well, as we still seem to be discussing it....

Rob: let me remind you of the original information given which was that

" a morbidly obese 48 year old woman with DM-2 and
Hemoglobin A1Cs of 10.5 came for the first time. She stated that she was here to get motivation to exercise and
improve her diet, since she was not exercising at all, and continued to eat lots of high fat foods. The group tried to
suggest various strategies that worked for them, but she quickly rejected them all. I then tried the "stick", since the
"carrot" clearly was unappetizing to her, and let her know that if she continued with her blood sugars at this level - due to
her weight, diet, and lack of exercise - then she was looking toward painful neuropathies, a series of amputations,
blindness, renal dialysis, heart disease, etc. She said that she knew all that, since her mother was on dialysis and died of
diabetes related factors, and her uncle who lived with them had his left leg amputated and was blind due to diabetes. I
asked her if she was resigned to having diabetes, and felt there was nothing she could do about it, to which she replied:
"No. I know that if I exercise and eat right that I can contol it. I just don't have the motivation. That's why I came here."

Now, where on earth in that lot do you get a personality disorder diagnosis, of any type? My analysis is that the group
may well have suggested things she had already tried and she was told things she already knew. The
medical/social/psychological system has failed her. I believe that it simply adds insult to injury to label her as a personality
disorder. The suggestions concerning motivational interviewing are good and will, I suspect, produce a good outcome
(incidentally, I just got Rollnick et al's new book, well worth looking at for this type of problem). The value of a
personality diagnosis? If I were to say, (as I would not choose to do) that I had inferred from our interchange that you
were suffering from narcissitic personality disorder, is that likely to be helpful (or acceptable) to you? The idea of making
and sharing a personality disorder diagnosis with this unhappy woman fills me with horror, because I think that it will be
harmful to her when there are sensible options available. I likewise think that an early intervention is not desirable. In my
relatively long experience of working with health anxious patients and "hypochondriasis" I have been struck by how well
engaged people are if they feel understood. A too-rapid intervention which fails because it is unsoundly based in
assessment of the person's problem is, in my opionion, a particularly counter-productive thing to do. To base it on a
notion of personality disorder, for which there is, as far as I can see, not a shred of justification, apalling. Please, please,
let's try to understand and empathise with this kind of problem, identify maintaining factors for the unhelpful beliefs and
behaviours, and help the person to change things for themself.

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