Star Athlete With a Blinking Fixation Struggling in College

Claudia L. Reardon, MD


December 29, 2021


This patient appears to have obsessive-compulsive disorder (OCD). OCD consists of obsessions and/or compulsions. Both are not needed to meet the diagnostic criteria for this disorder, although most commonly both obsessions and compulsions are present.[1]

Obsessions are recurrent and persistent thoughts, ideas, urges, or images that are experienced as intrusive and unwanted. The individual attempts to ignore or suppress such obsessions with some other thought or action (ie, by performing a compulsion). Compulsions are repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The obsessions and/or compulsions are time-consuming (typically at least 1 hour per day) or cause clinically significant distress or functional impairment. The patient in this case describes time-consuming and dysfunction-causing obsessions (thinking that something bad will happen if he does not do certain things a precise number of times to the point of feeling "just right") and compulsions (engaging in those repetitive behaviors: in this case, rearranging the items on his desk). In many cases, anxiety underlies the obsessions and compulsions.

The first-line medication treatment for OCD typically consists of a selective serotonin reuptake inhibitor (SSRI).[2] SSRIs may need to be prescribed at higher doses and for longer periods than are used for depression. Second-line medication options include clomipramine and augmentation with antipsychotic medications. Furthermore, psychotherapy and behavioral therapy, specifically exposure and response prevention, are important aspects of treatment for OCD.

In addition to OCD, this patient may have tics. Tics are usually single, repetitive, nonrhythmic, nonpurposeful movements (motor tics) or utterances (vocal tics). Tics may be preceded by a premonitory urge, in which the person senses that a tic is about to occur; the feeling then subsides after the tic occurs. Tics, especially simple motor tics, are very common. They occur in about 10%-5% of elementary school–age children and sometimes persist into adulthood.[3]

As many as 30% of individuals with OCD have a lifetime tic disorder.[4] Tic-associated OCD is most common in males with the onset of OCD in childhood — similar to this patient.[4] His blinking behavior probably represents a motor tic that may be diagnosable as a persistent motor or vocal tic disorder; the criteria for this disorder require the presence of a childhood-onset motor and/or vocal tic(s) for at least 1 year, not to the point of meeting the criteria for Tourette syndrome.[1] Tourette syndrome is a chronic tic disorder (ie, present for at least 1 year) in which patients have a waxing and waning course of both motor and vocal tics.[1]

OCD that is comorbid with tics may have features that distinguish it from non–tic-associated OCD.[4] For example, tic-associated OCD may be more likely to have its symptom severity peak in childhood than in adulthood (at about 12.5 years of age), followed by an increased likelihood of remission.[5] Tic-associated OCD is a highly familial condition.[4] In this case, the patient's father may have had childhood tics. Tic-associated OCD may be less likely to respond to the usual OCD treatment with SSRIs and may be more likely to benefit from SSRI augmentation with an antipsychotic medication.[4,6]


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