An Untreatable Case of Oppositional Defiant Disorder

by Carol W. Berman, M.D.

Everything that I said, Joe* contradicted. If I told him that he should take his meds, he would say, no. It was so frustrating. He solicited my advice, and then would contradict me about sleep hygiene, the best foods to eat, how to behave, etc.

Joe* was a fairly new patient who I was just getting to know. Even though he was 40 years old, it seemed that he had ODD, oppositional defiant disorder,[1] which is usually diagnosed in pre-school children and adolescents.

In ODD there is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures (namely, me). He often lost his temper and argued with me. He deliberately did things to annoy other people and blamed them for his own mistakes and misbehavior. He was touchy and easily annoyed by others. Also he was angry, resentful and vindictive. I was surprised that no one had given him an ODD diagnosis before, since hed seen other therapists. He had originally consulted me to see what could be done about his depression. He didnt have enough of the DSMV criteria to warrant taking medication so I suggested psychotherapy once a week for a few months at least. Amazingly enough, he agreed to have therapy. Looking back, I think he just wanted an authority figure to be angry at and not to listen to.

His symptoms probably began before he was eight, although he claimed he was perfectly normal and everyone else in his family and school were messed up. ODD has been linked to abnormal neurotransmitters and genes.

For children, ODD is often treated by doing family therapy and training parents in techniques of positive reinforcement.[2]

I tried to teach Joe* new positive ways to deal with his stress rather than being hostile or losing his temper.

He managed to run a small, family-owned business, in spite of his ODD, that he had inherited from his father. Hed married and divorced three times, blaming his ex-wives for all his troubles. His two children hated him and wanted no contact with him. He said he didnt care about them and wanted to have nothing to do with them either. When I asked him what he did care about, he stopped complaining for a minute and stared at me.

I care about my business. I know Ive got the best one in my field. It should be number one in all ways.

What do you have to do to make it number one? I asked, going along with his supposition.

Theres not much I have to do. Its already top-notch. Were special in all kinds of ways, he replied.

Previously hed let slip that his business was going downhill because of market pressures.

Then it suddenly came to me, not only did Joe have ODD, he also had narcissistic personality disorder (NPD). There was the grandiose sense of importance, his fantasies of unlimited success and power. He believed he and his business were special. He needed admiration and had that sense of entitlement narcissistic personalities have. He lacked empathy for everyone, including his own children. What a combination: ODD and NPD. I resigned myself to not getting too far with him.

You have to understand me, doc. Im just like Donald Trump , he said proudly.

Then I realized that he was right. He was just like our president and Trumps diagnosis became clear to me, too. Thats why people were comparing our president to a two-year-old who exhibits oppositional behavior. Yes, Joe* and the president had two of the most untreatable conditions: ODD and NPD. Previously Id stopped myself from thinking of the presidents diagnosis because the Goldwater rule in our ethics encourages us not to diagnose people we have never examined, i.e., political figures and celebrities, but it was so tempting when these people acted so bizarrely.

You look sad, doc, Joe said happily. I guess you voted Democratic, huh?

Youre right, I said, straightening up. My patient was in trouble because there wasnt much I could do for him. Oh well, Id do the best I could. Let him think I was sad only because Id voted Democratic and we lost. But because of Joes untreatable disorders he would be a loser too.

[1] DSMV

[2] This disorder is most often diagnosed in children.

*not his real name