| Abstract|| |
Dhat syndrome is a culture-bound syndrome prevalent in the natives of the Indian subcontinent characterized by excessive concern about harmful consequences of loss of semen (ICD-10). Treatment offered to the patients suffering from it continues to be esoteric, unstructured and without standardization. The present study aimed to develop and examine the feasibility of Cognitive - Behavior Therapy module for patients with Dhat syndrome. A draft module was developed based on existing theoretical knowledge and suggestions from five mental health professionals. This module was then applied on five patients with Dhat syndrome to assess and judge the suitability of the module. The pre and post-assessments were carried out using Sexual Knowledge and Attitude Questionnaire - II, Hamilton Depression Rating Scale, The Cognitive-Somatic Anxiety Scale, Screener for Somatoform Disorder, International Index for Erectile Function, Clinical Global Impressions, The World Health Organization Quality of Life Assessment - BREF. Experiences and insights gained from each patient were used to refine the module before applying on the next patient. The final module consisted of the following components was developed: Basic sex education, cognitive restructuring, relaxation training, imaginal desensitization, masturbatory training as homework and Kegel's exercises and 'start-stop technique' and 'squeeze technique' for sexual dysfunctions. Results of the study reveal that it is feasible to carry out the CBT module in clinical settings. Number of sessions ranged from 11 to 16 sessions. The duration of the session was 45 minutes on the average. Findings of the present study revealed improvement in sexual knowledge, anxiety, depressive and somatic symptoms. Implications and limitations of the study are highlighted and suggestions for future research offered.
Keywords: Cognitive behavior therapy, Dhat syndrome, feasibility, semen loss
|How to cite this article:|
Abdul Salam K P, Sharma MP, Prakash O. Development of cognitive-behavioral therapy intervention for patients with Dhat syndrome. Indian J Psychiatry 2012;54:367-74
| Introduction|| |
Dhat syndrome is a culture-bound syndrome characterized by excessive concern about loss of semen, vague somatic symptoms, fatigue, weakness and loss of appetite prevalent in the natives of Indian subcontinent. The patient attributes the symptoms to loss of semen in urine or through masturbation or excessive sexual activity.  The word 'Dhat' derives from the word 'Dhatu' which means the elixir of life in Sanskrit.  Traditional medicinal system of Ayurveda had considered semen as the most precious among the seven 'Dhatus' in human body. It had been believed that it takes 40 drops of blood to be converted into one drop of semen. Hence, conservation of semen was important by all means. 
There have been attempts to explain how this belief system arose in the Indian psyche. One explanation was that these people do not understand the complex anatomy and physiology of penis and believe that the blood that is collected in the cavernous spaces during erection gets converted into semen and thus, they are losing blood (and, thus energy) with each sexual activity.  Sexuality is considered a taboo in India, and sexual matters are generally not discussed in Indian families. The tabooed nature of sex and discussions related to it in Indian cultural context make it difficult for them to have discussions with peer groups, which prevents normalization of the experience of semen loss.  There is lack of sufficient research work on the treatment of Dhat syndrome and treatment offered to the patients suffering from it continues to be esoteric, unstructured and without standardization.  Sex education and relaxation exercises have also been a part of intervention programs.  Antidepressants are also advocated for patients with Dhat syndrome having depressive symptoms. 
Patients with Dhat syndrome experience somatic, anxiety and depressive symptoms and often present with sexual dysfunction. The cognitive behavioral therapy (CBT) has found effective in the treatment of depression, , anxiety disorders , and somatoform and other medically unexplained symptoms. , The efficacy of CBT in the treatment of psychosexual dysfunction has also been proved. , Since patients with Dhat syndrome experience overlapping symptoms of these disorders, it can be hypothesized that they would respond to CBT aimed at reducing symptoms experienced by them. CBT also appears to be most relevant intervention in view of faulty beliefs and misconceptions about the origin of their symptoms and sexual functioning. CBT would also address distinct illness behavior shown by patients with Dhat syndrome. Considering these factors, the present study is an attempt to develop a structured CBT module for patients with Dhat syndrome.
| Materials and Methods|| |
The study was conducted at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India with approval from Institutional Ethics committee. A single case design was used. The sample consisted of five male patients from the out-patient services of NIMHANS, who were diagnosed to have Dhat syndrome. All of the five consented patients were single and were in the age range of 25-36 [Table 1]. Four of the patients had consulted professionals from Ayurveda and one of them had consulted a Homeopath before consulting professionals in modern medicine.
Instruments for study
- Social-demographic and clinical data sheet: This data sheet was used to obtain social-demographic details of the patient i.e., age, and education, and socioeconomic status and clinical data of the patient including the chief complaints, history of presenting illness, pre-morbid personality and the diagnoses made by a qualified psychiatrist (OP).
- Semi-structured interview schedule: A semi-structured interview schedule was developed that included details of patient's sexual experiences like childhood experiences, masturbation, nocturnal emissions and details of Dhat discharge, duration, frequency, other associated problems, causative factors as believed by the patient and sources of information for his sexual knowledge.
- Behavior analysis performa  : This Performa involves assessment in seven domains, namely: analysis and problem situation, clarification of problems situation, motivational analysis, developmental analysis, analysis of self-control, analysis of social relationships and analysis of social-cultural-physical environment. It, thus, provides comprehensive data on various variables needed for selecting appropriate Cognitive-Behavioral intervention strategies.
- Sex knowledge and attitude questionnaire - II (SKAQ-II) : This self-administered questionnaire comprises of two parts: knowledge and attitude. The 35-item knowledge part consists of dichotomous scoring with the maximum attainable score of 35. The attitude part has 20 items, scored on a three-point linear scale (0.2), with maximum obtainable total score of 40. Higher the scores, the better the knowledge and more liberal is the attitude.
- Hamilton depression rating scale (HDRS)  : This 21-question multiple choice questionnaire rates the severity of a patient's major depression on 3-5 possible responses.
- The cognitive-somatic anxiety questionnaire (CSAQ)  : The 14 items in this questionnaire are randomly ordered into cognitive and somatic subscales. The sum of ratings on each subscale provides a measure of cognitive and somatic anxiety.
- Screener for somatoform disorder  : It is a 12-item screening instrument for somatoform disorders, which can be either self- or interviewer-administered. The suggested cut-off score is 3.
- International index of erectile function (IIEF)  : The IIEF is a 15-item questionnaire that addresses the relevant domains of male sexual function (that is, erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction), is psychometrically sound, and has been linguistically validated in l0 languages. In the present study, the scale was used a measure of erectile function pre and post intervention.
- Clinical global impression (CGI)  : The CGI is a 3-item observer-rated scale that measures illness severity (CGIS), global improvement or change (CGIC) and therapeutic response. In the present study, scale was used to assess severity of symptoms of Dhat syndrome preintervention and the response to the intervention program.
- The world health organization quality of life assessment-BREF (WHOQOL-BREF) questionnaire  : WHOQOL-BREF questionnaire is a 26-item version of the 100-item instrument of the World Health Organization Quality of Life (WHOQOL-100) that was developed to provide a short form QOL assessment concerned with the meaning of different aspects of life to the respondents, and how satisfactory or problematic are their experiences with these factors. It constitutes four domains- physical health, psychological health, social relationship and environment. In the present study, the tool is used as a measure of quality of life of patients with Dhat syndrome, pre and postintervention.
Descriptive statistics was used to describe the clinical and social-demographic data pertaining to the subjects. Clinically significant changes (50% and above) based on pretherapy and post-therapy data was used to assess the feasibility of therapeutic intervention.
| Development of CBT Module|| |
Initially, a draft module was prepared based on existing theoretical knowledge and conceptual understanding. The draft module was sent to five mental health professionals (three psychiatrists and two psychologists having expertise in Psychosexual Medicine) and the suggestions given by them were incorporated to finalize the intervention program. Subsequently, the prepared module was administered on the five patients recruited for the study sequentially. The experience and insights gained from each case was used to fine-tune the module and was employed for intervention with the next patient.
An initial draft of the module was developed based on the existing theoretical knowledge about Dhat syndrome. This initial module consisted of the following components:
Refinement of draft module
- Intake and assessment
- Basic sex education
- Cognitive restructuring
- Behavioral strategies such as arousal reduction training (Jacobson's Progressive Muscular Relaxation), 'start-stop technique', 'squeeze technique' and 'Kegel's Exercise'.
The draft module was sent to five different mental health professionals to assess and judge the suitability of the module. These experts suggested that information regarding the patient's pre-morbid personality has to be given due importance since this may be one of the vulnerability factors and that the patient's explanatory model of the condition should be elicited and properly understood. They also suggested that the cognitive-behavioral model should be presented to the patient before initiating sex education and that the patient should be educated on how the beliefs about precious value of semen were developed in the society and be helped in normalizing his experiences. The patient could be asked to educate about the nature of semen to his friends and others too to help him gain more clarity on the topic. Information about the nature of anxiety, depression, sexual dysfunction and other symptoms was to be given to the patient. Experts also suggested that information from general relationship counseling should also be provided and that the importance of emotional and relationship factors in sex has to be explained to the patient. These suggestions were incorporated in the module.
CBT intervention in patients
The module was applied to five different cases with Dhat syndrome. The experience and insights gained from each case was used to fine-tune the module and was employed for intervention with the next patient.
This patient was a 25-year-old single male teacher presented with from middle socioeconomic status and rural background. Patient complained of bodily weakness, pains and aches all over the body, lack of concentration, nocturnal emissions and excessive masturbation. He reported premature ejaculation since last 1 year. He was anxious about performing adequately sexually after getting married. He attributed all these symptoms to loss of semen ('vital energy', as considered by him). The components of CBT module draft was applied on this patient. Results [Table 2] indicated clinically significant improvement in sexual knowledge, somatic and depressive symptoms. However, there were no clinically significant improvements on the other measures.
It was also understood that sex education alone is not sufficient. The patient could intellectually understand that loss of semen was harmless. However, his beliefs about loss of semen were triggered again when he experienced pain and weakness the next time semen was lost through either masturbation or nocturnal emissions. It was, then, when the importance of cognitive processes and factors (especially selective attention to symptoms) was realized. It was found that the core belief of the patient was related to the cultural concept of 'masculinity'. His idea was that if a person was not 'sexually adequate'; he was not a 'real man'. All the depressive cognitions and lack of self-esteem was intrinsically related to this concept. The importance of addressing this core belief to bring about any therapeutic change was realized. It was thus decided to address the core schema systematically and vigorously related to masculinity to effect any change in subsequent patients. With these insights, it was decided that emphasis would be given to cognitive restructuring, addressing and modification of cognitive errors in the subsequent patients. There have been no studies earlier, which had utilized cognitive restructuring in the management of patients with Dhat syndrome. 
The second patient was a 23-year-old single male, matriculate, hotel waiter from lower socioeconomic status. He presented with complaints of night emissions, bodily weakness, and lack of concentration, erectile dysfunction and pain at the back, head and around the penis. His problems started with night emissions at the age of 16 years. He then started feeling that his body was becoming weak due to the loss of Dhat ('semen') during night emissions. On the day after night emission, he would have pain at the back and his pelvic region. He used to apply analgesic ointment ('balm') for this or occasionally take painkillers for the same. He had stopped going to work when presented. The module after modification was applied and the results after intervention [Table 2] showed clinically significant changes on sexual knowledge, somatic symptoms and parameter of WHOQOL - physical health.
It was observed that a mere intellectual understanding of the harmlessness of loss of semen alone would not help. It was important to bring in a behavioral change. Thus, masturbation was added as a behavioral homework assignment. Principles of single male sex therapy  were used in this regard. Another important understanding was the importance of understanding the role of performance anxiety in these patients. This was not just in the presence of a partner but also even during masturbation. This patient could not engage in masturbation for 'fear of failure'. This fear obviously led to inability to maintain erections. Principles of sensate focus were included in this context where the patient had to focus on the sensation of erection. This helped him to de-focus him from the performance aspect of it, which reduced his anxiety.
The third case was that of a 36-year-old single male, illiterate, employed as a tailor, from lower socioeconomic status and urban background. He presented with complaints of pain all over the body, nocturnal emissions and erectile dysfunction. At the age of 20 years of age, he had an experience where he felt his penis shrunk. He started having pain during masturbation after this and he stopped the practice. He had had two failed attempts to have sexual intercourse with commercial sex workers. Results after application of the module indicated clinically significant improvements were noted in sexual knowledge, depressive and somatic symptoms. The improvement also perceived in erectile dysfunction and parameters of WHOQOL - Physical and Psychological Health [Table 2].
An important insight gained during the intervention in this patient was about the self-fulfilling nature of the symptoms. It was noted that the patient expected to find some pains and weakness after the loss of semen, especially after night emissions. Such a hyper-vigilance, along with the attentional bias toward symptoms, invariably ended up in him finding them. Thus, it had acquired the nature of a self-fulfilling prophecy. This cycle had to be broken to bring about any effective change. This was incorporated in interventions with subsequent patients.
The fourth patient was a 24-year-old single male, pursuing graduation in engineering, from middle socioeconomic status and urban background. He presented with complaints of general weakness, inability to concentrate on studies and erectile dysfunction. He had been having sexual contacts with one relative. However, 3 months back, he had a failure in erection. Since then, he had been unable to maintain erection. He attributed it to excessive loss of semen through sexual intercourse. All forms of sexual activities including masturbation had been stopped by him since then. Results after intervention showed clinically significant improvement in most of the parameters [Table 2].
It was found that though the behavioral homework of masturbation was suggested, the patient was very reluctant to engage in the same. Careful exploration revealed that the imagery of passage of semen itself caused anticipatory anxiety about masturbation to the patient. Therefore, it appeared that imaginal desensitization would be a helpful strategy. The patient could be asked to imagine the loss of semen or sight of semen and could be desensitized to such a scene. This component was added to the module for use with subsequent patient.
This patient was a 25-year-old single male, employed as an engineer, from middle socioeconomic status and urban background. He had presented with complaints of inferiority feelings, anxiety in social situations, inability to concentrate on work, sweating, and dry mouth. He attributed these symptoms to loss of semen through excessive masturbation. He felt that others came to know that he engaged in masturbation by looking at his 'weak body'. He reported intense guilt and had stopped going for social functions. Results after application of the module indicated clinically significant improvement on most of the domains [Table 2]. In this patient, though some amount of anxiety was related to Dhat syndrome itself, it was found that his basic anxious temperament was also playing a large role. Cognitive restructuring was helpful in tackling this. Managing the basic anxiety remained the mainstay in this patient. The predisposing anxiety might have increased the likelihood of him having reacted to the cultural beliefs in a neurotic way, which has been one of the proposed pathways of development of Dhat syndrome. 
Final CBT module
The final module consisted of the following components:
- Intake and assessment (Sessions 1 and 2): A detailed phenomenological account of the patient's difficulties is obtained. The patient's own formulation of his problems is understood. Baseline data is obtained through administration of tools.
- Socializing the patient to CBT (Sessions 3 and 4): A working alliance is established with the patient. The patient is socialized to the style of CBT. The patient is provided a generic cognitive-behavioral model of psychological disorders. He is helped to conceptualize his problems from a Cognitive-Behavioral perspective.
- Basic sex education (Sessions 4 and 5): Sex education involves human sexual processes-sexual anatomy and physiology (including production of semen) using pictures and photographs. Patient is explained about the harmlessness of masturbation and other modes of loss of semen. The patient is told how the beliefs about loss of semen in the society were developed at a time when there were no means of objective testing or technology. It would also help them clarify their beliefs and misconceptions about production and loss of semen through masturbation/excessive sexual activity/night emissions.
- Cognitive restructuring and other techniques (Sessions 6 to 15):
- Cognitive restructuring: Patients with Dhat syndrome readily attribute their symptoms to semen loss without consideration of alternative explanations. Cognitive distortions/errors like selective attention, catastrophisation and personal beliefs result in the augmentation and maintenance of somatic, sexual and other symptoms. The symptoms are thus attributed to semen loss rather than to emotional and subjective factors. They may have core beliefs about masculinity, sexual power and so forth. The automatic thoughts that the patient experiences are elicited using thought listing and thought diary methods. Various standard methods of cognitive restructuring are used to modify the patient's cognitions and beliefs about his condition. Importance of emotional and relationship factors in sexual relations is explained. Since these patients are concerned about 'sexual power and performance', they experience immense performance anxiety during the sexual act. They are explained how performance anxiety hampers sexual performance. The schema of 'masculinity' has to be addressed specifically. These patients believe that 'masculinity' is intrinsically related to 'sexual power'. It is important to modify this strong belief.
- Relaxation (Jacobson's Progressive Muscular Relaxation-JPMR) Training  : Patients with Dhat syndrome have anxieties about health (physical or psychic) consequences of semen loss. Heightened arousal level leads to augmentation and maintenance of their cognitions and illness behavior. The patient is explained the rationale and taught Jacobson's Progressive Muscular Relaxation. Relaxation training helps them bring down their general level of arousal. The training is continued parallel to the sessions and terminated once the patient gains adequate mastery over the technique.
- Imaginal desensitization: Some clients may find it difficult to engage in masturbation or other sexual activities since the imagery of loss of semen or ejaculation itself causes distress to them. Therefore, they are desensitized to this imagery before actual engagement in masturbation or any other sexual activity.
- Masturbation as homework: Although the clients could understand the harmlessness of loss of semen intellectually after Basic Sex Education, they find it difficult to re-engage in sexual activities. Since these clients are mostly unmarried single, masturbation can be suggested as a behavioral homework. This aims at an emotional and experiential learning of the harmlessness of loss of semen. The therapist can guide them through the process of identifying cognitive errors and restructuring them. Principles of sensate focus can be incorporated to reduce the anxiety surrounding semen loss.
- Kegel's exercises and other specific techniques: A considerable group of clients have psychosexual dysfunctions, which are attributed by them to loss of Dhat. Kegel's exercises and other specific exercises like 'squeeze technique' and 'start-stop technique' are taught to the patient based on the difficulties that he has. The principles of sensate focus are used to reduce performance anxiety.
- Termination: The patient is asked to summarize the sessions and therapy. The concluding sessions focus on preparation of the patient for future, re-emphasizing his new learning and reiterating the principles of self-awareness and self-management.
Feasibility of the module
The developed CBT module showed significant improvements in symptomatology and other parameters [Table 2]. The number of sessions in applying the module with these patients ranged from 11 to 16 sessions. Out of the six patients recruited, only one of them dropped-out because of distance from the treatment center. All other patients were motivated to come back for sessions throughout the therapy. The duration of the sessions was 45 minutes on the average. There were no major difficulties reported by the patients in following the information given in the sessions or in carrying out the homework assigned. Thus, it can be concluded that the module is clinically feasible and is suitable for application within busy clinical settings.
| Discussion|| |
This is the first study of its kind to develop a structured treatment program for Dhat syndrome. The study shows the utility of application of Cognitive - Behavioral principles in the treatment of patients with Dhat syndrome. To the best of the knowledge, there is not a single systematic study which had applied Cognitive - Behavior Therapy in these patients.
The study cases showed that Dhat syndrome reflects the culturally embedded beliefs about the nature of semen and consequences of its loss. The subjects of the study shared the findings of previous studies , that sexual activity continues to be strongly influenced by culturally held beliefs. These studies also commented about the role of cultural acceptance of these beliefs in the development and maintenance of Dhat syndrome. The professionals from Ayurveda and Homeopathy had endorsed and reinforced the patients' beliefs about loss of semen.  Majority of patients exhibited illness behaviors as maintenance factors as reported in other studies. ,
Sex education was found to be an important part of therapy. Earlier, Avasthi and Gupta (1997)  had also voiced the need of sex education in these patients. Sex education would help the clients get a clear and more accurate understanding of human sexual processes and this information itself would help the patient in starting the process of re-attributing his somatic/depressive/ sexual symptoms to factors other than loss of Dhat.
In this CBT model, cognitive restructuring forms an important framework. Cognitive restructuring helps the patient to modify these cognitive distortions and dysfunctional beliefs. The principal aim is to make the client understand the core symptoms of anxiety, depression, somatisation or sexual dysfunction. This component is based on patients' belief that one's personal worth and self-esteem was directly related to one's 'sexual power'. The study confirmed that the schema related to 'masculinity' and 'sexual power' was important to bring about any therapeutic change. Sexual schema has been postulated to precipitate sexual dysfucntions.  These men perceived themselves to be sexually weak due to loss of semen. This can also be seen in the light of prevalent socio-cultural norms - men are "supposed to be strong" (sexuality being a principal area). This view about oneself being weak gives rise to emotional such as anxiety and sadness which further complicates the picture.
Jacobson's Progressive Muscle Relaxation (JPMR) procedure, a component of this module, has been clinically used to manage symptoms of chronic anxiety, physical tension and pains and stress. It produces a relaxed state consistent with a state of decreased sympathetic activity. JPMR helps the patients with Dhat syndrome to bring down their general level of arousal.
The study found that images of loss of semen itself were distressing to the patients. Such imageries are known to produce anxiety. Imaginal desensitization has been used to combat such imageries and has been found to be an effective technique in reducing anxiety.  Therefore, imaginal desensitization was added as a component in the module.
Specific techniques from cognitive - behavioral sex therapy like Kegel's exercise helps them manage their symptoms in a better way and thus give them a better sense of control over their symptoms, without readily attributing them to loss of Dhat. It is helpful then to make patients understand that there are ways to handle this. At this point, patient with Dhat syndrome is taught various ways of handling premature ejaculation and erectile dysfunction, like start-stop technique  and squeeze technique. 
The CBT treatment module for Dhat syndrome is effective, clinically feasible and takes 11 to 16 sessions of 45 minutes each. There were no major difficulties reported by the patients in following the information given in the sessions or in carrying out the homework assigned. Thus, it can be concluded that the module is clinically feasible and is suitable for application within busy clinical settings.
However, the authors recognize the limitations of the study. The sample size is small in this study. The efficacy of the module in comparison with other treatment protocols is not established. A single case design was adopted and therefore, the group could not be compared with controls. Future researches could apply the module to a larger sample in order to establish its effectiveness. The module has to be compared with other treatment modules to establish the efficacy of the module. Studies could be conducted with randomization and control group to enhance the confidence in the results.
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Department of Psychiatry, Consultant in Adult and Geriatric Psychiatry, Institute of Human behaviour & Allied Sciences (IHBAS), Dilshad Garden, Delhi 110095
[Table 1], [Table 2]