1. Introduction
Dhat syndrome is described as an exotic culture bound sex neurosis more commonly observed in Indian subcontinent and oriental cultures (1). The clinical presentation is quite varied and may include non-specific somatic complaints, anxiety, depression, psychosexual problems and hypochondriacal concerns. However, the defining feature is the overriding concern about the possibility of semen loss upon which all the somatic complaints are premised (2). Many modes of passage of Dhat are described in literature. The current paper presents a unique case of a young adult with complaints of semen loss from skin lesions in the aftermath of recovery from dermatitis artefacta.
2. Case Presentation
A 28-year-old single employed male, coming from a low socio-economic status and rural agrarian background of Tamil Nadu (a state in South India) was referred to the psychiatry outpatient department with predominant complaints of fatigue and inability to work or concentrate for long periods of time. Upon questioning, he endorsed diffuse body pains, anxiety and a feeling of insufficiency and low mood secondary to his inability to work or contribute to the family. He had been diagnosed with dermatitis artefacta a year ago and had received treatment with topical anti-microbial agents and made a sufficient recovery as per records. The patient was apparently unwilling for a psychiatry referral then. At the index presentation, he reported some itching but only mild skin excoriations were present on examination. He attributed all his current symptoms to the discharge from skin lesions which he believed to be an important fluid comprising of semen and pus, though he was at a loss to explain how semen could be discharged through the skin. He would periodically verify his suspicions by inspecting and examining the discharge and its sticky nature. He also discussed it with a few of his friends who agreed with him further reinforcing his belief. He was very worried that he would eventually lose all his manliness if the discharge continued unabated. His family tried to convince him otherwise but to no avail. When he consulted us, he was not working for the last two months citing tiredness and cognitive problems. The patient did not endorse any core depressive or anxiety symptom and did not qualify for any psychiatric diagnosis other than Dhat syndrome. At the outset of therapy, patient beliefs and explanations about semen loss were elicited. Subsequently, he was educated about the normal process of production, constituent and discharge of semen using analogies where appropriate and reassured him about the non-threatening nature of the skin discharge after which his concerns were somewhat assuaged. Oral clonazepam was initiated at 0.5 mg once daily for symptoms of anxiety which was stopped after two weeks as his symptoms responded completely. Currently, the patient has resumed his work and is as productive as before. Patient was explained about the need to disseminate the details of his illness for scientific advancement following which he voluntarily consented to report the case.
3. Discussion
Dermatits artefacta is a challenging primary psychiatric condition that is mostly encountered in dermatologic settings. It often requires a multi-disciplinary approach involving dermatologic and psychiatric expertise for effective management. The underlying psychiatric disorders are most commonly borderline personality disorder, depression, anxiety or rarely psychosis (3). To the best of authors` knowledge, Dhat syndrome following recovery from dermatitis artefacta is not reported in literature so far. The present case, thus, illustrated a unique onset and mode of passage of Dhat. The level of distress, dysfunction and dramatic nature of complaints were out of keeping with the severity of skin lesions which had healed almost fully. This led the patient to be referred for psychiatric evaluation. There is a lot of variability in literature on the mode of discharge of Dhat. While the most commonly reported channel is passage in urine (4), loss of Dhat through masturbation, nocturnal emissions and sexual encounters with debilitating consequences have also been reported (5, 6). There is also a lack of consensus among researchers about the constituents of Dhat (7). Many authors described it especially as semen whereas others labelled it as any whitish discharge (8, 9). Semen is described as a vital fluid in the ancient Hindu scriptures, the untimely discharge of which produces marked anxiety and dysphoria (10). The current study patient described the passage of Dhat through healed skin lesions and also explained the discharge as a vital fluid comprising of semen and pus both of which are uncommon explanations. The management of Dhat syndrome usually involves sex education, relaxation therapy and targeted medications. It is pointed out that the current understanding and explanations offered by modern clinicians are not received well by patients with Dhat syndrome leading to dissatisfaction with services (11). The authors wish to emphasize the need to elicit patient beliefs regarding their symptoms prior to any management in such cases as this may provide valuable inputs with regard to developing harmonious treatment models. It is hoped that this report alerts clinicians to the possibility of development of culture bound syndromes following recovery from dermatologic conditions.
