Commentary: stalking, threatening, and harassing behavior by patients--the risk-management response.

It has been said that no good deed ever goes unpunished. Perhaps it is the clinician’s burden to experience this firsthand, and it is in this context that Sandberg et al. have made, once again, an important contribution to research on stalking. Their study is the first not only to delineate the traits and behaviors of civil psychiatric patients who threaten, harass, and stalk clinicians, but also to detail the response strategies of clinicians to such disturbing events. Although their inquiry looked at a broad range of threatening and harassing behavior, not just stalking, it appears that mental health clinicians, especially female nurses, are at greater risk to be victimized by such behavior than the general population. Lifetime risk of stalking victimization, when rigorously defined, affects 1 in 12 adult women in the United States and 1 in 50 adult American men. The findings of Sandberg et al. should surprise no one, especially clinicians who have had extensive inpatient experience. In a similar vein, the clinical and demographic characteristics of the patients who stalked, threatened, and harassed staff in this civil study are almost identical with findings in forensic settings. Males are four times more likely to engage in this behavior than females, and they are typically a decade older than most males who act criminally or approach a criminal threshold for threatening behavior. They are clinically heterogeneous, and personality disorder is a likely comorbid diagnosis for almost half of them. Although Sandberg et al. did not attempt to map the Axis II geography of this sample further, we and other researchers have found a likelihood of Cluster B personality disorders in forensic samples, but a lower frequency of antisocial personality disorder when compared with other criminals. This latter finding appears to be a product of an attachment disorder that is preoccupied rather than dismissive. The patients in the study by Sandberg et al. were usually motivated by “angry, retaliatory behavior in response to some form of perceived mistreatment” (p 224). This finding, often the motivation for stalking in workplace settings, raises the further question of sensitivity among these patients: Why do they retaliate when most patients, subjected to similar treatments, do not? I suggest that a common thread among such patients is a pathological narcissism that increases the risk of humiliation in response to the more confrontational aspects of treatment, especially inpatient care. This ventral underbelly of shame sensitivity can stoke a fury that makes no distinction between the professional and private life of the clinician. The study underscores the importance of a comprehensive diagnostic workup that does not neglect both personality and substance abuse disorders, even in the face of a florid Axis I psychosis. These civil patients also do what most stalkers in forensic samples do: They threaten, harass through letters and the telephone, and follow. Fortunately, severe cases and physical attacks were rare in this study group. This is probably a product of two phenomena: the nature of the relationship to the victim and the risk-management response of the clinician. Interpersonal violence among forensic samples of stalkers ranges from 25 percent to 40 percent, and when stalkers of prior sexual intimates are studied Dr. Meloy is Associate Clinical Professor of Psychiatry, University of California, San Diego. Address correspondence to: J. Reid Meloy, PhD, PO Box 90699, San Diego, CA 92169. E-mail: jrmeloy@ san.rr.com