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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 36  |  Issue : 2  |  Page : 136-140

Dhat syndrome and its perceived impact on psychological well-being


Department of Psychology, Christ (Deemed to be University), Bengaluru, Karnataka, India

Date of Submission23-Mar-2019
Date of Decision01-Aug-2019
Date of Acceptance30-Oct-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Ms. Jyoti Das
Dhanalakshmi Residency, 406, 3rd Main, Tavarekere Main Road, Brindavan Nagar, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_22_19

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  Abstract 


Background: Dhat syndrome is a culture-bound syndrome originating in the Indian subcontinent, primarily among men characterized by the fear of loss of semen. Objective: The article discusses the perceived impact of Dhat syndrome on the overall psychological well-being of the individual. Method: Four patients from hospitals in Kolkata, West Bengal, were screened using MINI and then interviewed using semi-structured interview to assess presenting concerns, interventions, psychological well-being, attitude toward sex and masturbation, and their sociodemographic details. The data were then categorized based on the dimensions of the questionnaire, which was then analyzed individually and separately based on the dimensions. The differences and commonalities between the dimensions as conveyed by the participants were then reported. Results: The analysis showed that the participants reported lower levels of psychological well-being based on the categories of Seligman's PERMA model and attributed it to the symptoms experienced by them. They traced the beginning of the hindrances to achieving optimal well-being to the onset of symptoms. Conclusion: This article proposes the incorporation of integrative therapeutic interventions and advocacy of sex education to address the psychological well-being over the current symptom reduction interventions used.

Keywords: Accomplishments, Dhat syndrome, engagement, meaning, positive emotions, relationships


How to cite this article:
Das J, Dutt S. Dhat syndrome and its perceived impact on psychological well-being. Indian J Soc Psychiatry 2020;36:136-40

How to cite this URL:
Das J, Dutt S. Dhat syndrome and its perceived impact on psychological well-being. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Nov 29];36:136-40. Available from: https://www.indjsp.org/text.asp?2020/36/2/136/288105




  Introduction Top


Dhat syndrome is a culture-bound syndrome (CBS) originating in the Indian subcontinent among men. Dhat, also known as Dhatu dosa, is characterized by somatic, anxiety, depressive, and sexual symptoms which can ultimately be related to their idea of the loss of semen.[1] According to Ayurveda, Dhat is referred to as the “elixir” of life, or that which life is composed of. With the concept of elixir placed on semen, it can be concluded that semen was viewed as that which constitutes life. The importance placed on semen by the culture eventually leads to invoking fear in the individual leading them to feel a “sense of doom” if a single drop of semen is lost.[2] This feeling eventually produces a series of psychosomatic symptoms. The practitioners of Ayurveda and Homeopathy had validated and reinforced patient's beliefs about loss of semen.[3] The International Classification of Diseases classifies Dhat as a neurotic disorder (Code F48.8) and categorises it as a culture-specific disorder.[4]

Parmar, 2014, reports that patients who bring in the complaint of Dhat Syndrome usually show symptoms of depressed mood, loss of strength, lack of concentration, weight loss, anxiety, impairment in work, sexual dysfunction, etc., The author also explores into their complaints of loss of the semen through premature ejaculation, erectile impotence, and nocturnal ejaculation.[5] The clinical picture of Dhat Syndrome was dominated by severe anxiety and hypochondriasis.[6] Deb and Balhara, 2013, in their study, state the psychological complaints of Dhat Syndrome which include loss of appetite, disturbed sleep, loss of interest, weight loss, palpitation, fear of losing vital component of the body, weakness, guilt lethargy, loss of libido among others.[7]

However, it is widely observed that individuals diagnosed with Dhat Syndrome are chiefly offered pharmacotherapy, and their psychological and emotional needs are side-lined. Pharmacotherapy is designed to offer a temporary solution in minimizing the symptoms of anxiety, depression, and panic as reported by the patients. Nevertheless, the root cause of the problem itself – their thought patterns regarding semen – remains untouched. This study seeks to understand the implications of these thought patterns upon their lives.

Seligman, in his book, “Flourish: A visionary new understanding of happiness and well-being,” talks about the PERMA. The PERMA model speaks about five building blocks for an individual's well-being and happiness. The elements include positive emotion, engagement, relations, meaning, and achievement. Seligman stresses on each of these elements for the achievement of overall well-being.[8] An individual who is able to manage and focus in all these elements and their balance, they will be able to experience more happiness and well-being in comparison to one who has not.[9] The PERMA model is used to determine well-being and is used in multiple studies which focus on the same.

Khan, 2005, and Deb and Balhara, 2013, highlight the psychological symptoms experienced by patients reporting Dhat Syndrome ranging from mild anxiety to somatic symptoms and depression.[7],[10] However, it can be noticed that there is limited evidence of therapeutic interventions on the cause of the syndrome or its psychological implications on the individual. There is a significant lack of literature concerning the effect of Dhat syndrome on the individual's personal life as well as their emotional well-being.


  Methodology Top


Participants

The sample includes four participants who have been diagnosed with Dhat syndrome by a psychiatrist and are presently seeking treatment. The purposive sampling method is used. The age ranges from 20 to 32 years.

Inclusion criteria

Individuals diagnosed with Dhat Syndrome fluent in any one language among Hindi, English, or Bengali.

Exclusion criteria

Individuals diagnosed with disorders under DSM-4 TR. Screening tool, MINI Neuropsychiatric Interview was used to screen for psychotic symptoms.

Tools

MINI International Neuropsychiatric Interview 7.0.2 was used to screen patients for psychotic symptoms, other severe mental disorders. MINI includes items related to suicide, psychotic disorders, anxiety disorders, depressive disorders, obsessive-compulsive disorder, alcoholism, substance-related disorder, general mental disorder, stress-related disorders, posttraumatic stress disorder, etc.,

Questions for semi-structured interviews were prepared by using the PERMA model as framework. An interview with five psychiatrists handling cases with Dhat syndrome was conducted, focusing on the major areas of life effected by Dhat syndrome among their patients in the past and present. The data from this interview were analyzed to create dimensions for the questionnaire. The dimensions which correspond to the existing themes of the PERMA model were considered to assess well-being. PERMA model is crucial to studies that explore well-being. The questionnaire was prepared in consultation with a psychiatrist, a mental health therapist and a sexologist. The questionnaire seeks to explore the dimensions of chief complaints, sexual satisfaction, interventions, positive emotions, engagement, relationships, meaning in life, and accomplishments. The participants were questioned where the reported issue came from, for each dimension they informed experiencing limitations or inconvenience in.

Process

Semi-structured interviews were used for data collection. The questions were constructed based on the dimensions to be explored for the study. The questions were reviewed by a psychiatrist and a counselor for validation once before and then after translation and back translation. The data were collected from the outpatient departments of Bangur Institute of Neuroscience and Calcutta National Medical College– Calcutta Pavlov Institute. After the presentation of the consent form and explanation of the procedure to the patient, the MINI Neuropsychiatric Interview was conducted to screen for psychiatric disorders. Following this, a semi-structured interview was conducted. The informed consent and questions for interview have been translated from English to Hindi and Bengali and then back-translated by an individual fluent in both languages. The interviews have also been translated and verified by two individuals fluent in Hindi and Bengali. The research design and ethical guidelines have been validated by the Institute Review Board (Christ [Deemed to be University]).

The data collected was analyzed for each participant individually and then in comparison to each other. The similarities and differences presented by the participants in expressing each dimension of the questionnaire were then reported.


  Results Top


The cases presented highlight common themes among them. The categories explored allow insight into the overall psychological well-being of the individual, keeping the PERMA model of well-being proposed by Martin Seligman as a reference.[8]

All the participants presented the concern of being consistently tired and inability to find the energy for regular activities, which act as a hindrance to their jobs, other interests, and personal lives. Each participant held a strong belief about the loss of semen and the physiological symptoms such as shivering, body aches, weakness, and dizziness emerging from it. Participants D, B, and A believe they become weak post the ejaculation or involuntary expulsion of semen. Participant C held similar beliefs but reports much more physiological symptoms such as swelling of penis, liver pain, abdominal pain, numbness of body, and pain in testicles. According to Seligman, overall psychological well-being depends on experiencing positive emotions, engaging in interests outside of their jobs, having satisfying relationships, having a meaning and purpose in life and having goals.

The results are analyzed under the themes of chief complaints, interventions, positive emotions, engagement, relationships, meaning, and achievements.

Chief complaints

Most participants reported more physiological than psychological symptoms when inquired about their problems. Participant A reported loss of appetite or avoidance of food to ensure no semen is lost. He explains he believes protein-rich food results in more loss of semen. He explains feeling cold as the heat substance has left his body. Participant B reports frequent urination and loss of semen through it. He feels weak and tired after urinating and complains about shivering often. Participant C reports more somatic symptoms such as swelling of penis, liver pain, abdominal pain, chest pain, numbness of body, and pain in testicles. He also reports premature ejaculation, intense feelings of fear and shock associated with his symptoms. Participant D has strong feelings surrounding his symptoms. He believes his hormones and proteins are lost due to the loss of semen which is making him weak. “…all the energy from his body is being sucked out.” He reports weakness and lethargy.

Interventions

The participants report having visited several doctors for their symptoms. Participants A, B, and D have done several tests and visited doctors including homeopathy, allopathy, Unani medicine, and traditional healers. Participant C reports having visited one Kashmiri medicine practitioner. The hospital has provided calcium or vitamin tablets as placebos to al 4 participants.

Positive emotions

All the participants reported feeling more negative than positive emotions. They reported feelings of despair, shame, fear, anxiety, sadness, etc., associated with their symptoms of arising from the situations created by the symptoms. Participant reported having negative thoughts about his life and not feeling optimistic about his future. He believes the negative emotions of fear overpower his positive thoughts. “. Every time I think about the positive, this negative comes in front of me. And I keep worrying about it.” Participant B reported feeling like negative circumstances will occur in the future due to his symptoms. ”. But my problem, like if I think positive about something, other becomes negative”

Participant D reports feeling worried and tensed most of the time and unable to experience positive emotions. He feels he remains preoccupied with his symptoms most of the time.

Participant C, however, reported feeling optimistic about his future and experiencing positive emotions. However, on the other hand, he reports experiencing anxiety and fear, especially during sexual intercourse.

Engagement

Three out of four participants reported experiencing a significant lack of interest in activities they previously enjoyed outside of work. One participant reported experiencing some lack of interest but not completely.

Participant A reported feeling a lack of interest and motivation since his symptoms severed. “…Ever since this happened, I don't have the energy to do anything, work or other things.”

Participant B reports feeling a significant lack of energy to engage in activities he formerly appreciated, such as watching movies or engaging in sexual intercourse.

Participant C reported feeling less interested but not as much. “…If it was 100, now it is 80.” He was unable to point out interests he has outside of work because he has not spent much time in anything but work and family, according to him.

Participant D reported feeling unable to concentrate on anything other than his symptoms. He is unable to focus on meeting his friends or playing and watching football at a nearby establishment. “I don't get the energy in these things like I used to. I don't get the excitement like earlier, I feel like I'm losing interest, and it is drying up,”

The participants all attributed their loss of interest to feeling tired and exhausted and not having the energy anymore. They reported feeling tired and low owing to the loss of energy through semen loss.

Relationships

All the participants reported dissatisfaction in maintaining sexual relationships and achieving emotional intimacy. Participant A reported feeling satisfied with his relationships with his family. He was, however, afraid to approach women due to his symptoms. “I don't really talk to women as much. Not that I don't want to talk, but like, I was interested in a girl, but I didn't talk, so it didn't work out. I didn't talk to her because I was constantly worried about this (Dhat Syndrome).”

Participant B is highly satisfied in his relationship with his family and friends. He has a very close relationship with his wife in terms of emotional intimacy. However, he believes that he ejaculates immediately, which hampers their sex life. “I cannot go ahead for another second also in sex” He believes his symptom has caused a problem in his marital satisfaction. “There is a problem in the relationship. My wife probably does.”

Participant C feels that his wife is unsatisfied sexually due to his premature ejaculation. He is unable to continue having sex because of the fear of his body drying up. He believes his wife is unable to express and feels bad for her. “I'm happy but I feel my wife is a bit unsatisfied. She can't probably say it to me. But I feel she isn't satisfied.”

Participant D, like participant A, is afraid to approach women due to his symptoms. He believes it is pointless to speak to women when he won't be able to have sex. The participant expresses superficial aspects of relationships (sex, earning money for family, etc.) and rarely addresses the psychosocial dynamics.

Participants D and A believe their symptoms act as a barrier to them getting married and having children. Participants B and C believe their symptoms act as a hindrance to marital satisfaction.

Meaning

The participants were unable to determine the purpose of their lives. Participant A did not want to continue his daily job and do something more meaningful; however, he reported feeling exhausted to work on the same. He reports not having enough energy and being extremely weak to make major changes in his life right now, and he attributes this weakness to his diagnosis.

Participant B was unable to understand the purpose of his life. However, he reported issues outside of the area of research, which influenced his idea of purpose in life.

Participants C and D were unable to determine what constituted as meaningful work for them. They both attributed their loss of understanding of meaningful work to the symptoms of Dhat Syndrome.

Accomplishments

The participants, who reported having goals in life, strongly alleged that their symptoms hindered them from achieving them. Participant A wants to get married and have children, but his symptom acts as a barrier according to him.

Participant B does not report having any specific goals at the moment or in the past 3 years. He reports issues outside the area of research.

Participant C wants to change his area of work, but he has no plan to change it or another area in mind.

Participant D wants to start his own business; however, feel weak and unable to put in work to achieve his goals.

On the analysis of the five categories for psychological well-being, it can be reported that the participants reported low levels of psychological well-being. It can also be derived that their symptoms act as a barrier to them achieving higher level of psychological well-being, based on their answers. The research, therefore, indicates that Dhat Syndrome has a negative impact on an individual's psychological well-being. The participants reported getting interventions from different doctors in the form of medicines, Unani methods, dietary advice, and calcium tablets in the form of placebo.


  Conclusion Top


The focus of the study was to explore the impact of Dhat syndrome on the perceived psychological well-being of the participant. According to the result, the participants reported low levels of overall psychological well-being. This was indicated by their reports of feeling less positive emotions, experiencing a loss of interest in activities outside of daily work, fear of approaching women to achieve meaningful relationships, lack of purpose and meaning in life, and inability to set and achieve goals. Participants either reported lacking these or the experience being hindered by their symptoms suggesting the negative impact of Dhat Syndrome on the participant's psychological well-being. The interventions reported by the participants focus majorly on their physical symptoms and are based on the biological model of illness which concentrates on symptom reduction. However, psychological well-being remains unaddressed. Several research papers have recorded numerous psychological symptoms reported by patients across the country.[7],[10],[5],[3] This makes it imperative to address the impact of Dhat Syndrome upon one's personal life, psychological well-being, self-worth, and interpersonal relationships.

As stated, four out of five participants reported lower levels of psychological well-being based on the PERMA model.[8]

This article advocates a biopsychosocial model in favor of the biological models to offer interventions for Dhat Syndrome. The interventions need to focus not only on symptom reduction but also on the holistic treatment of the patient. Salam, Sharma and Prakash, 2012, proposed the development of cognitive behavior therapy (CBT) intervention for patients with Dhat Syndrome. However, there is a significant lack of literature concerning the use of therapeutic interventions for Dhat Syndrome. The use of the CBT module by Salam, Sharma, and Prakash included basic sex education, cognitive restructuring, JPMR, imaginal desensitization, masturbation as homework, and Kegel exercises. Given the effectiveness of this, it can be concluded that therapeutic interventions show effective results in the treatment of Dhat Syndrome.

This article proposes the development of an integrative therapeutic model for the treatment of Dhat Syndrome. Since each participant has different belief systems, values, problems, and ideas concerning the symptoms, it can be justified to suggest that each participant needs to be treated differently after an understanding of their specific symptoms. According to Zarbo et al., 2015,[11] therapies that are integrative in nature work for a wide range of disorders. They also suggest that no singular therapeutic approach can be effective and appropriate for every person. Integrative psychotherapy also focuses on effective intervention and its theoretical and empirical basis as opposed to eclectic psychotherapeutic practice. Several evidence-based researches advocate the practice of integrative psychotherapy.[10]

The symptoms of Dhat Syndrome vary from person to person in its manifestation and progress. Each patient also experiences different values and lifestyles. Given the complexity and variety in each case of Dhat Syndrome, it is only feasible to incorporate an integrative psychotherapeutic model in its treatment. The paper attempts to understand the social and cultural dynamics that are at play with regard to Dhat Syndrome considering the study done by Simons, 2001, among others suggest that CBS like Dhat can be understood as the local way of making sense of the environment. Dhat Syndrome stems from beliefs and ideas about sex and masturbation. These beliefs are woven out of the concept of repressing and avoiding an open discussion of sex and masturbation in society. Dhat and similar CBS are native to countries and societies that are particularly conservative and believe in the repression of sexual urges. Therefore, a clear conclusion can be drawn that the concepts promoted by conservative societies about the suppression and control of sexual thoughts and urges, can be a cornerstone for causing Dhat Syndrome. The participants who were interviewed were from rural West Bengal and Bihar, and were either uneducated or attended school till 8th Grade. They reported belonging to a lower socioeconomic status. Three out of five participants were unmarried and reported confusion about sex as a concept. This data are in accordance with a study by Dhikav et al., 2008, which reported 64.2% of participants of the study as unmarried and to have received education till 5th Grade at most.[12]

Culturally speaking, Dhat Syndrome is more pertinent in societies that put importance on the conservation and sacredness of sperm. The participants expressed strong religious views and reported being connected to their cultural backgrounds. Hinduism believes in the retention of sperm, which takes immense effort by the body to create as described in Charaka Samhita, an ancient Indian book about medicine. In the modern-day Hinduism, sex is repressed as a concept and masturbation are considered unholy. Islam and Christianity condemn masturbation and report any loss of sperm that is not for reproduction as a sin. Buddhism, Jainism, and Sikhism also promote similar views on sex and masturbation. According to Rao, 2004, the myths pertaining to the preservation of semen are still prevalent in India.[13] Dhat is native to the Indian subcontinent where cultural and societal pressures condemn sex and masturbation as is viewed by the religious and cultural guidelines. This being said, it is important to acknowledge the involvement of religion, culture, societal norms, and socioeconomic background of the patients reporting the symptoms.

This article, strongly advocates to bring about a change in the societal framework regarding sex and masturbation by promoting education and more open discussion in this regard, in urban as well as rural settings, especially with people who do not have the access to education, to deal with Dhat Syndrome at its core.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Grover S, Gupta S, Avasthi A. A follow-up study of patients with Dhat syndrome: Treatment pattern, outcome, and reasons for dropout from treatment. Indian J Psychiatry 2016;58:49-56.  Back to cited text no. 1
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2.
Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes: The story of dhat syndrome. Br J Psychiatry 2004;184:200-9.  Back to cited text no. 2
    
3.
Salam KP, Sharma MP, Prakash O. Development of cognitive-behavioral therapy intervention for patients with dhat syndrome. Indian J Psychiatry 2012;54:367-74.  Back to cited text no. 3
    
4.
Mehta V, De A, Balachandran C. Dhat syndrome: A reappraisal. Indian J Dermatol 2009;54:89-90.  Back to cited text no. 4
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Parmar DM. Dhat syndrome a clinical study. Int J Pharm Med Res 2014;2:16-22.  Back to cited text no. 5
    
6.
Malhotra HK, Wig NN. Dhat syndrome: A culture-bound sex neurosis of the orient. Arch Sex Behav 1975;4:519-28.  Back to cited text no. 6
    
7.
Deb KS, Balhara YP. Dhat syndrome: A review of the world literature. Indian J Psychol Med 2013;35:326-31.  Back to cited text no. 7
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8.
Seligman DM. Flourish: A Visionary New Understanding of Happiness and Well- being. New York: Free-Press; 2011  Back to cited text no. 8
    
9.
Mulder P. PERMA Model Toolshero; 2018. Available from: https://www.toolshero.com/psychology/personal-happiness/perma-model. [Last accessed on 2018 Jul 30].  Back to cited text no. 9
    
10.
Khan N. Dhat syndrome: Physical and psychological implications. Indian J Psychiatry 2005;47:547.  Back to cited text no. 10
    
11.
Zarbo C, Tasca GA, Cattafi F, Compare A. Integrative psychotherapy works. Front Psychol 2015;6:20-21.  Back to cited text no. 11
    
12.
Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in dhat syndrome. J Sex Med 2008;5:841-4.  Back to cited text no. 12
    
13.
Rao DT. Some thoughts on sexuality and research in India. Indian J Psychiatry 2004;45:3-4.  Back to cited text no. 13
    




 

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