A study of Dhat syndrome- a culture bound syndrome in Nepalese context

Introduction: Dhat syndrome is generally believed to be a culture-bound which is characterized by excessive preoccupation with loss of "Dhat", which is generally taken to be representing semen. The study evaluated the symptoms of patient with Dhat syndrome visiting three mental health clinics of Rupandehi district.Material and Method This descriptive cross- sectional study was conducted in three different Psychiatry outpatient clinics at Rupandehi district of Nepal. Purposive sampling, a type of non-random sampling was utilized for the study. A total 50 patients with Dhat syndrome were enrolled in the study. A semi-structured Performa containing socio-demographic and Dhat syndrome symptoms related information was filled by respondents after providing written informed consent.Results: The patients were predominantly young adults, male with mean age of 23.1±4.6. Majority of them were in age group 18-25 years, hindu by religion, living in non-urban areas, family income of 5000-10000 per month, literate and unmarried. A range of psychological and somatic symptoms associated with Dhat syndrome were revealed. Most common symptoms found in the study were excessive worries (96%), tingling sensation of body (86%), weakness (80%), decrease interest (80%), fatigue (76%), depressed mood (74%), and generalized body ache (72%).Conclusion: Dhat syndrome presented with a range of psychological and somatic symptoms. Any male patient presenting with multiple somatic symptoms must be evaluated for Dhat syndrome and the physician must enquire about the semen loss and the associated beliefs.J Psychiatrists’ Association of Nepal Vol .6(1), 2017, p.33-37


INTRODUCTION
The term Dhat syndrome was first used by Wig in 1960 to describe a culture bound sexual neurosis, for patients preoccupied with the excessive loss of semen by nocturnal emissions or in urine. 1 Both ICD-10 Classification of Mental and Behavioural Disorders (ICD-10) 2 and Diagnostic and statistical manual of mental disorders (DSM-5) 3 classified Dhat syndrome as neurotic disorder and culture specific Disorder respectively relating to loss of semen.][6][7][8][9][10][11] Most of the studies related to Dhat syndrome have been done in India, however, its concept has been also described in western cultures. 5Apart from Indian studies, a study done in Pakistan reported that about 30 % of the subjects complained of Dhat and the prevalence of Dhat was equal in patients with functional and organic diagnosis.
12 Similarly another study done on treatment seeking pattern of subjects with Dhat syndrome in Lahore found out about 50% of the subjects sought help from traditional healer (Hakims). 13In studies from Sri Lanka, Dhat syndrome has been reported in many patients, of them approximately half had somatic symptoms. 14,15Recent study by Grover and his colleagues 10 revealed range of psychological and somatic symptoms in patients with Dhat syndrome that include weakness; low energy; feeling down, depressed or hopeless; lack of interest or pleasure in doing things; mental weakness; anger; irritability; excessive worry; pain in arms, legs or joints (knees, hips, etc.), and disturbed sleep.This study aims to find out psychological and somatic symptoms experienced by patient with Dhat syndrome.The belief may also be accompanied by anxiety or depressive symptoms and the patient may present with or without sexual dysfunction. 17

MATERIAL AND METHOD
This descriptive cross-sectional study was conducted in three different Psychiatry outpatient clinics at Rupandehi district of Nepal.The study sample comprised a total of 50 male patients.Purposive sampling, a type of nonrandom sampling was utilized for the study.The male patients of age of 18 years and above presenting in our clinics with symptoms consistent with Dhat syndrome were screened by pre-defined criteria.Patients who fulfilled the ICD-10 2 diagnosis of Dhat syndrome were included in the study.Exclusion criteria of the study were existence of mental retardation /intellectual disability, psychotic illness, organic mental disorder, and physical cause for discharge per urethra.After obtaining written informed consent from participants, semistructured Performa which covered the sociodemographic and Dhat syndrome related questionnaire was provided to all participants.Data were entered manually into statistical package for social science (SPSS-20) and then it was analyzed by using descriptive statistics in term of frequency and percentage.Interpretation of the study was done on the basis of analyzed data using tables.

RESULT
The sample consisted of 50 male patients with mean age of 23.1±4.6.Table 1 explored the socio-demographic profile of respondents in which majority of them were in age group 18-25 years, Hindu by religion, living in non-urban areas, family income of 5000-10000 per month, literate and unmarried.Existing researches suggest that Dhat syndrome is more common in those residing in rural areas. 19,20 indings of the present study also support the same in which 82% respondents were living in non-urban areas.Low education was found to be associated with Dhat syndrome in many past studies which was also in concordance with our study findings.However, some studies found Dhat syndrome among people with all educational level. 10Further study in diverse population with an appropriate sample size could explore the association of Dhat syndrome and education level.Majorities of respondents' (72%) family income in our study was less than 10,000 rupees a month and had low socioeconomic status.Past studies revealed concordance findings and have reported that patients with Dhat syndrome more commonly belonged to lower socioeconomic status. 19,20 n contrast, Grover and his colleagues found Dhat syndrome among people belonging to middle socioeconomic status . 10ere is clear evidence that patients with Dhat syndrome have various accompanying psychological and somatic symptoms. 10,20,21 onsidering all past studies including our study, it is clear that a number of psychological and somatic symptoms were exhibited by patient with Dhat syndrome.Detail evaluation for co-morbidities such as depression, anxiety disorder, somatoform disorder and psychosexual disorder is essential to decrease associated morbidity and mortality.Presence of sexual co-morbidity is quite common among patients with Dhat syndrome. 10However; our study did not include sexual related symptoms among study participants.The findings our study is limited by the number of symptoms evaluated and limited sample size.The symptoms of patient with Dhat syndrome obtained as part of this study was limited to the content of the questionnaire used.It is quite possible that the questionnaire may not include some of the symptoms.The study was not based on use of qualitative method of assessment.The use of qualitative methods could have expanded the list further for assessment of various symptoms.Sample was taken from patients seeking clinical consultations at mental health clinics; therefore, results could not be generalized to other group of patients.

CONCLUSION:
Dhat syndrome presented with a range of psychological and somatic symptoms.Any male patient presenting with multiple somatic symptoms must be evaluated for Dhat syndrome and the physician must enquire about the semen loss and the associated beliefs.

CONFLICT OF INTEREST:
The authors report no conflicts of interest in this work, and are solely responsible for the content and writing of this paper.No funding has been received for this work.