Obsessive-Compulsive Disorder in The Aviator

The 2004 film directed by Martin Scorsese depicted the legendary life of billionaire and aviation tycoon Howard Hughes and his life from 1927 to 1947. During the 20 years portrayed in the movie, Hughes became a successful film producer and an aviation pioneer who led the production of the world’s largest plane ever built—the Hercules. As success proceeded, Hughes was more and more troubled by obsessive-compulsive disorder, for which he received no treatment and intervention of any kind. The diagnosis of the disorder was never mentioned in the movie. After a major plane accident, Hughes was seriously burnt and disabled while at the same time suffering worsened OCD. He self-quarantined for an extensive period of time, giving up all practices of self-hygiene prior to a public hearing for the governmental charges and social condemnation he faced. At the end of the movie, he miraculously defended his own company and set new goals for jet plane technology. The closing scene portrayed his recurrent palilalia, when he involuntarily uttered “the way to the future” repetitively.

The movie successfully constructed a strong-willed fictional figure in memory of the historical Howard Hughes for his talent and devotion to aviation. It’s without a doubt that the romanticization of the movie is more or less different from the actual documented life of Hughes. Therefore, all analyses I constructed will be based solely on the fictional figure portrayed by Leonardo DiCaprio in the movie. I will start by reaching a diagnosis for the mental condition Hughes suffered in accordance with the DSM-V criteria.

To be diagnosed with OCD, an individual should display both obsession and compulsion for an extensive period of time at an individually and socially disabling level (5th ed.; DSM-5; American Psychiatric Association). The recurrent and persistent thought Hughes experienced, though not explicitly stated in the movie, was revealed through his gradually worsened fear of germs. Early on in the movie when Hughes was dining with his employee in the press, he ordered milk with a request that it should be served “with the cap on.” After wiping his hand with the napkins, he threw the napkin on the floor and kicked it away with his foot. When someone took a nut from his plate using fingers, he stopped eating immediately and excused himself out of the room in clear distress. In the first half of the movie, Hughes primarily displayed concerns and disgust about germs. His behavior can arguably be categorized as personal quirks but as his condition worsened, he relentlessly traced the surface of his plane and insisted that “She (the plane) should be cleaned.” The audience was given a personal account of such an obsession when Hughes cut his foot during a pilot flight. He revealed to Katherine Hepburn (Cate Blanchett) his worsening fear of seeing things that were not meant to be there (“these ideas about things that may not really be there. Sometimes I truly fear that I’m losing my mind”). The quote was presumed to be referring to seeing the dirt or germs on exposed food or surface and the consequential excessive worry and fear of being contaminated. The list of obsession carried on when Hughes met Bob from TWA, demanding him to clean off a speck of dirt from his lapel and threw the cleaning napkin away in a bin. Hughes displayed great distress, repeatedly looking at the bin as the negotiation proceeded. Hughes was also unable to hand someone a towel directly in the bathroom, and was trapped in the bathroom fearing of touching the door handle. Last but not least, when Hughes saw the filthy janitor working in the factory, the camera focused primarily on the dirt-covered nails, the greasy hair, and the coughing and breathing, which were supposed to be a tracing of Hughes’ vision. Hughes told his fellow employee Odie to rid the janitor because “respiratory diseases are expensive.” Given that the chances of being infected by one single janitor working in an air-circulated factory was comparatively small, the anxiety of respiratory diseases was evaluated to be disproportional. At this point of the movie, Hughes’ reaction towards gears and dirt has changed completely from disgust to uncontrollable fear.

In terms of compulsion, major ones Hughes performed to address his anxiety included washing and cleaning in response to his obsessive fear of germs. He carried a bar of soap everywhere and after his argument with Juan Trippe, he compulsively washed his hands till they were raw and started to bleed. His cleaning compulsion existed beyond hand washing and included extreme forms including the burning of all his clothes after the break-up with Miss Hepburn. Though it is possible to argue such a behavior as an aggressive case of revenge after a major breakup, it again became excessive when Hughes took off all the clothes he was wearing at the burning scene and displayed hardship choosing one brand of clothing. Hughes’ difficulty in making a decision is not uncommon among OCD populations. Kim et al. (2015) found that patients with OCD experienced more difficulties making decisions under ambiguity relative to decision making under risk. Results also showed a significant difference between OCD patients and healthy participants’ Wisconsin Card Sorting Test scores. WCST is a test that requires participants to sort cards based on implicit patterns. Taken together, it’s reasonable to infer that OCD patients, like Hughes experience cognitive deficit evaluating implicit pros and cons, which explains his indecisiveness in choosing brands for clothes despite his ability to make executive decisions concerning the survival of his business.

Hughes’ compulsion reached its climax when the audiences followed the arrival of Ava Gardner into Hughes’ house where he carried a box of tissue and lived in what he created as “germ-free” zones that were covered with wrappings, divided into sections using tapes and strings. The progression of his compulsion also resulted in distressful helplessness in maintaining personal hygiene. Hughes, in order to secure a deal, forced himself to consume fish and drink he considered unclean when dining with Senator Brewster. He began self-isolation soon after this pivotal event. The anxiety of keeping clean became so overwhelming that it becomes meaningless for Hughes to even execute the compulsion. He stopped shaving, showering, cutting nails, and urinated in milk bottles. It’s not otherwise specified in the movie whether the progression of Hughes’ OCD symptoms after his major plane crash was negatively affected by his medication. The compulsion and obsession Hughes experienced were, as stated in DSM-V, unwanted, intrusive and harmful to the individual’s social life, to the level that this former aviation tycoon could not leave his own screening room to meet with clients, to communicate with his ex-lover or even to excuse himself for the bathroom temporarily. It can also be inferred from the movie that the cleaning and washing habits were quite time-consuming based on the proportion of time the movie dedicated to the depiction of Hughes’ compulsions. It’s thus reasonable to conclude the Howard Hughes suffered from chronic OCD.

In addition to OCD, Hughes also seemed to have a co-occurring condition of tic disorder, particularly Tourette’s Disorder (TD). TD is characterized by the presence of both multiple motor and one or more vocal tics at some time during the illness (5th ed.; DSM-5; American Psychiatric Association). Hughes at times displayed sudden, rapid, recurrent, and non-rhythmic motor movement including eye blinking and throat clearing as well as complex vocalization (i.e. palilalia) when he would repeat the last phrase he uttered repetitively yet involuntarily (e.g. “Show me all the blueprint” “the way to the future” “I don’t want to get you sick”). Although DSM-V listed the onset for TD as age 18, the movie did not offer enough information to back up this criterion. It seemed that Hughes, with the progression of his OCD gradually displayed symptoms of TD, which might have been a result of his medication after the injury. It’s also hard to draw a line of differentiation between tics and compulsions from time to time in the movie. A tic differs from a compulsion in that it’s involuntary and does not relieve the anxiety upon completion. When Hughes was distressed by the presence of a filthy janitor he fled into his car starting to spell repetitively the word “quarantine.” The behavior seemed intentional and relieved the panic state brought by the excessive fear of germs early on, therefore qualified as a compulsion. However, later when Hughes isolated himself inside the screening room, he was observed to have been involuntarily if not unconsciously spelling the word repeatedly, with no observable relief to his distress, thus making the spelling a tic rather than a compulsion. The varied function of the same behavior under different circumstances introduced in the film brought me to question the nature of the spelling.

The word “Quarantine” was in fact a word taught to Hughes in his childhood by his mother. The film seems to hint at the possibility of upbringing affecting the development of OCD. It is possible that early childhood exposure to extensive cleaning and information bout infectious diseases did affect Hughes with regard to the content of his obsession and compulsion. However, it would be an overstatement to conclude that Hughes’ upbringing determined his onset. Childhood-onset OCD is estimated to be 45 to 65% heritable whereas an onset during adolescence and adulthood is 27 to 47% heritable (Grant, 2014). The movie showed Hughes’ mother giving Hughes a bath and informed him of infectious diseases. Yet the information is not sufficient to decide whether the mother had OCD or not. Despite genetic factors, environmental risk factors for OCD in children, particularly the germ related OCD, include various infectious agents and a post-infectious autoimmune syndrome (5th ed.; DSM-5; American Psychiatric Association), which is hard to infer from the movie as well. Other environmental and personality risk factors in a broader OCD context may include social isolation, childhood conduct problems, regular moving, negative emotionality, etc (Grisham et al, 2011). To gain a better understanding of how Hughes developed OCD, more information about his personal and familial medical history and upbringing till late childhood and early adolescence needs to be collected.

Despite that major diagnostic criteria of OCD was met in the movie, there are a few instances where the mental illness was romanticized in favor of the character. It’s almost as if one moment Hughes was deeply troubled by OCD while in another capable of defending himself successfully at the public hearing. According to DSM-V, OCD, left untreated, is usually chronic in course, often involving waxing and waning symptoms (5th ed.; DSM-5; American Psychiatric Association). Some individuals might have an episodic course while a minority has a deteriorating course. As the plot of the movie proceeded, audiences can see Hughes displayed normal functioning personally and socially from time to time, thus qualified for an episodic course. Yet, his coming out of an episode of OCD seemed to be overly simplified and highly coincidental. For instance, Hughes was still isolating himself inside the house with designated germ-free zone and constant wiping when he was expected to go to a public hearing. A moment later, he allowed Ava Gardner to shave him and run water over his hands and face. While Hughes did inquire his female companionship about whether the water seemed clean to her, there was no further resistance beyond furrowed brows and a frown in the midst of an OCD episode. Building off that, Hughes’ obsession with germs is highly situational. While he resisted food sharing by leaving the table when someone took food with fingers from his plate, he intentionally shared a bottle of milk with Katherine Hepburn. His fear of germs also seemed to exclude his passion for aviation from time to time. When Miss Hepburn inquired of the cellophane on the steering wheel, Hughes explained that it was for avoiding the “crap of people’s hand.” No more cellophane was ever spotted again on any of the other aircrafts he piloted in, certainly not in the Hercules and there was no scene of cleaning and washing afterward. Hughes’ obsession about contamination was thus rather “tailored” for the sake of his career depicted in the movie. It is as if he was given the agency to choose what to fear and what not to while in reality obsessive thoughts are rather intrusive and uncontrollable. The portrayal of Hughes’ conditional fear of contamination could also mislead the audience to think of patients of OCD as responsible for their own sufferings—it is the desire of social and occupational engagement that caused the obsession and compulsion. A study by Abbey (2006) examined the effects of OCD on romantic relationships. Result suggested that intimacy is a significant moderator in the relationship between severity of obsessions and relationship satisfaction. Intimacy buffers the negative effects of obsession on a relationship. Patients like Hughes who has a fear of contamination might also have the concern of being contaminated through intimate behaviors with partners. That is not to deny the possibility of a healthy relationship and successful career for individuals with OCD but rather to say that the depiction of Hughes’ struggle in personal life was more or less idealized and fragmented for theatrical purpose.

Another interesting portrayal of Hughes’ life was his increasing and intrusive paranoia. The first scene of paranoia was when he burnt all his clothes after the breakup with Katherine Hepburn. He asked his assistant Noah whether he was recording their conversation about purchasing new clothes. Coming out of his hand-washing rituals after a hostile conversation with Juan Trippe, he demanded to fire Ray Loewy, his contractor, whom he claimed to be a spy of Trippe because Lowey knew all about Trippe’s buttons. He later chose to monitor all the conversations of Ava Gardner, claiming that bugging would make her safe. At the very end of the movie, he believed people walking at his gathering were going to hurt him, paranoid about the intention of the crowd. It’s not uncommon for patients with severe OCD to display paranoia or even at times psychotic symptoms. The symptom itself does not always correlate with the content of the obsession. Hughes was not necessarily paranoid about contamination but held suspicion about interpersonal relationships in general. The portrayal aligned with the result of the study by Tellawi, Williams, and Chasson(2016) examining interpersonal hostility and suspicious thinking in obsessive-compulsive disorder. The study suggested that individuals with OCD experience more feelings of hostility and suspicious thinking. Increased OCD severity was correlated with higher levels of hostility and overall suspicious thinking. Additionally, individuals with OCD might also struggle with suspicions and disordered thinking about others, resulting in their inflated sense of responsibility to protect. Hughes’ attempt to monitor Ava’s phone call was a good example of such. His angry outburst after Ava refused to accept his protection can be understood as coming from his resentment of Ava not being as responsible for her own safety as he was.

Finally, I address the possibility of a comorbid bipolar disorder. One of the major challenges for diagnosing Hughes, particularly the movie character with Bipolar Disorder was his socioeconomic status which enabled him to make bold and seemingly “impulsive” decisions. It’s unclear whether the protagonist’s persistence in building the largest plane, spending 18 million dollars to purchase TWA, or even piloting the Hercules was due to an impulsion or his entitlement and confidence rooted in his wealthy background and knowledge and passion about aviation. His plan for new innovation was scientifically based, bold but ultimately attainable. Despite his seemingly “king of the world” presentation at times, he was almost shy and uneasy in most public situations, therefore leading to the conclusion that his impulses were more of a personality quirk than the symptom of a mental disorder. In addition to that, there was no clear depiction of a major depressive episode in the movie. Impulsion and seemingly manic behaviors alone do not meet the diagnostic criteria for Bipolar Disorder.

In general, The Aviator offered a rather accurate portrayal of Howard Hughes as a legendary businessman and aviation pioneer suffering worsened OCD. Hughes was never officially diagnosed or treated in the movie and his condition went through waxing and waning as his career experienced ups and downs. It’s important to notice the romanticized version of the disorder and how in reality it could truly be impairing to one’s interpersonal and occupational life. Yet, it’s nevertheless the nature of movies to weave a dream of the impossible to offer hope, to de-stigmatize while at the same time unintentionally stereotype for the sake of cinematography. Viewers thus should be cautious to take in the information offered in movies and appreciate such a portrayal with a critiquing eye.

#academic#DSM5#accuracy