Former "A" Student Now Failing and Behaving Oddly

Anne McBride, MD; Glen Xiong, MD


July 25, 2023

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 19-year-old male student presents 6 months after returning home from college midway through his second semester. He was placed on probation by his school for poor attendance and participation. In high school, he was at the top of his class academically and had a close group of peers with whom he had been friends since middle school. During high school, he drank alcohol occasionally on weekends with friends. He tried marijuana on two occasions but did not enjoy it.

The student left for college with his best friend, who became his roommate. Initially, he attended classes regularly and turned in his work on time. He began to attend fraternity parties, and his drinking increased to every weekend. The patient, his roommate, and his family all confirm the patient has not used any substances other than alcohol. He became more withdrawn, started missing classes, and began "acting weird."

By late fall during his freshman year of college, his school attendance declined even further. He stopped attending social events and talked increasingly less with his roommate. He attended dormitory meals less frequently and commented to his roommate that the college was "poisoning their food." He started urinating in jars, which he stored in the dorm room closet as "proof" that he was being poisoned.

Concerned about the changes in his friend's personality, the student's roommate encouraged him to travel home for winter break. However, the student insisted on staying at the college so he could "catch up on work."

When the roommate returned for the second semester, he noticed that his friend was withdrawing even more from college life. Although previously a straight-A student, the student's first semester GPA was 1.7. He signed up for new classes but stopped attending completely after a few weeks. Occasionally, his roommate returned to find him sitting on his bed, mumbling to himself.

The student's hygiene declined because he stopped showering regularly. He lost a substantial amount of weight when he stopped eating at his dorm and only ate snacks from the vending machines. Eventually, after college administrators contacted his parents owing to his lack of attendance and failing grades, his parents took him home and encouraged him to seek medical care.


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