describing commonest culture bound syndromes in india

1. Dr BINOY D RAJ

2.  Culture plays a decisive role in coloring the psychopathology of
various psychiatric disorders.
 Some psychiatric syndromes are limited to certain specific
cultures. These disorders are called culture specific or culture
bound syndrome.

3. In India, common culture bound syndromes are
 Dhat Syndrome,
 Possession Syndrome
 Koro
 Gilhari syndrome
 Bhanmati
 Compulsive spitting
 culture-bound suicide (sati, santhra),
 Ascetic syndrome
 Jhin jhinia

4.  Evolution of the concept of Dhat syndrome
 The term “Dhat” was synthesized from the Vedic depiction of
body fluids called “Dhatus.”
 Among the seven different body fluids (Dhatus) mentioned in
Veda,semen is perceived to be most precious one.
 Ancient Ayurvedic literature also mentions genital secretions as
highly precious and purified body fluid and emphasizes about its
conservation.
 Charak Samhita (ancient text of Indian Medicine) describes a
disorder resembling Dhat Syndrome by the name ‘Shukrameha

5.  The belief that loss of semen may have a harmful effect on the
body is carried ahead over centuries by traditional healers.
 The concepts were imbibed in such a manner in the culture, that
individuals with orthodox views have strong beliefs about
different effects on the body due to semen loss.
 Dhat syndrome: Sujita Kumar Kar and Siddharth Sarkar1Department of Psychiatry, King George's
Medical University, Lucknow, J Hum Reprod Sci. 2015 Jul-Sep; 8(3): 130–134(pubMed)

6.  40 meals = 1 drop of blood
 40 drops of blood = 1 drop of Bone Marrow
 40 drops of bone marrow = 1 drop of semen
 This gives rise to belief that loss of excessive semen in any form
e.g. masturbation, nocturnal emissions etc. is harmful.
 Its preservation will lead to health and longevity.

7.  Professor N. N. Wig has coined the term “Dhat syndrome”in 1960
to the psycho-somatic attribution related to semen loss .
 Malhotra and Wig described Dhat syndrome due to loss of semen
through nocturnal emissions or passage in urine.
 The patients with Dhat syndrome attributed their symptoms to
semen loss through other means such as masturbation, during
defecation, and even sexual intercourse.

8.  Mostly young, recently married,
 Belonging to average or low socioeconomic status (perhaps a
student, laborer or farmer by occupation)
 From rural area and from family with conservative attitudes
towards sex.
 Indian J Psychiatry. 2007 Jul-Sep; 49(3): 208–210.

9.  Patients having Dhat syndrome can be further divided into three
categories.
 Dhat alone - Patients attributed their symptoms to semen loss;
presenting symptoms - hypochondriacal, depressive or anxiety
symptoms
 Dhat with comorbid depression and anxiety - Dhat was seen as an
accompanying symptom
 Dhat with sexual dysfunction

10.  The duration of presentation of these patients from the onset
varies from less than three months up to one year even up to 20
years.
 The patients reported that they lose their semen in sleep, with
urine, masturbation, hetero/homosexual sex.

11.  Erectile dysfunction (22-62%) and premature ejaculation (22-
44%) were the most commonly associated psychosexual
dysfunctions.
 depressive neurosis (40-42%), anxiety neurosis (21-38%),
somatoform/ hypochondriasis (32-40%) were the most reported
psychiatric disorders in the patients having diagnosis of Dhat
syndrome.
 Urine examination of these patients did not reveal any abnormality
except oxaluria (10%) and phosphaturia (6%).

12.  Majority believed that Dhat consisted of semen, followed by
pus, sugar, concentrated urine, infection or “not sure.”
 Majority considered masturbation and/or excessive indulgence in
sexual activities as important causative factor.
 Venereal diseases, urinary tract infections, overeating,
constipation or worm infestation, disturbed sleep or genetic
factors.

13.  Grover et al., had developed a comprehensive questionnaire for
the evaluation of Dhat syndrome.
 This instrument has been utilized in a multi-center study in India
and has been demonstrated to be applicable across various regions
in India.
 Before inclusion of Dhat syndrome in the classificatory systems
(ICD-10 and DSM-IV), a lot of debate was going on regarding its
nosological status.

14.  Questions were raised regarding its existence as a distinct
diagnostic entity
 A unique pattern of symptoms attributed to a unique reason in a
unique culture.( established it as a unique culture-bound syndrom)
 But it can be equivalent to depression/ used as a specifier of
depression /may be cultural way of manifesting the distress.
  it reached the glossary section of DSM-5 describing cultural
concepts of distress.
 ICD-10 (F 48.8) Other specified neurotic disorder
 ICD-11 (HA40.5) Associated with cultural factors

15.  Dhat syndrome is common among poorly educated males in their
second to third decade of life.
 The features like anxiety, depression, and multiple somatic
complaints are the core features of Dhat syndrome
 Commonly responds to anti anxiety or antidepressant
medications, as well as psychological interventions such as
psycho-education, counseling, and cognitive behavior therapy.

16.  Dhat syndrome -abnormal illness behavior of presenting semen loss in
the exaggerated form of somatization, as well as heightened emotional
(depression and anxiety) response.
 Time of onset of Dhat syndrome- people perceive their genital secretion
or semen discharge in a pathological manner excessive significance to
it.
 Every time they loss semen or have genital secretionstress (as it is not
culturally perceived as normal).
 The initial stress  amplified with time resulting in exaggeration of
psycho-somatic symptoms
 Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al. Comorbidity in patients with Dhat
syndrome: A nationwide multicentric study. J Sex Med. 2015;12:1398–401. [PubMed]

17.  Similar entity in females - “Dhat syndrome of females.”
 Females’ complaint about vaginal discharge and 32% of these
patients attribute their somatic symptoms to vaginal discharge.
 Study found that females with somatic symptoms more commonly
mis-attribute their symptoms to physiological vaginal discharge.
Chaturvedi et al

18. sexual dysfunction is
associated in more than
50% of patients with Dhat
syndrome .
It is the most common co-
morbidity associated with
Dhat syndrom

19.  1. The clinical features of Dhat syndrome have a lot of
morphological similarity with – depressive spectrum disorder,
anxiety disorder, and somatoform disorder.
 Hence, the possibility of falling into any one of these categories is
more likely.
 But the etio-pathogenesis, course, outcome, the target of
intervention, and the response to the intervention of Dhat
syndrome are quite different from the above three entities

21.  2. The etiology of Dhat syndrome is definite (due to loss of
semen), and all the symptoms are attributed to semen loss,
whereas in depressive spectrum disorders, anxiety disorders or
somatoform disorders, there is no single, definite etiological factor
that explains the illness entity.
 Hence, the existence of Dhat syndrome as an independent
diagnostic entity cannot be denied.

22.  3.Ubsuming Dhat syndrome under another diagnostic entity such as
depression, anxiety disorder, or somatoform disorder may dilute the
weight-age of this disorder as an independent clinical entity.
 This would thwart further understanding of the salient characteristics
of this condition / impair the development and delivery of specific
interventions for this syndrome.

23.  4. Dhat syndrome - whether it should be considered as a culture-bound
syndrome?
 Evidences regarding the existence of Dhat syndrome in different
cultures.
 Pakistan, Bangladesh, Nepal, Sri Lanka (Sukra Prameha) China (Sen-
k’uri),Malaysia, Indonesia, Japan, America, Russia, Spain, and other
European countries.
 The similar entity is known in different countries in different names.
 Though there is mixing of culture due to modernization, migration,and
many other ways but is it enough to explain the wide distribution of
Dhat syndrome?

25.  Integration with other disciplines will help in delivering a
comprehensive, more focused and culturally acceptable, highly
effective modality of treatment.
 It will also help in reducing the stigma associated with Dhat
syndrome, as well as imparting uniform information, about sexual
health.

26.  Collaboration with traditional healers may help in breaking the
barrier  patients may be referred to appropriate service
providers.
 Educating the traditional healers may help in resolving the sexual
myths that they carry and dissipate to the people in the
community.

27.  integrating sex education to regular educational curriculum
dispell misconceptions prevalent in the community.
 Explain normal sexual developments, normal anatomy, and
physiology of genital system, explain about the sexual myths,
during early adolescence.
 Relaxation therapy mainly consists of Jacobson's Progressive
Muscular Relaxation Technique.
 Sujita Kumar Kar and Siddharth Sarkar1Department of Psychiatry, King George's Medical University,
Lucknow, J Hum Reprod Sci. 2015 Jul-Sep; 8(3): 130–134(pubMed)

28.  The biggest barrier to the treatment of patients with Dhat
syndrome is convincing them of the psychological causation,
which is culturally alien to them.
 This would have to be tackled gradually and innovative ways for
doing the same are needed.
 Indian J Psychiatry. 2014 Jan;56(1)Sathya PrakashDepartment of Psychiatry, All India
Institute of Medical Sciences, New Delhi,

29.  In a depressive disorder, the idea of psychological illness is
acceptable to the patient .
 So he would be more prepared to observe his thoughts in therapy,
in sharp contrast, to a patient with Dhat syndrome who comes
with an idea of having a physical disorder.
 It is indeed doubtful Dhat syndrome patients would be ready to
accept only psychological causation so early in therapy.

30.  Diagnosable under Dissociative disorders.
 Patient is possessed usually by ‘spirit/soul’ of deceased relative or
a local deity.
 Speaks in changed tone, even gender changes at times if the
possessing soul is of opposite sex.
 Usually seen in rural areas or in migrants from rural areas.
 Majority of these patients are females who otherwise don’t have
any outlet to express their emotions.

31.  Many religious shrines hold special annual festivals where hundreds of
people get possessed simultaneously
 These people are looked upon as special by their families and villages
which reinforce the secondary gains
 Included in ICD-10 under Dissociative disorders

32.  Treatment includes careful exploration of underlying stress which
precipitated the possession attack.
 To decrease any secondary gains patient may be getting from this
behaviour.
 Antidepressants and anxiolytics .

33.  • Seen in northeastern states like Assam
 • Fear of genitalia retracting into abdomen leading ultimately to
death
 • Seen in both sexes
 • Person applies external retractors to the genitalia in form of
clamps, chains etc. to avoid it retracting back
 • It may occur as epidemics
 • Described as a syndrome in ICD-10( F 48.8) and DSM -5

34.  • First described by Neki in 1972
 • Appears in adolescents and young adults
 Characterized by social withdrawal, severe sexual abstinence,
practice of religious austerities, lack of concern with physical
appearance and considerable loss of weight.

35.  Short lasting epidemics of Mass Hysteria
 Hundreds to thousands of people were seen to be believing and
behaving in a manner in which ordinarily they wont.
 1. Monkey Man or Kala Bandar
 In 2001, the capital was struck by the horror of ‘Monkey Man’.
 People reported seeing a half man-half monkey like creature
roaming the streets of New Delhi, attacking people.
 Some described ‘Monkey Man’ as wearing a helmet, others
claimed he had metal claws.

36.  2. The ‘Sweet Water’ of Mahim Creek
 In 2006, Mumbai residents claimed that the water of the highly
contaminated Mahim creek, had suddenly turned sweet.
 Hundreds flocked to Mahim beach to taste the water, many began
attributing the ‘miracle’ to a Haji Maqdoom Baba.

37.  3. The ‘Muhnochwa’ Scare
 In the summer of 2002, locals in Uttar Pradesh’s Mirzapur were
terrorised by an object they called ‘Muhnochwa’, or the
face (muh) ripper (nochwa).
 Locals described it as a flying object that emitted beams of red or
green light, and sent shock waves through anyone who comes in
contact.
 The victims sustained injury marks that were similar to nail
marks. Described it as a hawk or doll-like object, a remote-
controlled device.

38.  Kerala’s Notorious ‘Black Man’
 In early 2015, an unidentified ‘Black Man’ was said to be
attacking women and children in Kerala.
 ‘Black Man’ reportedly wore a black mask and a black outfit.
 Some said he had a spring attached to his shoes to help him jump
high.
 The news spread fast through social media, creating panic among
people. This giving way to a few instances of attacks being carried
out by others in the name of ‘Black Man’.

39.  Tamil Nadu’s Blood-Sucking Vampire
 In 2016, hysteria about a ‘vampire’ kept residence of a Tamil
Nadu village confined to their homes.
 Villagers in Gundalapatti, Mottangurichi were mortified by their
cattle dying mysteriously and believed a blood-sucking vampire,
or Ratha Kaatteri, was on the prowl,

40. • Characterised by patient complaining of small swelling on the body
changing its position from time to time as if a gilhari (squirrel) is
tavelling in the body.
• Nosological status not clear

41.  It is a culture specific syndrome of painful urination and pelvic
“heat” familiar in south India , especially in the Tamil culture.
 It occurs in males and females.
 It is popularly attributed to an increase in the “inner heat” of the
body often due to dehydration.
 It is usually treated by -
 Applying a few drops of sesame oil or castor oil in the navel and
the pelvic region/ an oil massage followed by a warm water bath/
intake of fenugreek seeds soaked overnight.

42.  Jhin Jhinia
 • Occurs in epidemic from in India
 • Characterised by bizarre and seemingly involuntary contractions
and spasms
 • Nosological status unclear
 Bhanmati Sorcery (Seivinai)
 This CBS is seen in South India.
 It is believed to be due to psychiatric illness i.e. conversion
,disorders, somatization disorders, anxiety disorder , dysthymia ,
schizophrenia etc.
 • Nosological status unclear

43.  Sati : self-immolation by a widow on her husband’s pyre.
 Seen mostly in Upper Castes notably Brahmins and Kshatriyas.
 Banned in India since 19th century
 Seen mostly in Upper Castes notably Brahmins and Kshatriyas.
 Banned in India since 19th century.
 Only one known case since 1904 (in Rajasthan)

44.  Santhara/Sallekhana : voluntarily giving up life by fasting unto
death over a period of time for religious reasons to attain
God/Moksha
 Seen in Jain Community who celebrates these events as religious
festivals.
 Jouhar : Suicide committed by a women even before the death of
her Husband when faced by prospect of dis honour from another
man (usually a conquering king). Eg-Rani Padmini of Chittor
(Rajasthan)

45.  Five different patterns of spitting in India:
 (i) betel-chewing and spitting in spittoons which more or less
disappeared in recent times
 (ii) betel-chewing and spitting in public places and on the corners
of public offices, stairs
 (iii) compulsive spitting in public places and on the roads
 (iv) spitting from moving vehicles (cars, buses and trains)and
 (v) spitting for religious reasons

46.  Spitting into a “spittoon ,”a vessel meant for spitting, was a
common sight through most of the Mughal period and is seen in
some homes in India.
 Spitting has cultural significance as well.
 spitting on the sides of a child is believed to ward off the evil eye
or nazar (Debu 2015).

47.  Culture-bound syndromes were first described over60 years ago.
 The underlying premise was that certain psychiatric syndromes
are confined to specific cultures.
 There is no doubt that cultures influence how symptoms are
perceived, explained and from where help is sought.
 Cultures determine what idioms of distress are employed to
express distress.

48.  Rapid globalization and industrialization have made the world a
smaller place .
 cultures are being more influenced by other cultures.
 This has led to social and economic changes in parts of the world
where such syndromes were seen more frequently.

49.  The number of syndromes in the DSM-5 has been reduced,
acknowledging that these syndromes may be changing their
presentations.
 Clinicians need to be aware of social and economic changes that
may affect various psychiatric syndromes.
 Psychiatry and Clinical Neurosciences © 2015 Japanese Society of Psychiatry and Neurolog

50.  Anuja Kapoor et.al,Int J Cur Res Rev | Vol 10 • Issue 11 • June 2018
 Indian J Psychiatry. 2014 Jan;56(1)Sathya Prakash Department of Psychiatry, All
India Institute of Medical Sciences, New Delhi
 Jain A, Kamal Kumar V, Omprakash J, Suthar N (2014) “Gilhari (Lizard)
Syndrome” A New Culture Bound Syndrome. J Psychiatry 17: 117 doi:
10.4172/Psychiatry.1000117
 Dhat syndrome: Sujita Kumar Kar and Siddharth Sarkar1Department of Psychiatry,
King George's Medical University, Lucknow, J Hum Reprod Sci. 2015 Jul-Sep;
8(3): 130–134(pubMed)
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