Medically Unexplained Somatic Symptoms: Diagnostic and Treatment Issues on the Indian Subcontinent

Mr. S is a 17-year-old unmarried male, an only child, currently studying in 12th standard in a school in New Delhi. He originally hailed from a village about 100 km south of New Delhi. His family had moved to the city 3 years ago, primarily with the hope of providing him a better education. However, over the past 2 to 3 years, Mr. S had not been doing well in his studies; he had been getting much lower marks than what was expected of him from his previous performance. Mr. S acknowledged that this was the case. He complained of an inability to concentrate, forgetfulness, and fatigue. He also complained of vague body aches, abdominal discomfort, weakness, and sleep disturbances. These symptoms periodically worsened, followed by periods of relative improvement, but he was never totally symptom free. For the past 2 to 3 years, he had been experiencing nocturnal emissions and sometimes passed whitish discharge (which he referred to as “dhat”) in his urine. Such instances occurred two or three times a week. His symptoms worsened the day after such episodes, with some improvement in the intervening days. He had been told by his friends and had also read in magazines that the whitish discharge was semen, and that losing too much of it would be harmful to the body. The magazines described a variety of symptoms ranging from weakness and body aches to impotence and death.

Mr. S had consulted a local allopathic physician, who prescribed some vitamin supplements. The patient wondered how his symptoms could improve as long as he did not stop passing dhat, and he raised this question during a subsequent consultation. The physician dismissed his concern, saying that loss of semen was harmless. The patient felt that his physician did not understand his problems and stopped consulting him. He then consulted an Ayurvedic physician, who agreed with the patient’s understanding of the illness. The Ayurvedic physician prescribed certain herbal medications that were supposed to conserve semen and increase its density. However, despite several months of treatment, the discharge continued to occur, as did the other symptoms.

The patient consulted two other allopathic physicians but did not follow up regularly. He was initially seen by an internist at our hospital and was referred to the department of psychiatry. The patient reported the various symptoms detailed above to the psychiatrist as well. Thus, the patient was experiencing a number of somatic symptoms with an underlying preoccupation with loss of dhat and its debilitating effects. Significant distress and dysfunction were also evident. However, persistent, pervasive sadness and ideas of hopelessness, helplessness, or worthlessness were not evident. The psychiatrist made a diagnosis of “dhat syndrome” (other neurotic disorders) according to ICD-10. (Dhat syndrome is also described in DSM-5 in the Glossary of Cultural Concepts of Distress.)

Mr. S was scheduled for weekly counseling sessions. Keeping in mind the patient’s strong beliefs regarding the nature and causation of his illness, premature dismissal of a physical basis for his symptoms was avoided. This was particularly important given the fact that the patient had stopped consulting a physician who had earlier dismissed loss of semen as the cause of his symptoms. Instead, the first session focused on listening to the patient’s complaints in detail and acknowledging his distress and that his symptoms were real. This session also served to establish rapport with the patient and to make it clear to the patient that the psychiatrist did not ridicule his views regarding the illness. The second session focused on the patient’s perspective of the illness and its various symptoms, as well as which symptoms bothered him most and why. In the next session, the psychiatrist conducted a detailed history and physical examination focusing on possible medical causes. While acknowledging the patient’s distress, the psychiatrist conveyed to him that there was no serious underlying illness. A genital examination was also performed, and the patient was told that there was no abnormality in the genitalia and that his condition would not, in any way, interfere with his future sexual performance. The patient was quite reassured to hear this and said that he had been very worried about his sexual performance after marriage. In the next session, alternative methods of tackling his symptoms (other than stopping the whitish discharge) were considered without directly confronting the patient’s beliefs. The psychiatrist explained in simple terms the functioning of the male reproductive system and why the discharge occurred. He also explained that at the patient’s age a large number of young men similarly passed whitish discharge without experiencing the troubling symptoms that he experienced. Thus, in this session, the patient was prepared for considering alternative possibilities. In the next session, the psychiatrist suggested that the patient adopt a healthy lifestyle including a balanced diet and exercise regimen “to strengthen his body and protect it from damaging influences” (without directly reinforcing or negating the patient’s belief of loss of semen as a damaging influence). The subsequent three sessions focused on improving coping, attention to other important areas of life, and review of progress. By the end of 2 months, the patient’s symptoms had improved significantly. Although he reported that the whitish discharge continued, the other symptoms had mostly subsided, except for brief periods following the passage of discharge.