Obsessive–Compulsive Disorder

The Aviator
Sample Answer Key

Date:
Your name:
Name of the client you are assessing: Howard Hughes
Name of the movie: The Aviator

What is the chief complaint? (Why, in his/her “own words,”

would the client say he or she being assessed?)
Howard Hughes identifies that he is anxious and chronically
discontent as reflected in his statement “Sometimes it feels like I’m
losing my mind.” He has persistent anxiety and dissatisfaction in life.
He suffers from obsessive–compulsive behaviors such as
handwashing, cleanliness, and orderliness. He experiences extreme
stress during times of public appearances. He is also phobic of others
and isolates himself in his home, limiting contact with both business
and/or personal encounters.

Based on the above information and a close viewing of the

movie, what questions would you raise during history taking?
What are some possible answers?
You might base your questions on the:
History of your client’s present (and presenting) illness
Past psychiatric history, its treatment, and treatment
outcomes
Psychosocial history
Past significant medical history

1.) When did this behavior start? How long has it been going on?
Aside from issues related to cleanliness and order, what other
persistent thoughts or compulsive actions is Mr. Hughes aware of?
What events or situations trigger his behavior? What coping skills
does he use at present? How often and for how long does he engage
in ritualistic behavior?

2.) Has Mr. Hughes ever been treated for obsessive–compulsive

disorder, or any other anxiety disorder? What was the treatment
outcome? What is his pattern of alcohol or other drug use? Has he
ever suffered from depression? Has he had thoughts of hurting
himself or others? Is he sleeping well?

3.) Does Mr. Hughes have any close friends? How often does he see
other people? How has the anxiety diminished has quality of life?
What does he do on a daily basis for enjoyment? What kind of

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 relationships does he have with others? Has anyone in his family
suffered with an anxiety disorder?

4.) Has Mr. Hughes ever suffered from a respiratory, cardiac, or

endocrine disorder which could contribute to anxiety symptoms? Has
Mr. Hughes experienced any physical problems associated with
ritualistic behavior? Has his health suffered in any way as a result of
anxiety? Has he ever been seriously ill with an infectious disease or
other illness? Has he had any hospitalizations or surgeries? Is Mr.
Hughes taking any medications? What are they?

What observations do you have about the client’s behavior?

Mr. Hughes seems to purposefully isolate himself from others. He
prefers to take his dates on solitary events such as flying or golfing
rather than remain in public places. Under periods of extreme stress,
his anxiety worsens, evidencing periodic psychosis. He displays
disturbances in thought processes in repetitive speech patterns.
When his relationship with Kate ended, he burned all his clothing as if
purging himself from the emotional loss. He at the same time began a
ritual of wearing only sneaker-type shoes. Extreme stress resulted in
him isolating himself in his screening room, seeing no one, wearing
no clothing and neglecting his grooming.

The people whom he seems to have the most successful relationships

with are those who are firm and unwavering with him. His two female
companions did not unconditionally tolerate his attempts to control
them. In these two examples, control and predictability are present,
even though established by others. Mr. Hughes seems to tolerate
these relationships with lessening anxiety.

In your opinion, is the diagnosis discussed above accurate?

Yes.

What DSM-IV-TR criteria support (or negate) this diagnosis?

 Repetitive behaviors: Carrying his own soap, excessively
washing hands, certain rituals with food (chocolate chips
medium sized and away from the edge of cookies, milk served
with the cap on the bottle, vegetables not touching the meat).

 Obsessive thoughts: his obsessions are twofold; he demands

perfection with his work, whether it is filmmaking or aviation,
and cleanliness. Examples of cleanliness include clean
tablecloths, no smoking, covering the controls of his planes, and
later in the film, quarantining off rooms of his house as germ-
free zones.

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 Could the client have any other psychiatric disorder? If so, list
and include supporting DSM-IV-TR criteria.
Yes, possibly Schizophreniphorm disorder. Client had two or more of
the following:
 Delusions
 Hallucinations
 Disorganized speech**
 Grossly disorganized or catatonic behavior**
 Negative symptoms**

Client had significant social/occupational dysfunction since the

disturbance began.
Signs lasted at least one month but no longer than 6 months.

What treatment plan would you outline?

Medication management, with options including SSRIs,
benzodiazepines, Buspirone, beta blockers, or TCAs. Cognitive
behavior therapy should be implemented to sensitize to feared
situations, educate about OCD, increase tolerance of the object of
obsessions and teach coping skills. Coping skills include relaxation
techniques (meditation, muscle relaxation, visualization, and deep
breathing), and problem-solving skills. Relaxation techniques control
anxiety responses, and afford response prevention (helping him delay
or avoid performance of rituals).

With what expected outcomes?

 Howard will demonstrate and use adaptive coping strategies.
 Howard will demonstrate effective relaxation techniques.
 Howard will decrease incidence or intensity of anxiety.
 Howard will discuss feelings with another person.
 Howard will demonstrate effective use of behavior therapy
techniques.
 Howard will demonstrate effective use of problem-solving
techniques.
 Howard will experience improved interpersonal relationships.

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