PTSD

Steven, age 6, lives in a foster home and attends an intensive day program for treatment of severe aggressive and violent episodes, for which he has been hospitalized several times. The boy has been separated from his biological mother for 2 years, and her parental rights have been terminated because of allegations of neglect and severe abuse.

Steven’s mother has a long history of substance abuse. Her boyfriend, who lived with her, abused Steven physically and sexually. He beat him, tortured him, and burned him. He once inserted a hot curling iron into the boy’s rectum, causing severe burns.

It is not unusual for psychiatrists to encounter children such as Steven who have experienced abuse, trauma, or a life-threatening event, but the psychological aftermath of these experiences has only recently been fully recognized. Diagnostic criteria continue to change with evidence that posttraumatic stress disorder (PTSD) manifests differently in children and adolescents than in adults. Now research is showing changes in brain physiology in children who have experienced maltreatment.

Based on our experience and recent evidence, we discuss important features of PTSD that are being recognized in children and adolescents and describe trends and acceptable practices in treating this chronic, debilitating illness.

Diagnostic criteria

PTSD is reported to occur in 1 to 14% of the general population of children¹ and in 3 to 100% of children at risk (those exposed to violence, trauma, or abuse).^2,3 As diagnostic criteria have changed over the years, so may have prevalence rates.

PTSD was recognized as a diagnostic entity in adults in DSM-III and in children and adolescents in DSM-III-R. PTSD in children has a somewhat different presentation and expression of symptoms than in adults. According to DSM-IV-TR diagnostic criteria:

• A child’s response to a stressful event may be expressed as disorganized or agitated behavior instead of intense fear, helplessness, or horror.
• Children re-experience and express the traumatic event or aspects of it through repetitive play.
• Children’s dreams may be frightening but without recognizable content, or they may change into generalized nightmares of monsters, of rescuing others, or of threats to self or others.
• Children also tend to have more psychosomatic complaints, such as headaches and stomachaches, than adults with PTSD.¹

Box 1

Age-related symptoms. Appropriate diagnostic criteria for childhood PTSD have been debated for some time, in part because of differences in children’s symptoms at different ages and developmental stages. Since DSM-IV was introduced in 1994, several researchers have recommended modifications to its diagnostic characterizations of childhood PTSD.

To accommodate the developmental stage of children younger than age 4, for example, Scheeringa et al suggested changes to DSM-IV criteria for PTSD.^4,5 These changes (Boxes 1-5) are included in the American Academy of Child and Adolescent Psychiatry’s guidelines for assessing and treating PTSD⁶ and may be a valuable tool for the clinician treating young children.

Subsyndromal cases. Children whose symptoms fall below the diagnostic criteria for PTSD may demonstrate substantial functional impairment and distress, according to Carrion et al.⁷ In fact, these researchers found that children who fulfill the requirements for two of three symptom clusters—Cluster B, re-experiencing (Box 2); Cluster C, avoidance and numbing (Box 3); and Cluster D, hyperarousal (Box 4)—do not differ significantly from children who meet criteria for all three symptom clusters. Therefore—the researchers reported—the absence of this triad does not necessarily indicate a lack of posttraumatic stress in children but may stem from “developmental differences in symptom expression.”

Vulnerability. Traumatic experience contributes to PTSD development, and the “vulnerable, anxious child who is exposed to violence appears to be at greater risk,” according to Silva et al.⁸ After a regression analysis of 59 traumatized children, the research team concluded that PTSD risk is greatest when violence occurs within the family.

A review of 25 studies found that three factors appear to mediate the development of PTSD in children:

• the severity of the trauma exposure
• trauma related to parental distress
• temporal proximity to the traumatic event.⁹

Chronicity. PTSD is a long-lasting, chronic disorder for young patients. Symptoms have been found to persist in one-third of children 2 years after the initial diagnosis.¹⁰

Comorbidity in childhood PTSD is the norm. Among the conditions frequently encountered with childhood PTSD are major depression, dysthymia, substance abuse, anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder.

Steven’s story, continued. At psychiatric referral, Steven had a history of aggression towards other children. He had no friends and usually played alone. He had difficulty sleeping and awoke frequently during the night. Several times daily he displayed temper tantrums with kicking and screaming.

The boy was unable to discuss the abuse that had happened to him but displayed severe aggression when playing with dolls in the office. He stripped off their clothes, examined their private parts, then ripped them apart or threw them across the room. His language development showed significant delays, both in expression and comprehension.

Organic basis for PTSD in children?

Studies of the hypothalamic-pituitary-adrenal (HPA) axis and of brain volume have revealed physiologic changes that may indicate PTSD in children. These changes could be the result of PTSD or a risk factor for its development.

HPA axis dysregulation. One of the first controlled studies of biological and physiologic changes in children with PTSD found elevated levels of dopamine, norepinephrine, and free cortisol in 24-hour urine specimens of maltreated children. Urinary catecholamine and free cortisol concentrations were positively correlated with the duration of PTSD trauma and symptom severity.^11,12

Elevated afternoon salivary cortisol levels have been found in depressed, maltreated children compared with depressed children who had not been maltreated.¹³ Girls ages 5 to 7 who had been abused in the past 2 months were found to have lower salivary cortisol levels than normal controls.¹⁴ A controlled study found significantly elevated salivary cortisol levels in 51 children with PTSD, compared with 31 controls. Interestingly, cortisol levels in the PTSD group were significantly higher in girls than in boys.¹⁵

The effect of trauma on the HPA axis in children requires more research. Although these studies produced contradicting results, elevated cortisol levels seem to be found more consistently than depressed cortisol levels. The differences in outcome could be related to the groups studied or to variations in adrenal system response among subjects.

Brain volume. Changes in brain volume have been measured in maltreated children using MRI readings analyzed with IMAGE software developed by the National Institutes of Health. Intracranial and cerebral volumes of 44 children with PTSD were found to be smaller than those of 61 matched controls.¹² Specifically:

• Children who experienced abuse at the earliest ages and for the longest periods had the smallest brain volumes.
• Maltreated children with the smallest brain and corpus callosum volumes displayed the most severe PTSD symptoms (intrusive thoughts, avoidance, hyperarousal, and dissociation).
• Corpus callosum areas and cerebral volumes were reduced more in maltreated boys than in maltreated girls.
• Hippocampal volumes were not decreased in maltreated children, unlike findings reported in adults with a history of PTSD.

Box 2

In a recent study, the same researchers¹⁶ reported that superior temporal gyrus gray matter volumes measured with MRI were larger in 43 maltreated children and adolescents compared with controls, but white matter volumes were smaller in the maltreated group. The authors suggested these findings may represent developmental alterations in maltreated children. Other MRI studies have found:

Box 3

DSM-IV-TR: POSTTRAUMATIC STRESS DISORDER Criterion C: Avoidance and numbing

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the trauma
3. inability to recall an important aspect of the trauma
4. markedly diminished interest toward participation in significant activity
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

PROPOSED CHANGE FOR YOUNG CHILDREN

Only one symptom is needed from the following:

1. constriction of play
2. socially more withdrawn
3. restricted range of affect
4. loss of acquired developmental skills (especially language and toilet training)

Source: Adapted from DSM-IV-TR and Scheeringa et al. J Am Acad Child Adolesc Psychiatry 1995;34:191-200.

• attenuation in frontal lobe asymmetry and smaller total brain and cerebral volumes in children with PTSD, compared with controls¹⁷
• a lower N-acetylaspartate/creatine ratio in children with PTSD, which suggests altered anterior cingulate neuronal metabolism.¹⁸

These apparent changes in brain architecture and metabolism may have functional implications. Children with PTSD have been found to perform more poorly than do controls on measures of attention, abstract reasoning, and executive functioning.¹⁶

PTSD treatment in children

Treatment of PTSD in children is strongly influenced by the adult literature and practice guidelines. Most psychiatrists who treat children endorse drug therapy as the first line of treatment, followed by psychodynamic psychotherapy and cognitive-behavioral therapy (CBT). In a recent survey of treatment practices in childhood PTSD, 95% of psychiatrists endorsed the use of medications such as selective serotonin reuptake inhibitors (SSRIs) (47 to 49%), alpha-agonists (16 to 38%), tricyclic antidepressants (11 to 15%), and anxiolytics (12%).

Nonmedical therapists who were included in the survey endorsed the use of eye movement desensitization and reprocessing, CBT, family therapy, and nondirective play therapy.¹⁹

Psychotherapy. Preliminary evidence from five controlled trialsindicates that CBT may be an effective first-line treatment for children and adolescents with PTSD:

• In a study of 100 sexually abused children, PTSD symptoms improved significantly more when children received CBT alone or with their parents, compared with when only their parents received CBT.²⁰ Externalizing and depressive symptoms improved greatly when a parent was included in the child’s treatment, and this improvement was maintained 2 years later.²¹
• A randomized study of 80 sexually abused children found little difference between those who received traditional group therapy and others who received group therapy plus CBT.²²
• CBT was found more effective than nondirective supportive therapy in sexually abused preschool children, both initially and at 6- and 12-month intervals, as well as in children ages 7 to 14.^23,24
• After an earthquake in Armenia, children treated with school-based, grief/trauma-focused CBT showed significant improvement on self-reported measures of PTSD and depressive symptoms, compared with children who received no such treatment.²⁵

Pharmacotherapy

Open-label case reports and case series have examined a variety of pharmacotherapies in childhood PTSD, but no double-blind, placebo-controlled studies have been published.

Propranolol. Eleven children with histories of sexual and/or physical abuse exhibited significantly fewer PTSD symptoms during a 5-week regimen of the beta blocker propranolol than either before or after they received the medication.²⁶

Carbamazepine was given to 28 children and adolescents ages 8 to 17 with a primary diagnosis of PTSD. Complete symptom remission was observed in 22 children, and the other 6 had significant improvement—reporting only abuse-related nightmares. Carbamazepine dosages of 300 to 1,200 mg/d yielded serum levels of 10 to 11.5 mcg/ml.

Subjects with comorbid conditions (one-half the sample) required additional medications. Four children with ADHD received stimulants, three with major depressive disorder received SSRIs, and one patient was given imipramine.²⁷

Clonidine treatment resulted in moderate or greater improvement in target symptoms of PTSD in seven preschool children ages 3 to 6 with a history of severe sexual and/or physical abuse. Clonidine dosages ranged from 0.1 mg at bedtime to 0.05 bid plus 0.1 at bedtime.²⁸

SSRIs and other antidepressants. Citalopram was given in a comparison study to 24 children and adolescents and 14 adults with PTSD, with symptoms assessed every 2 weeks based on Clinician Administered PTSD Scale (CAPS) and Clinical Global Impression (CGI) scores. Mean CAPS total score, symptom cluster score, and CGI ratings were significantly reduced in both age groups. Children and adolescents showed greater improvement than adults in hyperarousal symptoms but less in re-experiencing and avoidance symptoms.²⁹

An 8-year-old girl with PTSD and comorbid anxiety disorder initially responded to fluvoxamine. When she relapsed, mirtazapine was added and her overall symptoms improved.³⁰

An adolescent with PTSD treated with nefazodone, up to 600 mg/d, showed improvement in hyperarousal symptoms and anhedonia.³¹

Summary. In the absence of conclusive scientific evidence—i.e., double-blind, placebo-controlled studies—these case reports reflect common practices in treating PTSD in children and adolescents. American Academy of Child and Adolescent Psychiatry practice guidelines defer to the psychiatrist’s judgment to determine the best pharmacologic approach.⁶ In most cases, evidence from the adult literature influences treatment decisions, and in some cases treatment targets comorbidities such as depression, panic disorder, ADHD, and anxiety.

Box 4

Confronting Steven’s demons. Steven was treated with paroxetine, 15 mg/d, targeting both his depressive and PTSD symptoms; clonidine, 0.05 mg at bedtime, targeting hyperarousal symptoms and ADHD; and risperidone, 0.5 mg bid, which was added last to target his severe aggression and violent behavior.

He also received speech therapy, milieu treatment with the structured setting at the day program, and individual play therapy from the day program’s interns. At home, wrap-around services—including a behavioral specialist and a therapeutic staff support worker—were provided to help his foster family deal with his aggression and difficult behavior.

Conclusion

Current approaches to diagnosis, assessment, and treatment of PTSD in children and adolescents depend in large part on the few available studies conducted in adults, which may not necessarily apply to younger patients. We need more clinical trials involving children and adolescents, better diagnostic instruments, and accurate symptom severity rating scales.

Box 5

Research is leading to new understandings of PTSD in childhood, from more refined diagnostic criteria to observations of changes in brain volume and secretion of stress hormones in maltreated children. Case reports are exploring the safety and efficacy of drug and psychotherapeutic treatments.

Acceptable treatment and management—as indicated by case reports and recommended by the American Academy of Child and Adolescent Psychiatry—includes CBT or dynamic psychotherapy, group therapy, and drug treatment, especially for PTSD’s comorbidities.

Related resources

• National Center for PTSD. www.ncptsd.org
• International Society for Traumatic Stress Studies. www.istss.org
• The PTSD Alliance. http://www.ptsdalliance.org
• National Center for Children Exposed to Violence (NCCEV) http://www.nccev.org

Drug brand names

• Carbamazepine • Tegretol
• Citalopram • Celexa
• Clonidine • Catapres
• Fluvoxamine • Luvox
• Imipramine • Tofranil
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Propranolol • Inderal
• Risperidone • Risperdal

Disclosure

Dr. Elizabeth Weller reports that she receives research/grant support from Forest Pharmaceuticals, Organon, and Wyeth Pharmaceuticals, and serves as a consultant to Johnson & Johnson, GlaxoSmithKline, and Novartis Pharmaceuticals Corp.

Dr. Shlewiet reports no affiliation or financial arrangement with any of the companies whose products are mentioned in this article, or with manufacturers of competing products.

Dr. Ronald Weller reports that he receives research/grant support from Wyeth Pharmaceuticals, Organon, and Forest Pharmaceuticals.

Steven, age 6, lives in a foster home and attends an intensive day program for treatment of severe aggressive and violent episodes, for which he has been hospitalized several times. The boy has been separated from his biological mother for 2 years, and her parental rights have been terminated because of allegations of neglect and severe abuse.

Steven’s mother has a long history of substance abuse. Her boyfriend, who lived with her, abused Steven physically and sexually. He beat him, tortured him, and burned him. He once inserted a hot curling iron into the boy’s rectum, causing severe burns.

It is not unusual for psychiatrists to encounter children such as Steven who have experienced abuse, trauma, or a life-threatening event, but the psychological aftermath of these experiences has only recently been fully recognized. Diagnostic criteria continue to change with evidence that posttraumatic stress disorder (PTSD) manifests differently in children and adolescents than in adults. Now research is showing changes in brain physiology in children who have experienced maltreatment.

Based on our experience and recent evidence, we discuss important features of PTSD that are being recognized in children and adolescents and describe trends and acceptable practices in treating this chronic, debilitating illness.

Diagnostic criteria

PTSD is reported to occur in 1 to 14% of the general population of children¹ and in 3 to 100% of children at risk (those exposed to violence, trauma, or abuse).^2,3 As diagnostic criteria have changed over the years, so may have prevalence rates.

PTSD was recognized as a diagnostic entity in adults in DSM-III and in children and adolescents in DSM-III-R. PTSD in children has a somewhat different presentation and expression of symptoms than in adults. According to DSM-IV-TR diagnostic criteria:

• A child’s response to a stressful event may be expressed as disorganized or agitated behavior instead of intense fear, helplessness, or horror.
• Children re-experience and express the traumatic event or aspects of it through repetitive play.
• Children’s dreams may be frightening but without recognizable content, or they may change into generalized nightmares of monsters, of rescuing others, or of threats to self or others.
• Children also tend to have more psychosomatic complaints, such as headaches and stomachaches, than adults with PTSD.¹

Box 1

Age-related symptoms. Appropriate diagnostic criteria for childhood PTSD have been debated for some time, in part because of differences in children’s symptoms at different ages and developmental stages. Since DSM-IV was introduced in 1994, several researchers have recommended modifications to its diagnostic characterizations of childhood PTSD.

To accommodate the developmental stage of children younger than age 4, for example, Scheeringa et al suggested changes to DSM-IV criteria for PTSD.^4,5 These changes (Boxes 1-5) are included in the American Academy of Child and Adolescent Psychiatry’s guidelines for assessing and treating PTSD⁶ and may be a valuable tool for the clinician treating young children.

Subsyndromal cases. Children whose symptoms fall below the diagnostic criteria for PTSD may demonstrate substantial functional impairment and distress, according to Carrion et al.⁷ In fact, these researchers found that children who fulfill the requirements for two of three symptom clusters—Cluster B, re-experiencing (Box 2); Cluster C, avoidance and numbing (Box 3); and Cluster D, hyperarousal (Box 4)—do not differ significantly from children who meet criteria for all three symptom clusters. Therefore—the researchers reported—the absence of this triad does not necessarily indicate a lack of posttraumatic stress in children but may stem from “developmental differences in symptom expression.”

Vulnerability. Traumatic experience contributes to PTSD development, and the “vulnerable, anxious child who is exposed to violence appears to be at greater risk,” according to Silva et al.⁸ After a regression analysis of 59 traumatized children, the research team concluded that PTSD risk is greatest when violence occurs within the family.

A review of 25 studies found that three factors appear to mediate the development of PTSD in children:

• the severity of the trauma exposure
• trauma related to parental distress
• temporal proximity to the traumatic event.⁹

Chronicity. PTSD is a long-lasting, chronic disorder for young patients. Symptoms have been found to persist in one-third of children 2 years after the initial diagnosis.¹⁰

Comorbidity in childhood PTSD is the norm. Among the conditions frequently encountered with childhood PTSD are major depression, dysthymia, substance abuse, anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder.

Steven’s story, continued. At psychiatric referral, Steven had a history of aggression towards other children. He had no friends and usually played alone. He had difficulty sleeping and awoke frequently during the night. Several times daily he displayed temper tantrums with kicking and screaming.

The boy was unable to discuss the abuse that had happened to him but displayed severe aggression when playing with dolls in the office. He stripped off their clothes, examined their private parts, then ripped them apart or threw them across the room. His language development showed significant delays, both in expression and comprehension.

Organic basis for PTSD in children?

Studies of the hypothalamic-pituitary-adrenal (HPA) axis and of brain volume have revealed physiologic changes that may indicate PTSD in children. These changes could be the result of PTSD or a risk factor for its development.

HPA axis dysregulation. One of the first controlled studies of biological and physiologic changes in children with PTSD found elevated levels of dopamine, norepinephrine, and free cortisol in 24-hour urine specimens of maltreated children. Urinary catecholamine and free cortisol concentrations were positively correlated with the duration of PTSD trauma and symptom severity.^11,12

Elevated afternoon salivary cortisol levels have been found in depressed, maltreated children compared with depressed children who had not been maltreated.¹³ Girls ages 5 to 7 who had been abused in the past 2 months were found to have lower salivary cortisol levels than normal controls.¹⁴ A controlled study found significantly elevated salivary cortisol levels in 51 children with PTSD, compared with 31 controls. Interestingly, cortisol levels in the PTSD group were significantly higher in girls than in boys.¹⁵

The effect of trauma on the HPA axis in children requires more research. Although these studies produced contradicting results, elevated cortisol levels seem to be found more consistently than depressed cortisol levels. The differences in outcome could be related to the groups studied or to variations in adrenal system response among subjects.

Brain volume. Changes in brain volume have been measured in maltreated children using MRI readings analyzed with IMAGE software developed by the National Institutes of Health. Intracranial and cerebral volumes of 44 children with PTSD were found to be smaller than those of 61 matched controls.¹² Specifically:

• Children who experienced abuse at the earliest ages and for the longest periods had the smallest brain volumes.
• Maltreated children with the smallest brain and corpus callosum volumes displayed the most severe PTSD symptoms (intrusive thoughts, avoidance, hyperarousal, and dissociation).
• Corpus callosum areas and cerebral volumes were reduced more in maltreated boys than in maltreated girls.
• Hippocampal volumes were not decreased in maltreated children, unlike findings reported in adults with a history of PTSD.

Box 2

In a recent study, the same researchers¹⁶ reported that superior temporal gyrus gray matter volumes measured with MRI were larger in 43 maltreated children and adolescents compared with controls, but white matter volumes were smaller in the maltreated group. The authors suggested these findings may represent developmental alterations in maltreated children. Other MRI studies have found:

Box 3

DSM-IV-TR: POSTTRAUMATIC STRESS DISORDER Criterion C: Avoidance and numbing

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the trauma
3. inability to recall an important aspect of the trauma
4. markedly diminished interest toward participation in significant activity
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

PROPOSED CHANGE FOR YOUNG CHILDREN

Only one symptom is needed from the following:

1. constriction of play
2. socially more withdrawn
3. restricted range of affect
4. loss of acquired developmental skills (especially language and toilet training)

Source: Adapted from DSM-IV-TR and Scheeringa et al. J Am Acad Child Adolesc Psychiatry 1995;34:191-200.

• attenuation in frontal lobe asymmetry and smaller total brain and cerebral volumes in children with PTSD, compared with controls¹⁷
• a lower N-acetylaspartate/creatine ratio in children with PTSD, which suggests altered anterior cingulate neuronal metabolism.¹⁸

These apparent changes in brain architecture and metabolism may have functional implications. Children with PTSD have been found to perform more poorly than do controls on measures of attention, abstract reasoning, and executive functioning.¹⁶

PTSD treatment in children

Treatment of PTSD in children is strongly influenced by the adult literature and practice guidelines. Most psychiatrists who treat children endorse drug therapy as the first line of treatment, followed by psychodynamic psychotherapy and cognitive-behavioral therapy (CBT). In a recent survey of treatment practices in childhood PTSD, 95% of psychiatrists endorsed the use of medications such as selective serotonin reuptake inhibitors (SSRIs) (47 to 49%), alpha-agonists (16 to 38%), tricyclic antidepressants (11 to 15%), and anxiolytics (12%).

Nonmedical therapists who were included in the survey endorsed the use of eye movement desensitization and reprocessing, CBT, family therapy, and nondirective play therapy.¹⁹

Psychotherapy. Preliminary evidence from five controlled trialsindicates that CBT may be an effective first-line treatment for children and adolescents with PTSD:

• In a study of 100 sexually abused children, PTSD symptoms improved significantly more when children received CBT alone or with their parents, compared with when only their parents received CBT.²⁰ Externalizing and depressive symptoms improved greatly when a parent was included in the child’s treatment, and this improvement was maintained 2 years later.²¹
• A randomized study of 80 sexually abused children found little difference between those who received traditional group therapy and others who received group therapy plus CBT.²²
• CBT was found more effective than nondirective supportive therapy in sexually abused preschool children, both initially and at 6- and 12-month intervals, as well as in children ages 7 to 14.^23,24
• After an earthquake in Armenia, children treated with school-based, grief/trauma-focused CBT showed significant improvement on self-reported measures of PTSD and depressive symptoms, compared with children who received no such treatment.²⁵

Pharmacotherapy

Open-label case reports and case series have examined a variety of pharmacotherapies in childhood PTSD, but no double-blind, placebo-controlled studies have been published.

Propranolol. Eleven children with histories of sexual and/or physical abuse exhibited significantly fewer PTSD symptoms during a 5-week regimen of the beta blocker propranolol than either before or after they received the medication.²⁶

Carbamazepine was given to 28 children and adolescents ages 8 to 17 with a primary diagnosis of PTSD. Complete symptom remission was observed in 22 children, and the other 6 had significant improvement—reporting only abuse-related nightmares. Carbamazepine dosages of 300 to 1,200 mg/d yielded serum levels of 10 to 11.5 mcg/ml.

Subjects with comorbid conditions (one-half the sample) required additional medications. Four children with ADHD received stimulants, three with major depressive disorder received SSRIs, and one patient was given imipramine.²⁷

Clonidine treatment resulted in moderate or greater improvement in target symptoms of PTSD in seven preschool children ages 3 to 6 with a history of severe sexual and/or physical abuse. Clonidine dosages ranged from 0.1 mg at bedtime to 0.05 bid plus 0.1 at bedtime.²⁸

SSRIs and other antidepressants. Citalopram was given in a comparison study to 24 children and adolescents and 14 adults with PTSD, with symptoms assessed every 2 weeks based on Clinician Administered PTSD Scale (CAPS) and Clinical Global Impression (CGI) scores. Mean CAPS total score, symptom cluster score, and CGI ratings were significantly reduced in both age groups. Children and adolescents showed greater improvement than adults in hyperarousal symptoms but less in re-experiencing and avoidance symptoms.²⁹

An 8-year-old girl with PTSD and comorbid anxiety disorder initially responded to fluvoxamine. When she relapsed, mirtazapine was added and her overall symptoms improved.³⁰

An adolescent with PTSD treated with nefazodone, up to 600 mg/d, showed improvement in hyperarousal symptoms and anhedonia.³¹

Summary. In the absence of conclusive scientific evidence—i.e., double-blind, placebo-controlled studies—these case reports reflect common practices in treating PTSD in children and adolescents. American Academy of Child and Adolescent Psychiatry practice guidelines defer to the psychiatrist’s judgment to determine the best pharmacologic approach.⁶ In most cases, evidence from the adult literature influences treatment decisions, and in some cases treatment targets comorbidities such as depression, panic disorder, ADHD, and anxiety.

Box 4

Confronting Steven’s demons. Steven was treated with paroxetine, 15 mg/d, targeting both his depressive and PTSD symptoms; clonidine, 0.05 mg at bedtime, targeting hyperarousal symptoms and ADHD; and risperidone, 0.5 mg bid, which was added last to target his severe aggression and violent behavior.

He also received speech therapy, milieu treatment with the structured setting at the day program, and individual play therapy from the day program’s interns. At home, wrap-around services—including a behavioral specialist and a therapeutic staff support worker—were provided to help his foster family deal with his aggression and difficult behavior.

Conclusion

Current approaches to diagnosis, assessment, and treatment of PTSD in children and adolescents depend in large part on the few available studies conducted in adults, which may not necessarily apply to younger patients. We need more clinical trials involving children and adolescents, better diagnostic instruments, and accurate symptom severity rating scales.

Box 5

Research is leading to new understandings of PTSD in childhood, from more refined diagnostic criteria to observations of changes in brain volume and secretion of stress hormones in maltreated children. Case reports are exploring the safety and efficacy of drug and psychotherapeutic treatments.

Acceptable treatment and management—as indicated by case reports and recommended by the American Academy of Child and Adolescent Psychiatry—includes CBT or dynamic psychotherapy, group therapy, and drug treatment, especially for PTSD’s comorbidities.

Related resources

• National Center for PTSD. www.ncptsd.org
• International Society for Traumatic Stress Studies. www.istss.org
• The PTSD Alliance. http://www.ptsdalliance.org
• National Center for Children Exposed to Violence (NCCEV) http://www.nccev.org

Drug brand names

• Carbamazepine • Tegretol
• Citalopram • Celexa
• Clonidine • Catapres
• Fluvoxamine • Luvox
• Imipramine • Tofranil
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Propranolol • Inderal
• Risperidone • Risperdal

Disclosure

Dr. Elizabeth Weller reports that she receives research/grant support from Forest Pharmaceuticals, Organon, and Wyeth Pharmaceuticals, and serves as a consultant to Johnson & Johnson, GlaxoSmithKline, and Novartis Pharmaceuticals Corp.

Dr. Shlewiet reports no affiliation or financial arrangement with any of the companies whose products are mentioned in this article, or with manufacturers of competing products.

Dr. Ronald Weller reports that he receives research/grant support from Wyeth Pharmaceuticals, Organon, and Forest Pharmaceuticals.

Steven, age 6, lives in a foster home and attends an intensive day program for treatment of severe aggressive and violent episodes, for which he has been hospitalized several times. The boy has been separated from his biological mother for 2 years, and her parental rights have been terminated because of allegations of neglect and severe abuse.

Steven’s mother has a long history of substance abuse. Her boyfriend, who lived with her, abused Steven physically and sexually. He beat him, tortured him, and burned him. He once inserted a hot curling iron into the boy’s rectum, causing severe burns.

It is not unusual for psychiatrists to encounter children such as Steven who have experienced abuse, trauma, or a life-threatening event, but the psychological aftermath of these experiences has only recently been fully recognized. Diagnostic criteria continue to change with evidence that posttraumatic stress disorder (PTSD) manifests differently in children and adolescents than in adults. Now research is showing changes in brain physiology in children who have experienced maltreatment.

Based on our experience and recent evidence, we discuss important features of PTSD that are being recognized in children and adolescents and describe trends and acceptable practices in treating this chronic, debilitating illness.

Diagnostic criteria

PTSD is reported to occur in 1 to 14% of the general population of children¹ and in 3 to 100% of children at risk (those exposed to violence, trauma, or abuse).^2,3 As diagnostic criteria have changed over the years, so may have prevalence rates.

PTSD was recognized as a diagnostic entity in adults in DSM-III and in children and adolescents in DSM-III-R. PTSD in children has a somewhat different presentation and expression of symptoms than in adults. According to DSM-IV-TR diagnostic criteria:

• A child’s response to a stressful event may be expressed as disorganized or agitated behavior instead of intense fear, helplessness, or horror.
• Children re-experience and express the traumatic event or aspects of it through repetitive play.
• Children’s dreams may be frightening but without recognizable content, or they may change into generalized nightmares of monsters, of rescuing others, or of threats to self or others.
• Children also tend to have more psychosomatic complaints, such as headaches and stomachaches, than adults with PTSD.¹

Box 1

Age-related symptoms. Appropriate diagnostic criteria for childhood PTSD have been debated for some time, in part because of differences in children’s symptoms at different ages and developmental stages. Since DSM-IV was introduced in 1994, several researchers have recommended modifications to its diagnostic characterizations of childhood PTSD.

To accommodate the developmental stage of children younger than age 4, for example, Scheeringa et al suggested changes to DSM-IV criteria for PTSD.^4,5 These changes (Boxes 1-5) are included in the American Academy of Child and Adolescent Psychiatry’s guidelines for assessing and treating PTSD⁶ and may be a valuable tool for the clinician treating young children.

Subsyndromal cases. Children whose symptoms fall below the diagnostic criteria for PTSD may demonstrate substantial functional impairment and distress, according to Carrion et al.⁷ In fact, these researchers found that children who fulfill the requirements for two of three symptom clusters—Cluster B, re-experiencing (Box 2); Cluster C, avoidance and numbing (Box 3); and Cluster D, hyperarousal (Box 4)—do not differ significantly from children who meet criteria for all three symptom clusters. Therefore—the researchers reported—the absence of this triad does not necessarily indicate a lack of posttraumatic stress in children but may stem from “developmental differences in symptom expression.”

Vulnerability. Traumatic experience contributes to PTSD development, and the “vulnerable, anxious child who is exposed to violence appears to be at greater risk,” according to Silva et al.⁸ After a regression analysis of 59 traumatized children, the research team concluded that PTSD risk is greatest when violence occurs within the family.

A review of 25 studies found that three factors appear to mediate the development of PTSD in children:

• the severity of the trauma exposure
• trauma related to parental distress
• temporal proximity to the traumatic event.⁹

Chronicity. PTSD is a long-lasting, chronic disorder for young patients. Symptoms have been found to persist in one-third of children 2 years after the initial diagnosis.¹⁰

Comorbidity in childhood PTSD is the norm. Among the conditions frequently encountered with childhood PTSD are major depression, dysthymia, substance abuse, anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder.

Steven’s story, continued. At psychiatric referral, Steven had a history of aggression towards other children. He had no friends and usually played alone. He had difficulty sleeping and awoke frequently during the night. Several times daily he displayed temper tantrums with kicking and screaming.

The boy was unable to discuss the abuse that had happened to him but displayed severe aggression when playing with dolls in the office. He stripped off their clothes, examined their private parts, then ripped them apart or threw them across the room. His language development showed significant delays, both in expression and comprehension.

Organic basis for PTSD in children?

Studies of the hypothalamic-pituitary-adrenal (HPA) axis and of brain volume have revealed physiologic changes that may indicate PTSD in children. These changes could be the result of PTSD or a risk factor for its development.

HPA axis dysregulation. One of the first controlled studies of biological and physiologic changes in children with PTSD found elevated levels of dopamine, norepinephrine, and free cortisol in 24-hour urine specimens of maltreated children. Urinary catecholamine and free cortisol concentrations were positively correlated with the duration of PTSD trauma and symptom severity.^11,12

Elevated afternoon salivary cortisol levels have been found in depressed, maltreated children compared with depressed children who had not been maltreated.¹³ Girls ages 5 to 7 who had been abused in the past 2 months were found to have lower salivary cortisol levels than normal controls.¹⁴ A controlled study found significantly elevated salivary cortisol levels in 51 children with PTSD, compared with 31 controls. Interestingly, cortisol levels in the PTSD group were significantly higher in girls than in boys.¹⁵

The effect of trauma on the HPA axis in children requires more research. Although these studies produced contradicting results, elevated cortisol levels seem to be found more consistently than depressed cortisol levels. The differences in outcome could be related to the groups studied or to variations in adrenal system response among subjects.

Brain volume. Changes in brain volume have been measured in maltreated children using MRI readings analyzed with IMAGE software developed by the National Institutes of Health. Intracranial and cerebral volumes of 44 children with PTSD were found to be smaller than those of 61 matched controls.¹² Specifically:

• Children who experienced abuse at the earliest ages and for the longest periods had the smallest brain volumes.
• Maltreated children with the smallest brain and corpus callosum volumes displayed the most severe PTSD symptoms (intrusive thoughts, avoidance, hyperarousal, and dissociation).
• Corpus callosum areas and cerebral volumes were reduced more in maltreated boys than in maltreated girls.
• Hippocampal volumes were not decreased in maltreated children, unlike findings reported in adults with a history of PTSD.

Box 2

In a recent study, the same researchers¹⁶ reported that superior temporal gyrus gray matter volumes measured with MRI were larger in 43 maltreated children and adolescents compared with controls, but white matter volumes were smaller in the maltreated group. The authors suggested these findings may represent developmental alterations in maltreated children. Other MRI studies have found:

Box 3

DSM-IV-TR: POSTTRAUMATIC STRESS DISORDER Criterion C: Avoidance and numbing

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the trauma
3. inability to recall an important aspect of the trauma
4. markedly diminished interest toward participation in significant activity
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

PROPOSED CHANGE FOR YOUNG CHILDREN

Only one symptom is needed from the following:

1. constriction of play
2. socially more withdrawn
3. restricted range of affect
4. loss of acquired developmental skills (especially language and toilet training)

Source: Adapted from DSM-IV-TR and Scheeringa et al. J Am Acad Child Adolesc Psychiatry 1995;34:191-200.

• attenuation in frontal lobe asymmetry and smaller total brain and cerebral volumes in children with PTSD, compared with controls¹⁷
• a lower N-acetylaspartate/creatine ratio in children with PTSD, which suggests altered anterior cingulate neuronal metabolism.¹⁸

These apparent changes in brain architecture and metabolism may have functional implications. Children with PTSD have been found to perform more poorly than do controls on measures of attention, abstract reasoning, and executive functioning.¹⁶

PTSD treatment in children

Treatment of PTSD in children is strongly influenced by the adult literature and practice guidelines. Most psychiatrists who treat children endorse drug therapy as the first line of treatment, followed by psychodynamic psychotherapy and cognitive-behavioral therapy (CBT). In a recent survey of treatment practices in childhood PTSD, 95% of psychiatrists endorsed the use of medications such as selective serotonin reuptake inhibitors (SSRIs) (47 to 49%), alpha-agonists (16 to 38%), tricyclic antidepressants (11 to 15%), and anxiolytics (12%).

Nonmedical therapists who were included in the survey endorsed the use of eye movement desensitization and reprocessing, CBT, family therapy, and nondirective play therapy.¹⁹

Psychotherapy. Preliminary evidence from five controlled trialsindicates that CBT may be an effective first-line treatment for children and adolescents with PTSD:

• In a study of 100 sexually abused children, PTSD symptoms improved significantly more when children received CBT alone or with their parents, compared with when only their parents received CBT.²⁰ Externalizing and depressive symptoms improved greatly when a parent was included in the child’s treatment, and this improvement was maintained 2 years later.²¹
• A randomized study of 80 sexually abused children found little difference between those who received traditional group therapy and others who received group therapy plus CBT.²²
• CBT was found more effective than nondirective supportive therapy in sexually abused preschool children, both initially and at 6- and 12-month intervals, as well as in children ages 7 to 14.^23,24
• After an earthquake in Armenia, children treated with school-based, grief/trauma-focused CBT showed significant improvement on self-reported measures of PTSD and depressive symptoms, compared with children who received no such treatment.²⁵

Pharmacotherapy

Open-label case reports and case series have examined a variety of pharmacotherapies in childhood PTSD, but no double-blind, placebo-controlled studies have been published.

Propranolol. Eleven children with histories of sexual and/or physical abuse exhibited significantly fewer PTSD symptoms during a 5-week regimen of the beta blocker propranolol than either before or after they received the medication.²⁶

Carbamazepine was given to 28 children and adolescents ages 8 to 17 with a primary diagnosis of PTSD. Complete symptom remission was observed in 22 children, and the other 6 had significant improvement—reporting only abuse-related nightmares. Carbamazepine dosages of 300 to 1,200 mg/d yielded serum levels of 10 to 11.5 mcg/ml.

Subjects with comorbid conditions (one-half the sample) required additional medications. Four children with ADHD received stimulants, three with major depressive disorder received SSRIs, and one patient was given imipramine.²⁷

Clonidine treatment resulted in moderate or greater improvement in target symptoms of PTSD in seven preschool children ages 3 to 6 with a history of severe sexual and/or physical abuse. Clonidine dosages ranged from 0.1 mg at bedtime to 0.05 bid plus 0.1 at bedtime.²⁸

SSRIs and other antidepressants. Citalopram was given in a comparison study to 24 children and adolescents and 14 adults with PTSD, with symptoms assessed every 2 weeks based on Clinician Administered PTSD Scale (CAPS) and Clinical Global Impression (CGI) scores. Mean CAPS total score, symptom cluster score, and CGI ratings were significantly reduced in both age groups. Children and adolescents showed greater improvement than adults in hyperarousal symptoms but less in re-experiencing and avoidance symptoms.²⁹

An 8-year-old girl with PTSD and comorbid anxiety disorder initially responded to fluvoxamine. When she relapsed, mirtazapine was added and her overall symptoms improved.³⁰

An adolescent with PTSD treated with nefazodone, up to 600 mg/d, showed improvement in hyperarousal symptoms and anhedonia.³¹

Summary. In the absence of conclusive scientific evidence—i.e., double-blind, placebo-controlled studies—these case reports reflect common practices in treating PTSD in children and adolescents. American Academy of Child and Adolescent Psychiatry practice guidelines defer to the psychiatrist’s judgment to determine the best pharmacologic approach.⁶ In most cases, evidence from the adult literature influences treatment decisions, and in some cases treatment targets comorbidities such as depression, panic disorder, ADHD, and anxiety.

Box 4

Confronting Steven’s demons. Steven was treated with paroxetine, 15 mg/d, targeting both his depressive and PTSD symptoms; clonidine, 0.05 mg at bedtime, targeting hyperarousal symptoms and ADHD; and risperidone, 0.5 mg bid, which was added last to target his severe aggression and violent behavior.

He also received speech therapy, milieu treatment with the structured setting at the day program, and individual play therapy from the day program’s interns. At home, wrap-around services—including a behavioral specialist and a therapeutic staff support worker—were provided to help his foster family deal with his aggression and difficult behavior.

Conclusion

Current approaches to diagnosis, assessment, and treatment of PTSD in children and adolescents depend in large part on the few available studies conducted in adults, which may not necessarily apply to younger patients. We need more clinical trials involving children and adolescents, better diagnostic instruments, and accurate symptom severity rating scales.

Box 5

Research is leading to new understandings of PTSD in childhood, from more refined diagnostic criteria to observations of changes in brain volume and secretion of stress hormones in maltreated children. Case reports are exploring the safety and efficacy of drug and psychotherapeutic treatments.

Acceptable treatment and management—as indicated by case reports and recommended by the American Academy of Child and Adolescent Psychiatry—includes CBT or dynamic psychotherapy, group therapy, and drug treatment, especially for PTSD’s comorbidities.

Related resources

• National Center for PTSD. www.ncptsd.org
• International Society for Traumatic Stress Studies. www.istss.org
• The PTSD Alliance. http://www.ptsdalliance.org
• National Center for Children Exposed to Violence (NCCEV) http://www.nccev.org

Drug brand names

• Carbamazepine • Tegretol
• Citalopram • Celexa
• Clonidine • Catapres
• Fluvoxamine • Luvox
• Imipramine • Tofranil
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Propranolol • Inderal
• Risperidone • Risperdal

Disclosure

Dr. Elizabeth Weller reports that she receives research/grant support from Forest Pharmaceuticals, Organon, and Wyeth Pharmaceuticals, and serves as a consultant to Johnson & Johnson, GlaxoSmithKline, and Novartis Pharmaceuticals Corp.

Dr. Shlewiet reports no affiliation or financial arrangement with any of the companies whose products are mentioned in this article, or with manufacturers of competing products.

Dr. Ronald Weller reports that he receives research/grant support from Wyeth Pharmaceuticals, Organon, and Forest Pharmaceuticals.

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

Since September 11, America has carried on under a cloud of fear. Though the cloud is lifting, it will not disappear for months or years. The terrorist attacks on New York City and Washington, DC, the resultant military action in Afghanistan, and the anthrax scare—combined with pervasive, nagging doubts about homeland security and the specter of another possible future terrorist attack—all are straining the nation’s collective emotional well-being.

Psychiatrists in America have reported new cases of terror-inspired acute stress disorder, anxiety, depression, and other illnesses, as well as recurrences of posttraumatic stress disorder (PTSD) in existing patients, in the weeks after the recent attacks and the anthrax scare. What will be the impact on psychiatric practice in the coming months and years?

“We are all at ground zero,” says Kenneth S. Thompson, MD, of Pittsburgh, an experienced disaster psychiatrist. But he and other subspecialists have identified four critical areas in which psychiatrists should be prepared:

1. Identifying how terrorist attacks and scares can exacerbate symptoms in patients now in your practice;
2. Diagnosing PTSD among comorbid conditions present in existing or new patients;
3. Treating—and avoiding over-treatment—of patients with acute stress disorder and PTSD;
4. Managing fear in your communities—in response to the Sept. 11 attacks, to the anthrax scare, or in anticipation of an impending catastrophe.

To bring you this special report, the editors of Current Psychiatry have reviewed the literature and interviewed psychiatrists nationwide and in countries such as Israel and Colombia, where terrorism has been a fact of life for years (see “PTSD lessons from Israel, Colombia,”).

Terror and your patients

Which symptoms are you most likely to see in existing patients subsequent to recent events? In the weeks following the Sept. 11 attacks, psychiatrists reported the most commonly seen symptoms as increased anxiety and worsened depression. Sleep disturbances, agoraphobia, suicidality, and severe reactions among patients with personality disorders also were reported.

Patients with previous PTSD or exposure to trauma face a high risk of new or recurrent PTSD in the wake of Sept. 11 than do those not previously exposed to trauma.¹ War veterans with prior posttraumatic symptoms have been particularly prone to recurrent PTSD after the attacks. James Allen, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center, calls this the “additive effect”: patients traumatized by military service in Vietnam experience a recurrence after seeing a major disaster or atrocity. Dr. Allen, who was extensively involved with Oklahoma City’s disaster psychiatry effort after the 1995 bombing there, recalls seeing patients who were traumatized in Vietnam suffer a recurrence after the Alfred P. Murrah Building attack, and then another relapse after Sept. 11.

“The Sept. 11 attacks were very similar to the war for them,” says Juan Corvalan, MD, of the PTSD Unit of the St. Louis Veterans Administration Medical Center, referring to the numerous war veterans he treated after the atrocities. “Seeing it on TV triggered many memories.” By early November, however, many who experienced recurrent PTSD had returned to their pre-Sept. 11 mental states.

Craig Katz, MD, director of emergency psychiatry services at New York’s Mount Sinai Medical Center, says that a patient’s psychiatric history is crucial to determining risk for PTSD or other terror-related sequelae:

“You can recognize that a given person is at high risk for PTSD post-trauma, based on any combination of these factors—having a psychiatric history, past trauma, high exposure to the event, psychosocial problems pre-disaster, or lack of supports post-disaster.”

The clinical interview is a vital tool in assessing patients with suspected PTSD or posttraumatic sequelae, says Arieh Shalev, MD, of the department of psychiatry at Hadassah University Hospital in Jerusalem, Israel. “It provides the opportunity to discuss the traumatic event with the patient, and to listen to his or her perceptions of the event and its effects” in order to carefully appraise the patient’s symptoms.²

The guidelines set forth in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) remain the gold standard for confirming a diagnosis of PTSD and discerning long-term posttraumatic sequelae from temporary acute stress disorder (Box 1). The guidelines have proved far from foolproof, however, and the existence of psychiatric comorbidities often clouds the picture.

Box 1

DSM-IV DIAGNOSTIC CRITERIA FOR PTSD

1. Exposure to a traumatic event with both of the following present:
2. The traumatic event is persistently reexperienced in one or more of the following ways:
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
5. Duration of symptoms in criteria B, C or D exceeds 1 month.
6. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if; Acute: if duration of symptoms is less than 3 months.

Chronic: if symptoms persist 3 months or more.

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

Acute stress disorder, whose symptom pattern is similar to that of PTSD, is distinguished from PTSD because the symptom pattern must occur and resolve within 4 weeks of the traumatic event. If the symptoms persist for more than 1 month and meet the criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Differential diagnosis of PTSD

Patients with PTSD are more likely to have substantial psychiatric comorbidity than are those without the disorder.³ Possible reasons include suspected self-medication of PTSD symptoms, particularly among patients with substance abuse, and the possible overreporting of symptoms by patients. Psychiatrists should maintain a high level of suspicion for PTSD when managing a new or existing patient with psychopathology.

Citing data from the National Comorbidity Study of the Institute for Social Research at the University of Michigan, Kessler and others in 1995 noted that more than 80 percent of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. Roughly half of PTSD sufferers met criteria for three or more comorbidities.³

Kathleen Brady, MD, professor of psychiatry at the Medical University of South Carolina in Charleston, noted in a 1997 study that affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders are common comorbidities of PTSD.⁵ Dr. Shalev and colleagues in one study found that a history of major depressive disorder may increase the severity of posttraumatic morbidity.⁶ Dr. Brady and others also have found that PTSD patients with a comorbid substance abuse disorder experience severe PTSD symptoms while in a withdrawal state.⁷

Box 2

PTSD often is overlooked in the presence of other psychiatric diagnoses. Meuser et al in 1998 studied 275 patients with schizophrenia and bipolar disorder. As many as 98 percent of patients reported lifetime exposure to at least one traumatic event. The researchers found diagnosable PTSD in 119 (43 %) of the subjects, but only three (2%) had the diagnosis in their charts.⁸

In a later study, Dr. Brady and others cited substantial symptom overlap between PTSD and other psychiatric diagnoses, particularly major depressive disorder. This can contribute to underdiagnosis of PTSD, the researchers found.⁷ (Box 2).

Box 3

WATCH FOR SIGNS OF PTSD IN CHILDREN

Children also have been experiencing stress disorders since Sept. 11, says Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. Such disorders manifest as sleep disturbances, anxiety, hyperarousal/hyperactivity, and nightmares.

Young children regress and cling to their parents, and are frightened of the dark or noises, Dr, Husain notes. Those who are toilet-trained can suddenly wet the bed, become neurotic, and demand attention. School-age children are more fearful; they may not want to go to school, their schoolwork may decline, and they may have trouble paying attention. Dr. Husain suggests discussing the trauma and devising a plan of action with them in case the trauma recurs.

The media’s role in reporting on the aftermath of the attacks—and triggering traumatic reactions as an unintended consequence—cannot be overlooked. Two recent studies performed after the Oklahoma City bombing suggest that television reports of that atrocity precipitated PTSD symptoms in middle-school children 7 weeks after the bombing,²³ and in geographically distant sixth-graders 2 years after the attack.¹² It was not clear whether any of these students had prior PTSD or other psychopathology.

Psychiatric education in the schools is especially crucial in light of the school violence that has occurred in America in recent years. Dr. Husain believes that the children who commit violence are victims of abuse. If teachers early on can identify children who show evidence of stress disorders, they can refer them to trained psychiatrists, catching those who need help before tragedies occur. “It is the psychiatric equivalent of CPR,” Dr. Husain says.

Dr. Brady recommends that psychiatrists and primary care physicians routinely screen patients for exposure to traumatic events. Ask patients specifically about their reaction to such events and encourage them to talk about it. Patients often feel either guilty or embarrassed about the traumatic event, or do not believe it affects their presenting complaints, she notes. Other approaches may be needed to identify the risk of PTSD in children (Box 3).

Identifying a traumatic event of an extreme nature, for example, a life-threatening experience, is key to diagnosing PTSD in the presence of comorbidities, Dr. Corvalan says. “Some of the symptoms—such as avoidance, numbing, and increased arousal—are present in other disorders and may have occurred before exposure to the traumatic event.” If they did, he says, PTSD is ruled out.

Gauging the extent of the patient’s exposure to the traumatic event is critical to determining the likelihood of PTSD onset. Dr. Allen, of Oklahoma City, points to studies that show that the closer and longer the patient has been exposed to a catastrophic event, the more likely he or she will develop PTSD.^9,10

Julia Frank, MD, associate professor and director of student education and psychiatry at George Washington University in Washington, DC, suggests screening for symptoms that are unique to PTSD as stated in the DSM-IV, such as nightmares, difficulty remembering the traumatic event, and extreme reactions to reminders of the trauma. She also proposes analyzing the past event and the patient’s reaction to it to confirm that it is a source of trauma.

Patients with PTSD symptoms are easily startled by loud or piercing noises. Dr. Shalev says this characteristic sets true PTSD cases apart from other psychopathology, particularly depression. In one study, Israeli combat veterans with PTSD exhibited a more pronounced heart rate and skin conductance when exposed to auditory stimuli than did combat veterans with no PTSD symptoms.¹¹

Drs. Allen and Frank note that patients who have anthrax-related fears and no prior PTSD symptoms are not likely to develop PTSD. They may, however, manifest symptoms of chronic fatigue, fibromyalgia, and generalized anxiety disorder. Patients may be jumpy, intense, or lethargic, with autonomic instability and rapid heart rate. They may feel alienated and mistrustful of the government. A nonspecific stress disorder and mixed anxiety depression are other possible effects.

Who to treat—and how

Psychiatrists nationwide have reported increased patient presentations after the Sept. 11 attacks and throughout the anthrax scare. Studies conducted after the Oklahoma City bombing also suggest that psychiatrists could be seeing more patients in the coming months.^12,13 As caseloads increase, so do the questions about who to treat, how, and how to avoid the possibility of overtreatment.

“In order to provide effective care to our patients it is necessary to have clear ideas on how to follow criteria for diagnosis and as a consequence for treatment,” Dr. Corvalan says. “The field at times is confusing; patients do not always follow the diagnostic criteria. The needs of the moment, limitations of recourses, intensity and variety of symptoms, urgency of the situation, etc., all conspire to make the job more difficult.”

Patients with anthrax-related anxiety should be encouraged to “try to function as normally as possible and keep an open communication with peers and those who they look to for information,” Dr. Frank notes. Dr. Allen adds that his patients with anthrax-inspired stress have responded well to breathing, meditation and other relaxation techniques.

Treatment of patients who are severely traumatized and exhibit true PTSD symptoms will vary based on severity of exposure, history of prior PTSD, and existence of comorbidities. A combination of pharmacological and psychosocial therapy is the common first-line treatment.

The selective serotonin reuptake inhibitor (SSRI) sertraline is specifically indicated for treating confirmed PTSD symptoms, and several studies have documented the agent’s effectiveness for this use.^14,15 Dr. Frank recommends dosages between 50 and 200 mg/d depending on the patient’s body weight or complaint of side effects (e.g., diarrhea, nausea, or sexual dysfunction). Other SSRIs, as well as tricyclics and MAO inhibitors, are alternatives. Fluoxetine, amitriptyline, phenelzine, and imipramine have all been found more effective than a placebo;^16-18 paroxetine also has been shown effective in specific populations.¹⁹

Box 4

Benzodiazapenes also may be prescribed to manage PTSD symptoms. Patients should be counseled against taking these sedating agents in the daytime, however, as they can lead to fogginess, detachment, and trouble functioning.

Assessing the patient’s available social support also is crucial to PTSD treatment. “Do patients talk to other people about the event?” Dr. Frank asks. “Are they trying to get back to a daily routine? Can they make sense of this experience? Are they incorporating the event into a world view?”

Dr. Thompson, the Pittsburgh disaster psychiatrist, agrees. Psychiatrists should encourage their patients to talk more about their trauma and how fear is affecting their lives. “We don’t discuss with our trauma patients as much as we might what the experience has been like for them,” he says.

Small-group therapy is the most conducive approach to psychotherapy for PTSD, according to Dr. Frank, although individual counseling can work in many cases. Several studies have found group therapy effective,^20,21 and 12-step group therapy has shown promise in PTSD patients with comorbid substance abuse disorder.²²

Managing fear

Just as people grieve and confront death in stages, Dr. Thompson, who helped coordinate Oklahoma City’s disaster psychiatry effort, has discovered that the public usually employs a similar subconscious process to cope with a traumatic event (Box 4).

But Americans have had no time to recover. As U.S. troops seek justice in Afghanistan, back home people grapple with the threat of anthrax contamination and the prospect of another terrorist attack. The ominously enhanced presence of security at airports, major bridges, sporting and entertainment events, and in other aspects of everyday life, has further fueled the sensation that all is not right.

“The September 11 tragedy brings trauma home,” adds Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. “The anthrax scare and the Nov. 12 plane crash of American Airlines Flight 587 only further remind people of their vulnerability and fears. If the anthrax scare were an accident, people would have been relieved. Since the plane crash was ruled an accident, it has offered people a chance to feel more in control. Accidents can be fixed with better maintenance. Terrorism cannot.”

Dr. Katz of New York City and other disaster psychiatrists are urging their colleagues to help manage public fear by reaching out through community efforts.

Dr. Katz is president of the volunteer group Disaster Psychiatry Outreach, which helped coordinate the city’s post-Sept. 11 trauma psychiatry effort. Visitors waiting at New York’s Family Assistance Center, a referral and help center for people who lost family and friends in the World Trade Center attack, were approached by Dr. Katz and other colleagues to let them know that psychiatric services were available if needed. By doing this, he says, Disaster Psychiatry Outreach clinicians have identified, treated, and referred scores of patients with terror-related stress who otherwise would have gone untreated.

Joseph Dorzab, MD, of the Holt-Krock Clinic in Fort Smith, Ark., also has offered his services. Members of his clinic’s psychiatry department have made several TV appearances, and have given and coordinated area lectures. Working with the local mental health association, the department also is starting a community forum called Mental Health Mondays, an open discussion group with coffee and cookies at a local coffee shop.

In Pittsburgh, Dr. Thompson is encouraging psychiatrists to educate their communities about how traumatic events affect the public. He proposes:

• Staging community meetings to brief religious and other leaders on how to manage traumatized people;
• Informing local news editors about the nature of psychiatric disorders;
• Instructing school administrators about detecting signs of distress in children;
• Contacting local government officials to offer input in devising the town’s emergency response plan.

Psychiatrists also can educate themselves about managing public trauma, thanks to scores of studies that have been done in recent years following major man-made and natural disasters, from Mount St. Helens and Hurricane Andrew, to Chernobyl and the Yom Kippur War. Dr. Thompson urges psychiatrists to seek out the papers of prominent leaders in trauma-related psychiatry, mentioning studies by Carol North, MD, Betty Pfefferbaum, MD, and Robert Ursano, MD, as examples. Other sources include the Web sites of the American Psychiatric Association and National Center for PTSD. (See Related Resources.)

In the end, psychiatrists have been well primed for dealing with public disaster—just by treating individual patients whose psychiatric disorders emanated from everyday life, Dr. Thompson says. “Psychiatrists know more about trauma than they recognize.”

Related resources

• National Center for PTSD Web site
• National Institute of Mental Health:
• Linenthal EJ. The Unfinished Bombing: Oklahoma City in American Memory. Oxford University Press, 2001.
• Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles of practice. Psychiatr Q. 2000; 71(3):207-226.
• American Psychiatric Association Web site:
• The Psychiatric Training Manual for Teachers and Mental Health Professionals

Drug brand names

• Amitriptyline • Elavil
• Bupropion • Wellbutrin
• Fluoxetine • Prozac
• Imipramine • Tofranil
• Paroxetine • Paxil
• Phenelzine • Nardil
• Sertraline • Zoloft

Since September 11, America has carried on under a cloud of fear. Though the cloud is lifting, it will not disappear for months or years. The terrorist attacks on New York City and Washington, DC, the resultant military action in Afghanistan, and the anthrax scare—combined with pervasive, nagging doubts about homeland security and the specter of another possible future terrorist attack—all are straining the nation’s collective emotional well-being.

Psychiatrists in America have reported new cases of terror-inspired acute stress disorder, anxiety, depression, and other illnesses, as well as recurrences of posttraumatic stress disorder (PTSD) in existing patients, in the weeks after the recent attacks and the anthrax scare. What will be the impact on psychiatric practice in the coming months and years?

“We are all at ground zero,” says Kenneth S. Thompson, MD, of Pittsburgh, an experienced disaster psychiatrist. But he and other subspecialists have identified four critical areas in which psychiatrists should be prepared:

1. Identifying how terrorist attacks and scares can exacerbate symptoms in patients now in your practice;
2. Diagnosing PTSD among comorbid conditions present in existing or new patients;
3. Treating—and avoiding over-treatment—of patients with acute stress disorder and PTSD;
4. Managing fear in your communities—in response to the Sept. 11 attacks, to the anthrax scare, or in anticipation of an impending catastrophe.

To bring you this special report, the editors of Current Psychiatry have reviewed the literature and interviewed psychiatrists nationwide and in countries such as Israel and Colombia, where terrorism has been a fact of life for years (see “PTSD lessons from Israel, Colombia,”).

Terror and your patients

Which symptoms are you most likely to see in existing patients subsequent to recent events? In the weeks following the Sept. 11 attacks, psychiatrists reported the most commonly seen symptoms as increased anxiety and worsened depression. Sleep disturbances, agoraphobia, suicidality, and severe reactions among patients with personality disorders also were reported.

Patients with previous PTSD or exposure to trauma face a high risk of new or recurrent PTSD in the wake of Sept. 11 than do those not previously exposed to trauma.¹ War veterans with prior posttraumatic symptoms have been particularly prone to recurrent PTSD after the attacks. James Allen, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center, calls this the “additive effect”: patients traumatized by military service in Vietnam experience a recurrence after seeing a major disaster or atrocity. Dr. Allen, who was extensively involved with Oklahoma City’s disaster psychiatry effort after the 1995 bombing there, recalls seeing patients who were traumatized in Vietnam suffer a recurrence after the Alfred P. Murrah Building attack, and then another relapse after Sept. 11.

“The Sept. 11 attacks were very similar to the war for them,” says Juan Corvalan, MD, of the PTSD Unit of the St. Louis Veterans Administration Medical Center, referring to the numerous war veterans he treated after the atrocities. “Seeing it on TV triggered many memories.” By early November, however, many who experienced recurrent PTSD had returned to their pre-Sept. 11 mental states.

Craig Katz, MD, director of emergency psychiatry services at New York’s Mount Sinai Medical Center, says that a patient’s psychiatric history is crucial to determining risk for PTSD or other terror-related sequelae:

“You can recognize that a given person is at high risk for PTSD post-trauma, based on any combination of these factors—having a psychiatric history, past trauma, high exposure to the event, psychosocial problems pre-disaster, or lack of supports post-disaster.”

The clinical interview is a vital tool in assessing patients with suspected PTSD or posttraumatic sequelae, says Arieh Shalev, MD, of the department of psychiatry at Hadassah University Hospital in Jerusalem, Israel. “It provides the opportunity to discuss the traumatic event with the patient, and to listen to his or her perceptions of the event and its effects” in order to carefully appraise the patient’s symptoms.²

The guidelines set forth in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) remain the gold standard for confirming a diagnosis of PTSD and discerning long-term posttraumatic sequelae from temporary acute stress disorder (Box 1). The guidelines have proved far from foolproof, however, and the existence of psychiatric comorbidities often clouds the picture.

Box 1

DSM-IV DIAGNOSTIC CRITERIA FOR PTSD

1. Exposure to a traumatic event with both of the following present:
2. The traumatic event is persistently reexperienced in one or more of the following ways:
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
5. Duration of symptoms in criteria B, C or D exceeds 1 month.
6. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if; Acute: if duration of symptoms is less than 3 months.

Chronic: if symptoms persist 3 months or more.

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

Acute stress disorder, whose symptom pattern is similar to that of PTSD, is distinguished from PTSD because the symptom pattern must occur and resolve within 4 weeks of the traumatic event. If the symptoms persist for more than 1 month and meet the criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Differential diagnosis of PTSD

Patients with PTSD are more likely to have substantial psychiatric comorbidity than are those without the disorder.³ Possible reasons include suspected self-medication of PTSD symptoms, particularly among patients with substance abuse, and the possible overreporting of symptoms by patients. Psychiatrists should maintain a high level of suspicion for PTSD when managing a new or existing patient with psychopathology.

Citing data from the National Comorbidity Study of the Institute for Social Research at the University of Michigan, Kessler and others in 1995 noted that more than 80 percent of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. Roughly half of PTSD sufferers met criteria for three or more comorbidities.³

Kathleen Brady, MD, professor of psychiatry at the Medical University of South Carolina in Charleston, noted in a 1997 study that affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders are common comorbidities of PTSD.⁵ Dr. Shalev and colleagues in one study found that a history of major depressive disorder may increase the severity of posttraumatic morbidity.⁶ Dr. Brady and others also have found that PTSD patients with a comorbid substance abuse disorder experience severe PTSD symptoms while in a withdrawal state.⁷

Box 2

PTSD often is overlooked in the presence of other psychiatric diagnoses. Meuser et al in 1998 studied 275 patients with schizophrenia and bipolar disorder. As many as 98 percent of patients reported lifetime exposure to at least one traumatic event. The researchers found diagnosable PTSD in 119 (43 %) of the subjects, but only three (2%) had the diagnosis in their charts.⁸

In a later study, Dr. Brady and others cited substantial symptom overlap between PTSD and other psychiatric diagnoses, particularly major depressive disorder. This can contribute to underdiagnosis of PTSD, the researchers found.⁷ (Box 2).

Box 3

WATCH FOR SIGNS OF PTSD IN CHILDREN

Children also have been experiencing stress disorders since Sept. 11, says Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. Such disorders manifest as sleep disturbances, anxiety, hyperarousal/hyperactivity, and nightmares.

Young children regress and cling to their parents, and are frightened of the dark or noises, Dr, Husain notes. Those who are toilet-trained can suddenly wet the bed, become neurotic, and demand attention. School-age children are more fearful; they may not want to go to school, their schoolwork may decline, and they may have trouble paying attention. Dr. Husain suggests discussing the trauma and devising a plan of action with them in case the trauma recurs.

The media’s role in reporting on the aftermath of the attacks—and triggering traumatic reactions as an unintended consequence—cannot be overlooked. Two recent studies performed after the Oklahoma City bombing suggest that television reports of that atrocity precipitated PTSD symptoms in middle-school children 7 weeks after the bombing,²³ and in geographically distant sixth-graders 2 years after the attack.¹² It was not clear whether any of these students had prior PTSD or other psychopathology.

Psychiatric education in the schools is especially crucial in light of the school violence that has occurred in America in recent years. Dr. Husain believes that the children who commit violence are victims of abuse. If teachers early on can identify children who show evidence of stress disorders, they can refer them to trained psychiatrists, catching those who need help before tragedies occur. “It is the psychiatric equivalent of CPR,” Dr. Husain says.

Dr. Brady recommends that psychiatrists and primary care physicians routinely screen patients for exposure to traumatic events. Ask patients specifically about their reaction to such events and encourage them to talk about it. Patients often feel either guilty or embarrassed about the traumatic event, or do not believe it affects their presenting complaints, she notes. Other approaches may be needed to identify the risk of PTSD in children (Box 3).

Identifying a traumatic event of an extreme nature, for example, a life-threatening experience, is key to diagnosing PTSD in the presence of comorbidities, Dr. Corvalan says. “Some of the symptoms—such as avoidance, numbing, and increased arousal—are present in other disorders and may have occurred before exposure to the traumatic event.” If they did, he says, PTSD is ruled out.

Gauging the extent of the patient’s exposure to the traumatic event is critical to determining the likelihood of PTSD onset. Dr. Allen, of Oklahoma City, points to studies that show that the closer and longer the patient has been exposed to a catastrophic event, the more likely he or she will develop PTSD.^9,10

Julia Frank, MD, associate professor and director of student education and psychiatry at George Washington University in Washington, DC, suggests screening for symptoms that are unique to PTSD as stated in the DSM-IV, such as nightmares, difficulty remembering the traumatic event, and extreme reactions to reminders of the trauma. She also proposes analyzing the past event and the patient’s reaction to it to confirm that it is a source of trauma.

Patients with PTSD symptoms are easily startled by loud or piercing noises. Dr. Shalev says this characteristic sets true PTSD cases apart from other psychopathology, particularly depression. In one study, Israeli combat veterans with PTSD exhibited a more pronounced heart rate and skin conductance when exposed to auditory stimuli than did combat veterans with no PTSD symptoms.¹¹

Drs. Allen and Frank note that patients who have anthrax-related fears and no prior PTSD symptoms are not likely to develop PTSD. They may, however, manifest symptoms of chronic fatigue, fibromyalgia, and generalized anxiety disorder. Patients may be jumpy, intense, or lethargic, with autonomic instability and rapid heart rate. They may feel alienated and mistrustful of the government. A nonspecific stress disorder and mixed anxiety depression are other possible effects.

Who to treat—and how

Psychiatrists nationwide have reported increased patient presentations after the Sept. 11 attacks and throughout the anthrax scare. Studies conducted after the Oklahoma City bombing also suggest that psychiatrists could be seeing more patients in the coming months.^12,13 As caseloads increase, so do the questions about who to treat, how, and how to avoid the possibility of overtreatment.

“In order to provide effective care to our patients it is necessary to have clear ideas on how to follow criteria for diagnosis and as a consequence for treatment,” Dr. Corvalan says. “The field at times is confusing; patients do not always follow the diagnostic criteria. The needs of the moment, limitations of recourses, intensity and variety of symptoms, urgency of the situation, etc., all conspire to make the job more difficult.”

Patients with anthrax-related anxiety should be encouraged to “try to function as normally as possible and keep an open communication with peers and those who they look to for information,” Dr. Frank notes. Dr. Allen adds that his patients with anthrax-inspired stress have responded well to breathing, meditation and other relaxation techniques.

Treatment of patients who are severely traumatized and exhibit true PTSD symptoms will vary based on severity of exposure, history of prior PTSD, and existence of comorbidities. A combination of pharmacological and psychosocial therapy is the common first-line treatment.

The selective serotonin reuptake inhibitor (SSRI) sertraline is specifically indicated for treating confirmed PTSD symptoms, and several studies have documented the agent’s effectiveness for this use.^14,15 Dr. Frank recommends dosages between 50 and 200 mg/d depending on the patient’s body weight or complaint of side effects (e.g., diarrhea, nausea, or sexual dysfunction). Other SSRIs, as well as tricyclics and MAO inhibitors, are alternatives. Fluoxetine, amitriptyline, phenelzine, and imipramine have all been found more effective than a placebo;^16-18 paroxetine also has been shown effective in specific populations.¹⁹

Box 4

Benzodiazapenes also may be prescribed to manage PTSD symptoms. Patients should be counseled against taking these sedating agents in the daytime, however, as they can lead to fogginess, detachment, and trouble functioning.

Assessing the patient’s available social support also is crucial to PTSD treatment. “Do patients talk to other people about the event?” Dr. Frank asks. “Are they trying to get back to a daily routine? Can they make sense of this experience? Are they incorporating the event into a world view?”

Dr. Thompson, the Pittsburgh disaster psychiatrist, agrees. Psychiatrists should encourage their patients to talk more about their trauma and how fear is affecting their lives. “We don’t discuss with our trauma patients as much as we might what the experience has been like for them,” he says.

Small-group therapy is the most conducive approach to psychotherapy for PTSD, according to Dr. Frank, although individual counseling can work in many cases. Several studies have found group therapy effective,^20,21 and 12-step group therapy has shown promise in PTSD patients with comorbid substance abuse disorder.²²

Managing fear

Just as people grieve and confront death in stages, Dr. Thompson, who helped coordinate Oklahoma City’s disaster psychiatry effort, has discovered that the public usually employs a similar subconscious process to cope with a traumatic event (Box 4).

But Americans have had no time to recover. As U.S. troops seek justice in Afghanistan, back home people grapple with the threat of anthrax contamination and the prospect of another terrorist attack. The ominously enhanced presence of security at airports, major bridges, sporting and entertainment events, and in other aspects of everyday life, has further fueled the sensation that all is not right.

“The September 11 tragedy brings trauma home,” adds Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. “The anthrax scare and the Nov. 12 plane crash of American Airlines Flight 587 only further remind people of their vulnerability and fears. If the anthrax scare were an accident, people would have been relieved. Since the plane crash was ruled an accident, it has offered people a chance to feel more in control. Accidents can be fixed with better maintenance. Terrorism cannot.”

Dr. Katz of New York City and other disaster psychiatrists are urging their colleagues to help manage public fear by reaching out through community efforts.

Dr. Katz is president of the volunteer group Disaster Psychiatry Outreach, which helped coordinate the city’s post-Sept. 11 trauma psychiatry effort. Visitors waiting at New York’s Family Assistance Center, a referral and help center for people who lost family and friends in the World Trade Center attack, were approached by Dr. Katz and other colleagues to let them know that psychiatric services were available if needed. By doing this, he says, Disaster Psychiatry Outreach clinicians have identified, treated, and referred scores of patients with terror-related stress who otherwise would have gone untreated.

Joseph Dorzab, MD, of the Holt-Krock Clinic in Fort Smith, Ark., also has offered his services. Members of his clinic’s psychiatry department have made several TV appearances, and have given and coordinated area lectures. Working with the local mental health association, the department also is starting a community forum called Mental Health Mondays, an open discussion group with coffee and cookies at a local coffee shop.

In Pittsburgh, Dr. Thompson is encouraging psychiatrists to educate their communities about how traumatic events affect the public. He proposes:

• Staging community meetings to brief religious and other leaders on how to manage traumatized people;
• Informing local news editors about the nature of psychiatric disorders;
• Instructing school administrators about detecting signs of distress in children;
• Contacting local government officials to offer input in devising the town’s emergency response plan.

Psychiatrists also can educate themselves about managing public trauma, thanks to scores of studies that have been done in recent years following major man-made and natural disasters, from Mount St. Helens and Hurricane Andrew, to Chernobyl and the Yom Kippur War. Dr. Thompson urges psychiatrists to seek out the papers of prominent leaders in trauma-related psychiatry, mentioning studies by Carol North, MD, Betty Pfefferbaum, MD, and Robert Ursano, MD, as examples. Other sources include the Web sites of the American Psychiatric Association and National Center for PTSD. (See Related Resources.)

In the end, psychiatrists have been well primed for dealing with public disaster—just by treating individual patients whose psychiatric disorders emanated from everyday life, Dr. Thompson says. “Psychiatrists know more about trauma than they recognize.”

Related resources

• National Center for PTSD Web site
• National Institute of Mental Health:
• Linenthal EJ. The Unfinished Bombing: Oklahoma City in American Memory. Oxford University Press, 2001.
• Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles of practice. Psychiatr Q. 2000; 71(3):207-226.
• American Psychiatric Association Web site:
• The Psychiatric Training Manual for Teachers and Mental Health Professionals

Drug brand names

• Amitriptyline • Elavil
• Bupropion • Wellbutrin
• Fluoxetine • Prozac
• Imipramine • Tofranil
• Paroxetine • Paxil
• Phenelzine • Nardil
• Sertraline • Zoloft

Since September 11, America has carried on under a cloud of fear. Though the cloud is lifting, it will not disappear for months or years. The terrorist attacks on New York City and Washington, DC, the resultant military action in Afghanistan, and the anthrax scare—combined with pervasive, nagging doubts about homeland security and the specter of another possible future terrorist attack—all are straining the nation’s collective emotional well-being.

Psychiatrists in America have reported new cases of terror-inspired acute stress disorder, anxiety, depression, and other illnesses, as well as recurrences of posttraumatic stress disorder (PTSD) in existing patients, in the weeks after the recent attacks and the anthrax scare. What will be the impact on psychiatric practice in the coming months and years?

“We are all at ground zero,” says Kenneth S. Thompson, MD, of Pittsburgh, an experienced disaster psychiatrist. But he and other subspecialists have identified four critical areas in which psychiatrists should be prepared:

1. Identifying how terrorist attacks and scares can exacerbate symptoms in patients now in your practice;
2. Diagnosing PTSD among comorbid conditions present in existing or new patients;
3. Treating—and avoiding over-treatment—of patients with acute stress disorder and PTSD;
4. Managing fear in your communities—in response to the Sept. 11 attacks, to the anthrax scare, or in anticipation of an impending catastrophe.

To bring you this special report, the editors of Current Psychiatry have reviewed the literature and interviewed psychiatrists nationwide and in countries such as Israel and Colombia, where terrorism has been a fact of life for years (see “PTSD lessons from Israel, Colombia,”).

Terror and your patients

Which symptoms are you most likely to see in existing patients subsequent to recent events? In the weeks following the Sept. 11 attacks, psychiatrists reported the most commonly seen symptoms as increased anxiety and worsened depression. Sleep disturbances, agoraphobia, suicidality, and severe reactions among patients with personality disorders also were reported.

Patients with previous PTSD or exposure to trauma face a high risk of new or recurrent PTSD in the wake of Sept. 11 than do those not previously exposed to trauma.¹ War veterans with prior posttraumatic symptoms have been particularly prone to recurrent PTSD after the attacks. James Allen, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center, calls this the “additive effect”: patients traumatized by military service in Vietnam experience a recurrence after seeing a major disaster or atrocity. Dr. Allen, who was extensively involved with Oklahoma City’s disaster psychiatry effort after the 1995 bombing there, recalls seeing patients who were traumatized in Vietnam suffer a recurrence after the Alfred P. Murrah Building attack, and then another relapse after Sept. 11.

“The Sept. 11 attacks were very similar to the war for them,” says Juan Corvalan, MD, of the PTSD Unit of the St. Louis Veterans Administration Medical Center, referring to the numerous war veterans he treated after the atrocities. “Seeing it on TV triggered many memories.” By early November, however, many who experienced recurrent PTSD had returned to their pre-Sept. 11 mental states.

Craig Katz, MD, director of emergency psychiatry services at New York’s Mount Sinai Medical Center, says that a patient’s psychiatric history is crucial to determining risk for PTSD or other terror-related sequelae:

“You can recognize that a given person is at high risk for PTSD post-trauma, based on any combination of these factors—having a psychiatric history, past trauma, high exposure to the event, psychosocial problems pre-disaster, or lack of supports post-disaster.”

The clinical interview is a vital tool in assessing patients with suspected PTSD or posttraumatic sequelae, says Arieh Shalev, MD, of the department of psychiatry at Hadassah University Hospital in Jerusalem, Israel. “It provides the opportunity to discuss the traumatic event with the patient, and to listen to his or her perceptions of the event and its effects” in order to carefully appraise the patient’s symptoms.²

The guidelines set forth in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) remain the gold standard for confirming a diagnosis of PTSD and discerning long-term posttraumatic sequelae from temporary acute stress disorder (Box 1). The guidelines have proved far from foolproof, however, and the existence of psychiatric comorbidities often clouds the picture.

Box 1

DSM-IV DIAGNOSTIC CRITERIA FOR PTSD

1. Exposure to a traumatic event with both of the following present:
2. The traumatic event is persistently reexperienced in one or more of the following ways:
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
5. Duration of symptoms in criteria B, C or D exceeds 1 month.
6. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if; Acute: if duration of symptoms is less than 3 months.

Chronic: if symptoms persist 3 months or more.

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

Acute stress disorder, whose symptom pattern is similar to that of PTSD, is distinguished from PTSD because the symptom pattern must occur and resolve within 4 weeks of the traumatic event. If the symptoms persist for more than 1 month and meet the criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Differential diagnosis of PTSD

Patients with PTSD are more likely to have substantial psychiatric comorbidity than are those without the disorder.³ Possible reasons include suspected self-medication of PTSD symptoms, particularly among patients with substance abuse, and the possible overreporting of symptoms by patients. Psychiatrists should maintain a high level of suspicion for PTSD when managing a new or existing patient with psychopathology.

Citing data from the National Comorbidity Study of the Institute for Social Research at the University of Michigan, Kessler and others in 1995 noted that more than 80 percent of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. Roughly half of PTSD sufferers met criteria for three or more comorbidities.³

Kathleen Brady, MD, professor of psychiatry at the Medical University of South Carolina in Charleston, noted in a 1997 study that affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders are common comorbidities of PTSD.⁵ Dr. Shalev and colleagues in one study found that a history of major depressive disorder may increase the severity of posttraumatic morbidity.⁶ Dr. Brady and others also have found that PTSD patients with a comorbid substance abuse disorder experience severe PTSD symptoms while in a withdrawal state.⁷

Box 2

PTSD often is overlooked in the presence of other psychiatric diagnoses. Meuser et al in 1998 studied 275 patients with schizophrenia and bipolar disorder. As many as 98 percent of patients reported lifetime exposure to at least one traumatic event. The researchers found diagnosable PTSD in 119 (43 %) of the subjects, but only three (2%) had the diagnosis in their charts.⁸

In a later study, Dr. Brady and others cited substantial symptom overlap between PTSD and other psychiatric diagnoses, particularly major depressive disorder. This can contribute to underdiagnosis of PTSD, the researchers found.⁷ (Box 2).

Box 3

WATCH FOR SIGNS OF PTSD IN CHILDREN

Children also have been experiencing stress disorders since Sept. 11, says Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. Such disorders manifest as sleep disturbances, anxiety, hyperarousal/hyperactivity, and nightmares.

Young children regress and cling to their parents, and are frightened of the dark or noises, Dr, Husain notes. Those who are toilet-trained can suddenly wet the bed, become neurotic, and demand attention. School-age children are more fearful; they may not want to go to school, their schoolwork may decline, and they may have trouble paying attention. Dr. Husain suggests discussing the trauma and devising a plan of action with them in case the trauma recurs.

The media’s role in reporting on the aftermath of the attacks—and triggering traumatic reactions as an unintended consequence—cannot be overlooked. Two recent studies performed after the Oklahoma City bombing suggest that television reports of that atrocity precipitated PTSD symptoms in middle-school children 7 weeks after the bombing,²³ and in geographically distant sixth-graders 2 years after the attack.¹² It was not clear whether any of these students had prior PTSD or other psychopathology.

Psychiatric education in the schools is especially crucial in light of the school violence that has occurred in America in recent years. Dr. Husain believes that the children who commit violence are victims of abuse. If teachers early on can identify children who show evidence of stress disorders, they can refer them to trained psychiatrists, catching those who need help before tragedies occur. “It is the psychiatric equivalent of CPR,” Dr. Husain says.

Dr. Brady recommends that psychiatrists and primary care physicians routinely screen patients for exposure to traumatic events. Ask patients specifically about their reaction to such events and encourage them to talk about it. Patients often feel either guilty or embarrassed about the traumatic event, or do not believe it affects their presenting complaints, she notes. Other approaches may be needed to identify the risk of PTSD in children (Box 3).

Identifying a traumatic event of an extreme nature, for example, a life-threatening experience, is key to diagnosing PTSD in the presence of comorbidities, Dr. Corvalan says. “Some of the symptoms—such as avoidance, numbing, and increased arousal—are present in other disorders and may have occurred before exposure to the traumatic event.” If they did, he says, PTSD is ruled out.

Gauging the extent of the patient’s exposure to the traumatic event is critical to determining the likelihood of PTSD onset. Dr. Allen, of Oklahoma City, points to studies that show that the closer and longer the patient has been exposed to a catastrophic event, the more likely he or she will develop PTSD.^9,10

Julia Frank, MD, associate professor and director of student education and psychiatry at George Washington University in Washington, DC, suggests screening for symptoms that are unique to PTSD as stated in the DSM-IV, such as nightmares, difficulty remembering the traumatic event, and extreme reactions to reminders of the trauma. She also proposes analyzing the past event and the patient’s reaction to it to confirm that it is a source of trauma.

Patients with PTSD symptoms are easily startled by loud or piercing noises. Dr. Shalev says this characteristic sets true PTSD cases apart from other psychopathology, particularly depression. In one study, Israeli combat veterans with PTSD exhibited a more pronounced heart rate and skin conductance when exposed to auditory stimuli than did combat veterans with no PTSD symptoms.¹¹

Drs. Allen and Frank note that patients who have anthrax-related fears and no prior PTSD symptoms are not likely to develop PTSD. They may, however, manifest symptoms of chronic fatigue, fibromyalgia, and generalized anxiety disorder. Patients may be jumpy, intense, or lethargic, with autonomic instability and rapid heart rate. They may feel alienated and mistrustful of the government. A nonspecific stress disorder and mixed anxiety depression are other possible effects.

Who to treat—and how

Psychiatrists nationwide have reported increased patient presentations after the Sept. 11 attacks and throughout the anthrax scare. Studies conducted after the Oklahoma City bombing also suggest that psychiatrists could be seeing more patients in the coming months.^12,13 As caseloads increase, so do the questions about who to treat, how, and how to avoid the possibility of overtreatment.

“In order to provide effective care to our patients it is necessary to have clear ideas on how to follow criteria for diagnosis and as a consequence for treatment,” Dr. Corvalan says. “The field at times is confusing; patients do not always follow the diagnostic criteria. The needs of the moment, limitations of recourses, intensity and variety of symptoms, urgency of the situation, etc., all conspire to make the job more difficult.”

Patients with anthrax-related anxiety should be encouraged to “try to function as normally as possible and keep an open communication with peers and those who they look to for information,” Dr. Frank notes. Dr. Allen adds that his patients with anthrax-inspired stress have responded well to breathing, meditation and other relaxation techniques.

Treatment of patients who are severely traumatized and exhibit true PTSD symptoms will vary based on severity of exposure, history of prior PTSD, and existence of comorbidities. A combination of pharmacological and psychosocial therapy is the common first-line treatment.

The selective serotonin reuptake inhibitor (SSRI) sertraline is specifically indicated for treating confirmed PTSD symptoms, and several studies have documented the agent’s effectiveness for this use.^14,15 Dr. Frank recommends dosages between 50 and 200 mg/d depending on the patient’s body weight or complaint of side effects (e.g., diarrhea, nausea, or sexual dysfunction). Other SSRIs, as well as tricyclics and MAO inhibitors, are alternatives. Fluoxetine, amitriptyline, phenelzine, and imipramine have all been found more effective than a placebo;^16-18 paroxetine also has been shown effective in specific populations.¹⁹

Box 4

Benzodiazapenes also may be prescribed to manage PTSD symptoms. Patients should be counseled against taking these sedating agents in the daytime, however, as they can lead to fogginess, detachment, and trouble functioning.

Assessing the patient’s available social support also is crucial to PTSD treatment. “Do patients talk to other people about the event?” Dr. Frank asks. “Are they trying to get back to a daily routine? Can they make sense of this experience? Are they incorporating the event into a world view?”

Dr. Thompson, the Pittsburgh disaster psychiatrist, agrees. Psychiatrists should encourage their patients to talk more about their trauma and how fear is affecting their lives. “We don’t discuss with our trauma patients as much as we might what the experience has been like for them,” he says.

Small-group therapy is the most conducive approach to psychotherapy for PTSD, according to Dr. Frank, although individual counseling can work in many cases. Several studies have found group therapy effective,^20,21 and 12-step group therapy has shown promise in PTSD patients with comorbid substance abuse disorder.²²

Managing fear

Just as people grieve and confront death in stages, Dr. Thompson, who helped coordinate Oklahoma City’s disaster psychiatry effort, has discovered that the public usually employs a similar subconscious process to cope with a traumatic event (Box 4).

But Americans have had no time to recover. As U.S. troops seek justice in Afghanistan, back home people grapple with the threat of anthrax contamination and the prospect of another terrorist attack. The ominously enhanced presence of security at airports, major bridges, sporting and entertainment events, and in other aspects of everyday life, has further fueled the sensation that all is not right.

“The September 11 tragedy brings trauma home,” adds Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. “The anthrax scare and the Nov. 12 plane crash of American Airlines Flight 587 only further remind people of their vulnerability and fears. If the anthrax scare were an accident, people would have been relieved. Since the plane crash was ruled an accident, it has offered people a chance to feel more in control. Accidents can be fixed with better maintenance. Terrorism cannot.”

Dr. Katz of New York City and other disaster psychiatrists are urging their colleagues to help manage public fear by reaching out through community efforts.

Dr. Katz is president of the volunteer group Disaster Psychiatry Outreach, which helped coordinate the city’s post-Sept. 11 trauma psychiatry effort. Visitors waiting at New York’s Family Assistance Center, a referral and help center for people who lost family and friends in the World Trade Center attack, were approached by Dr. Katz and other colleagues to let them know that psychiatric services were available if needed. By doing this, he says, Disaster Psychiatry Outreach clinicians have identified, treated, and referred scores of patients with terror-related stress who otherwise would have gone untreated.

Joseph Dorzab, MD, of the Holt-Krock Clinic in Fort Smith, Ark., also has offered his services. Members of his clinic’s psychiatry department have made several TV appearances, and have given and coordinated area lectures. Working with the local mental health association, the department also is starting a community forum called Mental Health Mondays, an open discussion group with coffee and cookies at a local coffee shop.

In Pittsburgh, Dr. Thompson is encouraging psychiatrists to educate their communities about how traumatic events affect the public. He proposes:

• Staging community meetings to brief religious and other leaders on how to manage traumatized people;
• Informing local news editors about the nature of psychiatric disorders;
• Instructing school administrators about detecting signs of distress in children;
• Contacting local government officials to offer input in devising the town’s emergency response plan.

Psychiatrists also can educate themselves about managing public trauma, thanks to scores of studies that have been done in recent years following major man-made and natural disasters, from Mount St. Helens and Hurricane Andrew, to Chernobyl and the Yom Kippur War. Dr. Thompson urges psychiatrists to seek out the papers of prominent leaders in trauma-related psychiatry, mentioning studies by Carol North, MD, Betty Pfefferbaum, MD, and Robert Ursano, MD, as examples. Other sources include the Web sites of the American Psychiatric Association and National Center for PTSD. (See Related Resources.)

In the end, psychiatrists have been well primed for dealing with public disaster—just by treating individual patients whose psychiatric disorders emanated from everyday life, Dr. Thompson says. “Psychiatrists know more about trauma than they recognize.”

Related resources

• National Center for PTSD Web site
• National Institute of Mental Health:
• Linenthal EJ. The Unfinished Bombing: Oklahoma City in American Memory. Oxford University Press, 2001.
• Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles of practice. Psychiatr Q. 2000; 71(3):207-226.
• American Psychiatric Association Web site:
• The Psychiatric Training Manual for Teachers and Mental Health Professionals

Drug brand names

• Amitriptyline • Elavil
• Bupropion • Wellbutrin
• Fluoxetine • Prozac
• Imipramine • Tofranil
• Paroxetine • Paxil
• Phenelzine • Nardil
• Sertraline • Zoloft