Dhat syndrome: Evolution of concept, current understanding, and need of an integrated approach

Dhat Syndrome: Epidemiology, Risk Factors, Comorbidities, Diagnosis, Treatment, and Management

Dhat syndrome is a culture-bound psychiatric syndrome most commonly found in the Indian subcontinent. It has been characterized as the experiential fear of losing semen through ejaculation, nocturnal emission, or other means. While Dhat syndrome is common in the Indian subcontinent, given the lack of representativeness, generalizability, and closer connection to Ayurvedic system, there have been limited studies or recognition of symptoms among healthcare providers around the world. In this review, we describe Dhat syndrome, its epidemiology, risk factors, comorbidities, diagnosis, treatment, and its management. For patients with Dhat syndrome, it becomes important to appreciate how generalized depression and anxiety may persist alongside the disorder and those symptoms can be common and non-specific. Related to its strong cultural connection with South Asia such as the belief on Dhat's role in health and vitality influence, it also becomes important to recognize that the syndrome can be found in other populations and the importance of cultural humility and nonconfrontational approach for patient care. In summary, this review provides an informative understanding of Dhat syndrome for non-Indian clinicians who may not be prepared for a patient encounter with vague somatic symptoms in the context of semen loss. Treatment for Dhat syndrome is the same as treatments for major depressive disorder.

Quality of Life and Disability in Patients with Dhat Syndrome: A Cross-Sectional Study

BACKGROUND

Dhat syndrome (DS) is considered a culture-bound syndrome of South East Asia. It is often associated with multiple sexual and psychiatric comorbidities. We aimed to assess the quality of life (QoL) and disability in patients of DS with and without comorbidity.

METHODS

This cross-sectional study included 117 patients with DS and 117 matched controls. DS was diagnosed based on the International Classification of Diseases, 10 version, Diagnostic Criteria for Research diagnostic criteria. Comorbidities were assessed on MINI 6.0.0, and the patients were divided into two groups (with and without comorbidity). The QoL and disability were estimated and compared between patients with and without comorbidity and their respective control groups consisting of healthy volunteers, using standardized tools.

RESULT

Most of the patients were unmarried males aged 18 to 25 years and from rural backgrounds. Most of the patients (72.64%) had comorbidities (psychiatric/sexual). The QoL of patients with DS was poor compared to healthy individuals. The QoL of patients with comorbidity was worse than that of those without them (P < o.ooo). The disability of patients with DS was more than that of healthy individuals (significant in all domains of the World Health Organization Disability Assessment Schedule [WHODAS]).

CONCLUSION

Patients having DS had poor QoL and higher disability than healthy controls. Patients having psychiatric or sexual comorbidities had less QoL and higher disability compared to healthy controls and those without comorbidities.

Dhat syndrome: Systematic review of epidemiology, nosology, clinical features, and management strategies

BACKGROUND

Dhat syndrome is a culture-bound syndrome prevailing in the Indian subcontinent, first described in the 1960s. Over time, newer studies are exploring various aspects of Dhat syndrome, including its epidemiology, nosology, clinical features, and management predominantly in South Asia. We aimed to review the epidemiology, nosology, clinical presentation, and management of Dhat syndrome over the last six decades through a systematic review of studies.

METHODS

We searched PubMed and Scopus using the following search terms - "Dhat syndrome," "Semen loss syndrome," "Semen loss anxiety" together with the Boolean operator OR. We collected the articles from inception till March 2021. We included articles in the English language published in peer-reviewed journals.

RESULTS

A total of 89 articles were included in the analysis. Most of the articles were published in the last decade (2011-2020). Most of the publications were cross-sectional studies and of unsatisfactory quality. Most of the studies lack representativeness of the population; hence the generalizability of the findings was poor. Most of the articles discussed phenomenology (64%), overview (52.8%), and cultural basis of Dhat syndrome. The comorbidities associated with Dhat syndrome were discussed in 37.1% of the articles. The nosological status of Dhat syndrome and management of Dhat syndrome was discussed in 18% of publications each; whereas, the outcome of Dhat syndrome was discussed in 5.6% of articles.

CONCLUSION

Though Dhat syndrome is a commonly diagnosed entity in the South Asian population, the research on Dhat syndrome is sparse and of poor quality.

A Bibliometric Analysis of Dhat Syndrome

Dhat syndrome is a culture-bound syndrome, mostly prevailed in South East Asia that has been systematically defined approximately six decades ago. Assessment of the published literature would help to identify the research density as well as the gaps. We aim to do a bibliometric analysis of published global scientific literature on dhat syndrome. The Scopus database was systematically searched by using the keywords “Dhat syndrome”, “Semen loss syndrome”, “Semen loss anxiety” from inception to 11th August 2021. A total of 89 articles on dhat syndrome were found in the Scopus database. Most of the articles were from India and were published in the Indian Journal of Psychiatry and Asian Journal of Psychiatry. The majority (>58%) of research on dhat syndrome was published in the last decade. The PGIMER (Chandigarh), AIIMS (New Delhi) & KGMU (Lucknow) are the leading institutes in dhat syndrome research. The year 2004 had the highest number of total citations (n = 135), while the year 1975 had the highest number of citations per article (60 citations per article). This bibliometric review identified that despite dhat syndrome is a common condition in the South East Asian countries, research on the condition is limited.

Distress Due to Nonpathological Vaginal Discharge: A New Face of Dhat Syndrome in Females

Female Dhat syndrome (FDS) is not yet an established clinical entity, but nonpathological vaginal discharge has been discussed in the scientific literature for quite a long time. Various studies have reported the existence of the phenomenon of nonpathological vaginal discharge. All the existing literature on Dhat syndrome was reviewed. Studies have reported that nonpathological vaginal discharge has a high prevalence among the rural and urban populations of Indian women (around 30%). The symptom of vaginal discharge has been an area of concern for a sizable proportion of women in the community, and anxiety related to this has been a frequent reason to seek medical attention. The ideas associated with vaginal discharge are similar to Dhat syndrome in males. The variations of associated symptomatology, course of illness, and somatization of the complaint make it challenging to diagnose and treat. The diagnostic criterion needs careful evaluation; management needs an appropriate multidisciplinary approach by various health team members, including psychological interventions and adjunct pharmacotherapy in effectively managing the FDS. Dhat syndrome in females has similar phenomenology to that in males. Unfortunately, this is under-researched and hence, underdiagnosed.

History and mystery of Dhat syndrome: A critical look at the current understanding and future directions

Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses. Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr. N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as "a culturally determined idiom of distress." It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients. The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.

Dhat Syndrome: A Review and Update

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.

Cultural aspects of anxiety disorders in India

Cultural factors have influenced the presentation, diagnoses, and treatment of anxiety disorders in India for several centuries. This review covers the antecedents, prevalence, phenomenology, and treatment modalities of anxiety disorders in the Indian cultural context. It covers the history of the depiction of anxiety in India and the concept of culture in the classification of anxiety disorders, and examines the cultural factors influencing anxiety disorders in India. We review the prevalence and phenomenology of various disorders, such as generalized anxiety disorder, panic disorder, social anxiety, and phobic disorder, as well as culture-specific syndromes such as dhat and koro in India. Finally, the review examines the wide range of therapeutic modalities practiced in India, such as faith healing, psychotherapy, ayurveda, psychopharmacology, Unani medicine, homeopathy, yoga, meditation, and mindfulness. We conclude by emphasizing the significance of cultural factors in making relevant diagnoses and offering effective and holistic treatments to individuals with anxiety disorders.

Where Lies the Fault in Diagnosing Dhat Syndrome among Females? Understanding through a Case Study

Dhat syndrome is a culture-bound syndrome of South-East Asia, common in young men. However, similar entity has also been described in female patients who attribute their symptoms to nonpathological or physiological vaginal discharge. The current diagnostic system for psychiatric illnesses does not encompass Dhat syndrome in females, and so these group of patients receive alternative diagnoses such as somatoform disorder or depression. As a result of which the focus of unique Dhat syndrome-centered management gets weakened, affecting the clinical outcome. This case study focuses on the diagnostic dilemmas related to Dhat syndrome in females and pitfalls in the current diagnostic system.

Cultural aspects of anxiety disorders in India

Cultural factors have influenced the presentation, diagnoses, and treatment of anxiety disorders in India for several centuries. This review covers the antecedents, prevalence, phenomenology, and treatment modalities of anxiety disorders in the Indian cultural context. It covers the history of the depiction of anxiety in India and the concept of culture in the classification of anxiety disorders, and examines the cultural factors influencing anxiety disorders in India. We review the prevalence and phenomenology of various disorders, such as generalized anxiety disorder, panic disorder, social anxiety, and phobic disorder, as well as culture-specific syndromes such as dhat and koro in India. Finally, the review examines the wide range of therapeutic modalities practiced in India, such as faith healing, psychotherapy, ayurveda, psychopharmacology, Unani medicine, homeopathy, yoga, meditation, and mindfulness. We conclude by emphasizing the significance of cultural factors in making relevant diagnoses and offering effective and holistic treatments to individuals with anxiety disorders.