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OPPOSITIONAL DEFIANT DISORDER IN THE ELDERLY

29 May, 2015

I have noted several searchers looking for information about oppositional defiant disorder in the elderly.  It concerns me that, apparently, there are psychiatrists out there making this diagnosis.  With the decline in physical abilities and, especially, the onset of dementia, seniors are faced with what Freud considered in his later years to be the ultimate humiliation – the growing inability to care for themselves and the loss of lifelong independence.  It should not be surprising that some (maybe many) get more than a bit cranky and resistant to direction from others.

I have observed that, neurobiological disorders like schizophrenia excepted, pretty much every so-called psychiatric disorder can be boiled down to being no more than complicated versions of grief.  Elderly persons who are losing their ability to cope with life’s demands will certainly experience grief, a chief component of which is irritability.

Though I hesitate to use the word “treatment”, since it implies a disorder, it must be said that treatment of oppositional behavior in the elderly would have to follow the usual caveat of treating a problem:  One cannot expect much in the way of outcome simply by trying to treat signs and symptoms that a problem exists.  The central question is, what is the etiology of the signs and symptoms* being treated?  One must know the cause of the ‘disorder’ and target it.  Imagine trying to treat MRSA with medications for fever and the like without recognizing that there is a bacteria causing the illness and treating that cause with antibiotics.  One wouldn’t expect much success focusing solely on the signs and symptoms of the illness.  Palliatives have their place, but signs and symptoms are supposed to help in establishing the cause of a problem and it is the problem that needs to be targeted in treatment.

Being infantilized rather than engaged as far as possible in mutual problem-solving should be expected to be met with resistance.  To call the last, desperate efforts to remain proudly independent a disorder is a psychiatric travesty. It is a natural response to the very sad loss of that independence.  “Treating” this “disorder” with medications to help subdue a person’s will to independence would be even worse.  It should surprise no one when resistance is encountered.  Engagement with a helpful attitude based upon a compassionate understanding of its etiology, rather than considering it a disorder, would go a long way to reducing that resistance.

The ‘disorder’ is a natural, expectable reaction to seriously troubling losses.  If only the signs and symptoms of that reaction are focused on, rather than the cause, both the person being treated and the person doing the treating are going to be frustrated and the situation is likely to be worsened, not relieved.


* Signs are anything that can be objectively observed by another party, either directly or through instruments.  Symptoms are experienced solely in the self and can only be revealed through the self report of the person suffering them.  Observing opposition and defiance focuses solely on signs at the expense of the symptoms.  Those symptoms would include grief, depression, anger, fear and hopelessness.  The humanity behind the behaviors appears to be ignored.

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