Acra Psychiatr Scand 1996: 94: 163-167 Prinred in U K - all rights reserved

Co~vrieht 0 Munkspaard 1996 ., Y

ACTA PSYCHIATRICA SCANDINAVICA ISSN 0001-690X

The ‘Dhat syndrome’: a culturally determined symptom of depression?

Mumford DB. The ‘Dhat syndrome’: a culturally determined symptom of depression? Acta Psychiatr Scand 1996: 94: 163-167. 0 Munksgaard 1996.

The status of the ‘Dhat syndrome’ is called into question by the results of an epidemiological study of men attending general medical clinics in Lahore. The Dhat complaint was reported by 30% of men attending medical clinics, and to an equal extent by patients with ‘functional’ and ‘organic’ diagnoses. It was strongly associated with depressed mood, fatigue symptoms, and a DSM-111-R diagnosis of depression. It is argued that the Dhat complaint should be primarily regarded not as the focus of a culture-bound syndrome, but as a culturally determined symptom associated with depression.

Introduction

The ‘Dhat syndrome’, a term coined by Wig in 1960, is regarded as a culture-bound sex neurosis widely prevalent in the Indian subcontinent (14) . The word dhat (semen) is derived from the Sanskrit word dhatu, meaning the basic or essential ele- ments which constitute the body, or the elixir of life. The pathognomonic feature of the ‘Dhat syn- drome’ is the belief that semen is being lost, and it is almost always thought to be passed in the urine. The man may describe a whitish discharge in the urine, although there is no objective evidence of such a discharge. Sometimes the sufferer may complain that the semen has become foul-smelling and less viscous (5) .

The ‘Dhat syndrome’ has a long history in Indian culture. An ancient treatise on Indian medicine, Charak Samhita, described a disorder resembling the Dhat syndrome called Shukrameha (spermatu- ria). In Ayurvedic medicine, loss of semen in any form is considered to lead to depletion of physical and mental energy (6). However, the Dhat com- plaint is not confined to Hindus, but is widespread in all communities of the Indian subcontinent; it has been reported among Sikhs in the Punjab (3,7), Buddhists in Sri Lanka (8), and Pakistani Muslim expatriate workers in the Gulf States (9). Beliefs about the dangers of semen loss are not unique to Indian culture, and there were interesting parallels in Victorian Britain (10, 11).

The ‘Dhat syndrome’ has more recently acquired further international recognition by being included

D. B. Mumford Department of Mental Health, University of Bristol. Bristol, UK

Key words: culture-bound syndrome; sexual dysfunction; semen; Dhat syndrome; depressive disorder

David B. Mumford. Department of Mental Health, University of Bristol, 41 St Michaels Hill, Bristol BS2 8DZ. UK

Accepted for publication January 6. 1996

in Annex 2 (culture-specific disorders) of the ICD- 10 Diagnostic Criteria for Research (12). The pre- amble of Annex 2 states the need for research to clarify the clinical descriptions of these proposed culture-specific disorders and for more reliable epidemiological information.

The ‘Dhat syndrome’ is usually said to consist of the complaint of loss of semen in association with multiple somatic symptoms, hypochondriasis, fatigue, physical weakness, anxiety, loss of appetite, guilt, and sometimes impotence or premature ejac- ulation (1). The ‘syndrome’ is reported to be more common in recently married men, in men of lower socio-economic status, in rural areas, and in men who belong to a family that has conservative attitudes towards sex (2, 5 , 7).

There have been several empirical studies of the ‘Dhat syndrome’ in hospital clinics in India. Behere and Nataraj (2) studied SO men, mostly of lower socio-economic status, who presented at a psychi- atric out-patient clinic in Varanasi with complaints of ‘Dhat’ discharge. In 90% of cases there were associated problems, including physical weakness, hypochondriasis, anxiety, impotence or premature ejaculation.

Singh (3) studied SO men with potency disorders who were attending a psychiatric clinic in Patiala, after excluding those with a primary psychiatric diagnosis. Two-thirds of the patients complained of Dhat as a major symptom. Singh found a strong association between the ‘Dhat syndrome’ and

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depressed mood rather than anxious mood. Over- all, 68% of the men in his sample received an additional psychiatric diagnosis, mostly of depres- sive illness. He commented that belief in loss of semen would be expected to produce a sense of grief. He also reported that a high proportion of his sample was literate and relatively well educated.

Chadda and Ahuja (6) found that 21 of 52 patients presenting with the Dhat symptom in their psychiatric clinic in Delhi received a diagnosis of neurotic depression, and 19 of these patients were diagnosed with anxiety neurosis; only seven patients received a simple diagnosis of Dhat syn- drome. However, these authors continue to regard the syndrome as ‘a sex neurosis of the Indian subcontinent’.

Bhatia and Malik (4) studied 93 men who reported the Dhat symptom, from a consecutive sample of 144 men with psychosexual disorders who were attending a psychiatric clinic in Delhi. The commonest associated psychiatric illness was neurotic depression. The ‘Dhat syndrome’ com- monly included weakness, fatigue, palpitations and poor sleep; impotence or premature ejaculation occurred frequently. Bhatia and Malik (4) claim that their study ‘supports the diagnostic status of Dhat syndrome in Indian culture’. However, their study would appear to raise doubts about the status of the Dhat complaint as a separate syndrome. What it shows is that the complaint of semen loss in the urine is very common among men presenting with psychosexual problems, and has a substantial overlap with impotence and premature ejaculation. The Dhat complaint is also strongly associated with depressive illness.

The present paper explores an alternative hypothesis, that the ‘Dhat syndrome’ is not a discrete syndrome at all, but a symptom associated with emotional distress in men. It is an ancient belief in Indian culture that the vital energy of a man resides in his semen ( 3 ) ; a combination of fatigue and loss of energy, perhaps together with urinary symptoms, might well give rise to the overvalued idea that semen is being lost in the urine. Previous studies have been based on men who present with the Dhat complaint in psychiatric or psychosexual clinics, and are therefore a self- selected population. The data analysed in the present study is derived from an epidemiological study of somatic symptoms among general medical clinic attenders in Pakistan, who were not selected for sexual or psychiatric problems.

This paper presents data which indicate how common the Dhat complaint is among men in Pakistan who do not present with psychosexual problems. How is the Dhat complaint related to psychiatric disorders such as anxiety states and

depressive illnesses? Does it show any characteris- tic socio-cultural correlates? In short, does the ‘Dhat syndrome’ deserve the status of a discrete syndrome, or is it best regarded as a culturally based symptom associated with emotional distress?

Material and methods

The data reported here were obtained from previ- ous studies of patients attending general medical clinics at Mayo Hospital, Lahore, Pakistan (13, 14). The Bradford Somatic Inventory (BSI) (15), a comprehensive inventory of ‘functional’ somatic symptoms, was administered in Urdu to 600 literate patients, and the physician’s diagnosis was recorded independently. The frequency of reporting of the Dhat symptom was calculated for the 394 men among the 600 patients who attended these clinics. Correlations between the Dhat item and other somatic symptoms in the BSI were obtained. A factor analysis was performed on data from patients without an organic diagnosis in order to determine to which cluster of symptoms the Dhat item belonged. The reporting of the Dhat symptom was also analysed in relation to age, educational level and occupation. Subsequently, a further 60 patients were recruited from the same clinics and interviewed by a psychiatrist who made a formal diagnosis according to the Diagnostic and Statistical Manual of the American Psychiatric Association

The Bradford Somatic Inventory (15) is a 46- item inventory of somatic symptoms reported by anxious and depressed subjects in the UK and the Indian subcontinent. BSI items were obtained from hospital case notes of Pakistani patients in Pesha- war and UK patients in Yorkshire who had been given clinical diagnoses of anxiety, depression, hypochondriasis or conversion hysteria. Two BSI items relate to sexual complaints in men: ‘Have you felt that you have been passing semen in your urine? and ‘Have you had difficulty getting full erection?’ Each BSI item has a three-choice response format: absent (score 0); present on less than 15 days during the previous month (score 1); and present on more than 15 days during the previous month (score 2).

The relationship between the Dhat symptom and formal psychiatric diagnoses was explored among the further 60 patients who were inter- viewed by a psychiatrist and who also completed the Hospital Anxiety and Depression Scale (HADS) (17) in a validated Urdu version (18). The HADS was designed for use among patients attending a general hospital; since it excludes somatic symptoms, there is no overlap of item content with the BSI.

(DSM-III-R) (16).

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Results

Of 394 male attenders at the medical clinics, 117 men (30%) endorsed the Dhat item of the Brad- ford Somatic Inventory. Of these, 55 men (14%) reported that they had experienced this symptom on more than 15 days during the previous month. There was no difference in the frequency of report- ing of the Dhat symptom between patients who received an organic diagnosis from the physicians (68 of 223 patients: 30%) and those who received a functional diagnosis or no diagnosis (51 of 171 patients: 30%).

The men who endorsed the Dhat item reported a much greater number of other BSI symptoms (mean 24.1, SD 8.8) than those who did not endorse the Dhat item (mean 16.2, SD 9.1); this difference was highly significant (t=7.94, P<O.OOl). The strongest correlations with other BSI symptoms (>0.25) were found with item 45 (‘Have you had difficulty getting full erection?’: p=0.32), item 40 (‘Have you had a burning sensation when passing urine?’: p=0.32), item 27 (‘Have you been feeling tired, even when you are not working?’: p=0.30), and item 10 (‘Have you felt a lack of energy (weakness) much of the time?’: p=0.29). These correlations were highly significant (P<0.001).

A principal-components analysis was carried out on the BSI responses of the 171 male patients who presented at these medical clinics without evidence of physical disease, using the same method as Mumford et al. (15). Applying the scree test (19) to the plot of eigenvalues, the change in the gradient suggested the extraction of six factors. Following varimax rotation, four of the factors corresponded closely to those obtained in the previous factor analysis: ‘head’, ‘abdomen’, ‘chest/ heart’ and ‘fatigue’. The Dhat item (BSI item 46) had a loading on the fatigue factor of 0.49; its loadings on the other three factors were each less than 0.20.

Of 394 men who were attending the medical clinics, the mean age of those reporting the Dhat symptom (31.1 years) was lower than that of men who did not report this symptom (34.0 years), but this difference was not statistically significant (t=1.75, P=0.08). There was no significant differ- ence in the mean number of years of education received by men who reported the Dhat symptom (10.2) and men who did not report it (10.6). With regard to occupation, the proportion of men reporting the Dhat symptom did not differ signifi- cantly between the professional, skilled and unskilled groups (3 x 2 Chi-square=0.55; NS).

Of the 60 patients in the second sample of medical clinic attenders who were interviewed by a psychiatrist, 30 patients were male. Ten men

(33%) endorsed the Dhat item of the BSI, and of these, three men (10%) reported that they had experienced this symptom on more than 15 days during the previous month. The Dhat item was endorsed by seven out of 15 men with a DSM-III- R psychiatric disorder (47%), and by two out of 14 men with no psychiatric diagnosis (14%). Due to the small numbers involved, this difference did not reach the level of statistical significance (Chi- square with Yates correction=2.24, P=0.13). The Dhat item was endorsed by a higher proportion of men with DSM-111-R depressive disorders (four out of six: 67%) than of men with DSM-111-R anxiety or panic disorders (three out of nine: 33%).

All but one of the 30 men completed the Hospi- tal Anxiety and Depression Scale in Urdu. The mean HADS depression score of men who reported the Dhat symptom (8.7) was very signifi- cantly higher than that of men who did not report it (5.1) (t=7.63, P=O.Ol). However, there was no significant difference between the mean HADS anxiety score of men who reported the Dhat symptom (8.8) and that of men who did not report it (9.1) (t=0.01, P=0.91).

Discussion

The principal findings of this epidemiological study of the Dhat complaint among men attending gen- eral medical clinics in Pakistan were as follows. First, 30% of attenders reported having the Dhat symptom during the previous month, and half of them reported having it on more than 15 days during the past month. The incidence was the same in patients who received an organic diagnosis from the physicians and in those who received a func- tional diagnosis or no diagnosis. Secondly, the reporting of the Dhat symptom correlated most strongly with four BSI items: erectile difficulty, burning sensation when passing urine, tiredness even when not working, and weakness or lack of energy. In a factor analysis of the BSI responses of functional patients, the Dhat symptom formed part of the fatigue factor. Thirdly, men reporting the Dhat symptom had much higher HADS depression scores than those who did not report it, but there was no difference in HADS anxiety scores. Four out of six men who fulfilled the DSM-111-R criteria for major depression or dysthymia endorsed the Dhat item on the BSI.

There were no significant socio-cultural corre- lates that differentiated men who reported the Dhat symptom from others who were attending these medical clinics. There was a trend towards a lower average age, but no association with level of education or occupational group. The previously reported association with younger age, low social

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status and rural background may reflect selection factors in those studies. However, this was a literate urban sample of individuals from the lower and lower-middle socio-economic classes, and differ- ences might have emerged if men from a rural population had been included.

It is interesting that the rate at which the Dhat symptom was reported was the same in patients who received an organic diagnosis from the physi- cians as in those who received a functional diagno- sis or no diagnosis. One possible explanation is that many physically ill patients experience fatigue and lack of energy, and some may fulfil the criteria for a psychiatric diagnosis of anxiety or depression. According to the hypothesis that the Dhat com- plaint is a culturally based symptom associated with any emotional distress, physically ill men would be as likely to report the Dhat item as those with formal psychiatric disorders. It is less likely that all of these men with physical illnesses also had a primary sexual neurosis.

On the evidence of the present study, the Dhat complaint is specifically associated with depressed mood (as measured by the HADS depression scale) and with a DSM-111-R diagnosis of depres- sive illness. The reporting of the Dhat symptom was not related to HADS anxiety scores. This associa- tion with depression is consistent with the findings of Singh ( 3 ) and of Bhatia and Malik (4), and may explain the therapeutic success reported in the latter study when treating Dhat syndrome patients with antidepressant drugs.

Is the Dhat syndrome a useful diagnostic entity? Bhatia and Malik (4) claim that the Dhat syndrome is ‘a true culture-bound sex neurosis’. On the evidence of this study, the status of the Dhat complaint as a syndrome is highly uncertain. A syndrome is a ‘running together’ of several symp- toms in a disease entity. It should be possible to develop formal criteria for diagnosis and clear boundaries separating it from other pathological conditions.

The Dhat complaint is reported by one-third of men attending these medical clinics, the frequency being the same in men with and without diagnosed physical illness. It is strongly associated with fatigue symptoms and with depressed mood. The Dhat complaint does not occur in a distinctive cluster of somatic and psychological symptoms which might distinguish it from other psychiatric disorders. It would certainly seem far-fetched to include all those men with depression and fatigue under the diagnostic category of ‘primary sex neurosis’.

It would appear to me to be more appropriate to regard the Dhat complaint, which commonly occurs among men from the Indian subcontinent, as a culturally determined symptom of depression.

The symptom arises out of the cultural belief that the vital energy of a man resides in his semen. For depressed men who experience fatigue and loss of energy, and perhaps also loss of libido and erectile difficulty, the Dhat symptom provides a ready- made explanation for their condition. They feel that their vital energy and sexual energy are drain- ing away, and they believe that this is because they are losing semen in their urine.

The Dhat complaint may still be a useful diag- nostic concept, not as a syndrome but as a symp- tom. Four out of six men who fulfilled the DSM- 111-R criteria for depression endorsed the Dhat item on the BSI, whereas only two of the 14 men with no psychiatric diagnosis did so. Alternatively, taking as ‘cases’ those men who scored 8 or more on the HADS depression scale, seven out of 12 men endorsed the Dhat item on the BSI, but only three out of 16 ‘non-cases’ did so. This is equivalent to a sensitivity of 58% and a specificity of 81%. In other words, the absence of the Dhat symptom does not exclude depressive illness, but its presence is quite strongly suggestive of depression. Routine enquiry about the Dhat symptom would therefore seem to be a useful screening item for depressed mood among men from the Indian subcontinent

Acknowledgements

The author thanks Professor I.A.K. Tareen and other col- leagues at King Edward Medical College and Mayo Hospital, Lahore, Pakistan, who helped to collect the original data in medical clinics.

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