Dhat Syndrome: Sexual Behaviour and Psychiatric Comorbidity

Dhat Syndrome familiar Behaviour and Psychiatric ComorbidityOriginal Research ArticleTitle Dhat syndrome and its association with versed behavior and pyschiatric comorbidities in Indian malesSahu R.N, MD ( abnormal psychology), doubt and Professor,Co- AuthorsSharma V K, MD, WHO Fellow (USA), Head and Professor, Department of Medicine Gandhi Medical College, Bhopal, Madhya Pradesh, IndiaAshutosh Kumar, Lecturer, Gandhi Medical College, Bhopal, Madhya Pradesh, IndiaChintan Bavishi, Lecturer, Manipal University, Manipal, Karnataka, IndiaBalaji More, Assistant Professor, Krishna Institute of Medical Sciences, Karad, MaharashtraTitle Dhat syndrome and its association with symptoms, sexual behavior and comorbidities in Indian male long-sufferings AbstractThe Context (Background) Dhat syndrome is often taken as culture bound syndrome of Indian subcontinent. There are many misconceptions which form free-base of symptoms and comorbidities.Aims Dhat syndrome is reported on basis of self d iagnosis. The ingest aims to study associated symptoms, sexual behavior and comorbidities in Indian population.Methods and Material This cross-sectional and case- ascendancy study, was carried with help of trained local anaesthetic interviewers at Department of Psychiatry and Medicine, Gandhi Medical College (GMC), Associated Hamidia Hospital, Bhopal, India. Cases were compared to healthy matched controls. The study was conducted using clinical interview, physical examination and other necessary investigations like urine abstract and microscopy.Results Of the 50 cases and control, each, age group was 21 to 25 years (48%) and education upto12th class (60%). 20% cases reported memorial of Masturbation. Extramarital or premarital sexual contact was found to have little significance on the syndrome. 76% of the patients met DSM-IV Diagnostic Criteria for Anxiety and 56% patients met for Depression. 23 patients (46.3%) were having a co-morbid somatic complains like bodyache, weakness and fatigue. Erectile dysfunction by 34% Premature ejaculation by 8% was reported. In Urine routine compend and microscope no oxalates or phosphates were noned.Conclusions Dhat syndrome is more(prenominal) common among low educated young population. Laboratory evidence of any pathological cause was not found. Contrary to popular belief, it had no direct coefficient of correlation with masturbation and pre and extra marital sexual contact.Key Words Dhat Syndrome, Semen, Sexual behavior, Somatic symptoms, Erectile DysfunctionIntroductionDhat syndrome is a Culture bound syndrome.1 provided it has been menti onenessd in medical history and reported by population worldwide. The culture has profound impact on the mental status of an individual. According to International categorisation of Diseases (ICD) 10 had classified Dhat syndrome had been classified in both neurotic disorder (F48.8) and into culture specific disorder caused by undue concern about the debilitating effects of the passage of semen. The cases are always self reported and they often report a set of symptoms. These vague somatic symptoms are fatigue / embodied weakness, headache, depression3, anxiety, loss of appetite, palpitation / tachycardia, guilt, poor concentration, forgetfulness.2 Due to existing belief it is often associated as a result of masturbation and cosmos sexually active foreign marriage. The comorbidities include erectile dysfunction, premature ejaculation and impotence.Patients reported semen loss in urine or involuntarily outside (spontaneously while sleeping during loosening or while showering) of sexual relations.4 A typical profile of Dhat Syndrome patient either is a young man, unmarried or recently married, less educated, and the one who holds strong traditional beliefs.5This category of disease involves mixed disorders of behavior, beliefs, and emotions which are of uncertain etiology and nosological status and which occur with particular frequency in certain cu ltures. The ethnic belief and pattern associated with Dhat syndrome make it different from delusional disorder. 6, 7Material and MethodsThe study is a case-control cross sectional study, aimed to evaluate the symptoms, beliefs and comorbidities related to Dhat syndrome. The study and control group of 50 each was assessed.The study was conducted at Gandhi Medical College (GMC), Associated Hamidia Hospital, Bhopal, India. Study group of 50 subjects was selected who had Dhat syndrome without any other organic disorder at OPD of Psychiatry Department. The control group of 50 patients was shortlisted from the Medicine Department. They were not diagnosed for Dhat syndrome and were matched with the case group in most aspects. Both groups were interviewed based on a structured interview. inclusion body criteriaCase groupComplain of whitish discharge in the urine and associating it with symptoms and comorbiditiesFulfilled DSM-IV TR criteria apartConsenting to clinical interviewControl group Inpatients who were not suffering from Dhat syndrome though they were suffering from other medical ailmentsMatched in other aspects with the case groupConsenting to clinical interviewExclusion criteria Presence ofgenitourinary disorderTesticular tumorVaricoceleOrganic sexual dysfunctionPelvic inflammatory diseaseEndocrine disordersSpinal cord traumaEthicsinstitutional review board and ethical committee approval was taken from GMC, Bhopal, India. All periodic adverse event reports were reported to them and appropriate guidance was taken.All interviewers were calculated about ethical and legal considerations. All identification information including names, initials and hospital numbers were avoided to keep the patient details in anonymity. Written information swallow after the details of the project were fully explained was obtained from all participants. There were no minors involved and hence no paternal consent involved in this study.Statistics The data was analyzed by using stat istical tests of mean and standard deviation. (P0.005)ResultsDhat syndrome is prevalent in younger age group. Anxiety is most prevalent followed by depression. They are related to sexual symptoms as ejaculatory dysfunction, premature ejaculation and impotence. (Fig. 1) Patients associated Dhat syndrome as a direct result of excessive indulgence in sexual action or masturbation or to nocturnal emissions. (Fig. 2) Dhat syndrome was prevalent in class of lower education, below class 12.Routine biochemical and urine laboratory military rating was conducted for all 100 participants.Other necessary investigations were carried out as per the requirement of the subjects to exclude organicity ( Sonography and Hormone Assay). None of the reports showed presence of oxalates or phosphates. A semen analysis founded out altogether 1 patient had azoospermia and 2 were having oligospermia.Figure 1 Co-morbid conditions associated with patients in study group and control groupFigure 2 Sexual histor y of patients in study group and control groupDiscussionAs a Culture bound syndrome, Dhat syndrome has been discussed for long time. Epidemiology and prevalence is noted in history of medicine all over the world.1, 8 The Dhat syndrome is not limited to Indian subcontinent. The origin of its name had a strong relationship with Indian culture, history and mythology.9, 10Dhat Syndrome forms an important health problem and the magnitude is also very high. In view of this it films a proper attention and sensitization amongst the health care providers for the proper treatment, counseling of these patients and referring them to related specialty. The patient presenting with Dhat syndrome is typically more likely to be recently married of average or low socio-economic status (student, jackstones or farmer by occupation), came from a rural area and belonged to a family with conservative attitudes towards sex.11The exact pathophysiology of Dhat syndrome is not known. The study demonstrated various other symptoms and morbidities being involved along with Dhat syndrome. The prevalence in relatively younger age group can be attributed to hormonal rush.12 Majority of these individuals visited self-claimed sex specialists and traditional combine healers. The contact with these health providers not only strengthen their misconception and false beliefs, but also compel the patients to pay huge cost of investigations and drugs which are not only non-effective but also hazardous. 5Among other studies the relationship between marital status or sexual contact outside marriage and Dhat syndrome is not discussed. This study establish contrary to the popular belief that no such cause-effect relationship exists. Dhat syndrome was most common among illiterate patients and less educated patients. There is a need for patient education and sex education in the eradication of syndrome. 13, 14 The spread of disease in all age groups indicate towards the need of patient education about th e disease in India. In many cases the syndrome is under diagnosed. In general, the deep-rooted misconceptions associated with anatomical and physiological aspects of sexuality are difficult to be correct with general counseling sessions.The further work in this field is required to know Whether Dhat is a Culture bound syndrome only in India? What is the pathophysiology crapper it? Is there any relationship of it with depression, anxiety or other mental health disorder? Whether there is any relationship between puberty and Dhat syndrome. mention We are thankful to all the interviewers who conducted data collection.ReferencesSumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes the story of Dhat syndrome. Br J Psychiatry. 2004 184 200-9.Bhatia M.S, Jhanjee A, Kumar P. Culture bound syndromes- a cross-sectional study from India. European Psychiatry. 2011 26448Dhikav V, Aggarwal N, Anand KS. Is Dhat syndrome, a culturally appropriate manifestation of depression? Med Hypothes es. 2007 69 (3) 698.Mehta V, De A, Balachandran C. Dhat syndrome a reappraisal. Indian J Dermatol. 2009 54(1) 89-90.El Hamad I, Scarcella C, Pezzoli MC, Bergamaschi V, Castelli F Migration Health Committee of the International Society of pilgrimage Medicine. Forty meals for a drop of blood. J Travel Med. 2009 16(1) 64-5.Behere PB, Natraj GS. Dhat syndrome the phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry. 1984 26(1) 76-8.World Health face (1992) International Statistical Classification of Diseases and Related Health Problems (ICD-10). Geneva WHO.De Silva P, Dissanayake SAW. The use of semen syndrome in Sri Lanka A clinical study. Sex Marital Ther. 1989 4195-204.Malhotra HK, Wig NN. Dhat syndrome a culture-bound sex neurosis of the orient. Arch Sex Behav. 1975 4(5) 519-28.Angst J, Gamma A, Gastpar M, et al. Depression Research in European Society Study. Gender differences in depression. epidemiological findings from the European DEPRES I and II s tudies. Eur Arch Psychiatry Clin Neurosci. 2002 252(5) 201-9.Singh G. Dhat syndrome revisited. April 198527(2)119-122Carroll BJ. Adolescents with depression. JAMA. 2004 Dec 1292(21)2578Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview. J Social Psychiatry 1986 2403-25Avasthi A, Jhirwal OP. The concept and epidemiology of Dhat syndrome. J Pak Psychiatry Soc. 2005 2 68.

Effect of Diet on Colorectal Cancer

Effect of Diet on Colorectal CancerCHAPTER 11.1 IntroductionColorectal crabby person is conside loss to be a major spend a penny of cancer morbidity and mortality. It accounts for over 9% of on the whole cancer relative incidences this makes it the third most common cancer cause with virtually 1.4 million new cases diagnosed in a year (WCRF, 2012) and the fourth most common cause of d tireh (WHO, 2002). Both men and women are moved(p) most equally for colorectal cancer 9.4% in men and 10.1% in women from all incident of cancer. However, it has a clear geographical variation which is not uniformly distributed passim the world. It has been estimated that, the developed countries with a western culture accounts for over 63% of all colorectal cancer cases (Fatima AH, 2009). Though data available to show the clear division in developing countries, growing deductions show that the problem would be withal a concern for the low and middle income countries. The International Age ncy for Research on Cancer (IARC) was estimate that in 2008 colorectal cancer (CRC) is the 5th most common cancer in SSA (Ferlay J, 2010 and Alice G et.al, 2012)Several risk factors can be linked with the incidence of colorectal cancer. Age and he lossitary factors are the most important factors on which an individuals cannot able to man ripen. The probability of being affected by colorectal cancer is increases after the age of 40. More than 90% of colorectal cancer cases reported among people in the age greater than 50 and older (Fairley TL , 2006). In addition, a large number of environmental and behavioral risk factors can as well contribute for the development of colorectal cancer among these fodderary factors are the major one (Fatima AH, 2009).With the help of different dietary estimate methods such as nourishment recalls and food record, wide range of epidemiologic studies revealed that diet can strongly influences the risk of colorectal cancer, and changes in food habits might reduce up to 70% of this cancer burden. Diets with high in prolific and calories, especially animal fat, protein rich, low level of calcium and vitamin D. are some of the nutrients which can be a risk factor for colorectal cancer. High warmness expenditure, of importly red pith and processed meat, is mainly associated with the development of colorectal cancer (Fatima AH and Robin P, 2009 Sandhu MS et.al, 2001 Norat T et.al, 2002 Larsson SC, 2006, Raphalle L, 2008). On the other hand, those people who eat diets low in fruits and vegetables may have to a fault a higher risk of developing colorectal cancer (Paul T et.al, 2001).For free living person, accurate estimation of routine dietary use of goods and services is very challenging in the study of diet and disease relationships (Jackson et. al, 2011). Moreover, there is no single method of assessment which is valid and optimal under all conditions to assess individuals habitual dietary intake, but because of its abilit y to rank subjects according to their intake and as well as it is relatively inexpensive, food relative frequency questionnaires (FFQs) are often used in most epidemiologic studies to assess accustomed dietary intake and disease development. In addition, Food frequency questionnaires (FFQs) have been used to assess long-term dietary intakes and an important exposure factor for the disease conditions (Sofi F et.al, 2008, and Streppel M, et. al, 2013). Therefore, the use of food frequency questionnaires has advantage over the other methods such as 24-hour recalls and food records since these methods do not reflect past diet intake or usual intake and they are also expensive (Jackson et. al, 2011).Even though the Food frequency questionnaires (FFQs) is a more than practical tool for assessing individual diets in large cohorts, it has also more associated with measurement errors than 24-hour recalls and dietary record assessment methods. In consequence, this can bias the relative r isk estimates of diet and disease risk (Lin L et.al, 2013). 1 approach to improve effect estimates is through validation studies, in which individual diets by questionnaire is compared with a more precise and accurate method such as weight dietary records (Jaceldo-Siegl et. al, 2009).The influence of dietary habit is central for the development of colorectal cancer but little is known about validity of dietary exposure assessment tools. The purpose of the study is, therefore, to evaluate the validity of the FFQ that will be used in assessing the relationship between dietary intake andcolorectal cancer.1.2 objective of the studyTo evaluate the food frequency questionnaires used to assessing the risks of dietary intake (at food group and nutrient level) for colorectal cancer with the three days weighted diet record methodCHAPTER 22.1 Literature Reviews2.1.1 The take up of validation studies for food frequency questionnairesThe division of dietary factors in the etiology of sever al cancers has been extensively investigated over the last few years including on colorectal cancer (Bazensky I, Shoobridge-Moran C, Yoder LH, 2007). However, accurate estimates of habitual dietary intake remain a challenge in the study of diet-disease relationships (Jackson et. Al, 2011). This is because dietary assessments could be affected by a number of factors such as motivation to complete assessments and reporting bias related with ambiguous eating patterns(Livingstone MB et. al, 2009). Besides these, design of the study, outcomes of interest, and resources availability need to be considered when selecting an appropriate dietary assessment tool for a particular study(Jyh Eiin Wong et. al, 2012).In epidemiological studies, Food-Frequency Questionnaire (FFQ) is often chosen assessment method for estimating dietary intake and can provide valid and reliable estimates of usual dietary intake in a variety of populations (Navarro A, et. al,2001) where as the other possible and prec ise methods such as food records and 24-hour recalls do not reflect past diet or usual intake and are generally expensive (Jackson et. al, 2011, Lin L et.al, 2013).The FFQ is easy to administer, has relatively low cost, and provides a rapid estimate of usual food intake. Due to having this advantages it is more practical and frequently used dietary assessment tool for assessing individual diets in large cohorts. However, compared to other dietary assessment methods it has more associated with measurement errors that usually overestimate relative risks in studies of diet and disease risk (Jaceldo-Siegl et. al, 2009 Zulkifli SN, 1992 Fraser GE, 2003 Lin L et. al, 2013 Streppel M et. al, 2013).Therefore, nutritional values reported from FFQ data are subjected to twain systematic and random errors that can significantly affect the design, analysis, and interpretation of nutritional epidemiologic studies (Carroll RJ, et. al, 1997). In addition, collect to possible differences in desi gn characteristics of the FFQ, e.g. the number of food items included, expressive style of administration, and also the need of cognitive process for portion size estimation, its validity can be affected (Jyh Eiin Wong et. al, 2012). Furthermore, the validity of the same FFQ may leave from one population to the other (Streppel M. al et, 2013).The above rationale can lead to the agreement that evaluation and validating of a FFQ is important in studying diet disease tie-ins. Thus validation studies need to be performed to evaluate the level to which the FFQ agrees with the subjects true dietary intake (Cade JE et. al, 2004). Moreover, validation studies can be also carried out to assess the level of measurement error associated with the FFQ (Streppel M et al, 2013 and Cade JE et. al, 2004).Providing the fact that there is no single method which is completely free from possible biases in dietary assessment, one approach to validate the estimates of effects through the help FFQ is b y comparing with a more precise method (reference method), such as weighted food record, multiple dietary recalls and use of biomarkers (Jaceldo-Siegl et. al, 2009 and Lin L et.al, 2013). However, memory (recalls) and nutrient data are still influence estimates from the reference method (Jackson et. al, 2011, and Daures JP et. al, 2000 ).Generally, due to differences in food supply and dietary habits, there is no universally accepted FFQ that can be used for all populations in all situations. clarification of dietdisease relationships requires dietary assessment methods which can sufficiently describe and quantify intakes, minimize errors and provide precise estimates of variability between individuals or groups(Kaaks R et. al, 1997 Carroll RJ e t.al 1997 and Lin L et.al, 2013). Therefore, it is vital to make sure that any FFQ must be reliable and valid to be used in the population of interest, need to be designed to meet the aims of study populations and has contain an up-to-date list of foods(Jyh Eiin Wong,et. al, 2012).2.1.2 Incidence and mortality of colorectal cancerColorectal cancer is one of the major cause of morbidity and mortality. Globally it accounts for over 9% of all cancer incidences the third most common cancer and the fourth most common cause of death. Men and women are almost equally affected by colorectal cancer it represents 9.4% in men and 10.1% in women (Jodi D Stoocky, et al, 1996). However, is not uniformly distributed end-to-end the world it has a clear geographical variation. Mainly, colorectal cancer is a disease of developed countries with a western culture. It is estimated this region accounts for over 63% of all cases. Worldwide mortality attributable to colorectal cancer is approximately half that of the incidence. In 2008, over 1.2 million new cases and 608,700 deaths estimated to have occurred (Fatima AH, 2009 and Dagfinn A, 2011).The WHO report in 2012 also showed that, in 2008 among the deaths of an estimated 7.6 million pe ople of all cancer cases colorectal cancer (CRC) accounted for over 600 000 of those deaths, with 70% occurring in low and middleincome countries (WHO, 2012 and Meetoo D, 2008). This indicates that though the number of cases of CRC in SSA is thought to be very low in comparison to those diagnosed in the Western world, it constitutes a significant proportion of the cancers in this region (Alice G et.al, 2012).2.1.3 risk of exposure factors for colorectal cancerColorectal cancer is widely considered to be an environmental disease include a wide range of cultural, social, and lifestyle factors which are associated with the incidence of colorectal cancer. Age and hereditary factors are those that an individual cannot control and other modifiable environmental and lifestyle risk factors are also plays an important role in the development of colorectal cancer (Fatima A. Haggar, Robin P. Boushey 2009).Among the modifiable risk factors, diet habit is a major one and strongly influences the risk of colorectal cancer, and changes in dietary habits might also decrease up to 70 percent of this cancer burden. Diets with high fat content, especially animal fat, considered to be a major risk factor to cause colorectal cancer. However results of meta analysis supports the hypothesis that only intakes of red and processed meat are convincing dietary risk factors for colorectal cancer (Dagfinn Aune, 2011). In addition, different studies also revealed that the association of CRC risk with processed red meat may be stronger than that of fresh red meat (Sandhu MS et.al, 2001 Norat T et.al, 2002 Larsson SC, 2006 and Raphalle L, 2008).The effect of fat consumption as possible etiologic factor for colon cancer is linked to favoring the development of a bacterial flora which capable of degrading bile salts to potentially carcinogenic compounds. The presence of heme iron in red meat believed to be the main mechanisms for the positive association in the development of colorectal cancer . In addition, exposing it to high temperatures could resulting the production of compounds such as heterocyclic amines and polycyclic aromatic hydrocarbons (Fatima A. Haggar, Robin P. Boushey 2009 and Genkinger JM, Koushik A, 2007).MS Sandhu et al in 2001 set in motion that red and processed meat could contribute for colorectal cancer a daily increase of 100 g of red meat and 25g of processed meat was associated with a 14% (OR1.14, 95% CI1.04 to 1.25) and 49% (OR 1.49, 95% CI 1.22 to 1.81) increased risk of colorectal cancer respectively (Sandhu MS et.al, 2001). On the other more recent follow up study by Cross, A.J et.al, the hazard ratios (HR) and 95% confidence intervals (95% CI) comparing the fifth to the first quintile for both red (HR 1.24 95% CI, 1.09-1.42 P Norat, T in 2001 also tried to conduct meta-analysis of articles published during 1973-99 in order to look the risk of consumption of red and processed meat for colorectal cancer. High intake of red and processed meat w as associated with significantly increase risk of colorectal cancer. Average Relative venture and 95% confidence intervals (CI) for the highest quantile of consumption was 1.35 (CI 1.21-1.51) for red meat and 1.31 (CI 1.13-1.51) for processed meat (Norat, T., et.al, 2002). A similar effect of red and processed meat also found in other meta-analysis of prospective studies published through March 2006 by Larsson SC and Wolk A in 2006. This meta-analysis of prospective studies support the hypothesis that high consumption of red meat and of processed meat is associated with an increased risk of colorectal cancer (Larsson, S.C. and Wolk, A., 2006).In addition, some studies suggest that people who eat a diet low in fruits and vegetables may have a higher risk of colorectal cancer. Differences in dietary theatrical role intake might have been also responsible for the observed geographic differences in the incidence rate of colorectal cancer (Janout V, and Kollarova H. 2001 and Fatima AH, 2009).Age is an important non modifiable factors in the development of colorectal cancer. As the increases the likelihood of colorectal cancer diagnosis increases as well. Mostly its diagnosis is common after the age of 40, then rising sharply after age 50. More than 90% of colorectal cancer cases occur in people aged 50 or older. The incidence rate is more than 50 quantify higher in persons aged 60 to 79 years than in those younger than 40 years. However, colorectal cancer appears to be increasing among younger persons (Ries LAG, et al.. 2008, and Fatima AH, 2009).2.1.4 dietary protective factors for colorectal cancer Vegetables, Dietary fiber, whole grainsGiven the roles of the colon and rectum as conduits for ingested food and the many potentially anti carcinogenic substances contained in fruit(8),vegetables(8),and cereals(9),these food groups are among the most widely studied in relation to colorectal cancer risk (Steinmetz KA, Potter JD. 1991, and Slavin JL, Martini MC et.al, 1999).Although the majority of studies have shown an inverse association between fruit and vegetable consumption and colorectal cancer risk, some prospective cohort studieshave also obtained inconsistent results no association between fruit and vegetable consumption and the risk of having or developing a colorectal neoplasm (Paul T et.al, 2001).Results from a meta-analysis of 13 casecontrol studieshave suggested that increased dietary fiber intake is associated with decreased risk of colorectal cancer, although some other prospective cohort studies do not supporting such an association (Steinmetz KA et.al, 1994). Nonetheless, evidence from animal studies and few clinical trials continues to suggest that cerealsespecially wheat bran, contain substances, such as fiber, phytic acid, various phenolic compounds, lignins, and flavonoids, that might lower the risk for colorectal cancers.Cereal fiber might also bind carcinogens and modify glycemic index(Slavin JL , 1999, and Paul T et.al, 2001)In a Paul T et.al study in 2001, they were tried to associate the role of fruit and vegetable consumption and colorectal cancer. In this study 61, 463 women were followed for an average of 9.6 years and 460 incident cases of colorectal cancer were observed (291, 159 and 10 cases of colon, rectal and both sites respectively). In the entire population of this study, total fruit and vegetable consumption was inversely associated with colorectal cancer risk. The association was also showed that there is a pointresponse effect more evident among individuals who consumed the lowest amounts of fruit and vegetables was observed. In particularly, those individuals who consumed less than 1.5 servings of fruit and vegetables per day had a 1.65 relative risk (95% CI = 1.23 to 2.20P = .001) for developing colorectal cancer compared with individuals who consumed more than 2.5 servings. However, no association between colorectal cancer risk and consumption of cereal fiber was observed in thi s study. In conclusion this particular study revealed that individuals who consume very low amounts of fruit and vegetables have the greatest risk of colorectal cancer (Paul T et.al, 2001)