The aviator on the couch

By the end of his life, Howard Hughes was so afraid of germs he wore tissue boxes on his feet. As a film about him opens, psychiatrist Raj Persaud analyses why the billionaire playboy became such a tortured recluse

Think of Howard Hughes and, for most people, the enduring image of a shabby, reclusive eccentric comes to mind. Open any biography on the legendary film-maker and you will read about any number of Hughes's extraordinary behavioural tics; so much so that his name is now synonymous with the stereotypical oddball billionaire.

Many of these details are alluded to in Martin Scorsese's new biopic, The Aviator. What audiences won't see, however, is the full extent of the "madness" that enveloped Hughes's final years, when he shuttered himself into sealed hotel rooms to which he had been secretly flown by his pilot; when he left his hair and fingernails uncut for years and became chronically addicted to codeine and obsessed with germs.

Explaining the omission of any detailed examination of Hughes's final and extremely disturbed years, the film's star Leonardo DiCaprio is reported to have said: "It wouldn't have been great cinema; just me sitting around naked with long fingernails, and tissues everywhere."

It seems extraordinary that a blindingly talented young man such as Hughes should have lived out his final days in a state of terrifying and unimaginable paranoia. How could anyone, least of all one of the richest, most successful men in Hollywood, develop such a pathological fear of germs that he forced his staff to carry out elaborate handwashing rituals, and to wear several pairs of white cotton gloves when handling documents he would have to touch? From where do such neuroses stem? And why did Hughes never accept any help?

Hughes's case of obsessive-compulsive disorder (OCD) is one of the most extreme and well-recorded in history, but during his lifetime he was terrified that encountering a psychiatrist might mean that he would be "put away". So he used his wealth and influence to keep the doctors at arm's length. If he walked into my office today, though, he would discover that the self-made super-rich are probably more prone to OCD than the rest of us, because they have often used their brains intensively to amass wealth. He would be told that OCD is more common in those who "think a lot".

By 1966, at the age of 60, Hughes was the world's wealthiest man, but by then he had such a terror of contagious disease that he avoided contact with anyone, if at all possible. Only his security guards and doctors saw him. He was injecting codeine, and had moved to Mexico to get hold of it more readily. He broke needles in his arms, which later showed up on autopsy X-rays. He wore tissue boxes on his feet, shunned clothing and let his hair and nails grow. His teeth rotted and fell out because he never brushed them. He never bathed. He urinated on the floor, but might sit on the toilet for 20 hours at a time because of extreme constipation as a result of the codeine addiction.

This paradox of living in excrement and dirt while suffering from a germ phobia is well known to psychiatrists; it is even referred to in some research papers as the "Howard Hughes dilemma". It is explained by the irrational fear of dirt becoming so intense that no amount of cleaning is seen to be good enough, and therefore cleaning is eventually abandoned altogether.

Hughes deteriorated physically and lost so much weight that his staff thought he would die. Spending hours cleaning every nearby surface, he discarded his clothes and remained nude (except for shoes, and sometimes a shirt) for the rest of his life. In 1976, on his way to a Houston hospital, he died, apparently of heart failure. His estate at the time was valued at $650m.

If Hughes sought my advice today about his condition, I would explore every aspect of his life in order to help him understand his affliction. In our early sessions, which I've no doubt would take place in Hughes's "germ free" clinic rather than my own, I would explore where his dread of germs and contamination had come from, and try to discover any clues that might have revealed themselves in his early childhood.

Howard Hughes was born in Houston, Texas on Christmas Eve, 1905. He was an only child and the object of excessive concern from his mother, who herself almost died at birth. Hughes was born at a time when polio was rife and awareness of the disease would have been high. His mother's fear of germs underscored his childhood.

In our sessions, I would explore the fact that Howard's father was frequently absent, and suggest that this possibly drove his shy mother to an even more overly intense and protective relationship with her only child. Her obsessively protective instincts would certainly have contributed to Hughes's sense of danger from the world outside. In summer, she bombarded camp counsellors looking after her son with correspondence. Once, she became so anxious to protect him from "the violent germs" of polio, which she felt could be carried "even by a well person", that she took him out of junior camp.

I would then ask Hughes to discuss the mysterious paralysis he developed in late adolescence. The affliction was never diagnosed, and it disappeared after several months, but Hughes was kept out of school for the period. The paralysis is now believed to have been primarily psychological, and the phase signals the beginning of Hughes's other major psychiatric difficulty - his discomfort with social interaction, leading to a deep avoidance of contact with others.

His parents, desperately afraid that he might indeed have the dreaded polio, brought a physician from New York to care for him full-time. So Hughes would be used to commanding personal attention from doctors, which is why I am so confident we would meet in his clinic, not mine.

Having explored this period, Hughes might then be encouraged to open up about the most painful events of his life. These occurred when his mother died during minor surgery when he was 16, and two years later, when his father died of a heart attack during a business meeting. This second sudden death would have traumatised Hughes, and resulted in a period of depression, over-concern with his health and increased social withdrawal.

I would discuss with him how the loss of the only two people with whom he had close relationships deepened his fears of death and increased his vulnerability to later psychological dysfunction. It would have been only natural that Hughes should become preoccupied with the possibility of any innocuous symptom being a harbinger of death. His growing fear of germs as a young man suggests the start of an obsessive-compulsive disorder. Obsessions are persistent, recurrent and distressing thoughts - such as the possibility of dying. Compulsions are repetitive behaviours designed to protect against a future situation - such as catching an infectious illness.

At 18, Hughes took over the family business in Houston. He would finally have found something over which he could feel mastery, and he would have set out compulsively to obtain more. It was clear to those who knew him that his ambitions were high - to be the richest man alive, and a top film producer and aviator. He managed all three, winning world fame in his early twenties. Yet he seemed embarrassed and uneasy with the visibility that this entailed. He dated famous actresses, but seemed more interested in collecting them than establishing serious relationships. Many elements of OCD manifest here; such people focus on worst-case scenarios and work to eliminate even the minutest chance of mistakes, while Hughes's collecting of women indicates the strong need for control over his environment.

I would try, at this stage, to show Hughes how his perfectionism and obsessiveness were so out of control that they were actually getting in the way of his ambitions. For example, he built the biggest airplane ever, called the Spruce Goose as it was built entirely of wood. But it flew only once, because he micro-managed the project so much that it fell further and further behind schedule, and was finally abandoned.

Nevertheless, I think the key problem I would encounter treating someone as successful as Hughes would have been persuading him that there was actually anything fundamentally wrong with him. After all, he produced a series of films, some of which are classics, including Two Arabian Knights, which he produced at the age of 20 and which won an Academy Award in 1928. As a pilot, he set cross-country and round-the-world speed records. And the income from the business he inherited provided him with almost unlimited funds.

The other problem in therapy would be that, being so rich, he wouldn't have had to curb his behaviour to fit in with others; they would have had to adapt to him. Convincing him of the need for personal change would be difficult. I'd try to persuade him that OCD causes severe stress, which would make him extremely miserable.

Another problem would be that he could, at the click of a finger, summon a new therapist with a different evaluation. I would insist that I would be his only physician and only source of prescriptions. To ensure an uninterrupted supply of codeine, he played his doctors off against each other. But would my therapeutic manoeuvre be interpreted with suspicion by those who were afraid of losing their influence over Hughes?

The issue of control is at the heart of OCD. The key reason Hughes could evade psychological expertise and treatment so completely was that he could use his power and wealth to get others to carry out his elaborate rituals - waving newspapers to scare away imaginary flies, opening doors with their feet to avoid touching the knobs, putting tape around windows, and washing their hands and everything else in sight.

The tragedy at the heart of Hughes's life is that he paid doctors simply to supply him with codeine to feed his addiction, but they never insisted he face up to his OCD. Would a modern psychiatrist fare any better against the manipulative billionaire?

I think that a battle over control would be at the heart of my therapy with Hughes. He would have to trust me enough to give over substantial control of his life to me. That trust could probably only develop if he understood that the therapist wasn't interested in his money, but in getting him better - an experience he never attained with his doctors. How can a billionaire ever learn that someone is interested in them, and not their money? That is why the super-rich might get better treatment on the NHS.

The irony is that wealth and power offer the enticement of easy escape from difficult psychological work. As Howard Hughes illustrates so perfectly, sometimes it is actually saner to be poor.

Professor Raj Persaud is consultant psychiatrist at the Maudsley Hospital in London. 'The Aviator' is released on 26 December