Jerusalem Syndrome

BRITISH JOURNAL OF PSYCHIATRY (2000), 176, 86^90

Jerusalem syndrome Subtype I(i): psychotic identification with biblical YAIR BAR-EL, RIMONA DURST,GREGORYDURST, GREGORY KATZ, JOSEF ZISLIN, characters ZIVA STRAUSS and HAIM Y. KNOBLER Individuals from this subtype strongly identify with characters from the Old or New Testament or are convinced that they themselves are one of these characters. Their conviction reaches psychotic dimensions. Jewish tourists generally identify with characters from the Old Testament, and Chris- tian tourists with characters from the New Testament; in the same vein, men and Background Jerusalem's psychiatrists Jerusalem, a city that conjures up a sense of women generally identify with male and expectto encounter, as the millennium the holy, the historical and the heavenly, it female personalities respectively. holds a unique attraction for people of sev- approaches, an ever-increasing number of eral of the world's faiths and religions ± tourists who, upon arriving in Jerusalem, especially Jews, Christians and Muslims. may suffer psychotic decompensation. When people dream of Jerusalem, they do not see the modern, politically controversial ExampleExample Aims To describethe Jerusalem Jerusalem, but rather the holy biblical and re- An American tourist aged in his 40s, suf- syndrome as a unique acute psychotic ligious city. Since 1980, Jerusalem's psychia- fering from paranoid schizophrenia, had state. trists have encountered an ever-increasing been admitted to hospital and treated over number of tourists who, upon arriving in the years in the USA. He began working on MethodMethod This analysis is based on Jerusalem, suffer psychotic decompensation. his body image, by exercising and weight- accumulated clinical experience and In view of the consistently high incidence of lifting, in the framework of a rehabilitation phenomenological data consisting of this phenomenon, it was decided to channel programme. Over time, he started to iden- all such cases to one central facility ± the tify with the biblical character Samson. cultural and religious perspectives. Kfar Shaul Mental Health Centre (Bar-El etet Eventually, he was overcome by a compul- alal, 1991,1991aa) ± for psychological counselling, sion to come to Israel in order to move one ResultsResults Three main categories of the psychiatric intervention and, if deemed ne- of the giant stone blocks forming the Wes- syndrome are identified and described, cessary, admission to hospital. Over the tern (Wailing) Wall which, in his opinion, with special focus on the category course of 13 years (1980±1993), 1200 tour- was not in the right place. On arriving at pertaining to spontaneous manifestations, ists with severe, Jerusalem-generated mental the Western Wall, he attempted to move unconfounded by previous psychotic problems have been referred to this facility. one of the stones. His actions instigated a Of these, 470 were admitted to hospital. terrible commotion, culminating in police history or psychopathology. On average, 100 such tourists are seen intervention and his placement in the Conclusions The discrete form of the annually, 40 of them requiring admission to hospital of the Kfar Shaul Mental Health hospital. Centre.Centre. Jerusalem syndrome is related to religious On the basis of clinical experience, we Contrary to accepted practice, the duty excitement induced by proximity to the have identified three main types of patient psychiatrist challenged the patient's delu- holyplacesof Jerusalem, andisindicatedby with Jerusalem syndrome (see Table 1). sional ideas, telling him that he could not seven characteristic sequential stages. possibly be Samson and that, according to the Bible, Samson had never been in Declaration of interest None. Jerusalem. The patient reacted to this with rage, became aggressive, broke a window, and escaped through it. A team was sent TYPE I: JERUSALEM out to look for him, and a student nurse SYNDROME SUPERIMPOSED found him standing at a bus stop. Demon- ON PREVIOUSPSYCHOTIC strating commendable wisdom, she told ILLNESSILLNESS him that he had proved that he possessed qualities similar to Samson's and that he Type I refers to individuals already diag- could now return to the hospital, which nosed as having a psychosis before their he did of his own volition. A hospital ex- visit to Israel. Their motivation in coming amination showed him to be in an acute to Israel is directly related to their mental psychotic state: he was convinced that he condition and to the influence of religious was Samson and that he had a mission ideas, often reaching delusional levels, to accomplish. After receiving anti- compelling them to come to Jerusalem psychotic medication, he calmed down and do `something' there. Type I can be and was able to fly back home, escorted divided into the following four subtypes. by his father.

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TaTable b l e 1 The Jerusalem syndrome: classification by by type type and and subtype subtype

TypeReason for coming to JerusalemTravel mode Pre-existing psychiatric illness Subtypes

Type IPsychiatric religious ideation, Usually alone Documented psychiatric history: I(i) Identification with character from bible need to accomplish mission schizophrenia or bipolar illness I(ii) Identification with religiousor political idea I(iii) Magical ideasconcerning health/sickness/ healing possibilities connected with Jerusalem I(iv) Problemswith family

Type IICuriosity plus strange (non- (non- Usually in groups, Non-psychotic mental disorders: II(i) Appearsin groups psychotic) thoughts or mission sometimes alone personality disorders; fixed idea II(ii) Individual

Type III (Jerusalem syndrome discrete type) Regular tourists With friendsor family; No previouspsychiatric history No subtypes: all cases characterised by seven (religioushome background) often aspart of organisedtour or psychopathology clinical stages

Subtype I(ii): psychotic Gogol travelled to Israel in 1848, but his disorder as a reversed Oedipus complex identification with an idea starved himself to death four years later which was manifest during manic phases. (Nabokov, 1971). His connection with Jerusalem is not clear; Individuals from this subtype strongly neither is it clear why he is drawn to Jerusa- identify with an idea (usually of a religious lem in seeking a solution to an imaginary nature, sometimes of a political nature) and Subtype I(iv): family problems problem created by his distorted pathologi- arrive in Jerusalem to act on this idea. culminating in psychosis in JerusalemJerusalem cal thought processes. This subtype comprises individuals whose ExampleExample mental disturbance is expressed in terms of TYPE II: JERUSALEM A Protestant from South America conceived family problems. This subtype is proble- SYNDROME SUPERIMPOSED a plan to destroy Islamic holy places in matic because, under the influence of the ON AND COMPLICATED BY order to replace them with Jewish holy places. psychosis, it is usually impossible to identify IDIOSYNCRATIC IDEATIONS The second stage of his plan was then to de- the core meaning of Jerusalem to the patient stroy them in order to start the war of Gog in association with the psychosis, or the mo- The Type II subgroup involves people with and Magog so that the Anti-Christ would tive for his travelling to Jerusalem. Yet these mental disorders such as personality disor- reveal himself, after which Christ would re- individuals choose to come repeatedly to ders or an obsession with a fixed idea, but appear. The patient succeeded in gutting Jerusalem, and while there develop florid who do not have a clear mental illness; their one of the most holy mosques in Jerusalem. psychosis.psychosis. strange thoughts and ideas fall short of de- Psychiatric examination was ordered by the lusional or psychotic dimensions. Type II court, and he was diagnosed as being un- can be divided into two subtypes: subtype ExampleExample able to differentiate between right and II(i) applies to individuals belonging to a wrong, not responsible for his deeds and A South African man, suffering from bi- group; subtype II(ii) which is less common, therefore not fit to stand trial. He was polar affective disorder and with a history applies to lone individuals. admitted to a local psychiatric institution of several stays in hospital in his homeland, Type II probably accounts for a rela- and later transferred to a mental health visited Jerusalem on four occasions, each tively large number of Jerusalem syndrome institution in his own country. following a manic episode culminating in sufferers. In groups, they are highly visible; admission to hospital. According to this they stand out in public places, especially man, he came to Jerusalem in order to kill holy ones. They are occasionally featured Subtype I(iii): `magical ideas' a man who had raped his daughter. His fa- in the media but they do not, on the whole, concerning connection between mily always forewarned the Israeli health reach professional psychiatric agencies. health and holy places authorities of his visits and, consequently, This subtype consists of patients with `ma- he was admitted to hospital immediately Subtype II(i): individuals belonging gical ideas' concerning sickness and health upon his arrival in Jerusalem. After receiv- to a groupgrouptoa and healing possibilities connected with ing treatment, he usually had the capacity Jerusalem. Interestingly, the famous to show a degree of insight, and to note that ExampleExample Russian writer Gogol, after psychosis had when he became manic, he got upset with Various Christian groups outside the main- ended his writing, had a revelation suggest- his daughter's husband. In remission, he stream of the established churches settle in ing that he would do well to visit Jerusalem was able to admit to his behaviour being Jerusalem in order, for instance, to bring and recite special prayers at holy burial pathological and to admit that he actually about the resurrection of the dead or the re- sites there in order to recover from his ill- admired and respected his son-in-law. Psy- appearance of Jesus Christ. Such groups ness and be able to start writing again. chologists who treated him have described usually consist of no more than about 20

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members. One group, previously located in worshipping graven images. The confronta- Third criterion Jerusalem, is now settled near Jericho, an- tion developed into a violent struggle; even- Subjects have, upon arrival in Jerusalem, an other is located in the Jerusalem Forest, tually, the subject started to destroy statues acute psychotic reaction that develops in and yet another is based in the centre of Jer- and paintings. The court ordered admission a consistently characteristic sequence of usalem. The members of these groups wear to hospital at the Kfar Shaul Mental Health seven identifiable clinical stages. distinctive clothing which, according to Centre for observation and psychiatric eva- them, is similar to that worn in the days luation. However, examination by experi- The seven clinical stages of type III of Christ.ofChrist. enced psychiatrists, including the District Various Jewish groups also have un- Psychiatrist of Jerusalem, revealed no psy- (a)(a)Anxiety,Anxiety, agitation, nervousness and usual ideas and intentions regarding Jerusa- chopathology, not even the mildest person- tension, plus other unspecified reactions. lem. We know of three groups currently ality disorder, all they could find was (b)(b)DeclarationDeclaration of the desire to split away attempting to `create' a red heifer based obsession with the fixed idea described from the group or the family and to on writings contained in the Old Testament above. Follow-up three years later again tour Jerusalem alone. Tourist guides (Numbers, XIX). In the Bible, the red heifer failed to indicate mental disorder, and the aware of the Jerusalem syndrome and was to be sacrificed and its ashes used for subject continues to work in his academic of the significance of such declarations purification rituals before entering the tem- position, to believe in the same religion may at this point refer the tourist to ple. Today, apparently, simply touching the and to spread his message, regretting only our institution for psychiatric evalua- red heifer will suffice. The problem is that a that he was unable to do this in Jerusalem. tion in an attempt to pre-empt the perfect, unblemished, completely red heifer subsequent stages of the syndrome. If has yet to be conceived. unattended, these stages are usually The members of these groups do not TYPE III: JERUSALEM unavoidable. usually undergo psychiatric examination SYNDROME ^ DISCRETE FORM,UNCONFOUNDED (c)(c)AA need to be clean and pure: obsession because they do not evoke problems, en- with taking baths and showers; danger others or break the law. Only three BY PREVIOUS PSYCHOPATHOLOGY compulsive fingernail and toenail individuals from such groups have been cutting.cutting. examined, as a result of a court order after a violent confrontation with neighbours; all The third type of the Jerusalem syndrome is (d)(d)Preparation,Preparation, often with the aid of hotel bed-linen, of a long, ankle-length, toga- three were diagnosed as suffering from perhaps the most fascinating, in that it de- like gown, which is always white. personality disorders. scribes individuals with no previous history of mental illness, who fall victim to a psy- (e)(e)TheThe need to scream, shout, or sing out chotic episode while in Israel (and espe- loud psalms, verses from the Bible, reli- Subtype II(ii): Lone individuals cially while in Jerusalem), recover fairly gious hymns or spirituals. Manifesta- Example spontaneously, and then, after leaving the tions of this type serve as a warning to A single German male aged 45, working in country, apparently enjoy normality. hotel personnel and tourist guides, an academic position, considered healthy, Hence, Type III is unconjoined to other who should then attempt to have the and without any recognisable problems, is psychopathologies, and can be described tourist taken for professional treatment. Failing this, the two last stages will obsessed, without being able to explain as the `pure' or `unconfounded' form of develop.develop. why, with the need to find the `true' reli- the syndrome. Numerically, type III is a re- gion. He spent five years studying the var- latively small category: between 1980 and (f(f))A procession or march to one of Jerusa- ious streams of Christianity and further 1993 there were 42 cases fitting the three lem's holy places. main diagnostic criteria described below. time studying the esoteric religions of an- (g)(g)DeliveryDelivery of a `sermon' in a holy place. cient Persia, China and Japan, and reached The sermon is usually very confused the conclusion that none of them qualified Main diagnostic criteria for type III and based on an unrealistic plea to as the `true' religion. He then took leave humankind to adopt a more whole- First criterion from work, came to Jerusalem, and started some, moral, simple way of life. studying Judaism at a university and in a Subjects have no previous history of psychi- Yeshiva (religious seminary). However, atric illness ± no prior psychotic episodes, Judaism was also rejected. Finally, this no significant problems regarding work or Treatment and recovery man decided that the only true religion family and no drug use. In other words, Type III does not usually involve visual or was, in his words, ``primitive Christian- the subjects can be defined as healthy and auditory hallucinations. Patients know ity ± the religion of Jesus before Peter and devoid of any mental disorder. who they are and do not claim to be anyone Paul ruined it''. He now felt it imperative else. If questioned, they identify themselves to bring this message to the people of Jeru- by their real name. However, they ask not salem, and set about preaching it at every Second criterion to be disturbed in the completion of their opportunity. One day, on a visit to the Subjects arrive in Jerusalem as regular tour- mission. Their condition usually returns to Church of the Holy Sepulchre in the Old ists, with no special mission or specific pur- normal within 5±7 days; in other words, City of Jerusalem, he succumbed to an at- pose in mind. They usually arrive with a short-lived episode followed by com- tack of psychomotor agitation and started friends or family members, often as part plete recovery. These individuals clearly shouting at the priests, accusing them of of a larger group on an organised tour of need treatment, and often receive it, but re- being pagans and barbarians and of Mediterranean countries. covery is quite often spontaneous and not

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necessarily due to the treatment. Experi- who would read it together at least once a (1962) and Singh (1961) list a number of ence has taught us that improvement is week. The Bible would also serve as a factors such as unfamiliar surroundings, facilitated by, or dependent on, physically source of answers to seemingly insoluble proximity to foreigners or strangers, inac- distancing the patient from Jerusalem and problems ± especially for the father, as tivity, a sense of isolation and culture clash. its holy places. On the whole, major medi- head of the family. For fundamentalist Factors such as these, compounded by the cal intervention is not indicated; minor believers of this type, Jerusalem assumes special significance of Jerusalem to Jews, tranquillisers or melatonin (as in cases of the highest significance: such people possess Christians and Muslims, may serve to trig- jet-lag psychosis) usually suffice. Our main an idealistic subconscious image of Jerusa- ger an acute psychotic episode. According treatment strategy is to facilitate return to lem, the holy places and the life and death to Cohen (1979), the èxistential' mode of the group or the renewal of family ties (in- of Jesus. It seems, however, that those travelling (one of five modes of tourism; cluding with family overseas), or, if deemed who succumbto type III of the Jerusalem this mode refers to journeys to a spiritual appropriate, access to a priest. Crisis inter- syndrome are unable to deal with the con- centre) constitutes a modern metamorpho- vention psychotherapy plays an important crete reality of Jerusalem today ± a gap ap- sis of the pilgrimage. It is worth noting that part in the recovery process. pears between their subconscious idealistic Freud (1936) reported having experienced a Upon recovery, patients can usually image of Jerusalem and the city as it ap- sense of derealisation while visiting the recall every detail of their aberrant behav- pears in reality. One might view their psy- Acropolis. The possibility that other place- iour. They are inevitably ashamed of most chotic state and, in particular, the need to oriented syndromes and the Jerusalem syn- of their actions, and feel that they have preach their universal message as an at- drome may share a common denominator behaved foolishly or childishly. They tempt to bridge the gap between these two even though they appear to be fundamen- sometimes describe their conduct as being representations of Jerusalem. tally different should not be dismissed. akin to that of a `clown' or a `drug addict'. In an attempt to arrive at a broader em- For instance, in the case of àirport wan- However, in most cases, they are reluctant pirical base we sent questionnaires to all 42 derers' or àirport syndrome' (Shapiro, to talk about the episode, and it has there- of our type III patients, but received re- 1982), a condition found among tourists fore been difficult to achieve a deeper un- sponses from only four of them ± and these who get lost and who experience psychotic derstanding of the phenomenon. Those merely stated that they were feeling good episodes in airports, it has been suggested who do talk after the episode often talk and thanked us for our treatment, with no that the airports symbolically highlight about a sense of ``something opening up further elaboration. None answered the pre-existing problems. However, unlike inside them'', their body movements questionnaire. Attempts to obtain infor- victims of the Jerusalem syndrome, people suggesting an outward disposition. After mation by telephone interview produced who develop airport syndrome forget their this sensation, they feel an obligation to the same disappointing result; the ex- identity, are unaware of where they have carry out certain actions or to relay their patients insisted that they were feeling well, come from or where they are going to and message.message. and that they did not want to talk about bump into people. Recovery is usually An example is provided by a Swiss law- their experiences of Jerusalem syndrome. spontaneous after minimal assistance, yer who arrived in Jerusalem on a group perhaps a drink and a short rest. tour of the Middle East which included one week in Greece, one week in Israel, and one week in Egypt. He had been per- DISCUSSION fectly healthy up to the time of the trip, The Stendhal syndrome and spent an enjoyable week in Greece. On- `Well-known-place' and travellers The condition most closely resembling the set of type III of the syndrome was indi- syndrome Jerusalem syndrome is the Stendhal syn- cated on his first night in Jerusalem. The The first question that arises in discussing drome identified by Magherini (1992), subject fitted the three diagnostic criteria the Jerusalem syndrome ± and, in particu- which describes a particular acute psychotic perfectly, and the development of the syn- lar, type III ± is whether it is unique to Jer- reaction arising among art-loving tourists drome followed the seven characteristic usalem, or whether other holy places visiting Florence. The syndrome is named stages faithfully. The whole process took induce similar syndromes. Hysterical or after the French writer Stendhal, who de- seven days, after which the syndrome psychotic manifestations related to scribed feelings of dejaÂjaÁ vu vude and disquiet after passed. The subject rejoined the tour, en- places ± such as those that appear at looking at works of art in Florence. Ma- joyed his visit to Egypt and returned home Mecca, holy places in India, Christian holy gherini in her book Sindrome di Stendhal in good health. Follow-up indicates that places where the Virgin Mary is wor- (1992) presented the statistical, socio- since returning home six years ago, the shipped, and evangelical rallies ± may well demographical, clinical and travel-related subject has been completely healthy. resemble our description; however, the variables of 106 tourists who were ad- In seeking out distinctive background Jerusalem syndrome documented here mitted to hospital in Florence between features of type III patients, we found that, remains a unique phenomenon which 1977 and 1986. She described cases in of the 42 cases, 40 were Protestants, one deserves thorough appraisal. which a small detail in a famous painting was Catholic, and one was a Jew who had Several explanations have been offered or sculpture evoked an outburst of anxiety, lived as a Protestant while in hiding during to account for psychotic breakdown among reaching psychotic dimensions. According the Second World War. All 40 Protestants travellers. Some of these explanations sug- to her, such reactions are usually associated came from what can be described as gest that the change of routine involved in with a latent mental or psychiatric distur- ùltra-religious families'. The Bible was travel influences mental state to a consider- bance that manifests itself as a reaction to the most important book to these families, able extent (Bar-El et aletal, 1991,1991bb). Flinn).Flinn paintings of battles or other masterpieces

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and culminates in the full-blown Florence or Stendhal syndrome. CLINICAL IMPLICATIONS

&& The Jerusalem syndrome is a unique psychiatric phenomenon that appears in some TOWARDSTHE MILLENNIUM tourists who visit Jerusalem.

At the time of going to press, we have && The recognition of religion-relatedpsychiatricreligion-related psychiatric disorders associated with proximity received reports as the millennium to holy placesisimportant becauseearly detection and intervention may halt the approaches,that various communities and progression of such episodes. congregations are planning to come to && A comprehensive knowledge of patients' religious background and beliefs is an Jerusalem and stay from Easter 1999 until Easter 2000 in anticipation of miraculous essential part of the crisis intervention. events. Type I and type II candidates head LIMITATIONS for Jerusalem in order to accomplish some-

thing there. For such people Jerusalem can && Thiswork isbasedonisbased on a phenomenological description and isnot a a research research study. study. be seen as a magnet that attracts them and induces them to carry out certain && The study lacks follow-up follow-up information. information. actions. Type III candidates will fall victim && The study does not taken into account changes in circumstances associated with to the syndrome irrespective of their initial the expected influx of tourists in the landmark year 2000. motivation for visiting Jerusalem. Finally, we would like to stress that this analysis is based mainly on phenomenological data consisting of the clinical experience of a multi-disciplinary team. As mentioned above, attempts to anchor the analysis on YAIRBAR-EL,YAIRBAR-EL,MD,RIMONADURST,MD,GREGORYKATZ,MD,JOSEFZISLIN,MD,ZIVASTRAUSS,MSW, MD, RIMONA DURST, MD, GREGORYKATZ, MD, JOSEF ZISLIN, MD, ZIVA STRAUSS, MSW, HAIM Y.KNOBLER, MD,Kfer Shaul Mental Health Centre, Jerusalem, Israel data obtained by systematic empirical research were thwarted by the reluctance of CorrespCorrespondence:ondence: Dr Rimona Durst,Kfar Shaul Mental Health Centre,Givat Shaul,Shaul,Jerusalem,Israel Jerusalem,Israel ex-patients to cooperate. A more detailed 91060.Tel: +972-2-6551550;Fax: +972-2-6512274 investigation would therefore be needed in order to arrive at a better understanding (First received 7 SeptemberSeptember1998, 1998, final revision 3131August August 1999, accepted 3131August August 1999) of the Jerusalem syndrome in general, and in particular its most intriguing version, the `pure, unconfounded' type III version. Cohen, E. (1979) A phenomenology of tourist Magherini, G. (1992) Syndrome di Stendhal. Milan: experiences. Sociology,, 1313,179^201.,179^201. Fettrinelli. REFERENCES Nabokov,V. (1971) GogolGogol..ReprintedinHebrew(1997) Reprinted in Hebrew (1997) Transient psychotic reactions during Flinn, D. B. (1962) (trans. D. Frenz). Tel Aviv:Yedioth Ahronoth. Bar-El, I.,Witztum, E., Kalian, M., et aletal (19 91aa)) travel. American Journal of Psychiatry,, 119, 173^174.,173^174. Psychiatric hospitalization of tourists in Jerusalem. Shapiro, S. (1982) Airport wandering as a psychotic Comprehensive Psychiatry,, 3232,238^244., 238^244. Freud, S. (1936) A disturbance of memory on the symptom. Psychiatria Clinica,, 1515,173^176.,173^176.

__ , Kalian, M. & Eisenberg, B. (1991bb)) Tourists andandTourists Acropolis. Reprinted (1953^1974) in the Standard Edition psychiatric hospitalization with reference to ethical of the Complete Psychological Works of Sigmund Freud Singh, H. A. (1961) A case of psychosis precipitated by aspects concerning management and treatment. (trans. and ed. J. Strachey), vol. 22, p. 239. London: confinement in long distance travel by train. American PsychiatryPsychiatry,, 1010, 487^492.,487^492. Hogarth Press. Journal of Psychiatry,, 117, 936^937.

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