Psychiatrist Doreen Orion, M.D., was just out of residency in Arizona when she admitted a woman with schizophrenia and suicidal ideation to a hospital where she was working. After treating her for two weeks, Orion discharged her to the care of her previous psychiatrist. Now, a decade and a move to another state later, the woman is, to Orion’s extreme distress, still an integral part of the psychiatrist’s life, having stalked her and made her life a nightmare come true.

A host of therapeutic and legal attempts to end the stalking, including jail terms, has all failed to deter the woman from her obsession with Orion.

"My story is a primer on what not to do" when faced with a stalker, Orion told a ballroom full of forensic psychiatrists at the annual meeting of the American Academy of Psychiatry and the Law (AAPL) in Baltimore in October.

The stalking began the day after the patient, whom Orion calls Fran, was discharged. The next day Orion found a note on her car that read in part, "I am surprised at your interest in me. . . . If you don’t respond, I will understand." Orion did not in fact respond, explaining that in her naiveté, she really believed that Fran would understand and leave her alone.

Fran, however, kept sending cards and calling, revealing that she had made an effort to learn intimate details of Orion’s personal life. Several weeks later, she accosted the psychiatrist in the hospital parking lot.

"I was very frightened," Orion explained, "but I told her calmly, ‘Don’t contact me again. I’m not your psychiatrist.’ " Orion believed this direct rejection would succeed. She was wrong.

It was at that point that Orion, who is a forensic psychiatrist and on the faculty of the University of Colorado psychiatry department, contacted Fran’s previous psychiatrist. That psychiatrist informed Orion that this behavior was a pattern Fran had exhibited in the past, a crucial fact about which Orion wishes the other psychiatrist had informed her earlier. That psychiatrist "reassured" her that the stalking would soon stop and did not pose a threat of harm, but Orion said if she had known of this pattern while she was treating Fran, she would have immediately referred her to a male psychiatrist.

It turned out, Orion explained that Fran is one of that small subset of stalkers—about 10 percent—who suffer from erotomania, a delusion that another person is in love with them. "What they lack in numbers, they make up in persistence," she told those at the AAPL meeting.

Orion has since become an expert in erotomania and has written the book I Know You Really Love Me: A Psychiatrist’s Journal of Erotomania, Stalking, and Obsessive Love about her experiences as a victim who also happens to be a mental health expert.

She pointed out that erotomanics usually "fixate on someone society deems to be desirable," such as a celebrity, doctor, or professor. Their delusion about the victim’s attraction to them centers on the belief that "if this person loves me, I can’t be so bad," Orion said. Their belief system is virtually unshakable since they are easily able to rationalize any attempt at dissuading them from their obsession.

Fran, for example, is convinced that Orion’s husband, also a psychiatrist, is possessive and jealous and is the main obstacle keeping her and Orion apart. These people also believe that the relationship they think they have with their victim "is universally approved of, and that other people are helping them" cement their bond, Orion pointed out. They commonly "embellish innocent symbols" with meaning. Sometimes they are convinced that even the criminal justice system’s involvement is sending the message that it wants the relationship to succeed.

In addition, she noted, stalkers with erotomania often avoid face-to-face contact with their victims, relying instead on constant phone calls, letters, and following at a distance. Orion’s stalker subjected her to all of these—and still does—but also schemes to have direct contact.

"It is a very adolescent way of relating," she said, adding that erotomanic stalkers rarely sustain friendships or romantic relationships and frequently are unemployed or working in menial jobs. Fifty percent of all stalkers, Orion also explained, have a mental illness, substance abuse disorder, or criminal history. "They are not just the boy-next-door types," and they can turn violent.

For Orion, Fran’s stalking quickly moved beyond annoyance and into frightening. After two years, during which time Fran moved to Colorado and into the same Boulder neighborhood to which Orion and her husband had relocated, Fran left a balloon tied to Orion’s car with a note stating the she knew Orion was pregnant. The note also said, "I know a family in California that wants to adopt. Let me know if you’re interested." Another note read, "It’s okey dokey to steal you."

At this point, with a shopping bag full of evidence in hand, Orion got the police to issue a restraining order against Fran. "It took her all of two hours to violate it," Orion said. She quickly called the police to arrest the stalker, "like they do on TV," but instead they "just gave her a good talking to."

It is critical, Orion warned, that victims know that a restraining order is no grounds to relax their guard; it is more often than not a tool with no teeth that offers little protection against a delusional, obsessed person.

In fact, Fran’s stalking of the psychiatrist intensified after the restraining order. She began to leave gifts in Orion’s garage and tape things to the house’s windows, making little effort to conceal her actions from neighbors. One time Fran was scared off by a patient whom Orion’s husband was treating for multiple personality disorder. That patient was parked outside the Orions’ home, where one of her multiples felt secure when under stress.

After about two dozen restraining-order violations, Fran was sentenced to six months of unsupervised probation. She resumed her stalking soon after this. It took 30 more violations and the fortuitous appearance at Orion’s house of a police officer who had himself been stalked, Orion noted ironically. He was thus willing to arrest Fran immediately and do what he could to keep her locked up.

Orion emphasized that before going to court for a restraining order, it is important to learn whether the local police are likely to enforce it. If not, it’s not worth the bother, Orion said, and will likely aggravate the behavior because the stalker may feel humiliated and provoke a "dramatic moment." Restraining orders work best with stalkers who are "the least emotionally invested in their subject," she added, pointing out that they rarely succeed in reining in erotomanic stalkers.

She also cautioned that stalking targets need to be alert to the increased danger that erotomanic stalkers could harm significant people in the target individual’s life that the stalker believes are obstacles to developing a loving relationship with the victim.

Orion cited studies indicating that about half of stalking victims suffer from PTSD, and about one-fourth have suicidal ideation.

Since many erotomania stalking episodes last about 10 years, she is hoping that she is nearing the end with Fran.