Dhat syndrome (DS) refers to a preoccupation with the physical and mental effects of the perceived loss of semen found among males in the subcontinent and Southeast Asian countries.[1,2] The nosological status of DS is in contention and it is highly comorbid with other psychiatric disorders.[2,3] We propose assessing the longitudinal association of symptoms of dhat with those of comorbid psychiatric disorders to clarify the relationship.
A 22-year-old male bachelor’s student belonging to the urban middle socioeconomic class of Pakistan presented with a 1-year history of recurrent intrusive thoughts, which were increasing in frequency and intensity. These thoughts revolved around political and sexual themes, were extremely distressing to the patient, and resisted his attempts to get rid of them. His family history was positive for obsessive-compulsive disorder (OCD) in his father. He reported that he had been passing dhat in urine for the last 10 years. According to him, semen loss was due to a previous habit of excessive masturbation and it led to mental and bodily weakness. He was started on tab sertraline 50 mg/day which was escalated to 150 mg/day over a period of 3 months and tab aripiprazole 5 mg HS was added. In addition, counselling was done regarding dhat and cognitive and behavioral interventions started for OCD.
Following initiation of treatment, the frequency of passing dhat increased as OCD symptoms worsened initially. With time, he accepted the explanation given for dhat. The frequency of these symptoms returned to baseline but the distress and preoccupation associated with it decreased. With the improvement of OCD, the symptoms decreased in frequency.
Written informed consent was taken from the patient before writing the case report.
In this case, thoughts related to sexual themes, including significant masturbatory guilt, were the focus of the patient’s distress and illness. Overvalued ideas are defined as a sustained belief that is strongly held but not to the extent of delusion and they exist in the continuum between obsessions and delusions.[4] Overvalued ideas are the central psychopathology in various psychiatric disorders including DS and OCD.[4] As this case shows, overvalued ideas can lead to significant distress and can form the overlap of psychopathology between these disorders. For instance, in DS, overvalued ideas might involve an inordinate belief about the consequence of semen loss and resulting repetitive behavior to check and prevent semen loss.[2] On the other hand, the distress and frequency of sexual obsessions of OCD can augment the overvalued ideas of DS as discussed in this case. Therefore, it is essential to address these overvalued ideas in the treatment of patients.
OCD is a relatively rare comorbidity of DS.[3] A study of the association of symptoms between dhat and comorbid conditions over time might prove helpful in clarifying the course and nosological status of DS. Our case showed that the symptoms of dhat preceded the onset of OCD by many years. The frequency and distress associated with these symptoms increased with the progression of OCD and formed an explanation for it.
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REFERENCES
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