This paper applies clinical psychology concepts to the portrayal of Howard Hughes in the film The Aviator, arguing that Hughes's behavior is most consistent with a Bipolar I disorder diagnosis under the DSM-5. The paper evaluates differential diagnoses of obsessive-compulsive disorder (OCD) and agoraphobia, explaining why these conditions are better understood as secondary symptoms rather than primary diagnoses. Four treatment modalities are then assessed — psychopharmacological, psychological (with an emphasis on cognitive behavioral therapy), family therapy, and biomedical approaches — with recommendations tailored to Hughes's personality and the stage of illness depicted in the film.
Howard Hughes would be diagnosed with Bipolar I disorder, with differential diagnoses consisting of obsessive-compulsive disorder (OCD) and agoraphobia. As the DSM-5 (2013) states, the diagnostic criteria for Bipolar I disorder are as follows: "For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes" (p. 123).
This diagnosis applies well to Howard Hughes as portrayed in the film The Aviator. Throughout the film, he demonstrates an impulsive personality and is not averse to taking enormous risks, placing his entire fortune and even his life on the line. He alternates between manic-depressive episodes — shutting himself away for months at a time — and moments where he emerges as a commanding, triumphant figure, as in the courtroom scene near the end of the film when he defends himself. These behaviors are indicative of Bipolar I disorder according to the DSM-5, as Hughes exhibits both hypomanic episodes and major depressive episodes.
At the same time, OCD may also be present. Hughes demonstrates a severe reaction to germs and exhibits agoraphobia — which he likely inherited or learned from his mother, as the film illustrates early on — and his mental intrusions (paranoia, including suspicion that his home is being monitored) could indicate OCD (Steketee, 2003). However, it is also possible that Hughes had legitimate reason to suspect surveillance, as the arrival of the FBI suggests. Similarly, the appearance of men in hazmat suits at the end of the film is enough to trigger a breakdown in Hughes, though this is more likely a trigger of his bipolar temperament than a collapse rooted in OCD or agoraphobia, given that he has already cycled from recluse to triumphant courtroom defender to successful developer and back to a panicked, manic state.
Were OCD the primary cause of Hughes's difficulties, he would likely be incapable of appearing in court and defending himself with such energy if he were a true agoraphobic sufferer. His OCD is more likely a symptom of his Bipolar I disorder, since it is the latter that appears to be the causative agent for his extreme mood swings throughout the life depicted in the film. Therefore, while one should not rule out OCD or agoraphobia as differential diagnoses, they should not be treated as the primary diagnosis. The primary challenge for Hughes is rooted in his wild mood swings, his reckless impulsivity, his blind determination, his alternating feelings of exaltation and despair, and his paranoia — in which adverse childhood events, such as his mother instilling in him a fear of germs, can serve as contributing factors (Upthegrove, Chard, Jones, Gordon-Smith et al., 2015, p. 191; Chouinard, 2012). A psychological assessment such as the MMPI could be conducted to further evaluate Hughes and inform a treatment plan.
Four different treatment options for Hughes, based on a diagnosis of Bipolar I disorder, are: (a) psychopharmacological treatments, (b) psychological treatments, (c) family therapy-based treatments, and (d) biomedical treatments.
A psychopharmacological treatment in Hughes's case would consist of a "first line with lithium, divalproex, or an antipsychotic medication" to treat his mania, while for his depressive episodes, quetiapine or lamotrigine could be utilized (Connolly & Thase, 2011, p. 2). While this treatment may be regarded as effective according to clinical guidelines, the use of medication alone might not be the most appropriate course of action given the patient's strong drive to pursue passion projects. Prescriptive drugs might be useful as a support, but they would not be recommended as a primary form of therapy. Instead, a psychological treatment supported by medication — as a precautionary measure — would be preferable.
The psychological treatment most beneficial in this case would be cognitive behavioral therapy (CBT), potentially supplemented by prescription medication for the bipolar disorder. CBT is recommended because of its goal-oriented approach, which suits Hughes's personality well. He is clearly capable of accomplishing goal-oriented tasks and sustaining a determined course of action once he has committed to it — the completion of the Spruce Goose is a striking example of this determination. This strength should not be stunted but rather embraced and utilized in his treatment. CBT is an effective approach for personality types like Hughes's.
CBT would also help Hughes address his thinking patterns, which are not always realistic. This is evidenced by his disconnection of related events — for instance, failing to link his mother's influence on him during childhood to his present agoraphobia, or his irrational mistrust of Ava's whereabouts. CBT could help Hughes change certain patterns in his thinking, particularly regarding how he views himself and others, which could in turn help him manage his emotions more effectively. Prescription drugs would be recommended only as a support and would not be insisted upon, especially if Hughes is reluctant to use them. However, to counteract the most crippling bouts of paranoia and agoraphobia, some medication might be necessary, and consultation between patient and therapist on this matter would be strongly advised.
"Family and biomedical approaches weighed and critiqued"
"Combined therapy strategies by illness stage"
Chouinard, V. (2012). Mapping bipolar worlds: Lived geographies of 'madness' in autobiographical accounts. Health & Place, 18(2): 144–151.
Connolly, K., & Thase, M. (2011). The clinical management of bipolar disorder: A review of evidence-based guidelines. Primary Care Companion for CNS Disorders, 13(4): 1–4.
Steketee, G. (2003). Clinical update: Obsessive compulsive disorder.
Upthegrove, R., Chard, C., Jones, L., Gordon-Smith, K., et al. (2015). Adverse childhood events and psychosis in bipolar affective disorder. British Journal of Psychiatry, 206(3): 191–197.
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