An Unusual Presentation of Dhat Syndrome

To the Editor: Dhat syndrome is considered a culture-bound syndrome (CBS) specific to the Indian subcontinent. Dhat derives from the Sanskrit word “dhatu,” meaning “metal” and, also, “elixir.”¹ In this condition, the individual ascribes the symptoms of weakness, fatigability, sexual dysfunction, and loss of virility and vitality due to the loss of valuable body fluid through urine/nocturnal emission or masturbation.²

We present an unusual case that presented with anal secretions that were labeled as “dhat.” Also, we aim at highlighting the limitation of the current nosological systems because of exclusion of CBS from the main diagnostic categories.

Case Description

“Mr. K.K.,” a 23-year-old “matriculate pass,” unmarried man from a rural background presented to the outpatient clinic with complaints of extreme fatigue, physical weakness, vague body aches, inability to work, impaired concentration, and erectile dysfunction for the past 3 months. These symptoms were associated with significant impairment in social and occupational functioning. He attributed these symptoms to the intermittent and repeated loss of a colorless, sticky fluid material through his anus whenever he would stand for long time or do strenuous work, and immediately after urination or resolution of erection. He would find a sticky, colorless material in the peri-anal region, which did not smell foul and was not associated with local itching. The patient was not sure of its nature or composition, but would remain preoccupied and worried about it, as he believed that he was losing something vital from his body, which resulted in physical and mental weakness. The little knowledge he had about sex was gained through local media and listening to elders. The patient believed that any secretion in and around the genital and anal region was the source of his vitality and virility.

The patient had experienced similar symptoms 2 years earlier. At that time, he attributed these symptoms to the loss of a white unknown material in his urine. The patient consulted a traditional healer and was told that his problems were due to loss of vitality through urine. At that time, he took traditional treatment and got relief within 2 months. Failing this treatment in the current episode, he consulted the surgical outpatient department, where a thorough physical examination and investigations revealed no physical abnormality.

The patient was diagnosed as having dhat syndrome (F48.8, per ICD-10). He had significant anxiety and depressive symptoms, and scored 12 and 14 on the Anxiety and Depression subscales, respectively, on the Hospital Anxiety and Depression Scale (HADS). He had poor knowledge and many misconceptions related to sexual issues and semen. When assessed with the Sex Knowledge and Attitude Questionnaire, he had a knowledge score of 8 (out of 35) and attitude score of 27 (out of 60). The patient was counseled and received psycho-education on sexual issues. We attempted to clarify his doubts and misconceptions. He was educated about the nature, formation, and secretion of semen and other normal body secretions. To allay his depression and anxiety, he was prescribed venlafaxine tablets 150 mg per day in two divided doses. The patient reported significant improvement over the next 4 weeks. He went back to work, but was lost to follow-up for unknown reasons.

Discussion

The case is an unusual presentation of dhat syndrome. The route of loss of vital fluid (dhat) in dhat syndrome is usually through the penis (either mixed in urine or through nocturnal emission). However the present case reported the discharge through the anus as dhat. However, the clinical features were in keeping with the typical presentation of the syndrome.

Dhat syndrome seen most commonly among young men age 20–38 years. The main complaint is a whitish discharge in urine that is interpreted as semen loss. Prevalence rates of 11.7% and 30% have been reported from India and Pakistan, respectively.³ A combination of antianxiety and antidepressant medication, together with counseling and cognitive-behavioral therapy, has been found to be effective in management of the condition.

In the current case, the whitish discharge in the peri-anal region was described by the patient as dhat. This unusual presentation reflects the knowledge and erroneous belief of the patient.

As described above, ICD-10 has included dhat syndrome in chapter F4.⁴ However, DSM-IV does not include the CBS in the main text. These conditions have been presented in the Appendix section of DSM-IV.⁵

If one looks at such cases in the context of DSM-IV, there could be two approaches. The first, rather oversimplistic, and currently the more acceptable one, would mean a referral to the glossary section of the DSM-IV (Appendix I) and a making a diagnosis of culture-bound syndrome, as described there. This would mean a label (of dhat syndrome in the current case) and management in terms of a disorder that is restricted to some specific cultures; hence, using a rather under-studied and under-researched and practically nonexistent management modalities. Such a diagnosis would subsume the associated features of extreme fatigue, anxiety, physical weakness, vague body aches, inability to work, impaired concentration, and erectile dysfunction.

The other approach, a more logical one being advocated by the authors, would mean due consideration of the anxiety and the depressive symptoms present in this case. Using this approach, one would consider the possibility of an underlying depressive disorder or an anxiety disorder or a combination thereof, that is, mixed anxiety and depressive disorder, depending on the predominance of the symptoms. A definitive diagnosis of this nature would involve awareness on the part of the clinician and thus a dedicated search for these psychiatric conditions. The patient presented above scored high on the Anxiety and Depressive symptoms of the HADS. The presence of the bodily symptoms in such cases would mean a manifestation of the underlying functional depressive/anxiety/behavioral syndromes or attributions on the part of the patients. This has been the case with the masked depression and somatic presentation of the mood symptoms as reported by other workers—concepts well accepted today. Such an approach would mean consideration of the associated mood and anxiety symptoms and, subsequently, use of more extensively researched intervention strategies for the management of these conditions.

We present an argument for reconsideration of labeling of such syndromes as culture-bound syndrome.⁶ The current presentation also highlights a need to widen the approach to such conditions and their inclusion in mainstream nosological systems, with appropriate relabeling.