Recurrent brief depressive disorder in Dhat syndrome: A biological or psychological phenomenon!

To the Editor

Dhat syndrome is a culture bound syndrome seen in South-East Asia that usually presents with psychosomatic complaints which the patient attributes to the passage of ‘semen’ in his urine (Prakash et al., 2014). Depressive symptoms, both as minor and major depression, are common (Prakash et al., 2014).

A 40-year-old male, non-diabetic, non-hypertensive, presented with brief-lasting episodes characterized by reduced energy, easy fatigability, low mood, guilt feelings, impaired concentration and reduced appetite and libido; these symptoms resulted in significant socio-occupational impairment. Each episode followed an act of masturbation and lasted for 3–4 days. The symptoms were never present in the absence of masturbation. He had 3 to 5 such episodes every month, over the last 20 years. Six years ago, he was diagnosed with obsessive-compulsive disorder (OCD) that improved with Fluoxetine up to 60 mg/day; however, he was poorly adherent to the treatment. Interestingly, even while on Fluoxetine, the brief-lasting depressive symptoms would occur following masturbatory acts. He had no family history of psychiatric disorders and no reported psychosocial stressors. Physical examination and biochemical investigations (hemogram, liver, renal and thyroid function tests) were normal. Psychiatric evaluation revealed a depressed affect, anhedonia, ideas of guilt and impaired concentration. He attributed all these symptoms to semen loss following masturbation. He was diagnosed with OCD with Dhat syndrome with Recurrent Brief Depressive Disorder. Fluoxetine was increased to 80 mg/day and later Clomipramine 50 mg/day was added along with relaxation exercises and cognitive behavior therapy (CBT) for OCD. Sexual myths were addressed. The patient showed improvement in symptoms of both OCD and depression.

Patients with Dhat Syndrome usually respond to counseling addressing sexual myths, CBT as well as antidepressants (Balhara and Goel, 2012). The nosological status of Dhat syndrome in the current classificatory systems is controversial; some argue that it is a cultural manifestation of depression rather than an independent entity (Prakash and Mandal, 2015).

Recurrent mood disorders (bipolar or recurrent depressive disorder) have strong biological rather than psychological underpinnings, while in unipolar depression, both may have a role. Remarkably, in our patient, the recurrent depressive episodes appear to have a psychological basis emanating from Dhat Syndrome.