Phenomenology and beliefs of patients with Dhat syndrome: A nationwide multicentric study

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1 591857ISP / International Journal of Social PsychiatryGrover et al. research-article2015 Article E CAMDEN SCHIZOPH Phenomenology and beliefs of patients with Dhat syndrome: A nationwide multicentric study International Journal of Social Psychiatry 1 10 The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalspermissions.nav DOI: / isp.sagepub.com Sandeep Grover 1, Ajit Avasthi 1, Sunil Gupta 2, Amitava Dan 3, Rajarshi Neogi 4, Prakash B Behere 5, Bhavesh Lakdawala 6, Adarsh Tripathi 7, Kaustav Chakraborty 8, Vishal Sinha 9, Manjeet Singh Bhatia 10, Amrit Patjoshi 11, TSS Rao 12 and Abhijit Rozatkar 13 Abstract Aim: To assess the phenomenology and associated beliefs in patients with Dhat syndrome. Methods: A total of 780 male patients aged more than 16 years were recruited from 15 centers spread across the country and were assessed on Dhat Syndrome Questionnaire. Results: The most commonly reported reasons for passage of Dhat were excessive masturbation (55.1%), sexual dreams (47.3%), excessive sexual desire (42.8%) and consumption of high energy foods (36.7%). The most common situation in which participants experienced passage of Dhat were as night falls (60.1%) and while passing stools (59.5%). The most common consequence due to passage of Dhat was weakness in sexual ability (75.6%). In terms of psychological and somatic symptoms, the common symptoms included bodily weakness (78.2%); feeling tired or having low energy (75.9%); feeling down, depressed, or hopeless (67.9%); and little interest or pleasure in doing things (63.7%). In terms of treatment expectations, about half of the patients (49.1%) expected that energizing medications like vitamins/tonics/ tablets were required and more than one-third (38.2%) expected that there was a need for taking energizing injections. Conclusion: Present study shows that Dhat syndrome is a distinct clinical entity seen all over India, with its characteristic features. Keywords Dhat syndrome, culture-bound syndrome, clinical picture, beliefs Introduction Dhat syndrome is a culture-bound syndrome which has been reported from many countries around the world, with majority of the literature emanating from India (Sumathipala, Sribaddana, & Bhugra, 2004). Some people argue that because of its wider geographic prevalence, Dhat syndrome should not be considered as a culture bound syndrome, but should be considered as a culturally determined idiom of distress (Sumathipala et al., 2004). Although there are a few reports from India (Behere & Natraj, 1984; Bhatia, 1999; Bhatia, Bohra, & Malik, 1989; Bhatia & Malik, 1991; Chadda & Ahuja, 1990; Dhikav, Aggarwal, Gupta, Jadhavi, & Singh, 2008; Grover et al., 2014; Jilek, 2000; Nakra, Wig, & Varma, 1977; Singh, 1985) with regard to the clinical features, associated beliefs, comorbid psychiatric disorders and sexual dysfunctions associated with Dhat syndrome, these studies vary in their findings depending on the method of assessment. The sample size of all these studies has been 50 or less (Behere & Natraj, 1984; Bhatia et al., 1989; Chadda & 1 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India 2 NIMS Medical College & Hospital, Jaipur, India 3 Calcutta National Medical College (CNMC), Kolkata, India 4 Medical College and Hospital (MCH), Kolkata, India 5 Jawaharlal Nehru Medical College, Wardha, India 6 B J Medical College & Civil hospital, Ahmedabad, India 7 King George s Medical University, Lucknow, India 8 College of Medicine & JNM Hospital, West Bengal University of Health Sciences (WBUHS), Kalyani, India 9 Sarojini Naidu Medical College, Agra, India 10 Guru Teg Bahadur hospital, University College of Medical Sciences, New Delhi, India 11 Hi-tech Medical College, Bhubaneswar, India 12 JSS Medical College, Mysore, India 13 Shaheed Hasan Khan Mewati Government Medical College, Mewat, India Corresponding author: Sandeep Grover, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh , India. drsandeepg2002@yahoo.com

2 2 International Journal of Social Psychiatry Ahuja, 1990; Dhikav et al., 2008; Grover et al., 2014; Jilek, 2000; Nakra et al., 1977), with occasional reports having a sample of more than 50 patients (Bhatia, 1999; Bhatia & Malik, 1991). The clinical picture reported across different studies has varied because of heterogeneity among the various studies in terms of symptoms coverage (Udina, Foulon, Valdés, Bhattacharyya, & Martín-Santos, 2013). Accordingly, there is a need to have large sample studies using uniform methodology to improve the understanding about this disorder. Recently, a self-rated questionnaire was designed to comprehensively assess the symptom profile, associated myths and beliefs related to treatment in patients with Dhat syndrome (Grover et al., 2014). In this background, this multicentric study aimed to assess the phenomenology and associated beliefs in patients with Dhat syndrome. Methodology This study was conducted across 15 centers in India. Ethical clearance was obtained from the Institute Ethics Committee of all the centers in which the study was conducted. Written informed consent was obtained from the patients prior to recruitment. The inclusion criteria for the study were age more than 16 years; able to read Hindi, English or one of the regional languages, that is, Punjabi, Kannada, Bengali, Oriya, Gujarati, Marathi, Tamil or Telugu. To be included in the study, the patients were required to fulfill the criteria for Dhat Syndrome as per 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria description (World Health Organization, 1992). According to ICD-10 description of Dhat syndrome, a person is considered to have Dhat syndrome if he is experiencing passage of whitish discharge in urine, which is interpreted as semen loss, has undue concern about the debilitating effects of passage of semen and has associated anxiety and somatic complaints such as fatigue and muscle pain, which are related to the fear of semen loss. Patients fulfilling this description of ICD-10 were recruited. However, in Indian setting, many patients report passage of Dhat in other situations too and do report the same syndromal description. These patients are also considered as having Dhat syndrome. Accordingly, this study was not limited to patients reporting passage of whitish discharge in urine only, but also included patients who reported passage of Dhat in other situations too, with or without passage of whitish discharge in urine. Patients with psychotic disorders, bipolar disorder, intellectual disability and organic brain syndrome were excluded. The study was initially started at the Post Graduate Institute of Medical Education and Research, Chandigarh, in January 2012 and was later extended to other centers from March 2014 to July The other participating centers were identified by the Investigators (first (S.G.) and second (A.A.) authors) taking into consideration the geographical region where the center is located in order to make the total study sample nationally representative, interest of the researchers in the subject of the study and their willingness to participate in the study. Initially, 19 centers were identified with 5 centers in North India, 2 centers in Central India, 4 centers in Eastern India, 5 centers in Southern India and 3 centers in Western India. However, finally 15 centers participated in the study. Among the centers which participated, 5 centers were in North India (Chandigarh, Jaipur, Faridkot, Mewat and New Delhi), 4 centers were from Eastern India (2 from Kolkata, 1 each in Kalyani and Bhubaneswar), 2 from Central India (Agra and Lucknow), 2 from Western India (Ahmedabad and Wardha) and 2 from Southern India (both at Mysore). Instruments ICD-10 criteria for various sexual dysfunctions. ICD-10 criteria were used to ascertain the presence of various comorbid sexual dysfunctions (World Health Organization, 1992). Dhat Syndrome Questionnaire. The questionnaire has multiple choice questions with yes/no responses and specific responses in various other rating formats, and open-ended questions covering various symptoms (duration of Dhat, frequency of passage of Dhat, quantity of Dhat passed each time, color and consistency of Dhat, associated somatic symptoms), beliefs/myths (content and composition, situation/time of passage of Dhat, cause of passage of Dhat, consequences of Dhat) and beliefs and behavior related to treatment (Grover et al., 2014). This questionnaire is reported to have adequate face validity. The original scale was designed in Hindi and was then translated to English. The Hindi and English versions have been shown to have good cross-language equivalence. The Hindi version has been shown to have good test retest validity, when completed by the same subjects on two separate occasions after few days. For this study, Hindi version of the scale was translated into Punjabi, Kannada, Bengali, Oriya, Gujarati, Marathi, Tamil and Telugu. For the translation purpose(s), World Health Organization (n.d.) methodology of translation and back translation was followed. For each translated version, initially, the Hindi version of the scale was translated into the particular language by three psychiatrists who were fluent in both the languages. Then these scales were reviewed by an expert group comprising of three mental health professionals and a consensus version was developed. The consensus version was sent to two experts who were not part of the original translation process for comparison of the translated version of the scale with the original version. Feedback obtained from the experts was provided to the psychiatrists who translated the scale and the scale was modified accordingly. The revised versions

3 Grover et al. 3 were again reviewed by the experts and any further modifications were suggested, and finally, the translated version was accepted. Initial pilot studies were done on two to three patients for the questionnaire in each language to ascertain the patient acceptability and their feedback was also considered. All the translation processes were done under the supervision of the researchers who developed the scale. Depending on the language, minor alteration in selection of words was allowed to suit the assessment in the local context. The questionnaire was translated into eight other regional languages other than Hindi and English. Procedure All the patients presenting to the psychiatrists and considered to have Dhat syndrome were approached and explained about the study. Those who provided written informed consent and fulfilled the selection criteria were evaluated further. The consenting patients were initially evaluated on ICD-10 criteria of Dhat syndrome, and those who fulfilled the ICD-10 description were considered further. They were evaluated by the investigators to ascertain the presence of comorbid psychiatric diagnosis by using ICD-10 criteria. Comorbid sexual dysfunction was assessed as per the ICD-10 criteria. Absence of comorbid physical disorder was ascertained on the basis of history provided, review of medical records, physical examination and investigations. Patients were asked to complete the Dhat syndrome evaluation questionnaire. In case the patient was not able to understand any of the questions, they were assisted by the investigators. Data with respect to the psychiatric comorbidity and sexual dysfunction of the study participants have already been presented in another manuscript (Grover et al., 2015). Statistical analysis Data were analyzed by using SPSS-14. Frequency, percentages, means and standard deviations (SDs) were used for descriptive purposes. Results Sample size and participating centers Across the 15 participating centers, 780 patients were recruited (Table 1). Overall, highest numbers of patients were from North India, followed by eastern part of the country. Least number of patients were recruited from the southern part of the country. Sociodemographic profile The sociodemographic details of the study participants are shown in Table 2. Clinical profile of patients The mean duration of passage of Dhat was 4.26 years (SD = 4.4 years; range: years) with a median of 3 years (interquartile ratio: 1 6 years). The mean age of onset of symptoms of Dhat was 23.9 years (SD = 8.5 years), with a range of years and a median of 22 years (interquartile ratio: years). Characteristics of Dhat syndrome More than one-third of the patients were passing Dhat two to three times per week, and another 38.2% of the participants were passing Dhat at least once a day. In terms of quantity of Dhat, about 60% were either passing a spoonful or more each time they experienced the passage of Dhat. In terms of consistency, the most common response was that of thin, milk like secretion (40.3%), followed by watery secretion (39.1%) and only 20.6% reported the consistency to be thick, oil like. In terms of color of Dhat, about two-fifth of the participants reported it to be of milk like color, about one-third reported it to be watery colored and one-fifth reported it to be of pus like color. Three-fifth of the patients reported that Dhat was made of semen, and one-sixth reported that they were not aware about the composition of the Dhat. Small proportion of patients reported it to be composed of fat like secretions, pus, urine and sugar. About one-fourth considered that semen was the major constituent of Dhat, another one-fourth reported that to be blood and one-seventh considered the Dhat to be made primarily of both semen and blood. However, about one-third were not sure about the major constituent of the Dhat. Situations in which there is passage of Dhat Patients were given nine specific options for the situations in which there is passage of Dhat and there was an additional option of any other time to report situations in which they experienced passage of Dhat (Table 3). Patients had the option of choosing as many options as they wanted to. Among the various situations given, the most common situation in which they experienced passage of Dhat were as night falls (60.1%) and through the penis, while passing stools (59.5%), while passing urine (56.5%), during sexual excitement (55.8%) and while watching/reading pornography (50.4%). Other situations in which the patients experienced passage of Dhat are shown in Table 5. In terms of number of situations reported, more than 90% of the patients reported more than one situation, with 70.4% reporting two to six situations. The mean numbers of situations reported were 4.45 (SD = 2.28), with a range of 1 10 and median of 4 (interquartile ratio: 3 6).

4 4 International Journal of Social Psychiatry Table 1. Distribution of patients across different centers. Center Frequency (%) Chandigarh 162 (20.8) Faridkot 8 (1.0) Jaipur 38 (4.9) Mewat 37 (4.7) New Delhi 49 (6.3) Kolkata-I (CNMC) 60 (7.7) Kolkata-II (MCH) 60 (7.7) Kalyani 50 (6.4) Bhubaneswar 45 (5.8) Agra 50 (6.4) Lucknow 53 (6.8) Ahmedabad 56 (7.2) Wardha 57 (7.3) Mysore-I (JSS MC) 39 (5.0) Mysore-II (MMC & RI) 16 (2.1) Total 780 (100) CNMC: Calcutta National Medical College, Kolkata; MCH: Medical College and Hospital, Kolkata; JSS MC: JSS Medical College, Mysore; MMC & RI: Mysore Medical College and Research Institute. Reasons for passage/suffering from Dhat For reasons for passage/suffering from Dhat, patients had 23 specific options and another option in the form of any other reason. Patients had the option of choosing as many options as they wanted to. As shown in Table 3, the most commonly reported reasons were excessive masturbation, sexual dreams, excessive sexual desire, consumption of high energy foods, wrong deeds of early childhood, due to urinary infection or problems of urinary tract, constipation, excessive sexual intercourse, eating unbalanced food and having premarital sexual intercourse. Other reasons are shown in Table 3. The mean numbers of explanations were 5.68 (SD = 4.12), with a range of 0 24 and a median of 5 (interquartile ratio: 3 7). More than three-fourth of the patients gave at least three explanations as the reason for passage of Dhat. Consequences of passage of Dhat As with situations and reasons for passage of Dhat, patients were given 10 specific options to be rated as yes/no with an additional option of any other reason, to be rated as yes/no for the consequences of passage of Dhat (Table 3). Patients had the option of choosing as many options as they wanted to. The most common consequence perceived by the patients due to passage of Dhat was weakness in sexual ability. Other common consequences are shown in Table 3.The mean number of reported consequences was 4.99 (SD = 0.35), with a range of 0 11 and median of 5 (interquartile ratio: 3 7). Majority of the patients reported more than one consequence of the passage of Dhat. Table 2. Sociodemographic profile of the study group. Variables Mean (SD)/Frequency (%) Age in years (8.67); range: Age groups (16%) (55.3%) (19.6%) (6.2%) (2.6%) >60 3 (0.4%) Marital status Single 398 (51.0) Married 364 (46.7) Separated/divorced/ 18 (2.3) widowed Education in years (4.26); range: 0 20 Education Illiterate 38 (4.9) Primary school 106 (13.6) Middle school 127 (16.3) High school 161 (20.6) Intermediate 149 (19.1) Graduate 183 (23.5) Profession 16 (2.1) Occupation Unemployed 207 (26.5) Employed 573(73.5) Family income (Indian Rupee) in month <7,500 (<125 US dollars/ (40.6) Euros approx.) 7,500 ( 125 US 463 (59.4) dollars/112 Euros approx.) Kuppuswamy socioeconomic class(kumar, Shekhar, Kumar, & Kundu, 2007; Kuppuswamy, 1981) Upper Lower 242 (31.0) Lower Middle 265 (34.0) Upper Middle 246 (31.5) Upper 27 (3.5) Religion Hinduism 536 (68.7) Islam 179 (22.9) Sikhism 60 (7.7) Others 5 (0.6) Family type Nuclear 346 (44.4) Extended/joint 434 (55.6) Locality Urban 318 (40.8) Rural 462 (59.2) SD: standard deviation. Accompanying psychological and somatic symptoms Accompanying psychological and somatic symptoms were assessed by a list of 31 symptoms. Participants were

5 Grover et al. 5 Table 3. Situations in which there is passage of Dhat and reason for passage of Dhat. Variables Frequency (%) Situations in which you experience discharge of Dhat Through the penis, while passing stool 464 (59.5) As night falls 469 (60.1) While masturbation 351 (45.0) While having intercourse with females 288 (36.9) Any time, with no associated specific situation 284 (36.4) While passing urine 441 (56.5) While having sexual excitement 435 (55.8) While feeling pressure or strain on the 222 (28.5) abdomen While watching/reading pornography 393 (50.4) Any other time 123 (15.8) Reasons for passage of Dhat Due to excessive masturbation 430 (55.1) Due to excessive sexual intercourse 191 (24.5) Due to having sexual intercourse with a 113 (14.5) woman while she was menstruating Due to premarital sexual intercourse 177 (22.7) Due to having sexual intercourse outside the 134 (17.2) wedlock Due to homosexual relationship 106 (13.6) Due to sexual intercourse with commercial 124 (15.9) sex workers Due to having sexual intercourse in unnatural 126 (16.2) way Due to having sexual dreams 369 (47.3) Due to low sexual desire 164 (21.0) Due to excessive sexual desire 334 (42.8) Due to lack of indulgence in masturbation 134 (17.2) Due to eating unbalanced food/absurd food 183 (23.5) Due to excessive eating 108 (13.8) Due to wrong deeds of past life 125 (16.0) Due to lack of sleep/improper sleep 141 (18.1) Due to constipation 210 (26.9) Due to worm infestation of GI tract 100 (12.8) Due to urinary infection or problems of 224 (28.7) urinary tract Due to hereditary reasons 102 (13.1) Wrong deeds of early childhood 255 (32.7) Due to consumption of high energy foods like 286 (36.7) ghee, eggs, non-vegetarian food Due to consumption of foods and drinks 229 (29.4) (milk, tea, coffee, while these are hot) Any other reason 70 (9.0) Consequences of passage of Dhat Weakness in sexual ability 590 (75.6) Early death 193 (24.7) Malformation of children 159 (20.4) Birth of more female children 109 (14.0) Loss of beauty of face and body 397 (50.9) Reduction in size of penis 396 (50.8) Mental illness 368 (47.2) Poor erection 485 (62.2) (Continued) Table 3. (Continued) Variables asked to rate their symptoms on a 4-point scale ( not at all, present for several days, present for more than half of the days and present nearly every day ) (Table 4). For computing the frequency of symptoms, all the ratings except for not at all were pooled and the symptom was considered to be present. The common symptoms present in about half of the patients included bodily weakness; feeling tired or having low energy; feeling down, depressed or hopeless; little interest or pleasure in doing things; mental weakness; anger; irritability; getting annoyed easily; excessive worry; pain in arms, legs or joints (knees, hips, etc.); trouble sleeping and feeling bad about yourself that you are a failure/have let yourself or your family down. Treatment expectations of the patients As shown in Table 5, majority of the patients considered that investigations of blood and urine were very essential and about half had undergone the same. Majority of the patients had consulted various other specialists before consulting the mental health specialists. In terms of treatment, majority (60.9%) of the patients reported that there was a need for consultation and discussion with a doctor. However, about half of the patients (49.1%) expected that energizing medications like vitamins/tonics/tablets were required and more than one-third (38.2%) expected that there was a need for taking energizing injections. Onethird also expressed that there was a need for change in the food. Other details are shown in Table 5. Patient s opinion about the questionnaire Frequency (%) Early ejaculation 518 (66.4) Weakness in body, weakness in stamina and 456 (58.5) thinness of physique Any other problem 221 (28.3) GI: gastrointestinal tract. About two-third of the patients (62.3%) considered that length of the questionnaire was adequate. Small proportion of patients reported that the questionnaire was very long (12.7%), a bit long (22.8%) and small (2.2%). In terms of extent to which they were able to express their problem through the questionnaire, about half (47.3%) reported that they were completely able to express their problem of Dhat, another two-fifth (39.9%) of the participants reported to a large extent and 12.2% reported to some extent. Only a small proportion (0.6%) reported that they were not able to express their problem at all.

6 6 International Journal of Social Psychiatry Table 4. Psychological symptoms accompanying Dhat syndrome (present in last 2 weeks). Variables Discussion Frequency (%) Bodily weakness 610 (78.2) Mental weakness 491 (62.9) Stomach ache 217(27.8) Back pain 366 (46.9) Pain in your arms, legs or joints (knees, hips, etc.) 400 (51.3) Pain or problems during sexual intercourse 234 (30.0) Headaches 244 (31.3) Chest pain 191 (24.5) Dizziness 307 (39.4) Fainting spells 106 (13.6) Feeling your heart pound or race 313 (40.1) Shortness of breath 238 (30.5) Constipation, loose bowels or diarrhea 253 (32.4) Nausea, gas or indigestion 318 (40.8) Little interest or pleasure in doing things 497 (63.7) Feeling down, depressed or hopeless 487 (62.4) Trouble sleeping 396 (50.8) Feeling tired or having low energy 530 (67.9) Poor appetite or overeating 373 (47.8) Feeling bad about yourself that you are a failure/ 393 (50.4) have let yourself or your family down Trouble concentrating on things, such as reading 383 (49.1) the newspaper or watching television Psychomotor agitation or retardation 233 (29.9) Thoughts that you would be better off dead, or 233 (29.9) of hurting yourself in some way Burning micturition 331 (42.4) Excessive straining while micturition 217 (27.8) Itching on/around the genitals 195 (25.0) Development of lesions on/around the genitals 95 (12.2) Difficulty in gaining weight or losing weight 301 (38.6) Excessive worry 438 (56.2) Restlessness to the extent that you have difficulty 233 (29.9) in sitting still Anger, irritability, getting annoyed easily 440 (56.4) To the best of our knowledge, this is the first multicentric study on patients of Dhat syndrome from India. Although previous studies from India, Sri Lanka and Pakistan have evaluated the sociodemographic and clinical profile of patients with Dhat syndrome (Behere & Natraj, 1984; Bhatia, 1999; Bhatia et al., 1989; Bhatia & Malik, 1991; Chadda & Ahuja, 1990; De Silva & Dissanayake, 1989; Deb & Balhara, 2013; Dewaraja & Sasaki, 1991; Dhikav et al., 2008; Grover et al., 2014; Jadhav, 2004; Jhanjee, Bhatia, & Kumar, 2011; Jilek, 2000; Khan, 2005; Mumford, 1996; Nakra et al., 1977; Perme, Ranjith, Mohan, & Chandrasekaran, 2005; Sawant & Nath, 2012; Singh, 1985), these studies are limited by relatively small sample size and heterogeneous method of assessment. Table 5. Treatment expectations of patients. Variables Frequency (%) Opinion about need for investigations of blood and urine to get relief from the problem of passage of Dhat Very essential 551 (70.6) Less essential 130 (16.7) Not at all 99 (12.7) Ever underwent any investigations of blood 424 (54.4) and urine for the Dhat Prior consultations for the problem of Dhat Vaid, Hakim 268 (34.4) Unani, Ayurvedic or homeopathic doctor 263 (33.7) Traditional sex specialist 159 (20.4) MBBS doctor 243 (31.2) Surgeon 69 (8.9) Skin specialist 72 (9.2) Mental health specialist (psychiatrist) 122 (15.6) Others 70 (9.0) Opinion regarding treatment for Dhat Change in food 263 (33.7) By taking energizing medications like 383 (49.1) vitamins/tonics/tablets By taking energizing injections 298 (38.2) By taking medications which can increase 136 (17.4) the sexual desire By applying certain creams on the genitals 69 (8.8) By taking medications to reduce infection 84 (10.8) By taking medications used for treatment of 178 (22.8) mental problems Consultation and discussion with a doctor 475 (60.9) There is no treatment 57 (7.3) Medications to reduce sexual desire 126 (16.2) By talking to doctors, that is, counseling 262 (33.6) Others 21 (2.7) All these studies have been based on the use of selfdesigned instruments for assessment of clinical descriptors of Dhat syndrome, and due to this, there is considerable variation in the sociodemographic and clinical descriptors of Dhat syndrome from one center of the study to another. Accordingly, although Dhat syndrome has been included in the nosological classification (i.e. ICD-10), its clinical description in the manual does not provide details with regard to the situations in which patients experience passage of Dhat, reasons for passage of Dhat, consequences of passage of Dhat, associated psychological and somatic symptoms, comorbidities, treatment expectations and so on. Hence, the nosological validity of this disorder is at times questioned and considered by some to be cultural variant of depression (Mumford, 1996). World Health Organization is in the process of revising the ICD-10. Accordingly, there is an urgent need to have proper clinical description of the disorder using standard assessment tools.

7 Grover et al. 7 Till recent time, no specific standard instrument was available for assessment of Dhat syndrome. Recently, a self-rated questionnaire was designed to comprehensively assess the symptom profile, associated myths and beliefs related to treatment in patients with Dhat syndrome (Grover et al., 2014).This provided the opportunity to study the clinical description of this disorder comprehensively. The present study involved assessment of patients with Dhat syndrome from multiple sites spread across various parts of India using the same methodology and using the translated version of the same scale. The sample size of this study was 780, which is much larger than any other previous studies. Accordingly, it can be said that the present study attempted to overcome some of the limitations of the existing literature. The mean age of the study sample was years, with more than half (55.3%) of the patients aged between 21 and 30 years. Overall, those aged less than or equal to 30 years formed 71.3% of the total sample. Therefore, this study supports the previous evidence (Behere & Natraj, 1984; Chadda & Ahuja, 1990; Grover et al., 2014; Nakra et al., 1977) that has reported Dhat syndrome to be most commonly seen in young adults. However, findings of the present study also suggest that Dhat syndrome can be seen in all age groups, although those aged more than 40 years less commonly present with these symptoms. Previous studies (Bhatia et al., 1989; Bhatia & Malik, 1991; Behere & Natraj, 1984; Nakra et al., 1977) indicate that Dhat syndrome is commonly seen in those with lower level of education. In contrast, the mean and median duration of education of the study sample included in this study was close to 10, and 44.6% of the patients were educated beyond matriculation. It can thus be concluded that Dhat syndrome is seen in patients with all educational levels. It is also possible that over the years, the literacy rate and level of education have generally increased in this country, and this has possibly influenced the relationship of Dhat syndrome with the level of education. Existing literature suggests that Dhat syndrome is more common in those residing in rural areas (Bhatia et al., 1989; Bhatia & Malik, 1991; Behere & Natraj, 1984; Nakra et al., 1977). Findings of the present study also support the same. In the present study, more than two-third of the patients were Hindus, which is also in concurrence with the existing literature (Bhatia and Malik, 1991). Previous studies have reported that patients with Dhat syndrome more commonly belonged to lower or middle socioeconomic status (Bhatia et al., 1989; Bhatia & Malik, 1991; Behere & Natraj, 1984; Nakra et al., 1977). However, the present study clearly shows that majority of patients belong to middle socioeconomic status. Our finding in this regard could be considered more reliable because the socioeconomic status of the patients was determined by using a standardized Kuppuswamy socioeconomic class scale with recent revision. Again, this discrepancy from the findings of earlier reports could be the influence of overall change in the socioeconomic status of the country, where the proportion of those below poverty line has reduced over the years (Bhagwati & Panagariya, 2013). Overall, it can be said that Dhat syndrome is seen across all age groups, in those with all levels of educational background and more often in those belonging to middle socioeconomic status, although on other sociodemographic variables, there are similarities with the existing literature. The mean age of onset of the symptoms of Dhat syndrome was about 24 years, with a range of years and a median of 22 years. Accordingly, it can be said that in most of the patients, the symptoms of Dhat syndrome start in young adulthood. In terms of duration of symptoms prior to assessment, the mean duration of symptoms was 4.26 years and the median duration was 3 years. This finding suggests that patients present quite late to the mental health professionals. When we look at the prior health seeking behavior of these patients, it is evident that majority of the patients consulted various traditional healers and health specialists practicing Unani, Ayurveda or Homeopathy and physicians/surgeons before consulting mental health professionals. Therefore, it is important to understand the pathways to care of patients with Dhat syndrome and to reduce the duration of untreated symptoms. For a majority of the patients, the primary source of information for Dhat was a friend. Additionally, other common sources of information were media, faith healers, Ayurvedic doctors, registered medical practitioners and traditional healers. If one hypothesizes that these sources provide inadequate or improper knowledge to vulnerable subjects, thus contributing to the onset or continuation of symptoms of Dhat syndrome, then a case can be made for urgent need of introducing proper sex education at various levels. There is also a need for mental health professionals to inform the various health care providers about the nature of the condition and associated comorbidity to improve the management and proper referral of patients to reduce the duration of untreated illness. Findings of the present study suggest that the most common situation in which patients with Dhat syndrome experience passage of Dhat are night falls (60.1%), while passing stools (59.5%), while passing urine (56.5%), during sexual excitement (55.8%) and while watching/reading pornography (50.4%). Previous studies have also reported passage of Dhat while passing urine, in the form of night-falls and during sexual excitement and so on (Bhatia et al., 1991; Chadda & Ahuja, 1990; Grover et al., 2014). Passage of Dhat in some of these specific guilt ridden situations may account for developing the clinical descriptor of the disorder. Passage of Dhat is misattributed to various causes like sexual dreams, excessive masturbation, constipation and urinary infection or problems of urinary tract, premarital sexual relationships, extramarital sexual relationships,

8 8 International Journal of Social Psychiatry homosexual relationships venereal diseases, overeating, worm infestations, disturbed sleep and genetic factors (Behere & Natraj, 1984; Chadda & Ahuja, 1990; Grover et al., 2014; Singh, 1985). In the present study, passage of Dhat was attributed commonly to excessive masturbation (55.1%) and sexual dreams (47.3%). Further like in previous studies, the index study too suggests that for each patient, the passage of Dhat is misattributed to multiple reasons. Any attempt to treat these patients should focus on addressing these dysfunctional beliefs to improve the outcome of Dhat syndrome. According to the present study, the most common consequence perceived by the patients due to passage of Dhat was weakness in sexual ability (75.6%), closely followed by other consequences like early ejaculation (66.4%) and poor erection (62.2%). These findings indicate that the presence of comorbid sexual dysfunction in patients with Dhat syndrome is secondary to the core belief system. Thus, addressing the symptoms of Dhat syndrome may help in amelioration of sexual dysfunction. The treatment guidelines formulated by Indian Psychiatric Society for management of Dhat syndrome has also recommended the same algorithm for management of comorbidity (Avasthi, Rao, Grover, Biswas, & Kumar, 2006). There is also a need to study the temporal correlation between the onset of sexual dysfunction and that of Dhat syndrome in order to understand their relationship. According to the existing literature, patients with Dhat syndrome have various accompanying psychological and somatic symptoms (Behere & Natraj, 1984; Bhatia et al., 1989; Grover et al., 2014; Singh, 1985). The findings of these studies are limited by the number of symptoms evaluated. In the present study, an exhaustive list of such symptoms also included various symptoms of depression and somatoform disorders. The commonly noted psychological and somatic symptoms in the present study include bodily weakness; feeling tired or having low energy; feeling down, depressed or hopeless; little interest or pleasure in doing things; mental weakness; anger; irritability; getting annoyed easily; excessive worry; pain in arms, legs or joints (knees, hips, etc.), trouble sleeping and feeling bad about yourself that you are a failure/have let yourself or your family down. The prevalence of these symptoms was also seen to be affected by presence of comorbid psychiatric disorders and sexual dysfunction. Of the various symptoms, presence of bodily weakness is more common in those without comorbidity, and accordingly, this can be considered more specific to Dhat syndrome, and this must be emphasized while evolving the clinical descriptor for the disorder. Majority of the patients with Dhat syndrome expect that they should be subjected to investigations and go through complicated pathways of care before reaching the mental health professionals. In terms of their expectations from treatment, it is important to note that many patients come with expectation of receiving energizing medications and injections. Previous studies have also reported the beneficial role of use of placebos and multivitamins in improving the outcome of the disorder (Bhatia & Malik, 1991). Accordingly, there is need for conducting trials for evaluating the beneficial effect of these interventions in improving the outcome of disorder. Traditionally, Dhat syndrome has been considered as a culture bound syndrome. However, researchers have argued that Dhat syndrome should not be considered as a culture bound syndrome, but should be considered as a culturally determined idiom of distress because of its wider geographical occurrence (Sumathipala et al., 2004). Some consider it as a culturally appropriate form of depression (Dhikav et al., 2008; Mumford, 1996) or a subtype of Depression (Rajkumar & Bharadwaj, 2014). Diagnostic and Statistical Manual of Mental Disorders Fifth revision (DSM-5) has discarded the culture-bound syndrome terminology and has recommended use of the term cultural concepts of distress. When we look at the findings of the present study, it is evident that Dhat syndrome as a clinical manifestation is seen in all parts of India and a significant proportion of the patients with Dhat syndrome occur without syndromal depression and anxiety disorders (Grover et al., 2015). Existing data suggest that in many countries, including those from West, semen is considered to be important for healthy functioning of male (Sumathipala et al., 2004). The core feature of Dhat syndrome, that is, fear or distress of losing semen, can be considered to be influenced by the cultural belief systems across various countries. Accordingly, loss of semen leads to psychological distress which manifests as Dhat syndrome. Taking the findings of the present study into consideration and presence of Dhat syndrome in many geographical locations across the world, it can be said that Dhat syndrome cannot be considered just a subtype or culturally appropriate form of depression seen in some cultures. Instead, Dhat syndrome should be considered as an independent disorder, which has its own clinical manifestations. Accordingly, any male patient presenting with multiple somatic symptoms must be evaluated for Dhat syndrome and the clinicians must enquire about the semen loss and the associated beliefs. When present, these core dysfunctional beliefs must be addressed to improve the outcome. This study has few limitations. The clinical description of Dhat syndrome obtained as part of this study was limited to the content of the questionnaire used. It is quite possible that the questionnaire, despite being comprehensive, did 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 other aspects of Dhat syndrome. Sample was taken from patients seeking clinical consultations from psychiatry outpatient departments (OPDs);

9 Grover et al. 9 therefore, results could not be generalized to other group of patients. Future studies must overcome these limitations. Future studies also must attempt to design intervention strategies for patients with Dhat syndrome and evaluate the efficacy of the same. Furthermore, there is a need not only to evaluate the syndrome of Dhat syndrome across countries but also to study the comorbidity and the stability of the diagnosis. Presence of similar manifestations across different countries can help in establishing the nosological status of this disorder more firmly. To conclude, the present large sample study included a very large sample of patients with Dhat syndrome to study the phenomenology, beliefs and comorbidity in patients with Dhat syndrome presenting to various treatment settings across India and assessed on a standard too. This study demonstrated that Dhat syndrome is commonly seen in young males, of all educational level and socioeconomic status. Among the various situations given, the most common situation in which participants experienced passage of Dhat are night falls and while passing stools. The most commonly reported reasons for passage of Dhat are excessive masturbation, sexual dreams, excessive sexual desire and consumption of high energy foods. The most common consequence due to passage of Dhat was weakness in sexual ability. In terms of psychological and somatic symptoms, the common symptoms included bodily weakness; feeling tired or having low energy; feeling down, depressed or hopeless; and little interest or pleasure in doing things. In terms of treatment expectations, about half of the patients expect that energizing medications like vitamins/tonics/ tablets are required and more than one-third expect that there was a need for taking energizing injections. 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