Stalking in clinical psychiatry: when the doctor becomes the victim.

The term “stalking” dates back to the 1990s, referring to specific behavior characterized by one person’s insistent and unwelcomed attempts to approach another, leading to significant distress and fear in the victim.1,2 These approach attempts can involve different strategies, including following the victim, surveillance, phone calls, email and other electronic messages, and initiating spurious legal actions.3 Stalking victimization prevalence is approximately 11% (up to four times more frequent among women).4 Stalking is associated with impaired quality of life and psychological and/or physical damage, sometimes becoming life-threatening and contributing to the development of mental disorders.5

Following the example of other countries, Brazil has recently included stalking behavior in its criminal code by enacting law 14.132/2021; the crime of reiterated harassment by any means is described in Article 147-A.6 Psychiatrists are particularly vulnerable to this type of criminal behavior, which could represent an important source of work-related illness.7,8 Nevertheless, this phenomenon has been poorly studied in mental health settings, and professionals are highly susceptible to this kind of behavior.

We report the case of a 50-year-old male, currently divorced and unemployed, who lives with his mother and stepfather. He has an incomplete college degree in information systems and for the last 20 years has worked as a tattoo artist, body piercer, and body modifier (scarification, corneal tattooing, and subdermal implants). He has a history of polysubstance abuse, including alcohol, nicotine, amphetamines, cocaine, methylphenidate, benzodiazepines, heroin, ecstasy, LSD, and cannabis. Last year, he was admitted to a psychiatric inpatient unit due to a major depressive episode associated with significant self-neglect. During this period, he became infatuated with a vulnerable woman who suffers from intellectual disability and was pregnant at that time. He was discharged after 3 months, having undergone several treatment strategies, including electroconvulsive therapy and ketamine. After being discharged, he repeatedly attempted to get in touch with this patient, even visiting her house uninvited, ceasing only when the patient’s mother threatened to call the police. A few months later, he started receiving outpatient follow-up treatment from a female resident in the psychiatry department, who was responsible for his treatment for a total of 9 months. According to her report, during this period she received several emails from him that included personal compliments. He also insisted on meeting in person, although at that time all psychiatric appointments were exclusively online. In addition, sometimes he would drop by the hospital where she was working, and he covertly followed her on the streets on another occasion. She reported feelings of fear, anxiety, distress, guilt and frustration towards him, eventually resigning from the case. He was then referred to another female resident and no longer displayed stalking behavior. Approximately 1 year after the aforementioned hospitalization, he was again admitted to the psychiatric unit due to another episode of treatment-resistant major depression. At this time, he was assessed by forensic psychiatrists, revealing that he had once been convicted of attempted rape. After this assessment, he was diagnosed with antisocial and narcissistic personality disorder, presenting symptoms such as a sense of entitlement, grandiosity, difficulty conforming to social norms, impulsivity, aggressiveness, and irresponsibility. The patient provided written consent for this case report.

The type of stalking behavior illustrated in this case can be classified as the “simple obsession,” the most prevalent and violent type, in which the aggressor has a previous relationship with the victim, such as a doctor-patient relationship.9 In addition, this patient has many characteristics commonly reported in stalkers, such as Cluster B personality disorders, a prior criminal record, unemployment, and difficulty in social relationships.10 Stalking is associated with a wide variety of potential consequences to victims and their relatives, including psychological distress, psychiatric symptoms, reduced quality of life, work and/or academic impairment, and mobility and activity restrictions.3,7 Psychiatrists may be more vulnerable to this type of situation, which could be related to treating severely ill patients, who sometimes present troubled attachment patterns and may experience difficulties understanding the boundaries of the therapeutic relationship.10,8 For instance, a study found that 21% of UK-based psychiatrists believe they had been stalked, which rose to 33% when determined according to legal criteria.7 Additionally, because psychiatrists are more accustomed to working in violent environments, they may downplay the risks.11 Even though there is no single approach to dealing with stalkers, it is recommended that as soon as professionals become aware that they are being stalked, they should warn their patient that this kind of behavior is problematic and will not be tolerated. Professionals who feel unsafe may resign from the case, referring the patient to another therapist.12

In conclusion, this case illustrates how a psychiatrist may become the stalking victim of a patient. The anti-stalking law, recently passed in Brazil, makes this kind of behavior a criminal offense, protecting professionals from similar situations. Brazilian psychiatrists and other health professionals should be vigilant against this emerging and potentially dangerous phenomenon.

Disclosure

The authors report no conflicts of interest.