The continuing story of dhat syndrome
I read with interest the article by Sumathipala et al (2004) – an excellent review on dhat syndrome, a clinical entity highly prevalent in the Asian continent and not considered an entity in the Western world. This article is not free from publication bias. I wish to make the following observations based on our work in different parts of India over a period of 15 years. Dhat syndrome, a concept developed from Sanskrit literature, is based on a cultural belief in people who live in the Indian subcontinent. The syndrome is highly prevalent not only in India but also in its neighbouring countries such as Pakistan, Nepal, Burma (Myanmar), Sri Lanka and others. It is more prevalent among men in early adulthood, starting in late adolescence. Patients present with multiple somatic and psychological symptoms in the background of loss of semen. Surprisingly, patients have their first contact with departments other than psychiatry, for example urology, dermatology and general medicine, and are then referred to psychiatry. We presented our first observations from northern India on dhat syndrome from patients presenting with weakness, anxiety symptoms with sexual difficulties such as premature ejaculation and impotence (Behere & Nataraj, 1984). In further work by myself and others in the southern part of India, we were able to observe that the belief underlying dhat syndrome had a dimensional impact in clinical practice. While it was common to find anxiety and phobic symptoms, it was also extended to encompass hypochondriacal, obsessive and body dysmorphic symptoms. Affective symptoms were also common. Uncommonly, some patients presented with delusional beliefs. Thus, from a clinical perspective, the symptoms in dhat syndrome may cluster to give a spectrum of diagnostic possibilities ranging from anxiety to somatoform disorders, affective disorders and, rarely, psychosexual delusional disorder (further details available from the author on request). This multiplicity of clinical presentation makes it difficult to classify dhat syndrome purely as neurotic. We question the validity of dhat syndrome being incorporated as a single neurotic disorder in ICD–10, where it is included under ‘other specific neurotic disorders’ (F48.8; World Health Organization, 1992). No single diagnosis encompasses the clinical presentation of dhat syndrome; the presentation of symptoms needs to be seen from a clinical perspective rather than viewing it as a neurotic disorder alone. This might help to formulate the management comprehensively on a biopsychosocial model depending upon its clinical presentation.