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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 iden- tify with characters from the Old or New Testament or are convinced that they them- selves are one of these characters. Their conviction reaches psychotic dimensions. Jewish tourists generally identify with char- acters 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. 86 Downloaded from https://www.cambridge.org/core. 27 Sep 2021 at 18:42:20, subject to the Cambridge Core terms of use. JERUSALEM SYNDROME 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.
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