In their comprehensive review of dhat, Sumathipala and colleagues (Reference Sumathipala, Siribaddana and Bhugra2004) have made some interesting observations on the syndrome being culture-related rather than culture-bound. Their suggestion that the label ‘culture-bound’ may exclude such syndromes from mainstream psychiatric classifications and hamper their understanding is also pertinent. However, we believe there are certain issues beyond the label which are as yet unresolved. As mentioned in the review, such syndromes cut across diagnostic categories, and it may be particularly difficult to classify a high proportion of these cases, for example of ‘pure’ dhat (Reference Chadda and AhujaChadda & Ahuja, 1990; Reference Bhatia and MalikBhatia & Malik, 1991). The other problems with ubiquitous presentations such as dhat, which also have a great degree of cultural sanction, is the blurring of boundaries between normal and pathological that complicates the diagnostic process. The authors’ contention that multi-axial classifications with due importance to cultural factors will obviate the necessity of such diagnoses has yet to be tested. For example, primary-care physicians are often the first port of call for most of these patients; how familiar can such doctors be expected to be with culturally sensitive diagnostic formulations? Diagnostic issues apart, the nature of treatment to be offered still remains uncertain, given that most do not seem to feel the need for any psychiatric treatment (Reference Malhotra and WigMalhotra & Wig, 1975). High drop-out rates from psychiatric clinics also indicate dissatisfaction with whatever is done in terms of treatment or causal explanations (Reference Chadda and AhujaChadda & Ahuja, 1990). Finally, the prediction that with industrialisation/urbanisation dhat will vanish from the East as it has done in the West might not turn out to be true. Instead, dhat might persist and be labelled differently, as has happened with neurasthenia and chronic fatigue syndrome. Both conditions have been considered medical illnesses, underlying stress being the presumed cause, acting either via depletion of nervous energy (neurasthenia) or via immune dysfunction (chronic fatigue). However, neurasthenia, a very common diagnosis at one time, is hardly encountered any more (Reference Abbey and GarfinkelAbbey & Garfinkel, 1991).

Thus, although incorporating ‘culture-bound’ syndromes in mainstream nosology seems to be an ideal solution for the future, abandoning such categories may be premature at present.