A 35-year-old married man was referred from the neurology department for psychiatric evaluation for complaints of sudden involuntary bilateral eye closure occurring for around 1–2 minutes and occurring repeatedly. These would be exacerbated by air pollution, wind, exposure to bright light, movement, and stress and would be relieved by talking, relaxation, and sleep. There was no history of any chronic physical illness, including neurological illnesses such as parkinsonism, Wilson's disease, epilepsy, stroke, nor a history of ocular pathology (e.g., blepharitis, conjunctivitis, or iritis) or intake of any drug in the recent past. He did not have any other abnormal body movements. There was no family history of any movement disorder. A diagnosis of essential blepharospasm was made. He was treated with various drugs including antipsychotics, tetrabenazine, clonazepam, trihexyphenidyl, and lubricating eye drops without much response. General physical examination, laboratory investigations, including venereal disease testing, EEG, brain MRI, and ocular examination including fundus examination were normal.
Detailed psychiatric assessment revealed that the patient would try to resist these movements but would not be able to do so. Also, there was a history suggestive of mild obsessive-compulsive symptoms in the form of contamination obsessions, repeated hand-washing, and pathological doubt for the last 15 years. However, the patient was not distressed by these symptoms and did not have significant socio-occupational dysfunction because of these symptoms; he was distressed by blepharospasm. Also, family history revealed a history of obsessive-compulsive disorder in the patient's mother and maternal aunt. Mental status examination revealed frequent eye closures, contamination obsessions, and pathological doubt. The patient was in marked distress because of blepharospasm. In view of this, he was started on clomipramine 25 mg per day, increased to 200 mg per day. No other medication was started. The patient gradually started showing improvement in blepharospasm as well as in his obsessions and compulsions and was completely symptom-free after 4 months of regular therapy.