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.

INTRODUCTION

Dhat syndrome is a culture-bound syndrome seen commonly among young, unmarried males in South-East Asian region.[12] Patients often have the core belief about the preciousness of semen and severe adverse consequences associated with semen loss.[12] Dhat syndrome is clearly described in the context of males, but the description in the context of females is limited to few case studies.[34] However, some earlier studies on females discussed the possibility of Dhat syndrome in females.[56] The study by Chaturvedi in 1988 had described the entity as “psychasthenic syndrome associated with leukorrhea.”[6] Patel et al. had studied on a large cohort of reproductive age females and found a psychological causation behind leukorrhea in South Asian women.[7] He also discussed the potential role of psychological intervention in the management of these patients.

In South Asian culture, genital secretion (vaginal discharge) carries a negative cultural meaning, and the persistence of the cultural belief results in the persistence of symptoms.[8] All these studies and case reports highlight that the psycho-somatic symptoms in these patients were centered on per vaginal whitish discharge.[345678]

CASE REPORT

A 30-year-old uneducated female from a rural background had presented to our psychiatric outpatient department with complaints of episodes of intense anxiety and feeling of impending doom for 5 years. Initially, she had one episode (each lasting for 15–30 min) in every 2–3 months the frequency of which has increased to 2–3 episodes per month for the past 1 year. She also complained of decreased subjective energy, decreased interest in work, and easy fatigability during this period (for the past 4–5 years). For these complaints, she had consulted multiple traditional healers, practitioners of alternative system of medicines, and general medical practitioners in the past before consulting here without much benefit. She was investigated for medical illnesses, and her investigations did not reveal any abnormality. Her past history and family history were unremarkable. Her mental status examination revealed predominantly anxious affect and excessive somatic concern. On detailed exploration with confidentiality ensured, she revealed about the unrelenting passage of “Dhat” (per vaginal whitish discharge) for the past 15 years. The patient has been a sexually active female and has two children. She would attribute all her physical and psychological symptoms exclusively to the passage of “Dhat” per vaginum.

At the onset, when the patient reported this to the elders in the family, they told her that “this will subside following marriage.” She got married at the age of 18 years and conceived within a year. However, the per vaginal discharge continued for which the patient consulted traditional healers. She was told that the passage of Dhat may cause serious harm to her, and some herbal remedies were prescribed to treat her ailment. Due to nonresponse, she consulted various practitioners as mentioned above. She would report her discharge to be mucoid nature which frequently stains the undergarments.

Differential diagnoses of “other specified neurotic disorders” (Dhat syndrome) and “somatoform disorder” with panic disorder were considered as per the International Classification of Diseases-10 (ICD-10) diagnostic criteria. She was prescribed sertraline (50 mg per day) and clonazepam (0.25 mg as and when required). Supportive psychotherapy was done, and the patient was explained about physiological vaginal discharge. She had shown response to this treatment.

DISCUSSION

Our patient had the onset of her symptoms during adolescence which was acknowledged to be nonpathological by the patient after being consoled by the family members. However, its persistence after marriage and even after childbirth increased her worries which led to help-seeking behavior. Illiteracy, unawareness, faulty sociocultural beliefs, and easy accessibility directed her to seek initial consultations from traditional healers and unqualified practitioners. Erratic information from these unreliable sources provided to her, have possibly attributed to her psychosomatic symptoms. Chronicity of symptoms may have some role in deciding the symptom's severity of Dhat syndrome, association of comorbidities with it, and impairment. In our patient, the complaint of the passage of Dhat (whitish vaginal discharge) is of long duration (15 years) and the patient had not received any consultation from psychiatrist for long time. Her initial consultations from traditional healers and unqualified doctors misguided her and proved her myths and undue concerns to be genuine.

Comorbidities are commonly seen in patients with Dhat syndrome.[9] However, there is no study which evaluated comorbidities in females presenting with leukorrhea (whitish per vaginal discharge). Our patient had comorbid panic disorder. As there is no distinct diagnostic category to pick up such issues of females, the patients may receive some alternative diagnoses or may receive the diagnosis of comorbid psychiatric disorder as their primary diagnosis.[610] ICD 10 does not describe the similar entity in females who use the term Dhat for nonpathological genital discharge.[11] As a result of which patients with similar phenomenology are diagnosed as somatoform disorder in clinical settings.[10]

In South Asian cultures, similar entity in male counterparts has been mentioned as a culture-bound syndrome – Dhat syndrome. The ICD-10 categorizes Dhat syndrome as “other specified neurotic disorders” and refers it to the pathological concern associated to the loss of semen.[11] However, owing to similar cultural milieu, the term has been in use among common folk even for persistent disabling vaginal discharges.

Men with undue concern about semen loss usually share similar sociodemographic and clinical characteristics to women with pathological attribution to vaginal discharge. Moreover, the therapeutic modalities effective in management are similar. Women with excessive concern for their nonpathological vaginal discharge need supportive counseling as well as focussed psychoeducation explaining normal structural and functional aspects of genital system along with resolution of myths related to sexuality for treatment. Using restrictive diagnostic criteria (exclusively considering the passage of semen under Dhat syndrome) may result in these female patients being classified elsewhere. As a result of which a Dhat syndrome-specific psychosocial intervention loses its focus. It may likely affect the clinical outcome. Thus, redefining Dhat syndrome to encompass undue concerns related to the passage of genital secretions in both the gender may result in focused therapeutic intervention and better clinical outcome in females as well.

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Conflicts of interest

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