Mental Status Exam: The Aviator Has OCD
Amy Lichtfuss
Rush University
NSG 534
Mental Status Exam: The Aviator Has OCD
Psychiatric History
Identifying Data
Assessment
begins about 2:05:00 in the film The
Aviator. Date of Service:
8/1/1947. Mr. Howard Robard Hughes, Jr.
is a 42-year-old single, white, male, who is a very wealthy aviator, filmmaker,
and businessman. Patient did not
graduate high school, yet demonstrated a high level of intelligence throughout
adolescence and young adulthood. Currently he lives in a large estate with a personal
staff but no family members. Patient was
referred by his personal physician, Dr. Wilbur Thain, who was called upon by
the patient with complaints of feeling ill.
He has never been hospitalized for a mental condition before. Today’s interview is taking place in his home
outside of his screening/theater room. He
claims he has been here for months because
it is a perfect place to “sit in a chair, think, and sleep”. Despite
persistent efforts, patient refused to come out of the room and speak face-to-face
justifying he could be heard through the door and did not want to get anyone
sick. Patient is a reliable historian. Dr.
Thain, patient’s CEO, Noah Dietrich, and a few members of patient’s staff also
interviewed for additional information.
Chief complaint
“There
are spies in my midst”; “Q-U-A-R-A-N-T-I-N-E”
HPI
Patient
reports obsessive thoughts and anxiety started in his mid 20s at the beginning
of his career and few years after both of his parents died. He states his
mother instilled a fear of germs in him at an early age, making him spell the
word “Quarantine” over and over, eventually making introverted and afraid of catching
illnesses. Patient reports incessantly
thinking of how to make money, produce films beyond his time, and build the biggest,
best, and fastest planes; thoughts that consume the majority of every day. He has high-expectations for his co-workers
and requires perfection to the point of repeating or redoing the task until it
is perfect. Per Noah, patient was always
very particular with how his food is made, plated, and served (for example, 12
peas lined up in two rows of six, 10 chocolate chips, medium size, and not too
close to the edge). He fears being contaminated
by people or objects and, therefore, avoids crowded places as much as
possible. He avoids touching people
because, “you have no clue what kind of crap people have on their hands.” When conditions are not controlled to his
standards patient feels sweaty, his heart rate increases, he has difficulty
breathing, and he feels like he is choking.
Early
in his career he was able to control his symptoms by staying busy with work. But about seven years ago he began to have
difficulty hiding them when his personal, occupational, and social life started
falling apart. When Katherine Hepburn broke off their engagement a few years
ago he burned his entire wardrobe, including the clothes off his back, because they
felt dirty. He became more impulsive in
his business deals spending millions of dollars without hesitation and ignoring
flight protocols; such choices led to multiple plane crashes over the course of
his career. Over time patient became increasingly
paranoid about people spying on him and, despite coworkers disproving this,
proceeded to fire some “suspicious” employees, bugged his home with microphones,
recorded telephone calls, and hired a private investigator to watch his estate.
Eventually compulsions appeared
including washing his hands until they bled, avoiding touching people,
repeating phrases at random moments, like, “there are spies in my midst,” “show
me the blueprints,” and spelling quarantine
repetitively. After a serious plane
crash last year his symptoms and fears became even more prominent. He even imposed his compulsions onto his staff
requiring them to wear gloves while preparing his food.
At
this point patient has become a recluse, not having left his screening/theater
room for months. The last event before
this episode was a lunch with Senator Brewster where patient was asked to give
up his company, TWA, to Pan Am. Patient states
he was served horrible food and a dirty glass with a fingerprint on it. As soon as he left the lunch he had a panic
attack. These feelings were strong
enough to elicit a full-blown obsessive-compulsive and psychotic episode and
patient withdrew into his theater room. He
has not worked or socialized in months. Milk
is his primary source of nutrition and he refuses to wear clothes. He ironically has not showered or maintained
his hair or nails, is collecting bottles of his urine (lined up in a row),
rarely sleeps, and sometimes is found by his staff just sitting and staring for
hours. Per patient’s staff, he spends
multiple hours reciting specific instructions for them on how to prep and
deliver his food. For example, patient recorded, “He is to open the bag with
his right hand and hold the bag out to me at a 45 degree angle so I can reach
into the bag without touching the paper.” Patient added, “If there is any
variation of these instructions, even to the smallest degree, the entire
process must be repeated from the beginning, repeated from the beginning…” Patient
reports he does not want his competitors to know of his illness because they
will blackmail him.
Past illnesses
Patient
reports having headaches since childhood and recalls catching an illness that
kept him out of school for one year.
This illness caused temporary paralysis and tinnitus with hearing loss
that continues to worsen into adulthood. Patient has been in multiple plane crashes and
suffered many head injuries. Last year’s
crash was the worst sending patient to the hospital with numerous fractures of
the head, face, chest, arms, and legs, and burns over 80% of his body. Patient
denies use of alcohol, tobacco, and drugs.
Patient denies drug or environmental allergies. He denies having a history of tumors,
seizures, vision changes, confusion, or disorientation. He also denies history of other medical
conditions including hay fever, asthma, rheumatoid arthritis or other
autoimmune disorders, thyroid disorders, GI disorders, cardiovascular or
pulmonary disorders. He also denies a
history of syphilis or HIV/AIDS although has never been tested.
Family history
Both
parents were deceased by the time patient was 18 years old and he is not in
contact with other family members. He
reports his family was Episcopalian but did not actively participate in many
traditions. Father was an oil drill tool
manufacturer with his own company who passed his fortune to the patient when he
died. Patient states he feels proud of his father’s accomplishments and he was
happy to inherit the business after his death. His mother was a homemaker who doted on and
sheltered him; he claims she was the best mother a child could have. His mother had OCD tendencies and a fear of
contamination (Frontier Psychiatry, 2008), and although no official diagnosis
was made patient does recall extended family members who also suffered from
similar symptoms.
Personal history
Patient
does not recall any adverse events during infancy and early childhood,
therefore, unable to determine mother-child attachment (feeding habits,
separation anxiety, etc.), infant personality traits, or other developmental
delays or behavioral problems during this phase. However, knowing patient’s mother possibly
had OCD infers there may have been unusual mother-child interactions (APA,
2013). Patient recalls having a close relationship with his parents during late
childhood through adolescence and is an only child. He was introverted and exceptionally
intelligent in math and engineering having accomplished extraordinary tasks by
age 11 (i.e., set up Houston’s first wireless broadcast (Frontier Psychiatry,
2008). He recalls his mother instilling a fear of germs, frequently washing him
with special soap, and obsessing over his teeth and bowels (Frontier
Psychiatry, 2008). She stressed learning
about communicable diseases like cholera and typhus while spelling words like
“Quarantine” and saying “you are not safe”.
She refused to let him socialize,
go to school, or go to summer camps for fear of catching disease; therefore, he
did not have any friends or any intimate relationships during this time. Patient’s parents both died by age 18 making
him an orphan. He then took over his
father’s multi-million dollar empire and subsequently took on the responsibilities
of adulthood at a young age. He founded his own aviation business (Hughes
Aircraft) by age 28, set speed/flying records, and created “box-office hits” in
the midst of the great depression (Frontier Psychiatry, 2008). With his wealth he was able to pay off anyone
he wanted in order to get the job done right.
Patient also expresses a high level of ambition, impulsivity, and
egotistical behaviors. Throughout
adulthood he has had multiple romantic relationships, often at the same time,
and is known as a “playboy” by the public.
His first marriage was at age 20 but ended in divorce two years
later. He was previously engaged to
actress, Katherine Hepburn, who broke off the engagement after three years
claiming he was adulterous. His current
longest relationship is with Ava Gardner, which has been on and off over the
last few years. Most of his socializing
involves activities related to work, like movie premiers or special dinners,
although he prefers to avoid these situations due to anxiety. At this point patient does not socialize or
work at all, having lost the ability to concentrate on anything but his illness. Patient denies a history of violence, arrests,
or other litigations because he pays people off to leave him alone. He reports his only legal problem now is due
to Senator Brewster and Juan Trippe blackmailing him in court to take TWA. Patient reports always having difficulty sleeping. He denies alcohol or drug use.
Mental Status Exam
Appearance
Patient
appears sickly, malnourished, and disheveled with long hair and unkempt beard, fingernails
and toenails are long and yellow, and he refuses to wear clothing. He also refuses to shower. At times he
appears anxious, restless, and tense as he paces back and forth with rapid
breathing, wringing hands, and twitching eyes, and other times he is still for
hours on end. Patient is cooperative
with examiner yet becomes defensive and suspicious easily with questioning and
had some difficulty staying on topic for the duration of the exam. Some rapport has been established at this
point as patient has allowed examiner to enter the room.
Speech
Speech
is mostly spontaneous and normally responsive to the interviewer, although
sometimes hesitant or pressured, and varies in speed, rate, and volume. Volume ranges from quiet to loud depending on
the topic. Patient is generally able to
carry on a conversation when prompted but requires great effort to avoid
repeating words. When speaking to himself his speech becomes disorganized and
monotonous.
Mood/Affect
Patient’s
mood and affect are congruent and appropriate. His mood is labile, ranging from empty to
depressed to anxious with occasional outbursts of hostility and aggression. His behavior is erratic and bizarre, clearly
portrayed by his collection of urine and a room that is in shambles. Patient’s affect varies from normal range to
flat and constricted. Emotional
responses are short-lived, likely related to his short attention span.
Process and Content
Patient’s
thoughts are circumstantial with perseveration, occasional thought blocking, and
flight of ideas, although with great effort thoughts can be relevant (like when
Juan Trippe came to speak to him about TWA and Pan Am). He is preoccupied with perfectionism and contamination;
he exaggerates his fears (germs) and is intolerant to the unknown (what-if that
milk is sour?). He repeats phrases
often, such as, “It’s the way of the future,” and “Come in with the milk.” He requires his staff to complete tasks in a
very specific order and they must be repeated until done perfectly. Patient has difficulty completing tasks himself,
unsure of how to proceed and in what order (i.e., “I shouldn’t pick up the
bottle of milk with my right hand, I shouldn’t take the top off with my left
hand, and put it in my left pock, left pocket…”). It would also be helpful to
know what the patient thinks would happen if he did not perform these
compulsions. For example, “What do you believe
would happen if you did not repeat these phrases?” or “What do you believe
would happen if your staff did not do this?”
It would also be prudent to ask patient about suicidal/homicidal
ideation at this point (Sadock & Sadock, 2007).
Perceptions
Patient
seems to have persecutory or paranoid delusions with beliefs that people are spying
on him and recording him. He also said, “I
see things,” but it is unclear at this point whether what the patient is
referring to. There was no obvious evidence of patient seeing people or objects
but does allude to seeing germs in water.
Therefore, it could be an illusion of germs on his hands, in water, and
on other objects, which explains why patient has not showered. Patient will not
touch anything without a barrier between his hands and other objects, usually
tissue paper. Clarifying questions that
should be asked at this time include, “What are you seeing?” “How often?” and
“Do you hear voices?” If any of theses answers are “Yes” follow up questions
include identifying the content and frequency of the hallucinations (i.e.,
command hallucinations) (Sadock & Sadock, 2007).
Sensorium/cognition
Patient
is alert and oriented to person, place, and time. Concentration and attention
are impaired with thoughts deviating to obsessions and compulsions. Patient responded better to tasks with
numbers than words. Remote, recent, and
immediate memories are intact. Patient’s general fund of knowledge related to
his work was exceptional (i.e., math, engineering, business, geography, etc.) and
other subjects like vocabulary and history were satisfactory and appropriate
considering patients level of education.
Abstract thinking would need to be addressed here to test the
appropriateness of patients answers related to his ability to conceptualize his
ideas. For example, ask the patient to explain the phrase “A rolling stone
gathers no moss,” (Sadock & Sadock, 2007).
Insight
At
this point patient has fair insight. He
knows his compulsions and obsessions are irrational and he tries to hide them
from visitors, yet he cannot stop himself from fearing contamination and giving
in to the compulsions. Although he
vocalizes agreement that help is needed, he refuses professional help.
Judgment
Patient
has poor judgment. His impulsiveness and
egocentrism causes him to make irrational decisions socially and
professionally. His behavior at this
point is inappropriate and harmful to himself. He states he can pay people to do what needs
to be done until he is ready to come out of the room. When asked what he would do if his theater caught
on fire he replied, “I can’t go outside because I don’t have shoes to wear.”
Further
Diagnostic studies
A
comprehensive physical exam and neurological exam are advised. Laboratory tests
are advised, such as CO2, sodium bicarbonate, FBS, GnRH, MHPG, urine analysis, and
thyroid function to rule out medical causes for his anxiety (Sadock &
Sadock, 2007). Interviews with Katherine Hepburn and Ava Gardner may give
further insight into patient’s personal and social functioning, and a family
member could give insight into his childhood and other family history. Testing
for syphilis and HIV is also recommended due to patient’s precarious sexual
history.
Summary of Findings
The
etiology of his symptoms and psychodynamic factors related to the patient’s
episodes are very characteristic of a mental illness. Patient is displaying
characteristics of an obsessive-compulsive anxiety disorder that seems to have
implanted in childhood and manifested in early adulthood. There are possible genetic influences as well
as environmental stressors impacting his illness. Related symptoms include obsessive thoughts
about perfection and contamination, compulsive symptoms of repeating phrases
and counting, and anxiety during situations that threaten control of his obsessions. The patient also portrays some psychotic
features that are complicating his illness and may warrant a secondary
diagnosis. Related symptoms include persecutory
delusions (paranoia), flight of ideas, likely hallucinations, and negative symptoms
like disheveled appearance and inability to engage in goal-oriented behaviors. The extent of patient’s
condition has markedly impacted his personal, social, and occupational
functioning. Additional information to include
here are medications and dosages, laboratory results, and psychological and neurological
results.
Diagnosis
Obsessive
Compulsive Disorder, 300.3
(F42), with fair insight, with panic attacks, tic related. The Patient meets all of the following
criteria from American Psychological Academy’s DSM 5 (2013):
(a)
Presence of obsessions
and/or compulsions (patient has both); patient’s obsessions are recurrent, persistent,
and unwanted (contamination, being the best, fastest, richest, etc), and cause
marked anxiety or distress; the patient attempts to suppress the obsessions
(using tissue paper between hands and to cover mouth), or neutralize them with other
actions (i.e., performing compulsions); the patient feels driven to perform repetitive
behaviors or mental acts (repeating words and counting phrases) in response to
obsessions according to rules that must be applied rigidly and are aimed at
reducing anxiety, (b) Obsessions or compulsions are time-consuming, cause
clinically significant distress or impairment in social and occupational
functioning, (c) Symptoms are not attributable to a substance or another
medical condition, and (d) The disturbance is not better explained by another
mental disorder.
Patient’s panic attacks are best demonstrated by palpitations, sweating,
trembling, shortness of breath, feelings of chocking (loosening his tie), and feeling
unsteady, all of which he experiences after his lunch meeting with Senator
Brewster. The patient’s symptoms are quite incapacitating at this stage, causing
patient to lose some insight and giving in to the compulsions, although he is
still aware that his symptoms are abnormal by wishing to hide them from people. His eye twitches and vocal tics warrant a
“tic related” specifier.
Psychosocial
and contextual factors include being single with no family members, suffering
traumatic loses of both parents at a young age, extraordinary wealth and ability
to pay people to do anything he wants, suffering from multiple head injuries in
last few years and last year’s major plane crash, recent break up with Ava
Gardner, government searching his home and making it dirty, competitors
threatening to take TWA. Patient’s
symptoms worsen after times of stress, which is typical for patients with OCD
(Sadock & Sadock, 2007).
Differential Diagnoses
Psychotic
Disorders: Brief psychotic disorder,
schizophrenia, and schizoaffective disorder are all differentials that should
be considered. His hallucinations, delusions,
bizarre behavior, disorganized thoughts, disheveled appearance, and inability
to complete goal-oriented tasks are indicative of something more than OCD,
likely schizophrenia or paranoid schizophrenia.
However, it is difficult to diagnosis the patient without further
evaluating the duration and pervasiveness of the symptoms. For instance, in schizophrenia the
disturbances must be evident for at least 6 months (including prodromal or
residual phases) and there is not enough evidence at this point to confirm
this. It is, however, very likely that
the patient meets criteria for schizophrenia since he portrays many positive
and negative symptoms.
Obsessive-compulsive personality disorder: Patient does not fully meet criteria for obsessive-compulsive
personality disorder, although many of his symptoms could be argued to
represent both OCD and a personality disorder. And about 23-32% of people with
OCD also have obsessive-compulsive personality disorder (APA, 2013) so it could
be possible that he has both. Although
he has perfectionistic characteristics, he does not portray a pervasive pattern
of preoccupation with orderliness and neatness, rather he was preoccupied with
avoiding germs and contamination. At
this point in time, patient does succumb to mental and interpersonal control at
the expense of completing a task (i.e., not eating until food is prepared and
delivered perfectly and completely “clean”), which could be representative of
both OCD and the personality disorder. His
repetitive behaviors and obsessions are more characteristic of OCD.
Anxiety disorders and specific
phobias: The patient does meet many criteria for generalized
anxiety disorder, however the APA (2013) states the symptoms cannot be
associated with another mental disorder (such as OCD). Also, the recurrent thoughts that are present
in generalized anxiety disorder are usually about real-life concerns, whereas
the obsessions of OCD typically involve odd or unusual concerns. Additionally, compulsions are apparent in the
patient’s
case, which would not be apparent in anxiety disorder or specific phobia. Lastly, patient’s fear of crowded and public
places is related to
his obsession with contamination, rather than a fear of the social situation
itself.
Major
Depressive Disorder: More information is needed to diagnose
patient with a major depressive episode.
While he meets many of the criteria for major depression, it is
sometimes unclear whether the symptoms are related to depression or OCD and
symptoms cannot be counted for both (APA, 2013). For example, patient has shown psychomotor
agitation and retardation in the last two weeks or more, but this could be
related to the OCD or other psychotic disorder.
Also, patient has lost a significant amount of weight but it is not
clear if his has lost his appetite or is just having difficulty eating related
to obsessions. Patient is also showing a
decreased ability to concentrate but it is unclear as to whether this is due to
depression or persistent obsessive thoughts. While he did seem depressed after Kate Hepburn
visited him there is no indication for the length of time these feelings
lasted. And finally, depression can be
associated with anxious distress, mixed features, or psychotic features, which
further complicates diagnosing this condition.
If patient found to meet the criteria for this diagnosis with psychotic
features, patient’s prognosis would be poor (APA, 2013; Sadock & Sadock,
2007).
Bipolar
I Disorder, most recent episode depressed, severe with psychotic features: It
could be argued that patient’s impulsivity, ambition, and insomnia are
characteristic of bipolar disorder with a current episode of depression,
however patients obsessions and compulsions are indicative of OCD rather than
bipolar. However, it is common for an
individual with OCD to also suffer from depressive or other mood disorders
(APA, 2013) so this option should not be ruled out without further evaluation.
Tic
Disorder: Patient does not meet criteria for tic
disorder because there is no evidence of motor or vocal tics being present
before age 18, which is required for diagnosis (APA, 2013). If patient or other reliable source confirmed
tics were apparent early on then he would meet criteria for Persistent (Chronic) Motor or
Vocal Tic Disorder, 307.22. This is a
common finding as up to 30% of individuals
with OCD have a lifetime tic disorder (APA, 2013).
Prognosis
Patient’s prognosis is poor at this point
in time. He has fully yielded to his
compulsions and it is unlikely he will commit to a regimented schedule of medications. It is also likely that he is suffering
from more than just OCD since his psychotic features are prevalent. Comorbidities of anxiety and depression
complicate treatment and patient is already refusing professional help. Without receiving
treatment the course of this disease will be chronic with symptoms waxing and
waning over the course of his lifetime. It is likely his condition will
continue to deteriorate. Remission rates
in early adulthood are about 40% (APA, 2013) but with symptoms persisting well
into mid-adulthood this is unlikely in his case. Patient is at risk for harming himself
and at risk for harming others by forcing his compulsions onto his staff. With treatment,
prognosis is fair. As many as 20-30% of
people with OCD see significant improvement and 40-50% have moderate
improvement (Sadock & Sadock, 2007).
Comprehensive Treatment
Recommendations:
A combination of pharmacotherapy and
behavioral therapy should be considered for patient and is likely to produce
the best outcomes (Sadock & Sadock, 2007).
Effective medication options include serotonin-specific drugs like SSRIs
(Prozac, Paxil, Zoloft, etc.) or Clomipramine.
If patient does not respond well to these alternative pharmacological
strategies may be considered, like valproate, lithium, or carbamazepine, for
example (Sadock & Sadock, 2007). Behavior therapy can be inpatient or
outpatient and includes methods like desensitization, thought stopping, flooding,
implosion therapy, and aversive conditioning.
The patient must make a full commitment to improve for behavior therapy
to be effective (Sadock & Sadock, 2007). Family therapy would be beneficial
for the people closest to patient (Ava Gardner, Noah Dietrich) for providing
emotional support and advise on how to manage and respond to the patient
(Sadock & Sadock, 2007). Due to the
intensity of his illness at this point, it does not seem likely that patient
would commit to outpatient therapy or stick to a regimented medication schedule
without assistance. Hospitalization is
advised to remove patient from external environmental stresses. If hospitalization is refused, consider a home
health nurse or 24-hour caregiver who can provide one-on-one care. If all else fails, ECT or psychosurgery may
be considered and while ECT is not as effective as a cingulotomy or capsulotomy,
it should be tried first (Sadock & Sadock, 2007).
References
American
Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, DSM-5 (5th ed.). Arlington, VA: American
Psychiatric
Association. doi: www.dsm.psychiatryonline.org
Frontier
Psychiatrist (2008, September 23). [Web log message]. Retrieved from
hughes/
Sadock,
B., & Sadock, V. (2007). Kaplan and sadock's synopsis of psychiatry
behavioral
sciences/clinical psychiatry . (10th ed.). Philadelphia, PA: Williams
and Wilkins.
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