Hughes would be diagnosed with bi-polar disorder, with differential diagnoses consisting of obsessive-compulsive disorder (OCD) and agoraphobia. As DSM-V (2013) states, the diagnostic criteria for Bipolar 1 Disorder are as stated, "For a diagnosis of bipolar 1 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 may very well apply to Howard Hughes, as throughout the film The Aviator, he demonstrates an impulsive personality and is not adverse to taking enormous risks, in which his entire fortune and even life are on the line. He alternates between manic-depressive moments, where he shuts himself away for months, and moments where he emerges as a king-of-the-world type of figure (as in the court room scene towards the end of the film, when he defends himself). These behaviors are indicative of an individual who suffers from Bipolar 1 according to the DSM-V, as Hughes has both hypomanic moments and major depressive episodes. At the same time there may be occurring OCD, as Hughes demonstrates a severe reaction to germs and agoraphobia (which he likely inherited or learned from his mother, as the film demonstrates early on), and his mental intrusions (paranoia -- suspecting his home of being tapped) could indicate OCD (Steketee, 2003). However, it could also be that Hughes had legitimate reason to suspect that he might be spied on (as the arrival of the FBI indicates). Also, the appearance of men in Hazmat suits at the end of the film is enough to cause Hughes to have a breakdown -- though this is likely more a trigger of his bi-polar personality than a crumbling due to OCD or agoraphobia (as he has already swung from recluse to triumphant defender in court to successful developer and then back to panicked, manic-stricken man feeling out of control).

Were OCD the main cause of Hughes' problems, Hughes would likely be incapable of appearing in and defending himself in court with such energy were he a true agoraphobic sufferer, and his OCD is more likely a symptom of his Bipolar 1 disorder as it is the latter that appears to be the causative agent for his extreme ups and downs throughout his life as portrayed in the film. Thus as far as differentials are concerned, one should not rule out OCD or agoraphobia but should not treat them as the primary diagnosis, because the primary challenge for Mr. Hughes is rooted in his wild swings from one mood to another, 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's instilling in him a fear of germs, can serve as a factor) (Upthegrove, Chard, Jones, Gordon-Smith et al., 2015, p. 191; Chouinard, 2012). But a possible psychological test (MMPI) could be conducted in order to further assess Mr. Hughes and provide a path to possible best treatment.

Four different treatment options for Hughes based on a diagnosis of Bipolar I disorder would be a) psychopharmacological treatments, b) psychological treatments, c) family therapy-based treatments, and d) biomedical treatments.

A psychopharmacological treatment in Mr. Hughes 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 viewed as effective in clinical guidelines, the use of drugs on the patient might not be the most appropriate course of action, given the patient's strong desire to pursue courses of action that relate to his passion projects. Thus, there may be a better approach to treating his bipolar 1. Prescriptive drugs might be useful as a support but I would not recommend them as a main form of therapy. Instead, I would advocate a psychological treatment, supported by prescriptive drugs (as a precautionary method).

The psychological treatment that would be most beneficial in this case would cognitive behavioral therapy and prescription drugs, which may be needed for possible bipolar disorder. I would recommend cognitive behavioral therapy (CBT) because of its goal-oriented approach (which I believe would suit Mr. Hughes well as he is obviously able to accomplish goal-oriented tasks and continue on a determined course once he has committed himself to it). The finishing of the Spruce Goose is an example...

This is not an aspect of his behavior that should be stunted but rather embraced and utilized in his treatment. CBT is an effective approach to utilizing such personality-types. It would also help Mr. Hughes in his thinking, which is not quite realistic at this time (as evidenced by his dissociation of events, which should be connected in his mind but are not, such as his mother's effect on him in childhood and his present condition of agoraphobia, or his mistrust of Ava's whereabouts). CBT could help Mr. Hughes to change certain patterns within his thinking (especially regarding the way he thinks about himself and others), which could then be helpful in managing his feelings more effectively. Prescription drugs I would recommend only as a support but I would not insist on them at this point in the treatment, especially if Mr. Hughes is reluctant to use them. However, to counteract the crippling bouts of paranoia and agoraphobia, they might be necessary, and some consultation in this matter would be greatly advised between patient and therapist.
As for family therapy-based treatment, this approach would utilize members of Mr. Hughes' family and/or loved ones, and all could participate together in the treatment. The downside of this is that it might come across more as an intervention and with Mr. Hughes feeling particularly paranoid about others at this moment in his life and career, having so many people in a room talking about him may not be a right solution or effective form of therapy. Family therapy may have been more helpful in Howard's youth when his mother had more of a direct impact on his life. Her own compulsive behavior might have been more readily checked so that it did not have such a negative impact on her son. However, marital therapy might also be useful (or at least it might have been more useful earlier in the film before his separation from Katherine -- though of course the two were not married, so this may have presented complications), but in his current state with Ava, this could perhaps be of some value, as Ava clearly still cares for him (as is evidenced by her visit to Hughes in the midst of his depression and her dressing him and helping him to get ready for court). Clearly there is still some love and compassion there so it could be effective in helping with the treatment were she to participate in a form of marital therapy or family-based therapy.

Biomedical treatment in this case would be similar to a psychopharmacological treatment and would require the use of antidepressants, anti-psychotics, and anti-anxiety drugs. I would not recommend any of these as a primary method of treatment as I prefer to treat symptoms with the use of too many drugs or drugs (if at all possible) as they can in the case of a person like Mr. Hughes run the risk of triggering even more paranoia and suspicion on his part. The best way to deal with a case like that of Mr. Hughes's is to address the individual on a person-to-person basis and take one of his strengths and use it to help him overcome some of his weaknesses.

Thus, in this case, his strength would be his passion for intellectual and technological pursuits and his thirst to accomplish great feats in aviation. While his obsession with aviation is evident, and may stem from a possible OCD symptom (as his repetition of "the future" at the end of the film as he collapses under the weight of his paranoia and agoraphobia would indicate), the likelihood that this behavior can be overcome through cognitive behavior therapy is high given the right approach and relationship between counselor and patient. Obviously, the therapist would need to be very sympathetic to Mr. Hughes' plight and not make any insisting demands that might otherwise cause the experience to turn negative (Campbell, 2001).

In terms of combining therapies, this could also be of use, as family-based therapy could be utilized in conjunction with CBT as well as a psychopharmacological and/or biomedical treatment. Antidepressants and anti-anxiety drugs might be appropriate in the case of Mr. Hughes's more extreme breakdowns, such as the incident at the end of the film, where Mr. Hughes is rendered nearly incapable of pulling himself together. Some form of medication will likely need to be applied in this case.

Therefore, depending at what point in the film (that is, in the life of Mr. Hughes) that treatment is given or pursued, the different approaches would yield different results. For an early life…