Author Index Article's Keywords Index GuestBook

The Concept And Epidemiology Of Dhat Syndrome

Journal:
January-June 2005 Volume 2(1)

Review Article

Author(s):
Ajit Avasthi, Om Prakash Jhirwal
Page No:
6

ABSTRACT

Culture bound syndromes refer to prevalence of some syndromes in specific cultures. Dhat syndrome (semen loss related psychological distress) is a culture-bound entity seen in natives of Indian sub-continent. Due to its clinical significance, it has been included in ICD-10. It is suggested that such a perception is reflective of the unusual emphasis placed on the qualities of semen in ancient holy treatises. The clinical picture includes symptoms of hypochondriacal quality, with or without psychosexual dysfunction. The symptoms usually disappear if the misconceptions about semen loss are effectively dealt with proper sex education and relaxation exercises. It is expected that with increasing literacy and progress in sexual knowledge among the general population of this region, the syndrome will become less common. Key Words: Culture bound syndrome; Semen; Dhat syndrome; Management.

INTRODUCTION

The last three decades have witnessed an increased interest in the field of trans-cultural psychiatry. Trans-cultural psychiatry mainly delineates the cultural factors in the occurrence, symptom patterns, recognition, course and outcome of psychiatric disorders1.  The concept of ‘culture-bound syndromes, initially introduced by Yap2 in the 1950’s and 1960’s, refer to psychopathological entities having a geographically defined prevalence, and are largely determined by the beliefs and assumptions prevalent in the native culture. In most cultures including Indian culture, sexual adequacy in man is the hallmark of masculinity, virility, personal adequacy and fulfillment3. Semen loss related psychological distress has been reported consistently in Asian and western cultures. Dhat syndrome-a term coined by Wig (1960)4, is deemed a common culture-bound preoccupation regarding semen-loss among patients in the Indian sub continent. This condition strictly speaking is not a psychosexual dysfunction but a sex-related disorder and often considered a culture-specific sexual neurosis5.

CONCEPTUAL EVOLUTION

Ayurveda teaches the physiology of the production of semen. According to that, there are seven essential constituents of the body (the seven Dhatus: chyle, blood, flesh, fat, bone marrow and semen), which are produced through a cycle of successive internal cooking and transformations. After ultimate distilling, the most concentrated elixir among the constituents of the body is semen (Dhatu). Its preservation guarantees health, longevity, and supernatural powers6.

In Charak Samhita, disorders of Dhatus have been elaborated and a syndrome resembling modern day Dhat syndrome by the name of Sukrameha (Shukra=sperm+ meha= passage in urine) finds prominent place. In Susruta Samhita, loss of semen in any form leads to a draining of physical and mental energy and vitality3,7. This is further reinforced by the belief enshrined in religious scriptures according to which, 40 meals produce one drop of blood, 40 drops of blood make one drop of bone marrow and 40 drops of bone marrow form one drop of semen8.  Therefore, a large segment of the general public from all socio-economic classes believes that semen loss is harmful and it should be preserved which further constitutes an organized belief system. Considered in this religio-cultural perspective that is deeply ingrained in the minds of common folk of Indian sub-continent, psychogenesis of the Dhat syndrome is easy to comprehend3.

EPIDEMIOLOGICAL ASPECTS

Dhat syndrome is widely prevalent in the natives of Indian subcontinent 9-14 including Nepal, Bangladsh and Pakistan9,15.  It has been also reported among Buddhists in Srilanka 16 and Pakistani Muslim ex-partite workers in the Gulf-states17.  Immigrants from these countries seen in European and North American clinics5 do present with this sex-related disorder. The studies except one18 reported so far pertain almost exclusively to male patients. The patient presenting with Dhat syndrome is typically more likely to be recently married; of average or low socio-economic status (perhaps a student, labourer or farmer by occupation), comes from a rural area and belongs to a family with conservative attitudes towards sex5,7,19. 
‘Dhat Syndrome’ has acquired further International recognition by being included in Annexure 2 (culture-specific disorders) of the ICD-10 Diagnostic Criteria for Research20.
 
CLINICAL FEATURES
 
Dhat syndrome is usually said to consist of the loss of semen in young men while passing urine or straining to pass stools21. The presenting symptoms in this syndrome have a hypochondriac quality. Associated symptoms include vague and multiple somatic and psychological complaints such as fatigue, listlessness, loss of appetite, lack of physical strength, poor concentration, forgetfulness, and other vague somatic troubles. These symptoms are usually associated with an anxious and dysphoric mood state. These patients may also present with or without psychosexual dysfunction7,13,22. The patient ascribes his symptoms, including sexual dysfunction, to the passage of ‘Dhat’ (semen or some whitish substance presumed to be semen by individual) in urine as a direct result of excessive indulgence in sexual activity or masturbation or to nocturnal emissions3, 23.  Sometimes the sufferer may complain that semen has become foul smelling and less viscous23. Apart from a whitish discharge with urine, there are no other urinary symptoms. Despite the patient’s assertion and concern about the passage of semen in urine, there is no objective evidence of presence of semen in the urine21.  Urine examinations fail to reveal any discoloration, sperms or any other abnormal constituents except for the occasional oxaluria or phosphaturia7 Neurotic depression followed by generalized anxiety disorder are the commonest psychiatric disorders seen in patients with Dhat syndrome. 13,24 Absence of concomitant systemic illnesses (resulting in turbidity in urine e.g. diabetes mellitus, in-born metabolic disorders, urinary tract infections etc), sexually transmitted diseases, local genital abnormalities must be ruled out before labeling Dhat syndrome5.  Some research workers 21 distinguished Dhat syndrome into three subgroups: -a) Dhat syndrome alone; b) Dhat syndrome with anxiety and depressive symptoms; and c) Dhat syndrome with sexual dysfunction. It is important to mention that an interview schedule for assessment of Dhat syndrome (DSIS) has already been introduced by research workers 25 at Chandigarh in order to assess this syndrome in the Indian male population.

PATIENT’S KNOWLEDGE, ATTITUDE AND EXPECTATIONS TOWARDS DHAT SYNDROME

Regarding the composition of Dhat, a majority of patients belonging to Indian sub-continent believe that it is semen, followed by those who believe it to be pus, sugar, concentrated urine, infection or not sure of its composition5.  Masturbation and/or excessive indulgence in sexual activities, venereal diseases, urinary tract infections, overeating, constipation or worm infestation, disturbed sleep or genetic factors are believed to be the main etiological factors5,19. Majority of these patients get the information about Dhat syndrome from friends, colleagues or relatives whereas some get information from posters, advertisements in mass media, magazines or quacks. Therefore, these patients prefer to visit STD clinics, urologists and physicians rather than approaching psychiatrists.

MANAGEMENT

The management of Dhat syndrome needs serious attention. This syndrome has become the domain of traditional therapeutic resources i.e. quacks, ayurvedic or Unani practitioners. The understanding of this condition by the modern medicine fails to impress most patients and the explanation and reassurances offered prove to be not of much use26. Some research workers 26 recommended emphatic listening, a non-confrontational approach, reassurance and correction of disbeliefs, along with the use of placebo, antianxiety and anti-depressant drugs, wherever required. Avasthi and Gupta (1997) 27 have developed a standardized treatment package for single males presenting with Dhat syndrome that mainly includes sex education and relaxation exercises. Sex education mainly focuses on anatomy, physiology of sexual organs, their functioning with reference to masturbation, semen, nocturnal emissions, and the functioning of genito-urinary system etc. Relaxation therapy includes Jacobson’s Progressive Muscular Relaxation Technique combined with Bio-feed back (so as to facilitate objective evidence and mastering of anxiety by the patient), which should be practiced 2-3 times/day regularly, especially after therapy sessions are over. If there is the presence of associated anxiety or depressive symptoms that may impede the process of therapy, anxiolytics or/and antidepressants can be added for the least possible time and in the least possible doses. Not surprisingly, Lorazepam was found to be most useful at the end of 4 weeks of treatment5.

CONCLUSION

There is sufficient clinical evidence to support Dhat syndrome as a culture specific problem. Due to the contribution of Professor Wig and other researchers, this syndrome was included in the Tenth edition of the International Classification of Diseases (WHO, 1992) 28 under other specified neurotic disorders (F48.8) with the provision of further research. Apparently, this syndrome has a varied clinical picture. Some have the pure form of the disorder; others have concomitant diagnosable depression and anxiety disorder. Dhat syndrome may also have co-morbid psychosexual dysfunction ranging from concern about potency to frank impotence and premature ejaculation either alone or in combination. However, its phenomenology, long term course and prognosis need to be studied further before this entity is accorded international acceptance.

REFERENCES
1. Lipsedge M, Littlewood R. Transcultural psychiatry. In Recent Advances in Clinical Psychiatry, no. 3(ed. Granville-Grossman). Edinburgh: Churchill Livingstone, 1979.
2. Yap PM. Classification of the culture-bound reactive syndromes. Aust N Z J Psychiatry 1967; 1: 172-9.
3. Kulhara P, Avasthi A. Sexual dysfunction on the Indian subcontinent. International Rev Psychiatry 1995; 7:231-9.
4. Wig NN. Problem of mental health in India. J Clin Social Psychiatry (India) 1960; 17:48-53.
5. Bhatia MS, Malik SC. Dhat syndrome-a useful diagnostic entity in Indian culture. Br J Psychiatry 1991; 154:691-5.
6. Malhotra HK, Wig NN. Dhat Syndrome: A culture bound sex neurosis of the orient. Arch Sexual Behav 1975; 4: 519-28.
7. Chadda RK, Ahuja N. Dhat syndrome: A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990; 156:577-92.
8. Akhtar S. Four culture bound psychiatric syndromes in India. International J Social Psychiatry 1988; 34:70-4.
9. Wig NN. Psychiatric research in India. In Psychiatry in India, Eds. De Souza A, De Souza DA. Bhilani, Bombay, 1984, pp. 703-32.
10. Neki JS. Psychiatry in South East Asia. Br J Psychiatry 1973; 123:257-69.
11. Sethi BB. Culture bound symptoms in India. Indian J Psychiatry 1978; 20:295-6.
12. Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview. J Social Psychiatry 1986; 2:403-25.
13. Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985; 27:119-22.
14. Gandhi N, Mahatme S. A psychiatrist’s approach to Dhat syndrome. Indian Practitioner 1989; 42:533-6.
15. Mumford DB. The ‘Dhat syndrome’: a culturally determined symptom of depression? Acta Psychiatr Scand 1996; 94: 163-7.
16. De Silva P, Dissanayake SAW. The use of semen syndrome in Sri Lanka: A clinical study. Sex Marital Ther 1989; 4:195-204.
17. Hay J. Are Non-western beliefs false? (Letter). Br J Psychiatry 1992; 160:870-1.
18. Singh GD, Avasthi A, Pravin D. Dhat Syndrome in a female: A case report. Indian J Psychiatry 2001; (4): 345-8.
19. Behere PB, Natraj GS. Dhat syndrome: the phenomenology of a culture-bound sex neurosis of the orient. Indian J Psychiatry 1984; 26:76-8.
20. World health organization. The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research Geneva: World Health Organization, 1993.
21. Avasthi A, Nehra R. Sexual disorders: A review of Indian Research. Mental Health in India (19952000), ed. Murthy RS. People’s action for mental health, Bangalore, 2001, pp. 42-53.
22. Nakra BRS, Wig NN, Varma VK. A study of male potency disorders. Indian J. Psychiatry 1977;19:13-8.
23. Jilek WG. Culturally related syndromes. In New Oxford Textbook of Psychiatry vol. 1, Eds. Gelder MG, Lopez-Iber JJ, Andreason N. Oxford University Press, Oxford, 2000, pp. 1061-6.
24. Patil B, Nadkarni R, Dhavale HS. Sexual misconceptions in male patients attending sex group. Abstract. Indian J Psychiatry 1996; 38(2) (Suppl): 199.
25. Sharan PS, Avasthi A, Gupta N, Mohanty M, Gill S, Jain A. Development of Dhat Syndrome Interview Schedule (DSIS) for Indian male population. Presented at Annual National Conference of Indian Psychiatric Society at Hyderabad, January 2003.
26. Wig NN. Dhat Syndrome. In Therapy of common sexual problems-A hand book, ed. Brahmbhatt R. Family Planning Association of India, Mumbai, 1998.
27. Avasthi A, Gupta N. Manual for standardized management of single males with sexual disorders. Marital and Psychosexual Clinic, Dept. of Psychiatry, PGIMER, Chandigarh, 1997.
28. World Heath Organization. The ICD-10 classification of mental and behavioural disorders; Clinical description and diagnostic guidelines 1992, WHO; Geneva.

JPPS © 2015 All rights reserved