We are delighted to note the varying and huge response to our paper (Sumathipala et al, 2004). It is interesting to note that most of the comments are from the Indian subcontinent where the dhat syndrome is prevalent.
Drs Kuruppuarachchi & Wijeratne point out that semen loss anxiety is a form of communicating distress. We agree, but our conjecture is that male preoccupation with semen loss has been universal and we need to place the related depression and anxiety in the specific context. Our contention with which Kuruppuarachchi and Wijeratne agree is that ICD–10 and DSM–IV–TR are culturally influenced classificatory systems. Wig's (1994) suggestion that culture-bound syndromes should be integrated into existing rubrics of psychiatric classification is an appropriate one. Most of the correspondents feel that culture-bound syndromes should be separate, which is an assertion we disagree with.
Drs Painuly & Chakrabarti's suggestion that there are cases of ‘pure’ dhat also reflects the possibility that there are cases of ‘pure’ depression. To argue that treatments should reflect the diagnosis is putting the horse before the cart. It is not true to say that neurasthenia does not exist any more. Neurasthenia as a diagnosis exists not only in China but also in France, once again emphasising that idioms of distress do cross cultural boundaries.
Dr Gonjanur misses the point we were making. The semen loss anxiety which led to Kellogg and Graham marketing corn flakes and Graham crackers, respectively, as treatment (for semen loss) has disappeared from the West because of changes in the social, political and economic climate. Why have the symptoms that were widely prevalent and described in the UK, USA and Australia in the 19th century disappeared over time? Dr Shankar seems to argue that Ayurveda is a culture; it is a system of medicine developed at a specific time. It should be left to historians to discern whether Ayurveda reflects the culture or the culture is influenced by Ayurvedic concepts in exactly the same way as Western medical systems reflect or influence Western cultures. We believe that culture-bound syndrome as a nosological category is a colonial invention and deserves to be dumped in the bin of history. We agree that culture plays a key role in how symptoms are allowed and encouraged to be developed and expressed by individuals. However, the role of culture is essential for all our patients and not a few selected ones. Everyone has culture.
One of the key factors that the correspondents have chosen not to discuss is the distinction between disease and illness. Dhat as a symptom and syndrome reflects illness in the broadest term. The clinicians are trying to place this in a disease category, thereby paying lip service to cultural influences only in the pathological diagnostic sense, not in a broader idiom of distress. Although some acknowledgement is made to the heterogeneity of the syndrome, we believe that cultures themselves are markedly heterogeneous and the clinicians must address not only the cultural values and identity of individuals but also those of the cultural groups to which the individual belongs, and place the expression of distress in its historical and social context. It would appear that our correspondents are arguing for exemption for a geographical syndrome. It is indeed a pity that Westermeyer & Janca's (1997) argument is not universally accepted in the classificatory and nosological systems as it deserves to be – the exact point we have striven to put across. Culture-bound syndromes have fascinated anthropologists and psychiatrists alike as accounts of strange syndromes, myths and symbols. We urge clinicians to place these symptoms in the context of cultural values and not simply medicalise and pathologise distress that can be dealt with using other models. Another question that deserves to be raised and answered is why amok in Malaysia is seen as a culture-bound syndrome but similar behaviour of random shootings and running ‘amok’ is not seen in this way in the USA? It is time that we gave up the ghost of colonialism and looked at culture-bound syndromes with a new eye. We acknowledge that culture is an important pathogenic and pathoplastic influence but our belief is that culture-bound syndromes are a historical anomaly. Dhat as symptom is important but the classification of dhat syndrome is problematic.