Dhat Syndrome: A Review and Update

Abstract

Abstract

Dhat syndrome is known as a culture-bound syndrome of South East Asia. Its manifestations mimic the phenomenology of neurotic spectrum disorders. Myths related to semen loss are the core belief around which anxiety, depressive as well as somatic symptoms develop. Often the patients respond to psychoeducation focusing on resolving the sexual myths and misconceptions. There is an ongoing controversy regarding the nosological status of Dhat syndrome. Extensive research on Dhat syndrome may provide an answer to this controversy through understanding about the entity. This review is a synthesis of literature on Dhat syndrome from its inception till date.

Introduction

Over a past few decades, Dhat syndrome has been recognized as an essential diagnostic entity in South East Asian region. It is considered as a culture-bound syndrome. Understanding the Dhat syndrome enables us the enormous impact of culture on the psyche of an individual. ¹ Dhat syndrome is an understudied entity, though over the past 2 decades there is increasing interest among the researchers to understand various aspects of this entity. Most of the researches working on this syndrome are from South East Asia: particularly from India. As per the search from PubMed database until September, 2019, 73 research publications exist on Dhat syndrome, of which 5 articles are from Europe and 1 from Oman. Search was made in PubMed database by using the term “Dhat syndrome.” All the articles were evaluated for conceptual evolution of Dhat syndrome, its nosological status, phenomenology, course, outcome, assessment, and management.

Various reasons might be responsible for an eccentricity in research on Dhat syndrome. The prominent reason might be rarity of the entity in other parts of the world (except the South East Asian subcontinent), making it infeasible to carry out the research. Poor understanding about the South East Asian culture by the Western researchers might be a discouraging reason to carry out research on the Dhat syndrome. Other reasons such as high comorbidity and phenomenological overlapping with depression, somatoform disorder, and anxiety disorders raise the suspicion about its real existence. Many researchers believe it to be a cultural manifestation of some other psychiatric disorders, hence, showing reluctance to carry out research on it.

Conceptualization of Dhat Syndrome

The term Dhat has been derived from a Sanskrit word Dhatu which literally refers to metal. Metal is an essential element. Vedic literature gives description of 7 different forms of essential body elements, of which semen is perceived to be the most important one; hence, emphasis is given to its preservation. The perceived preciousness regarding semen is due to the underlying belief that semen is formed from the consumed food by a series of steps of ultracondensation in the body. The individuals who are able to preserve semen can have a better and harmonious life whereas those who lose semen by any means can face adverse health-related consequences. ²

Late Professor N. N. Wig gave the term “Dhat syndrome” in the year 1960. Loss of semen irrespective of the mechanism (during urination, defecation, masturbation, nocturnal emission, and even sexual intercourse) is considered worrisome by patients suffering from Dhat syndrome. ² The ancient Ayurvedic literature mentions the preciousness of semen and gives vivid description about how semen is formed in the body. As per the literature, semen is formed from ingested food by a multistep process of ultracondensation.^2–4 Emphasis has been given on the preservation of semen as it is believed that preservation of semen could add to the longevity and vitality of an individual.^{3, 5} Many people believe that blood of the engorged penis is lost as Dhat, which might be attributing to the symptoms. ⁶

Many sexual myths are harbored by patients with Dhat syndrome. Patients believe that excessive masturbation, reading and watching pornographic content, sex with impassionate women, excessive sexual desire, and even homosexuality may result in development of Dhat syndrome. ⁷ The beliefs about semen loss are not confined to only Hindu religion or India. Evidences suggest that the entity Dhat syndrome also exists in the other parts of the world (Central Asia, Europe, America, Russia, China, Pakistan, and Bangladesh).^{3, 8}

Nosology of Dhat Syndrome

Dhat syndrome is considered as a culture-bound syndrome. Both International Classification of Diseases, Tenth Revision (ICD-10) and Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) had given importance to culture in the assessment of psychiatric disorders. ICD-10 considers Dhat syndrome under the diagnostic category as “other nonpsychotic mental disorders (F48).” However, DSM-IV mentions Dhat syndrome in the appendix section. ⁷ Both these diagnostic systems consider Dhat syndrome as a culture-bound syndrome. ⁵ Recently, the DSM-5 had kept Dhat syndrome under the section of “cultural concepts of distress.” ² Many researchers argue that the position of Dhat syndrome is not justified. ⁹

Researchers also questioned the diagnostic stability of Dhat syndrome. A recent study revealed that during follow-up (average duration of follow-up was 6 ± 3.5 years), only one-third of the patients retain their diagnosis of Dhat syndrome. ¹⁰ Rajkumar and Bharadwaj attempted to see the clinical profile of patients with Dhat syndrome with positive family history of depression and compared them with those who had negative family history. ¹¹ The authors advocated Dhat syndrome as a part of depressive spectrum disorder with different cultural expression. Considering the existing evidences regarding overlapping phenomenology with depression,^{12, 13} it is worthy to study the longitudinal course and outcome of Dhat syndrome in future research. Evidences also suggest that patients suffering with Dhat syndrome have unique pattern of illness behavior and similarities in various categories of somatoform disorder; hence, it was considered to be a culture-specific manifestation of somatoform disorder. ¹⁴

Lots of controversies exist regarding the position of Dhat syndrome in the current and forthcoming classificatory systems (ICD-11). Prakash et al had conducted a qualitative study on patients with Dhat syndrome and doctors, and traditional healers that facilitate care, to see the concordance of psychopathology of Dhat syndrome. ¹⁵ The findings of the above study not only suggest about agreement on certain aspects of phenomenology of Dhat syndrome but also disparity in the view about the nature of illness and management. There is gross disparity in the understanding and conceptualization of Dhat syndrome in modern system and alternative systems of medicine (Ayurveda, Yoga, Unani, Siddha, and Homeopathy). ¹⁶ This disparity also confuses the patients as they visit multiple health care providers.

Clinical Presentation of Dhat Syndrome

Patients with Dhat syndrome are often young males from rural background with poor level of education.^{2, 17} The onset of symptoms often occurs in the second or the third decade of life. ¹⁸ Oftentimes, they harbor the belief that semen is precious and its loss may have several adverse consequences. There is a strong attribution of the symptoms to the loss of semen or semen-like substances. The clinical manifestations of Dhat syndrome can be broadly classified under the following domains:

Affective symptoms: Low mood, anxiety, worry, apprehension, irritability, inability to experience pleasure.

Somatic symptoms: Body ache, lethargy, numbness, burning micturition, low energy, tiredness.

Behavioral symptoms: Withdrawn behavior, loss of libido, reduced sleep, reduced appetite.

Cognitive symptoms: Pessimistic view about future, preoccupation related to semen loss, catastrophization.

Patients with Dhat syndrome most commonly attribute their semen loss (passage of semen in urine) to reasons such as excessive masturbation, erotic dreams, and excessive sexual desire. Night fall (nocturnal emission) and passage of semen during defecation are reported to be the most common situations of semen loss. Patients with Dhat syndrome often fear the consequence of semen loss and commonly have the belief that it will lead to decline in sexual performance. ¹⁹ The most common presenting symptoms in patients with Dhat syndrome are weakness of the body, tiredness, low energy, and low mood.^{19, 20}

Patients with Dhat syndrome demonstrate abnormal illness behavior. ²¹ Chadda had studied illness behavior characteristics in patients with Dhat syndrome and had found that hypochondriasis and emotional distress are significantly higher in patients in comparison to healthy controls. ²² Rarely, symptoms of Dhat syndrome are reported as the prodromal phase of schizophrenia. ²³ Two case reports mentioned that patients attributed the per-anal mucoid discharge as the loss of semen and attributed their symptoms to the per-anal discharge of mucous.^{24, 25}

Dhat syndrome is rarely discussed in the context of females. Females of South East Asia also report similar kind of symptoms unlike Dhat syndrome and attribute these symptoms to nonpathological vaginal discharge.^{26, 27} However, the current diagnostic systems in psychiatry do not refer to Dhat syndrome in the context of females; hence, females who have features of Dhat syndrome with attribution of symptoms to per-vaginal discharge are often diagnosed as other psychiatric disorders (somatoform disorder, depression, dysthymia, or anxiety disorders). ²⁸

Females of South East Asian region also attribute to a similar pattern of manifestations and attribute their symptoms to vaginal discharge.^29-31 Physiological vaginal discharge is mostly perceived pathologically; hence, this entity is commonly referred to as “female Dhat syndrome.”

Comorbidities with Dhat Syndrome

Patients with Dhat syndrome often have various comorbid psychiatric illnesses. A recent multicentric study from India had revealed that nearly two-thirds of patients with Dhat syndrome had some or other psychiatric comorbidities. ²⁶ Sexual dysfunction was found to be the most common comorbidity in patients with Dhat syndrome in the abovementioned multicentric study and was reported in more than half (51.3%) of the cases. One-fifth patients had comorbid depression and another one-fifth had comorbid stress and neurotic disorders. ²⁶ However, there were variations in the prevalence of various comorbid psychiatric disorders in Dhat syndrome in earlier studies. ¹⁷ Earlier studies report depression to be the most common comorbid condition with Dhat syndrome.^{18, 20, 32} The common sexual dysfunctions associated with Dhat syndrome are premature ejaculation and erectile dysfunction. ³²

Patients of Dhat syndrome with comorbid depression have more features of hypochondriasis and high somatosensory amplification than those having Dhat syndrome without comorbidity. ¹⁷ High scores of neuroticism are also reported in patients with Dhat syndrome. ¹⁸ Rarely, Dhat syndrome may be associated with recurrent brief depressive disorder. ³³

Outcome of Dhat Syndrome

Outcome of Dhat syndrome has been studied in various follow-up studies. Grover et al, in their study, found the drop-out rate to be more than 50% by the end of 6 months. ³⁴ Majority of patients who completed their treatment had sought psychiatric consultation and had better knowledge about the illness with positive attitude toward sex. ³⁴ More than 45% of the patients reported no improvement with treatment at the end of 6 months in follow-up.

Sameer et al had conducted a follow-up study of patients with Dhat syndrome and found that nearly one-fourth of the patients initially diagnosed with Dhat syndrome remain still symptomatic due to incomplete remission. Similarly, nearly two-thirds, initially diagnosed with Dhat syndrome, qualify for other diagnostic categories during follow-up, of which the most common category is somatoform disorder. ¹⁰

Pathways and Models of Care in Dhat Syndrome

Patients with Dhat syndrome often reach the mental health professional for consultation, late. Evidences from North India reported that a person with Dhat syndrome spends 6.78 ± 6.94 years with the illness before reporting to a mental health professional. ³⁵ Majority of patients with Dhat syndrome first consult a nonqualified doctor or an Ayurvedic practitioner for treatment.^{35, 36} Singh et al in their study found that patients seek help for the first time for Dhat syndrome after an mean duration of 1.85 ± 2.14 years and that the time taken from first consultation to seeking help from a mental health professional was 4.63 ± 5.3 years. ³⁶ Patients with Dhat syndrome follow a long pathway of care and visit 3 to 4 practitioners before reaching to a psychiatrist. ³⁶

A sociosomatic explanatory model has been suggested for patients with Dhat syndrome. ³⁷ The patients have illness characteristics similar to those with medically unexplained symptoms. Psychosocial factors play an important role for the development and persistence of symptoms.

Researchers also emphasize integrated approach for Dhat syndrome, as patients with Dhat syndrome seek help from a diverse group of care-providers with different concepts about Dhat syndrome. ² Also, integration requires bringing all mental health professionals together, collating allied medical specialties through collaboration, and establishing linkages with practitioners from alternative systems of medicine. ²

A person-centered management model is an innovative model of care in Dhat syndrome. Each patient of Dhat syndrome has certain unique characteristics and has specific health care needs. Understanding the unique needs of the patients helps the clinician in planning a holistic management. The person-centered model emphasizes the individualized care of the patients, rather than nonspecific general care. ³⁸

Management of Dhat Syndrome

Patients with Dhat syndrome often expect energizing medications, tonics, vitamins, and injections for their illness. ¹⁹ Patients with Dhat syndrome require comprehensive assessment. Grover et al developed a comprehensive questionnaire for the assessment of Dhat syndrome. ³⁹ It has been used for clinical as well as research purposes. It helps in measuring the clinical symptoms in terms of their pattern and severity.

Bhatia and Malik found the role of antidepressant and antianxiety medications in management of Dhat syndrome. ²⁰ Dhikav et al reported the usefulness of selective serotonin reuptake inhibitors and counselling in the management of Dhat syndrome and comorbid depression. ³² Global improvement might be due to improvement of the depressive features alone. Depression and anxiety disorders are common comorbidities with Dhat syndrome; hence, antidepressants and antianxiety medications are commonly found to be useful in Dhat syndrome. Other researchers also agree with the role of antianxiety and antidepressant medications in the management of Dhat syndrome. ⁴⁰

Salam et al had developed cognitive-behavior therapy intervention module for the management of Dhat syndrome. ⁴¹ The module comprised of imparting sex education and resolving the sexual myths, corrections of cognitive errors, imaginal exposure with desensitization, as well as homework assignment in the form of masturbatory training. Additionally, patients with comorbid sexual dysfunction were trained on Kegel’s exercise, squeeze technique, and start–stop techniques. Sessions were structured as brief (lasting for 45 min) and range from 11 to 16 in number.

Conclusion

Dhat syndrome is being reported from different corners of the world; globalization and cultural exchange might have some role in reporting such phenomenon in the other parts of the globe, which is likely to more intensely increase in future. Dhat syndrome is an important diagnostic entity in clinical practice in South East Asia. There is a need to carry out intensive research on Dhat syndrome to understand its clinical stability, course, and outcome.