Delusion of dhat: The quandary of the form-content dichotomy!

Sir,

“The presence of the phenomenon of “dhat” in psychoses raises conceptual difficulties as psychosis is counter-intuitive to the basic concept of “dhat syndrome.”[1]

We discuss here an adolescent male with clear cut delusions related to “dhat” severely compromising his functioning. The utilization of form-content dichotomy in establishing the diagnosis and in making the management plan is demonstrated.

This 14-year-old male had initially presented with pain and burning sensation in the entire body for 4 months with minimal response to cap fluoxetine 40 mg/day. His mental status examination revealed difficulty in establishing rapport, restricted affect, and decreased speech output. He had fleeting ideas of pain due to loss of whitish substance from penis.

His provisional diagnosis was “dhat syndrome” (International Classification of Diseases-10 [ICD-10]: F48.8)[2] and cap duloxetine started at 20 mg gradually increased to 30 mg bid.

No improvement prompted reassessment. The idea of “pain and weakness occurring due to loss of a whitish substance from his penis” was held with high degree of conviction, was unshakeable, persistent, led to revised diagnosis of “other nonorganic psychotic disorders” (F28) with dhat symptoms as per ICD-10. Tablet haloperidol 5 mg HS was started and increased to 10 mg/day with tablet clonazepam 0.5 mg bid. He was discharged after 30 days with some improvement.

After 3 months, the presence of catatonic features such as mutism and posturing (4–6 h continuous upside down position) caused admission. Electroconvulsive therapy (ECT), tablet lorazepam 2 mg daily and tablet clozapine 25 mg daily were started. After four ECTs, posturing reduced significantly. After 2 weeks, ECT and lorazepam were discontinued, and clozapine was titrated to 450 mg/day; with good tolerance.

He reported of anxiety on having penile erections with belief that erections cause thinness and weakness. He adopted upside down posturing to induce penile detumescence and hence avoid losing strength. He believed his penile discharge was “semen” and was causing all his problems.

Distraction techniques, yogasanas, were taught as an adaptive way of releasing the anxiety of incipient erection to which he responded well.

Continuous somatic delusion with catatonic symptoms for 1-month with severe socio-occupational dysfunction led to final ICD-10 diagnosis of schizophrenia.

As per MacArthur-Maudsley Delusion Assessment Scale, the score was 24 with high scores on items of conviction, action, negative affect, and preoccupation.[3] The manifestations in the patient were beyond cultural credibility contributed to the diagnosis of delusion of “dhat.”[4]

The “content”-based approach, (passage of “dhat” as the cause) is difficult to explain the delusion and psychosis. “Form”-based approach as per the psychopathology and the ICD-10 system can explain the presence of delusion (of “dhat”) and psychotic illness (schizophrenia) respectively. The patient's perspective that loss of semen is causing symptoms can be perceived as the explanatory model of his illness.[5]

Management plan incorporated both aspects, that is, theme of semen loss through supportive measures and form of psychosis through anti-psychotics and ECT.

Our case highlights an unusual presentation of “dhat syndrome” in psychotic form and provides an opportunity to study the form-content dichotomy of psychopathology related to this phenomenon.