We read with interest the historical overview on dhat syndrome by Sumathipala et al (Reference Sumathipala, Siribaddana and Bhugra2004). We agree with the authors' contention that categorising it as a culture-bound syndrome is not likely to advance research. The authors examine the nosological significance of this disorder and suggest the possibility of culturally influenced somatoform disorder, although they do not offer a detailed model. In the spirit of Sumathipala et al's conclusion that there are no absolute truths when it comes to classificatory systems, we propose the following formulation.

Fatigue is a common symptom in dhat syndrome (Reference Bhatia and MalikBhatia & Malik, 1991). Disorders with fatigue as the main symptom are often grouped together as functional somatic syndromes (Reference Barsky and BorusBarsky & Borus, 1999). The basic cognitive formulation offered to explain these disorders is based on somatosensory amplification, misattribution and abnormal illness behaviour. We have incorporated societal and cultural factors along the lines of the socio-somatic model (Reference Kirmayer and YoungKirmayer & Young, 1998) to explain dhat syndrome as a functional somatic syndrome.

In cultures where open discussion about sexual issues is taboo and fears about masturbation exist, the urogenital system is likely to be the focus of preoccupation. Under stress, persons predisposed to amplification of somatic symptoms and health anxiety may focus attention on physiological changes such as turbidity of urine and tiredness, and misattribute them to loss of semen in the light of widely prevalent health beliefs. These beliefs may then be confirmed by friends and other lay sources as well as by local practitioners subscribing to similar models.

We have recently completed a study showing significantly higher scores on measures of amplification, hypochondriacal beliefs and abnormal illness behaviour in patients with dhat syndrome compared with medical controls. The above model needs to be examined further in both quantitative and qualitative studies. The practical implication of this formulation is that it suggests a viable treatment model based on psychoeducation and culturally informed cognitive–behavioural therapy, which has been demonstrated to be feasible in the Indian subcontinent (Reference Sumathipala, Hewege and HanwellaSumathipala et al, 2000).