Star Athlete With a Blinking Fixation Struggling in College

Claudia L. Reardon, MD


December 29, 2021

OCD, tics, and attention-deficit/hyperactivity disorder (ADHD) represent a classic triad of disorders that frequently occur together.[7] This patient has evidence of possible ADHD. In particular, he describes symptoms of inattentiveness dating back to before the age of 12 (eg, difficulty sustaining attention in tasks, difficulty organizing tasks, often losing things, frequent forgetfulness, difficulty concentrating). He is fidgety and distractible during the clinical interview. He describes dysfunction in school related to these factors. His accidents and sports injuries that led to broken bones and concussions, although not uncommon in childhood athletes, may be more frequent in distractible children with untreated ADHD.

A more thorough evaluation should be undertaken to definitively diagnose ADHD. That assessment would probably include:

  • Collateral information from informants, such as his parents

  • Confirmation of dysfunction in multiple settings

  • A review of academic records

  • The use of objective, validated screening instruments and psychological tests

ADHD can sometimes remain undiagnosed during childhood due to various factors, including a lack of parental willingness to have the child undergo evaluation. In this case, the patient's teachers may have looked the other way when it came to his academic performance because of his status as a star athlete.

This patient was unaware of any family history of ADHD, but it could be present in his brother, who has had his own academic struggles. Moreover, although it is certainly not diagnostically definitive, it is interesting that both of his parents ended up in careers that are very physical and may be appealing to those with an underlying tendency toward ADHD. Finally, his mother has a nicotine use disorder, and it has been reported in the literature that maternal nicotine use during pregnancy may be associated with ADHD in offspring.[8]

Treatment for ADHD may include a combination of psychosocial approaches and medications. Psychosocial interventions include skills training and, for younger patients, individualized education plans, and parental education and skills training. Medication options include stimulants (such as those in the methylphenidate and amphetamine salts families) as well as nonstimulants (such as atomoxetine).

Among the conditions to consider in the differential diagnosis, generalized anxiety disorder (GAD) may be present and can be comorbid with OCD, tics, and ADHD.[1] However, the core feature of GAD is excessive anxiety and worry that occurs more days than not for at least 6 months about a number of events or activities, along with several associated symptoms, such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.[1] This patient describes his worry as largely circumscribed to the need to perform compulsive behaviors in order to feel that he can avoid harm. That said, a full psychiatric diagnostic interview is warranted to evaluate for other anxiety disorders, such as GAD.

Schizophrenia and other psychotic disorders typically include symptoms such as delusions, hallucinations, disorganized speech, grossly disorganized behavior, and negative symptoms (eg, diminished emotional expression).[1] Although this patient's need to perform certain behaviors a certain number of times might seem odd, it is not to the degree that is typically seen in a psychotic disorder. Moreover, in OCD, there is usually (though not universally) insight into the fact that one's obsessions and compulsions are illogical. That is, this patient could probably express that he realizes it is nonsensical that he has to organize his desk items a certain number of times before he is able to do something else but nonetheless cannot seem to stop the behavior. Patients who have odd behaviors and delusional thinking associated with psychotic illnesses typically lack that degree of insight.

It is worth considering other conditions in the differential diagnosis (Huntington disease and tardive dyskinesia) that might explain the patient's unusual facial movements (blinking). However, involuntary movement disorders (such as chorea and choreoathetosis, dystonias, myoclonus, and dyskinesias) are more rhythmic, not suppressible, and not preceded by a premonitory urge.[9] Stereotypical movements associated with autism spectrum disorder typically have an earlier age of onset, are more rhythmic, and tend to involve the extremities (eg, hand flapping).[10] Other considerations, depending on the particular presentation, may include seizures, postviral encephalitis, drug-induced tics, head trauma, stroke, carbon monoxide poisoning, hiccups, fasciculation, reflexes (eg, startle), tremors, spasmodic torticollis, and torsion spasms.[1] Most of these conditions are rarer than tic disorders, and a thorough history and examination may be sufficient to exclude them.


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