Form–content dichotomy in psychopathology

We read the article on dhat syndrome (Sumathipala et al, 2004) with interest. The apparent disappearance of the syndrome in the Western world and its persistence in the East can be explained by the form–content dichotomy related to psychopathology. Typically, patients with the syndrome present with a variety of ‘neurotic’ symptoms. The patients also offer ‘loss of semen’ as the explanation for these disabling symptoms. Such patients are diagnosed as having dhat syndrome if the physician is aware of the label and the explanation, and if he or she focuses on the content. These patients could also receive a label of anxiety, depression or somatisation if the physician emphasises the form of the presentation. The patient perspective of ‘loss of semen’ as the cause of the symptoms would then be perceived as the patient's explanatory model of his illness.

It has long been recognised that contemporary themes are often incorporated into psychopathology. The culture in south Asia tends to highlight sexual causes for a variety of neurotic phenomena. These explanations generate more acceptance and understanding for the patient than anxiety, depression or somatic symptoms would. Such beliefs are reinforced by traditional Indian systems of medicine which subscribe to these concepts and whose physicians and healers are often the first contact in the pathway to care. Thus, such beliefs are reinforced and perpetuated.

Sexual misconceptions related to dhat are also observed among patients with schizophrenia, substance dependence, bipolar disorders, delusional disorders and major depression.

The focus on form allows psychiatrists to differentiate the different syndromes (Sims, 1988). International classifications have emphasised form over content as a response to the various treatment modalities, based on the recognition and treatment of the clinical syndrome. This does not imply reduced importance being placed on the person's culture and beliefs. It would mandate the management of the patient's explanatory model. This is also true for other culture-bound syndromes such as koro.

Clinicians focusing on content make such presentations appear exotic. Physicians emphasising form are able to recognise behavioural syndromes across cultures. The management of patients with such presentations is the same, irrespective of the diagnostic labels employed.