Is the DSM-5 position on dhat syndrome justified?

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The DSM-5 lists dhat syndrome under the section ‘Glossary of cultural concepts of distress’. It describes dhat syndrome as ‘anxiety and distress about the loss of dhat in the absence of any identifiable physiological dysfunction.’ It further clarifies that ‘despite the name, it is not a discrete syndrome but rather a cultural explanation of distress’. This is a marked deviation from the DSM-IV-TR where the syndrome is described under the section ‘glossary of culture bound syndromes’ as a ‘folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns associated with discharge of semen. . .’ It is also a deviation from the ICD-10 which had also given dhat syndrome a separate status under the section ‘neurotic disorders, other’ although it does mention that the syndrome is of uncertain etiology and nosologic status. So, has enough evidence accumulated in the last two decades to change our view on dhat syndrome in this manner? A Pubmed search using the search term ‘dhat syndrome’ yields a total of 44 results of which 38 were published after 1994. Of them, only 8 papers (Table 1) have discussed the issue of its nosological status in some detail. This includes only 3 original articles. We will briefly discuss whether these articles made a good case for the change in stance taken by DSM-5 or not. Mumford (1996) noted that men reporting dhat symptom had higher Hospital Anxiety and Depression Scale (HADS) depression score but not anxiety scores. Also, four out of six men who were diagnosed with depression or dysthymia endorsed the dhat symptom. Based on these findings, Mumford concluded that dhat syndrome was a culturally appropriate form of depression. However, this study had certain major flaws. A fundamental error was to enquire regarding dhat ‘symptom’ and not ‘syndrome’. This issue of dhat ‘symptom’ vs dhat ‘syndrome’ merits further discussion as this is a source of much confusion. Mere reporting of passage of dhat (without associated preoccupation or distress), in a patient presenting to the clinic for some other health condition, that too on being asked a leading question by a clinician, does not constitute dhat syndrome. It is usual for one to encounter in clinical practice a patient reporting occasional passage of dhat on being specifically asked by the clinician. But many such patients suggest that they are not concerned about it or have no problems that they believe are arising due to it. Considering all such patients to have dhat syndrome is obviously incorrect. An analogy to this is the presence of low mood alone without other associated symptoms of depression in a manner that is not persistent and