Victorian Institute of Forensic Mental Health, Fairfield, Victoria, and Department of Psychological Medicine, Monash University, Clayton, Victoria, Australia
Correspondence: Dr Rosemary Purcell, ORYGEN Research Centre, Department of Psychiatry, The University of Melbourne, Locked Bag 10, Parkville, Victoria 3052, Australia. Tel: +61 3 9342 2800; fax: +61 3 9342 2948; e-mail: rpurcell{at}unimelb.edu.au
Declaration of interest None. Funding detailed in Acknowledgement.
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ABSTRACT |
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Aims To examine the associations between stalking victimisation and psychiatric morbidity in a representative community sample.
Method A random community sample (n=1844) completed surveys examining the experience of harassment and current mental health. The 28-item General Health Questionnaire (GHQ28) and the Impact of Event Scale were used to assess symptomatology in those reporting brief harassment (n=196) or protracted stalking (n=236) and a matched control group reporting no harassment (n=432).
Results Rates of caseness on the GHQ28 were higher among stalking victims (36.4%) than among controls (19.3%) and victims of brief harassment (21.9%). Psychiatric morbidity did not differ according to the recency of victimisation, with 34.1% of victims meeting caseness criteria 1 year after stalking had ended.
Conclusions In a significant minority of victims, stalking victimisation is associated with psychiatric morbidity that may persist long after it has ceased. Recognition of the immediate and long-term impacts of stalking is necessary to assist victims and help alleviate distress and long-term disability.
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INTRODUCTION |
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METHOD |
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Of the 3700 surveys distributed, 74% could be accounted for, including completed surveys (n=1844), known refusals and surveys not received (e.g. person no longer at that address, deceased, or overseas). Adjusting for the 697 surveys not received, the valid response rate was 61%. The response rate did not differ according to gender. Survey respondents were representative of the base electoral population in relation to gender, marital status, highest level of education, employment and occupational status. However, the sample contained fewer people aged 1825 years (10 v. 19%) and more individuals aged 56 years and over (39 v. 31%).
Each respondent completed questions regarding their demographic characteristics, the experience of harassment and aspects of their current general health. The study was conducted with the approval of the Human Ethics Committee at Monash University.
Definition of harassment and stalking
Consistent with previous research (e.g.
Tjaden & Thoennes, 1998) the survey employed a behavioural definition of harassment. Respondents were
asked whether any person, male or female, had ever: followed them; kept them
under surveillance; loitered around their home, workplace or other places they
frequent; made unwanted approaches; made unwanted telephone calls; sent
unwanted letters, faxes or e-mails; sent offensive materials; ordered things
on their behalf that they did not want; or interfered with their property.
Respondents who recorded any of these behaviours were asked to indicate the
frequency with which they occurred (once, twice, 39 times, 10 or more
times) and whether they were fearful as a result of the behaviour. Those who
had been harassed on more than one occasion by different individuals were
asked to refer only to the experience with the one person they best
remembered. This was to ensure that the index event referred only to one
discrete episode of harassment, rather than an aggregation of the
respondents experiences of harassment.
In keeping with legal definitions of stalking (see Purcell et al, 2004a), respondents who acknowledged two or more intrusions that induced fear were broadly classed as victims. However, analysis indicates that there is heuristic value in distinguishing between two types of repeated intrusiveness: short-lived harassment and protracted stalking (Purcell et al, 2004b). Short-lived harassment involves an intense burst of intrusiveness that usually abates within days but may continue for up to 2 weeks. This form of harassment is usually perpetrated by strangers and largely confined to unwanted telephone calls and intrusive approaches. Intrusions that persist beyond the threshold of 2 weeks are likely to continue for months, be perpetrated by someone known to the victim and involve numerous methods of pursuit. This study distinguished between victims of short-lived harassment and protracted stalking, with 2 weeks being the threshold (for empirical validation of the 2-week threshold see Purcell et al, 2004b).
Nature of the victimisation
Respondents who reported experiencing repeated intrusions completed items
examining the nature of the behaviour, including whether the conduct had
occurred in the 12 months prior to the survey, the duration of the harassment
(number of days) and the nature of the prior relationship with the perpetrator
(ex-intimate, acquaintance, estranged relative or friend, work-related
contact, or stranger). Respondents were also asked to indicate whether there
had been associated violence during the course of the pursuit, including
threats and/or physical or sexual assault.
Indices of current mental health
All respondents completed the 28-item General Health Questionnaire
(GHQ28; Goldberg & Hillier,
1979), which provides an indication of current psychological
health. Respondents are asked to rate the recent (past month) intensity of
certain symptoms in comparison with their usual experience. Questions are
rated on a four-point scale (e.g. from better than usual to
much worse than usual). The 28-item version of the GHQ provides
scaled scores in four domains: somatic complaints, anxiety and insomnia,
social dysfunction and severe depression. These sub-scales do not reflect
psychiatric diagnoses and are not independent. The GHQ28 has been
validated in community samples (Banks,
1983; Romans-Clarkson et
al, 1989) as well as in studies examining chronic forms of
victimisation, including domestic violence
(Mullen et al, 1988;
Scott-Gliba et al,
1995) and stalking (Blaauw
et al, 2002).
The Impact of Event Scale (IES; Horowitz et al, 1979) was used to assess post-traumatic stress symptomatology. In relation to a specific index event (in this study, the experience of harassment), respondents are asked to rate the applicability of each of 15 items over the preceding 7 days (never, rarely, sometimes, often). The IES comprises two sub-scales measuring the common post-trauma reactions of avoidance and re-experiencing phenomena. Seven items enquire about intrusive thoughts and images related to the event and eight items assess attempts to avoid thoughts or reminders of the incident. The IES has been extensively used in trauma-related research, including studies examining the impact of domestic violence (Scott-Gliba et al, 1995) and stalking (Blaauw et al, 2002).
Data analyses
The rates of psychiatric symptomatology were compared between victims of
brief harassment (n=196; median duration 2 days), victims of
protracted stalking (n=236; median duration 6 months) and a control
group of respondents that had never experienced harassment (n=432).
We have previously reported the demographic characteristics of the victim
group (Purcell et al,
2002), which were highly skewed (e.g. 75% female, 43% aged
1630 years, 76% in paid employment). Non-harassed individuals were
therefore selected to match the victim group according to gender, age, highest
level of education and employment status. Marital status could not be
controlled between the groups, as the rates of separation and divorce were
significantly higher among victims of stalking (16.1%) than among both the
victims of brief harassment (5.1%) and the controls (7.1%;
2=19.8, d.f.=2, P=0.003).
Data scoring
The GHQ28 was analysed both as a continuous score and categorically,
the latter indicating probable caseness. The term
case refers to the existence of significant psychological
symptoms that are likely not only to adversely effect the respondents
quality of life, but are of a level frequently found among individuals seeking
help from mental health professionals. The categorical scoring method involves
the application of weights to the four response alternatives
(0011). Binary scoring (range 028) was then
applied in the evaluation of threshold caseness morbidity levels using the
conservative cut-off 5/6, in which those scoring a total of six or more are
considered a probable case (Goldberg et
al, 1997). For each of the four seven-item sub-scales, the
Likert method of scoring was applied (0123; range
021). The IES was also analysed as a continuous score and
categorically. Measured as a continuous variable, the scale yields three
scores: a total score (0135; range 075) and
sub-scale scores for symptoms of avoidance (range 040) and intrusion
(range 035). As the avoidance and intrusion sub-scales were highly
correlated (r=0.80, P=0.001), only the IES total score was
analysed. A total score of 35 or more on the IES has previously been taken to
indicate probable caseness reflecting significant post-traumatic reactions
(Scott-Gliba et al,
1995).
Statistical analyses
Discrete variables were analysed using 2-tests. Odds ratios
(ORs) and 95% CIs were calculated where appropriate. Continuous variables were
compared between groups using independent groups t-tests or analysis
of variance, with post hoc analyses of group main effects conducted
using Tukeys honest significant difference. Pearsons
product-moment correlation coefficients were calculated to examine the
association between psychiatric morbidity and the nature of the intrusions. In
order to minimise type I error associated with multiple comparisons, the error
rate required to demonstrate significance was set at 0.01.
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RESULTS |
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Victims of stalking notably had elevated scores on the index of severe depression. As high rates of suicidal ideation have previously been identified among stalking victims (Pathé & Mullen, 1997), the four GHQ28 items assessing suicidality were examined (items 24, 25, 27 and 28). Victims of stalking were more likely than victims of short-lived harassment and controls to endorse recent suicidal ideation (Table 2).
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Post-traumatic psychopathology
Only those who reported harassment completed the IES. Victims of stalking
were three times more likely to meet the threshold for caseness on the IES
(16.3%) than victims of short-lived harassment (5.1%; OR=3.6, 95% CI
1.77.4; P=0.001). Total IES scores were also higher among
victims of stalking (mean (s.d.)=12.9 (17.7)) compared with victims of
short-lived harassment (5.2 (10.6); t=5.5, d.f.=426,
P=0.001).
Relationship between psychiatric morbidity and recency of victimisation
To examine whether victimisation is associated with acute or chronic
disturbance, the proportion of victims meeting the criteria for caseness on
the GHQ28 and IES was compared between those victimised in the 12
months prior to the survey and those whose victimisation occurred before that
time (Table 3). The rates of
psychiatric morbidity among victims of harassment did not differ according to
the recency of the victimisation. Among the victims of stalking,
post-traumatic symptoms were higher among those victimised in the 12 months
prior to the survey, although the rates of general psychopathology did not
differ.
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Relationship between psychiatric morbidity and nature of the harassment
The number of harassment methods experienced (range 19) did not
correlate with total scores on the GHQ28 or IES among victims of either
brief harassment or stalking (in all cases r < 0.15, P
> 0.01). Among victims of harassment, the proportion meeting the criteria
for caseness on the GHQ28 and IES did not differ according to whether
they were exposed to explicit threats or physical assault. For victims of
protracted stalking, those subjected to explicit threats were significantly
more likely than non-threatened victims to be classified as a case on the IES
(27.2 v. 9.0%; OR=3.6, 95% CI 1.77.6, P=0.001).
Post-traumatic symptoms were also elevated among victims of stalking who were
assaulted in comparison with their non-assaulted counterparts (25.0
v. 13.6%), although this failed to reach statistical significance
(2=4.07, P=0.04). The proportion of victims of
stalking meeting the criteria for caseness on the GHQ28 did not differ
according to exposure to threats or assault.
The nature of the prior relationship between victim and perpetrator
Associations between the nature of the prior relationship with the
perpetrator and rates of caseness morbidity on the GHQ28 and IES were
examined for the victims of stalking. For these victims, the perpetrator was a
stranger in 17.5% of cases, an ex-intimate partner in 21.4%, a casual
acquaintance in 30.3%, an estranged relative or friend in 8.5%, or a work
contact in 22.2% of cases. There was no association between the nature of the
prior relationship to the stalker and morbidity on either the GHQ28
(=2.6, d.f.=4, P=0.62) or IES (
2=6.4, d.f.=4,
P 0.16), suggesting that psychopathology in victims of stalking is
largely independent of who engages in the pursuit.
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DISCUSSION |
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The impact of persistent stalking: general psychiatric morbidity
Those who reported being victims of stalking had high levels of anxiety and
depression, as evidenced by their scores on the GHQ28. Approximately
10% of victims acknowledged recent suicidal ideation, with one in eight having
strongly considered the possibility of taking their own life in the month
prior to the survey. This finding alone is disquieting and underscores the
need for greater clinical recognition of the desperation that may accompany
such persistent forms of pursuit and victimisation.
The rates of general psychiatric morbidity among the victims of stalking were not associated with the methods of pursuit, the prior relationship with the perpetrator or the experience of threats and violence. The nature of the victimisation therefore contributed little to the rates of anxiety and depressive symptomatology. Interestingly, the recency of the stalking also failed to moderate the levels of general psychiatric distress, with an equivalent proportion of victims stalked in the 12 months prior to the study meeting the threshold for caseness on the GHQ28 as those stalked more than a year earlier (43 and 34%, respectively).
Reports of high levels of anxiety and depression by a third of victims long after the stalking had ended emphasise the chronic course of impairment that can accompany such victimisation. Persistent anxiety appears the most common legacy of stalking (Pathé & Mullen, 1997; Kamphuis & Emmelkamp, 2001). Faced with repeated intrusions over which they have little control, victims often come to perceive the world as inherently dangerous and their safety and well-being wholly compromised. In this context, hypervigilance, panic and insomnia are not unexpected. Pervasive symptoms of depression may also emerge among those whose sense of autonomy has been eroded by the stalking and who perceive their quality of life as having been irreversibly altered. It is critical that victims of stalking receive appropriate assistance both to end the intrusions and to relieve potentially enduring symptoms of anxiety and depression.
Post-traumatic morbidity
Some 16% of victims of stalking reported elevated scores on the IES,
indicating significant avoidance and re-experiencing phenomena associated with
their victimisation. Unlike the rates of general psychiatric morbidity, the
levels of post-traumatic psychopathology differed according to the recency of
victimisation, with a higher proportion of victims stalked in the year prior
to the survey meeting the threshold for caseness than those whose stalking
ended more than a year earlier. These findings suggest that although symptoms
of anxiety and depression often persist, the severity of intrusive reminders
and restrictive avoidance behaviours are for most victims likely to diminish
over time.
The rates of post-traumatic symptomatology varied according to the nature of the stalking, with those exposed to associated violence more likely to meet the criteria for caseness on the IES. Specifically, victims who had been threatened by the perpetrator were three times more likely than their non-threatened counterparts to report significant post-trauma symptoms. However, actual physical assaults failed to moderate the levels of post-traumatic symptomatology. This suggests that threats may be more emotionally damaging to victims than the reality of physical harm. Although perhaps counter to expectations, this is in accordance with Pathé & Mullens (1997) earlier observation that several victims in their clinical study felt they may have coped better with the more tangible damage of physical assault (p. 15) than the sense of looming vulnerability that accompanies threats.
It should be noted that the rates of post-traumatic symptomatology in this community sample are considerably lower than those observed in clinical settings. Pathé & Mullen (1997) reported that over 30% of the victims in their sample met the full diagnostic criteria for post-traumatic stress disorder, with an additional 20% meeting all the conditions except criterion A (i.e. an actual threat to ones physical integrity). Kamphuis & Emmelkamp (2001) similarly reported high levels of post-traumatic psychopathology in their Dutch sample of female victims of stalking seeking assistance from an anti-stalking foundation. Although the average total IES score in the Dutch study was three times higher than that reported here (mean=39.7, s.d.=17.0), victims in that study were predominantly stalked by ex-intimates (73%) and subjected to high levels of threats (74%) and violence (55%) (Kamphuis & Emmelkamp, 2001). These factors likely contributed to the substantial levels of reported distress. None the less, the results from this community sample suggest that significant post-traumatic reactions affect a minority of victims, particularly in the immediate period post-victimisation and in the context of threats of violence.
The effects of short-lived harassment
The behaviours associated with stalking overlap with other experiences
which, however unwelcome and unsettling, are relatively common (e.g. repeated
prank telephone calls or being followed in the street). In this
study, the proportion of participants meeting the criteria for caseness on the
GHQ28 was equivalent between those exposed to such brief bursts of
harassment and controls not experiencing harassment. This is not to say that
those experiencing short-lived harassment have no ill-effects. Such conduct
creates fear and apprehension and may precipitate in some cases a sense of
vulnerability or a preoccupation with safety. None the less, this form of
harassment is not associated with the longer-term emotional disturbance that
can accompany protracted stalking, which highlights the importance of early
intervention to avert persistent psychiatric morbidity.
Limitations
There are several limitations of the current study which may limit the
generalisability of the results. We utilised a single questionnaire in which
enquiries regarding the experience of harassment were included alongside
questions about current general health. It cannot be discounted that this
approach influenced the levels of psychiatric morbidity observed. This is
unlikely, however, as the results demonstrated a dissociation in the rates of
psychopathology. Only those victims who disclosed a protracted episode of
pursuit reported elevated rates of psychiatric morbidity. Victims who reported
a brief burst of intrusiveness did not differ from matched controls in their
levels of psychopathology. This dissociation would not be expected if victims
of harassment perceived an imperative to report a decline in their current
general health in conjunction with their victimisation.
In addition, although a significant proportion of stalking victims reported psychological difficulties, the majority did not. Even among those stalked in the year prior to the survey, more than half did not report elevated levels of psychopathology. It is likely that other factors unrelated to stalking contribute to resilience or vulnerability to psychological impairment in this group, for example the availability of social support, the adequacy of coping resources or the experience of other forms of violence, such as childhood abuse or domestic violence. This study did not consider the extent to which variance in psychopathology is accounted for by factors unrelated to stalking, an issue that remains pertinent to future research.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Blaauw, E., Winkel, F. W., Arensman, E., et al (2002) The toll of stalking:The relationship between features of stalking and psychopathology of victims. Journal of Interpersonal Violence, 17, 60 63.
Budd, T. & Mattinson, J. (2000) The Extent and Nature of Stalking: Findings from the 1998 British Crime Survey. London: Home Office Research, Development and Statistics Directorate.
Goldberg, D. & Hillier, V. P. (1979) A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139 145.[Medline]
Goldberg, D. P., Gater, R., Sartorius, N., et al (1997) The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological Medicine, 27, 191 197.[CrossRef][Medline]
Hall, D. M. (1998) The victims of stalking. In The Psychology of Stalking: Clinical and Forensic Perspectives (ed. J. R. Meloy), pp. 113 137. San Diego, CA: Academic Press.
Horowitz, M., Wilner, N. & Alvarez, W. (1979) Impact of event scale. A measure of subjective distress. Psychosomatic Medicine, 41, 209 218.[Abstract]
Kamphuis, J. H. & Emmelkamp, P. M. G.
(2001) Traumatic distress among support-seeking female
victims of stalking. American Journal of Psychiatry,
158, 795
798.
Mullen, P. E., Romans-Clarkson, S. E., Walton, V. A., et al (1988) Impact of sexual and physical abuse on womens mental health. Lancet, i, 841 845.
Pathé, M. & Mullen, P. E. (1997) The impact of stalkers on their victims. British Journal of Psychiatry, 170, 12 17.[Abstract]
Purcell, R., Pathé, M. & Mullen, P. E. (2002) The prevalence and nature of stalking in the Australian community. Australian and New Zealand Journal of Psychiatry, 36, 114 120.[CrossRef][Medline]
Purcell, R., Pathé, M. Mullen, P. E. (2004a) Stalking. Defining and prosecuting a new category of offending. International Journal of Law and Psychiatry, 27, 157 169.[CrossRef][Medline]
Purcell R., Pathé, M. & Mullen, P. E. (2004b) When do repeated intrusions become stalking? Journal of Forensic Psychology and Psychiatry, 15, 571 583.[CrossRef]
Romans-Clarkson, S. E., Walton, V. A., Herbison, G. P., et al (1989) Validity of the GHQ28 in New Zealand women. Australian and New Zealand Journal of Psychiatry, 23, 187 196.[Medline]
Scott-Gliba, E., Minne, C. & Mezey, G. (1995) The psychological, behavioral and emotional impact of surviving an abusive relationship. Journal of Forensic Psychiatry, 6, 343 358.
Tjaden, P. & Thoennes, N. (1998) Stalking in America: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice and Centers for Disease Control and Prevention.
Received for publication July 30, 2004. Revision received December 9, 2004. Accepted for publication December 21, 2004.
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