**6. The diagnosis and treatment by a clinical perspective**

This topic presents a personal perspective of a clinical psychiatrist who has practiced in several mental health settings and who aims to present one illustrative case.

During almost 20 years of clinical practice of psychiatry, I have observed several patients with what was once called "epileptical personality," possibly involving temporal lobe disorders. They do not necessarily have seizures or absence of crises. Some of them have what it is called Geshwin's syndrome. They usually have migraine, with photophobia and misophonia (these last two symptoms may occur not necessarily during migraine crisis). They often have reports of somnambulism (i.e., sleepwalking), night terror, nocturnal enuresis while infants or during puberty (or even in adults), and/or history of feverish crisis while in infants.

An important number of them have some relatives (grandparents, parents, cousins, siblings) with classical epilepsia, involving seizures or partial epilepsy complex, which suggests that they may have inherited a low threshold to resist a convulsion. However, they usually also have an acquired factor: premature birth delivery with complications, head trauma in the first year of life, encephalitis, and so on.

A large number of these patients evolve, usually, after puberty with changes in behavior. Some of them develop episodes of rage and mood swing. In girls, it is notorious after the menarche and gets worse during the menstrual period, showing that hormones play a very important role in these phenomena.

In males, the symptoms can be more constant because there is no hormones see-saw involved, but the onset of behavioral disturbance is related to puberty too. In addition, it can be related to violence or hostility more frequently, reminding of the explosive intermittent disorder's described features.

With this in mind, the aim of presenting this previous information is to report a few cases of BDD patients I have seen all over these years too. They are 12 patients, and in all of them, I could find traits of epileptical personality; some of them had alterations in the electroencephalogram (EEG) test, frequently on the right temporal lobe or in both. A reduced number of cases had alterations in the frontal lobe too.

I am going to report a case of a young man who was 19 years old at the time of his first appointment. He was taken to my private practice by his parents, because he had no conscious of his sickness. At the day before the appointment, he had punched his father's face. It never happened before. The patient was really regretted and scared with his own behavior. His parents were really worried and shocked because, on top of all, he had just given up on Law School and was obsessed by his own image on the mirror, spending 6–9 h a day in gym working out and more than 3 or 4 h in front of the mirror, checking each part of his body. However, he wasn't happy with himself, like in the case of Narcissus myth; he was in real pain, frustrated, and the parents could hear him whispering "I'm weak, I'm thin." No matter how strong his body was, he could not notice it. He was very concerned about his hair too.

His mother said she noticed 6 months before that he was becoming a little agitated and hostile. She tried to talk to him. But he was evasive and avoidant, then she looked through his medicines and found out he was taking steroids for muscles and finasteride for hair loss. I asked about his neonatal history; his mother answered she had a little trouble during labor delivery and he was born with a reduced Apgar score, but nothing that compromised his development; he had some episodes of feverish crisis until 5 years old. But lately, in the past 4 or 5 months, he started to have night terror episodes, which he never had before. However, his younger brother used to have it at the age of 3–4 years. In addition to the night terror, he started to have intense migraine episodes during the day, with photophobia and misophonia.

The parents said he was "normal" until 6–8 months before; described him as "just a little over concerned about physical shape, but like other youngster." They confirm that he was introvert and shy during his childhood and became a little more confident after 16 years old when he started to work out. He said to me, after getting better with medication, that he used to be teased at school for being shorter than the other boys.

I deduced that this patient had some temporal lobe level of instability which leads him to feel very intense about his emotional pains. The use of steroids and finasteride may have impaired some of his brain functions, reducing his convulsive threshold. The result was more aggressivity, mood swing, and the severe BDD symptoms escalating from an original simple unhappiness with his body features.

He mentioned social anxiety since he was a boy. Therefore, he decided to work out to get stronger. At certain point, influenced by a friend, he started to take steroids and finasteride.

He started to get better after quitting the hormones and finasteride. The social anxiety and the BDD were controlled after a week taking oxcarbazepine 600 mg/day and citalopram 10 mg/day. After 6 months of treatment, he stopped medication and continued psychotherapy. I have not heard from him since 4 years ago.
