (Eventually, after several legal and psychiatric evaluations, the stalking stopped.)

Dr. Orion’s book is a cautionary tale. Knowing the patient’s history by reviewing prior records and contacting former treating clinicians can uncover a past pattern of stalking. However, as we are well aware today, terrorists may not become known as such until their first terrorist act; with stalkers, a previous pattern may not be apparent in some cases.

It is important to recognize stalking behaviors for what they are and to act quickly. As psychiatrists, we may be more able than other clinicians to do this because we are trained to ask the patient questions, then simultaneously observe and monitor both the patient’s behavior and our reactions to it. Gavin DeBecker’s book, The Gift of Fear,⁵ details the survival properties of being in tune with one’s fear response as protective.

Typically, stalking has an insidious onset and may even seem initially harmless, perhaps noted as an erotic transference. But you must pay attention to the behavior and how it makes you feel. Be aware that it may escalate and be prepared to take measures to protect yourself.

Questions to ask yourself might include:

• What are your clinical impressions?
• Are axis I and/or axis II disorders present that may respond to treatment?
• Is your therapeutic relationship with the patient fairly new, or is this an established doctor-patient relationship?
• Is the patient an otherwise stable person who is under stress and engaging in uncharacteristic behavior?

Consider the answers carefully, bearing in mind the typology or typologies involved (Table 1). Stalking encompasses a continuum of unwanted behaviors, ranging from the innocuous to overt and harmful stalking. Your clinical decision-making depends on the typology and intensity of the behavior, as well as your own tolerance for such behaviors.

Table 1

STALKER CLASSIFICATION SYSTEM*

Interestingly, a female patient also exhibited unwanted behavior toward Dr. Orion’s psychiatrist husband. This patient frequently parked in front of their home in the evenings. Unlike Fran, whose stalking behaviors became increasingly intrusive, frightening, and violent, this patient did not escalate her behavior. It was an unwanted intrusion, but he did not feel fearful or victimized by it. Therefore, it didn’t meet the clinical or legal definition of stalking—the unwanted behaviors must produce fear in the victim. Another psychiatrist, however, might consider the same scenario to be fearful.

Terminating the therapeutic relationship

Once you have reviewed the case with a colleague and/or a threat-assessment professional and determined that you feel uncomfortable and unsafe, it’s time to terminate the doctor-patient relationship.

Ethical and professional care dictates that you provide the patient with a reasonable written notice (e.g., 30 days) prior to termination. Three referral options with phone numbers are typically provided. This also protects you from a potential malpractice tort of abandonment while the patient still needs treatment. If you sense possibly imminent danger, however, you may need to abbreviate the 30-day notice.

Write a summary note in the patient’s chart that includes, in addition to the usual case summary components, the following:

• Your reason(s) for termination. Include discussion with colleagues and/or threat assessment or law enforcement professionals;
• Your diagnostic and treatment impressions, the treatment provided, and the patient’s response to treatment;
• Your referral choices and the rationale for those decisions, e.g., “female patient with schizophrenia and erotomanic delusions and a history of same-sex stalking referred to a male psychiatrist.” The referral should be made to an outside agency or system. (Once Dr. Orion realized that she was being stalked, she initially made the mistake of transferring her patient to a male colleague who shared her office suite, thus making it easy for Fran to continue to stalk Dr. Orion in her own office.)
• Documentation of your discussion with professionals to whom you are referring the patient, along with the patient’s release of information permitting you to do so.
• Documentation of your discussion with the patient. If applicable, include your statement that you feel it is in the patient’s best interest to continue psychiatric care.
• A copy of the termination letter.

If the stalking persists, the psychiatrist should follow guidelines for victims provided later in this article.

J.P. and his ‘ex-girlfriend’

J.P., 19, met Ms. T. when both were 16 and still in high school. Ms. T. was a “partying friend”; they smoked pot together and “hung out.” Although they never dated nor had a romantic relationship, J.P. found Ms. T. to be “pretty and fun,” and developed secret romantic feelings for her.

In their senior year, J.P. wrote Ms. T. a letter professing his love for her. She laughed at it, was dismissive of his feelings, and shared it with friends. He subsequently felt humiliated and rejected and, in retaliation, began spreading rumors that she was a “witch” and a “lesbian.”

After their graduation, they saw each other on a few occasions at parties, but rarely spoke. About a year and a half later, J.P. saw Ms T. with a man he had once fought. He regarded this man as “no good” and a poor choice on Ms. T.’s part. He obtained her phone number from one of their mutual high school acquaintances and called her. They spoke briefly; he accused her of “using drugs and dating an asshole.”

Box 1

Box 2

Thus began a pattern of unwanted phone calls and letters left through the mail slot of her parents’ front door and on her car windshield. One letter featured a drawing of 2 tombstones, one with his name and one with hers, with R.I.P. (Rot In Pieces) scrawled below her tombstone. When asked how he thought she might respond to this, J.P. shrugged and explained it was “funny.” He claimed he was “just imitating Eminem,” a well-known “badboy” rapper who has a similar tattoo on his abdomen.

One letter indicated his desire to become a professional baseball player and his belief that if he had her love, he could succeed at this endeavor. He seemed unaffected by her lack of interest in him.

The situation escalated further when J.P. coincidentally showed up at a downtown club on a night when Ms. T. and her boyfriend were there. The boyfriend (the same one that J.P. had criticized Ms. T. for becoming involved with) hit J.P. A fight ensued; both men were thrown out of the club.

Complicating J.P.’s problems was his ongoing substance abuse including marijuana, alcohol, and weekend ecstasy (MDMA, a mixed hallucinogen/amphetaminelike drug). J.P. had also complained to a psychiatrist of attention-deficit/hyperactivity disorder-like symptoms and was placed on an amphetamine, which he also abused, according to his mother. Finally, the removal of his wisdom teeth necessitated a codeine prescription for pain, which he overused.

J.P. presented to the psychiatric emergency room with full-blown psychosis, about 2 months after he allegedly began stalking Ms. T. He reported paranoid ideations, i.e., communications through the TV and computer, male coworkers reading his mind, and thoughts of killing his “ex-girlfriend” (a misnomer describing Ms. T.).

J.P. was hospitalized and placed on antipsychotic and mood-stabilizing medications, quickly recompensated and was discharged. Diagnostically, he had a myriad of rule-outs at the time and was discharged on mood stabilizing and antipsychotic medications.

Mediation was attempted in an effort to end the stalking, but J.P. appeared “disorganized” and alarmed both Ms. T. and her parents. J.P. then was scheduled for a court trial and underwent a court-ordered psychiatric evaluation. He did not qualify to plead not guilty by reason of insanity as defined by Ohio statute.

J.P. was found guilty of menacing by stalking and was sentenced to a year probation. He was ordered to continue psychiatric treatment and was barred from any contact with the victim. To my knowledge, the stalking has stopped.

What this case illustrates

Stalking is not a new crime; it has been around for centuries.⁶ But what was once romanticized as a persistent and devoted lover’s pursuit is now considered intrusive and a violation of an individual’s basic right to be left alone.⁷ See Box 1 for legal and clinical definitions of stalking.

In the case vignette, Ms. T. made several good choices that are in line with current recommendations for stalking victims. She did:

Box 3

• Inform neighbors and friends and provide them a description of the stalker;
• Screen calls and block calls from his number (Box 2);
• Notify police and file an affidavit against him (Box 2);
• Buy new locks and secure her doors with deadbolts;
• Add exterior and motion-detector lighting;
• Document and record all incidents involving the stalker, and save all unwanted correspondence (e.g., letters) from him.

But Ms. T. also made some poor choices contrary to current recommendations. She did not:

• End all contact and communication with the stalker; instead she tried to be nice (after all, they were old high school friends) and to chat with him superficially. This encouraged his continued stalking behaviors.
• Refuse to attend the proposed mediation process. This illustrates a lack of understanding of stalking. Her attendance unwittingly reinforced the stalker and failed to curb his behaviors.

You must take into consideration the stalker’s typology, which will aid in predicting his or her likely response to legal intervention. Several stalker classification systems have been devised. The one created by Mullen et al (Table 1) is most widely accepted at this time. It is based on:

• The stalker’s motivation;
• His or her prior relationship with the victim;
• Whether the stalker is psychotic.

Knowing the typology can help determine the risk to victims and guide effective and protective victim responses. Typologies may overlap. Both psychotic and nonpsychotic stalkers are equally likely to threaten, but nonpsychotic stalkers are twice as likely to assault.

Restraining orders typically do not sway intimacy-seeking and delusional stalkers. In fact, stalkers may view restraining orders merely as obstacles they must overcome in order to achieve union with their beloved. A restraining order might work in some instances but it is wise to know the law in your state and what steps law enforcement will actually take if the order is violated. If the violation results in just a citation, not arrest or incarceration, it probably isn’t worth the trouble. Even if the law takes further steps, it is typically for a brief time and the action may ultimately enrage the stalker and escalate him to a violent act. Violent episodes are typically not preceded by a specific threat.⁸

Aside from law enforcement, publicly funded and private threat-assessment teams are located throughout the country. [See “Related resources,” below.] These can help you review the stalking situation in detail and arrive at the most effective response.

Finally, it is important to document the stalking behaviors in order to establish a pattern of conduct that could later be used to prosecute the stalker. Written documentation can be detailed in a log book (Box 3). Saving all physical evidence such as letters, gifts, objects, and e-mails can help establish a pattern of stalking behaviors.

Related resources

• National Organization for Victim Assistance (NOVA) 1757 Park Rd., NW Washington, DC 20010 (800) 879-6682 or (202) 232-6682.
• National Center for Victims of Crime www.ncvc.org (703) 276-2880
• Stalking Behavior. www.stalkingbehavior.com
• The Stalking Assistance Site. www.stalkingassistance.com
• National Victim Center help guide for stalking victims http://www.ojp.usdoj.gov/ovc/assist/nvaa/ch21-2st.htm