Star Athlete With a Blinking Fixation Struggling in College

Claudia L. Reardon, MD


December 29, 2021

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.


An 18-year-old college student presents to his university's counseling center. He has been struggling academically. It is mid-semester, and he is failing three out of his four classes. He finds it very difficult to focus on his reading and writing assignments. His mind wanders within 5 minutes of sitting down in class. He often simply forgets to do assignments entirely. He loses classroom materials and has trouble gathering his materials in order to start homework. He also constantly thinks about his inability to manage his work.

These problems are all very familiar to him, dating back to at least second grade. However, because his parents "don't believe in mental health," they have never had him evaluated. In high school, he never did well in class but was always given Cs, even though he believes that he probably did not do passing work. He was a standout player on the football and basketball teams at his small school and suspects that none of the teachers wanted to be responsible for making the star player academically ineligible by failing him.

His medical history is significant for a broken arm from falling off of the monkey bars at school and two concussions while playing high school sports, with apparent full recovery. After each concussion, he was unconscious for at least a minute. The figure below shows similar CT findings in a different patient with a concussion.

Figure 1.

The patient takes no medications. He does not consume caffeine or use nicotine or illicit drugs. A couple of times each week, he has a few beers with his friends. He states that he has never experienced a blackout from drinking. In terms of family history, the patient notes that his younger brother also struggled in school and had to repeat a grade. His father, who works in construction, had an "eye blinking problem" in grade school. The patient also feels the need to blink his eyes frequently.

He also feels that if he does not perform behaviors (eg, rearranging his desk a set number of times) before doing certain activities, something bad will happen. These types of behaviors have gradually improved but never completely resolved. During the transition to college, these rituals have worsened and now occupy at least an hour of his time each day. As a result, he often misses class or other important obligations because of the need to perform these behaviors. His mother is a fitness instructor and has no known significant medical history, including psychiatric, other than a presumed nicotine use disorder. He is unaware of any diagnosis or treatment of mental health disorders in any family members.


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