A Female Variant of Dhat Syndrome and Associated Co-Morbidities: A Case Report

INTRODUCTION

The word “dhat” is derived from the Sanskrit word “dhatus,” which refers to the seven fundamental components of the human body, including the “sukra” semen.^[1] The Indian subcontinent’s cultures are most familiar with the Dhat syndrome. The majority of the symptoms are somatic, including exhaustion, anxiety, guilt, and loss of semen-related sexual dysfunction. Numerous people think that this is a global illness that resembles “jiryan” in Southeast Asia, “prameha” in Sri Lanka, and “shen-k’uei” in China.^[2] Another way to describe it is as an uncommon “neurosis of the orient.” In 1960, Prof. N.N. Wig first used the name “Dhat Syndrome.”^[3] It is thought that 40 meals yield one drop of blood, 40 drops of blood yield one drop of bone marrow, and 40 drops of bone marrow yield one drop of semen, which is why it is valuable.^[4] Only a few studies have described Dhat Syndrome in females.^[5,6] But Chaturvedi’s 1988 report had referred to the condition as “psychasthenic syndrome associated with leukorrhea.”^[7] Patel et al.’s investigation on females in the reproductive age range revealed a psychological explanation for vaginal discharge in South Asian women.^[8] These research investigations and case reports emphasize that vaginal discharge was the focal point of the somatic symptoms and related illnesses such as sadness and anxiety.

CASE REPORT

A 22-year-old woman, a homemaker from a rural background with 12 years of formal education and a lower-middle socioeconomic status, came to the psychiatric outpatient department complaining of anxiety, depression, loss of interest in once-pleasurable activities, hopelessness, and worthlessness.

These symptoms were present for the last 2 years but had increased in the last 6 months.

She also complained of backache, headache, and generalized weakness for the last 2 years.

Upon further questioning, she would blame the vaginal discharge, which she claimed has been there for the past 2 years, for all of her problems. The discharge, in her words, is mucoid, has no disagreeable odor, and is not connected to itching.

It all started 2 years back when she used to go to college and attained sexual knowledge from her friends. She indulged in watching pornography videos with her friends after the classes.

Subsequently, she started experiencing vaginal discharges whenever there were any erotic thoughts and sex-related dreams. According to her, it was not a pleasurable experience, and this vaginal discharge caused distress in her. She thought that with time, it would deplete vital fluids of her body.

When she discussed this with her family members, they considered this as a disease that might make her look ugly and decrease her sexual ability.

Her family members took her to traditional healers. She was advised not to take warm food and drinks and also to decrease the intake of non-vegetarian items. She was also prescribed some herbal medications. There was no response to the treatment.

The patient also consulted a general medical practitioner who advised all routine investigations and vaginal swab testing, the reports of which were normal. The doctor prescribed antibiotics and multivitamins, which had no effect on her symptoms.

She is married for the last 8 months. During the initial 2 months, any thought of sexual intercourse or the act itself, which leads to vaginal discharge, made her feel weak. Due to her ongoing fear of getting weaker with vaginal discharge and her thoughts of decreasing sexual ability, she decided to remain abstinent from sexual intercourse for the last 6 months. According to the patient, she had a low mood during this period. She also described the mood of her husband as irritable, as he feels that the patient is less affectionate toward him. This constant thought of marital disharmony has further aggravated the abovementioned symptoms. She had no past history of significant physical or mental illness.

Before marriage, the patient hailed from a conservative joint family, where there was no concept of sex education, and there were many cultural beliefs regarding genital discharges.

Her mental status examination revealed dysphoric affect with thoughts of hopelessness, worthlessness, and somatic concerns associated with vaginal discharge and with anticipation of marital disharmony.

On the Sex Knowledge and Attitude Questionnaire, she received a knowledge score of 10 (out of 35) and an attitude score of 30 (out of 60). These results indicate that she has little understanding of the anatomy and physiology of the female reproductive system, sexual desire, and masturbation, as well as a negative attitude toward sex education. The Hamilton Rating Scale for Depression (HAM-D) was used to determine the patient’s level of depression. A score of 12 was noted, indicating a mild level of depression. According to the International Classification of Diseases (ICD-10), she was given a provisional diagnosis similar to that of “other specified neurotic disorders,” which includes undue concern about the debilitating effects of the passage of semen (Dhat syndrome), along with other disorders. Although in Diagnostic and Statistical Manual of Mental Disorders (DSM V), Dhat syndrome itself or as an inclusion does not have any diagnostic criteria or codes, cultural disposition for explaining health problems and symptoms with reference to dhat-related concepts are discussed in section iii of DSM-V (emerging measures and models).

ICD-11 has also mentioned culture as one of the etiological factors for sexual dysfunction and sexual pain disorders.

Sexually transmitted diseases, nonsexually transmitted infections, noninfective causes (e.g., malignancy of the genital tract, cervical polyps), and brain tumors have been ruled out by proper gynecological examination and investigations.

She was educated about the female reproductive system and the physiological vaginal discharge and was prescribed one sertraline 50 mg tablet on a daily basis and a tablet of clonazepam 0.5 mg at bedtime. She came for a follow-up twice. Her worries about her health and concern with vaginal discharge improved as a result of the treatment. Also, since receiving treatment, her depressive symptoms have decreased.

DISCUSSION

Similar to a few other studies, a female version of Dhat syndrome has been observed in this instance.^[9]

The patient is a female of the reproductive age group, similar to a previous case report by SK Kar and A Singh.^[10] A similar study was also done by SK Chaturvedi, which included 31 women of reproductive age.^[11] According to our patient, vaginal discharge is composed of bodily fluid that is essential. Existing studies have also reported similar findings.^[6,12] In our case, the patient described the vaginal discharge as mucoid, nonoffensive in smell, and nonitchy, which was reported in an earlier study too.^[12]

In this case, a belief that warm and nonvegetarian food causes vaginal discharge was noticed, which is consistent with other studies.^[13-17]

Our patient’s comorbid depression is comparable to a research conducted in South India by Chaturvedi, who assessed women who had vaginal discharge and noted that over 50% of the patients had depression, which was considered to be comparable to the “Dhat syndrome.”^[7] A study by Trollope-Kumar found that many women were concerned about losing their genital secretions and reported that these losses were linked to vague somatic symptoms and progressive body weakness. The patient in this case also complains of generalized weakness, headache, and backache, which she attributes to vaginal discharge.^[15] Similar result was also observed in other studies.^[13,17,18] In this case, the patient has poor knowledge and negative attitude regarding sexual matters, similar to a previous study, using the same questionnaire.^[9]

CONCLUSION

Thus, Dhat syndrome in females is a condition that is not well understood. Although studies on female Dhat syndrome have been conducted, there is still much to learn about the disorder. For early detection and effective intervention, it is important to comprehend the cultural beliefs of women who arrive with nonpathological vaginal discharge. Women should be made more aware of the typical anatomy and physiology of the human reproductive system through health education. Also, encountering this variant of Dhat syndrome could help researchers in the future to categorize the same as Dhat syndrome, which is gender neutral, that is, present in both men and women.