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‘Scheherazade syndrome’: How to keep your patients on task

Patients might employ distraction to avoid unpleasant experiences in the course of diagnosis and treatment.

Vol. 7, No. 2 / February 2008

Psychiatrists, like all physicians, sometimes ask patients to endure painful or unpleasant procedures in the course of diagnosis and treatment. Patients want treatment, but they also want to avoid pain—so we expect ambivalence and resistance. Distraction is one of the most effective forms of patient resistance.

Distraction can be very effective, as described in an Arabian folk tale in The Book of One Thousand and One Nights. The story tells of a cruel Persian king who marries a virgin every night, and every morning he has his new wife executed. On the night the king marries Scheherazade, she tells him a story but leaves off the ending. The king keeps Scheherazade alive for another day to find out how the tale ends, but she then starts telling another story. This practice keeps Scheherazade alive for 1,001 nights.

Like Scheherazade,patients can employ distraction to avoid an unpleasant experience. A recently retired schoolteacher consulted me because he wanted to travel but was afraid of flying, driving long distances, and spending the night alone away from home. He and I agreed on exposure and response prevention therapy, and he made good progress at first. But then treatment stalled.

My patient was a kind man from a large, turbulent family. He was always rescuing someone from divorce, bankruptcy, school failure, or criminal indictment. Discussing these crises started to dominate our treatment sessions, and there never was a good time to get down to business.

In my experience, this pattern of regular, distracting crises occurs often with:

  • patients undergoing treatment for anxiety disorders
  • drug and alcohol abusers
  • patients referred by other physicians because the patient is avoiding a necessary procedure.

These strategies can help you refocus a distracting patient and manage “Scheherazade syndrome”:

Consider time-limited therapy when appropriate.

Quickly decide if a crisis that disrupts treatment is genuine or merely a distraction. A patient who has lost a loved one or suffered a life-threatening illness can be excused, but view lesser emergencies as suspect. My schoolteacher always had a good reason to avoid working on his fears, but the regularity of his excuses was a clue.

Confront the patient when you detect a pattern of avoidance. Make sure he remains interested in accomplishing the original objective.

Consider negotiating a new treatment plan. Your patient may need preliminary cognitive therapy, a gentler schedule, medication, or inpatient treatment.

Propose more structured therapy. Instruct the patient to keep a treatment diary and bring it to sessions. Sign a treatment contract, recommend a support group, or enlist the help of family members.

Reconsider the diagnosis if nothing is working. Attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, posttraumatic stress disorder, psychosis, or other cognitive problems can seem like anxiety or procrastination.

Dr. Lakritz is a psychiatrist at the Lahey Clinic Medical Center in Burlington, MA.

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