Kfer Shaul Mental Health Centre, Jerusalem, Israel
Correspondence: Dr Rimona Durst, Kfar Shaul Mental Health Centre, Givat Shaul, Jerusalem, Israel 91060. Tel: +972-2-6551550; Fax: +972-2-6512274
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ABSTRACT |
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Aims To describe the Jerusalem syndrome as a unique acute psychotic state.
Method This analysis is based on accumulated clinical experience and phenomenological data consisting of cultural and religious perspectives.
Results Three main categories of the syndrome are identified and described, with special focus on the category pertaining to spontaneous manifestations, unconfounded by previous psychotic history or psychopathology.
Conclusions The discrete form of the Jerusalem syndrome is related to religious excitement induced by proximity to the holy places of Jerusalem, and is indicated by seven characteristic sequential stages.
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INTRODUCTION |
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On the basis of clinical experience, we have identified three main types of patient with Jerusalem syndrome (see Table 1).
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TYPE 1: JERUSALEM SYNDROME SUPERIMPOSED ON PREVIOUS PSYCHOTIC ILLNESS |
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Subtype I(i): psychotic identification with biblical characters
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 Christian
tourists with characters from the New Testament; in the same vein, men and
women generally identify with male and female personalities respectively.
Example
An American tourist aged in his 40s, suffering from paranoid schizophrenia,
had been admitted to hospital and treated over the years in the USA. He began
working on his body image, by exercising and weightlifting, in the framework
of a rehabilitation programme. Over time, he started to identify with the
biblical character Samson. Eventually, he was overcome by a compulsion to come
to Israel in order to move one of the giant stone blocks forming the Western
(Wailing) Wall which, in his opinion, was not in the right place. On arriving
at the Western Wall, he attempted to move one of the stones. His actions
instigated a terrible commotion, culminating in police intervention and his
placement in the hospital of the Kfar Shaul Mental Health Centre.
Contrary to accepted practice, the duty psychiatrist challenged the patient's delusional ideas, telling him that he could not possibly be Samson and that, according to the Bible, Samson had never been in Jerusalem. The patient reacted to this with rage, became aggressive, broke a window, and escaped through it. A team was sent out to look for him, and a student nurse found him standing at a bus stop. Demonstrating commendable wisdom, she told him that he had proved that he possessed qualities similar to Samson's and that he could now return to the hospital, which he did of his own volition. A hospital examination showed him to be in an acute psychotic state: he was convinced that he was Samson and that he had a mission to accomplish. After receiving antipsychotic medication, he calmed down and was able to fly back home, escorted by his father.
Subtype I(ii): psychotic identification with an idea
Individuals from this subtype strongly identify with an idea (usually of a
religious nature, sometimes of a political nature) and arrive in Jerusalem to
act on this idea.
Example
A Protestant from South America conceived a plan to destroy Islamic holy
places in order to replace them with Jewish holy places. The second stage of
his plan was then to destroy them in order to start the war of Gog and Magog
so that the Anti-Christ would reveal himself, after which Christ would
reappear. The patient succeeded in gutting one of the most holy mosques in
Jerusalem. Psychiatric examination was ordered by the court, and he was
diagnosed as being unable to differentiate between right and wrong, not
responsible for his deeds and therefore not fit to stand trial. He was
admitted to a local psychiatric institution and later transferred to a mental
health institution in his own country.
Subtype I(iii): magical ideas concerning connection between health
and holy places
This subtype consists of patients with magical ideas concerning sickness
and health and healing possibilities connected with Jerusalem. Interestingly,
the famous Russian writer Gogol, after psychosis had ended his writing, had a
revelation suggesting that he would do well to visit Jerusalem and recite
special prayers at holy burial sites there in order to recover from his
illness and be able to start writing again. Gogol travelled to Israel in 1848,
but starved himself to death four years later
(Nabokov, 1971).
Subtype I(iv): family problems culminating in psychosis in
Jerusalem
This subtype comprises individuals whose mental disturbance is expressed in
terms of family problems. This subtype is problematic because, under the
influence of the psychosis, it is usually impossible to identify the core
meaning of Jerusalem to the patient in association with the psychosis, or the
motive for his travelling to Jerusalem. Yet these individuals choose to come
repeatedly to Jerusalem, and while there develop florid psychosis.
Example
A South African man, suffering from bipolar affective disorder and with a
history of several stays in hospital in his homeland, visited Jerusalem on
four occasions, each following a manic episode culminating in admission to
hospital. According to this man, he came to Jerusalem in order to kill a man
who had raped his daughter. His family always forewarned the Israeli health
authorities of his visits and, consequently, he was admitted to hospital
immediately upon his arrival in Jerusalem. After receiving treatment, he
usually had the capacity to show a degree of insight, and to note that when he
became manic, he got upset with his daughter's husband. In remission, he was
able to admit to his behaviour being pathological and to admit that he
actually admired and respected his son-in-law. Psychologists who treated him
have described his disorder as a reversed Oedipus complex which was manifest
during manic phases. His connection with Jerusalem is not clear; neither is it
clear why he is drawn to Jerusalem in seeking a solution to an imaginary
problem created by his distorted pathological thought processes.
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TYPE II: JERUSALEM SYNDROME SUPERIMPOSED ON AND COMPLICATED BY IDIOSYNCRATIC IDEATIONS |
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Type II probably accounts for a relatively large number of Jerusalem syndrome sufferers. In groups, they are highly visible; they stand out in public places, especially holy ones. They are occasionally featured in the media but they do not, on the whole, reach professional psychiatric agencies.
Subtype II(i): individuals belonging to a group
Example
Various Christian groups outside the mainstream of the established churches
settle in Jerusalem in order, for instance, to bring about the resurrection of
the dead or the reappearance of Jesus Christ. Such groups usually consist of
no more than about 20 members. One group, previously located in Jerusalem, is
now settled near Jericho, another is located in the Jerusalem Forest, and yet
another is based in the centre of Jerusalem. The members of these groups wear
distinctive clothing which, according to them, is similar to that worn in the
days of Christ.
Various Jewish groups also have unusual ideas and intentions regarding Jerusalem. We know of three groups currently attempting to create a red heifer based on writings contained in the Old Testament (Numbers, XIX). In the Bible, the red heifer was to be sacrificed and its ashes used for purification rituals before entering the temple. Today, apparently, simply touching the red heifer will suffice. The problem is that a perfect, unblemished, completely red heifer has yet to be conceived.
The members of these groups do not usually undergo psychiatric examination because they do not evoke problems, endanger others or break the law. Only three individuals from such groups have been examined, as a result of a court order after a violent confrontation with neighbours; all three were diagnosed as suffering from personality disorders.
Subtype II(ii): Lone individuals
Example
A single German male aged 45, working in an academic position, considered
healthy, and without any recognisable problems, is obsessed, without being
able to explain why, with the need to find the true religion. He spent five
years studying the various streams of Christianity and further time studying
the esoteric religions of ancient Persia, China and Japan, and reached the
conclusion that none of them qualified as the true religion. He then took
leave from work, came to Jerusalem, and started studying Judaism at a
university and in a Yeshiva (religious seminary). However, Judaism was also
rejected. Finally, this man decided that the only true religion was, in his
words, "primitive Christianity the religion of Jesus before
Peter and Paul ruined it". He now felt it imperative to bring this
message to the people of Jerusalem, and set about preaching it at every
opportunity. One day, on a visit to the Church of the Holy Sepulchre in the
Old City of Jerusalem, he succumbed to an attack of psychomotor agitation and
started shouting at the priests, accusing them of being pagans and barbarians
and of worshipping graven images. The confrontation developed into a violent
struggle; eventually, the subject started to destroy statues and paintings.
The court ordered admission to hospital at the Kfar Shaul Mental Health Centre
for observation and psychiatric evaluation. However, examination by
experienced psychiatrists, including the District Psychiatrist of Jerusalem,
revealed no psychopathology, not even the mildest personality disorder, all
they could find was obession with the fixed idea described above. Follow-up
three years later again failed to indicate mental disorder, and the subject
continues to work in his academic position, to believe in the same religion
and to spread his message, regretting only that he was unable to do this in
Jerusalem.
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TYPE III: JERUSALEM SYNDROME DISCRETE FORM, UNCONFOUNDED BY PREVIOUS PSYCHOPATHOLOGY |
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Main diagnostic criteria for type III
First criterion
Subjects have no previous history of psychiatric illness no prior
psychotic episodes, no significant problems regarding work or family and no
drug use. In other words, the subjects can be defined as healthy and devoid of
any mental disorder.
Second criterion
Subjects arrive in Jerusalem as regular tourists, with no special mission
or specific purpose in mind. They usually arrive with friends or family
members, often as part of a larger group on an organised tour of Mediterranean
countries.
Third criterion
Subjects have, upon arrival in Jerusalem, an acute psychotic reaction that
develops in a consistently characteristic sequence of seven identifiable
clinical stages.
The seven clinical stages of type III
Treatment and recovery
Type III does not usually involve visual or auditory hallucinations.
Patients know who they are and do not claim to be anyone else. If questioned,
they identify themselves by their real name. However, they ask not to be
disturbed in the completion of their mission. Their condition usually returns
to normal within 5-7 days; in other words, a short-lived episode followed by
complete recovery. These individuals clearly need treatment, and often receive
it, but recovery is quite often spontaneous and not necessarily due to the
treatment. Experience has taught us that improvement is facilitated by, or
dependent on, physically distancing the patient from Jerusalem and its holy
places. On the whole, major medical intervention is not indicated; minor
tranquillisers or melatonin (as in cases of jet-lag psychosis) usually
suffice. Our main treatment strategy is to facilitate return to the group or
the renewal of family ties (including with family overseas), or, if deemed
appropriate, access to a priest. Crisis intervention psychotherapy plays an
important part in the recovery process.
Upon recovery, patients can usually recall every detail of their aberrant behaviour. They are inevitably ashamed of most of their actions, and feel that they have behaved foolishly or childishly. They sometimes describe their conduct as being akin to that of a clown or a drug addict. However, in most cases, they are reluctant to talk about the episode, and it has therefore been difficult to achieve a deeper understanding of the phenomenon. Those who do talk after the episode often talk about a sense of "something opening up inside them", their body movements suggesting an outward disposition. After this sensation, they feel an obligation to carry out certain actions or to relay their message.
An example is provided by a Swiss lawyer who arrived in Jerusalem on a group tour of the Middle East which included one week in Greece, one week in Israel, and one week in Egypt. He had been perfectly healthy up to the time of the trip, and spent an enjoyable week in Greece. Onset of type III of the syndrome was indicated on his first night in Jerusalem. The subject fitted the three diagnostic criteria perfectly, and the development of the syndrome followed the seven characteristic stages faithfully. The whole process took seven days, after which the syndrome passed. The subject rejoined the tour, enjoyed his visit to Egypt and returned home in good health. Follow-up indicates that since returning home six years ago, the subject has been completely healthy.
In seeking out distinctive background features of type III patients, we found that, of the 42 cases, 40 were Protestants, one was Catholic, and one was a Jew who had lived as a Protestant while in hiding during the Second World War. All 40 Protestants came from what can be described as ultra-religious families. The Bible was the most important book to these families, who would read it together at least once a week. The Bible would also serve as a source of answers to seemingly insoluble problems especially for the father, as head of the family. For fundamentalist believers of this type, Jerusalem assumes the highest significance: such people possess an idealistic subconscious image of Jerusalem, the holy places and the life and death of Jesus. It seems, however, that those who succumb to type III of the Jerusalem syndrome are unable to deal with the concrete reality of Jerusalem today a gap appears between their subconscious idealistic image of Jerusalem and the city as it appears in reality. One might view their psychotic state and, in particular, the need to preach their universal message as an attempt to bridge the gap between these two representations of Jerusalem.
In an attempt to arrive at a broader empirical base we sent questionnaires to all 42 of our type III patients, but received responses from only four of them and these merely stated that they were feeling good and thanked us for our treatment, with no further elaboration. None answered the questionnaire. Attempts to obtain information by telephone interview produced the same disappointing result; the expatients insisted that they were feeling well, and that they did not want to talk about their experiences of Jerusalem syndrome.
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DISCUSSION |
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Several explanations have been offered to account for psychotic breakdown among travellers. Some of these explanations suggest that the change of routine involved in travel influences mental state to a considerable extent (Bar-El et al, 1991b). Flinn (1962) and Singh (1961) list a number of factors such as unfamiliar surroundings, proximity to foreigners or strangers, inactivity, a sense of isolation and culture clash. Factors such as these, compounded by the special significance of Jerusalem to Jews, Christians and Muslims, may serve to trigger an acute psychotic episode. According to Cohen (1979), the existential mode of travelling (one of five modes of tourism; this mode refers to journeys to a spiritual centre) constitutes a modern metamorphosis of the pilgrimage. It is worth noting that Freud (1936) reported having experienced a sense of derealisation while visiting the Acropolis. The possibility that other place-oriented syndromes and the Jerusalem syndrome may share a common denominator even though they appear to be fundamentally different should not be dismissed. For instance, in the case of airport wanderers or airport syndrome (Shapiro, 1982), a condition found among tourists who get lost and who experience psychotic episodes in airports, it has been suggested that the airports symbolically highlight pre-existing problems. However, unlike victims of the Jerusalem syndrome, people who develop airport syndrome forget their identity, are unaware of where they have come from or where they are going to and bump into people. Recovery is usually spontaneous after minimal assistance, perhaps a drink and a short rest.
The Stendhal syndrome
The condition most closely resembling the Jerusalem syndrome is the
Stendhal syndrome identified by Magherini
(1992), which describes a
particular acute psychotic reaction arising among art-loving tourists visiting
Florence. The syndrome is named after the French writer Stendhal, who
described feelings of
déjà
vu and disquiet after looking at works of art in Florence. Magherini in
her book Sindrome di Stendhal
(1992) presented the
statistical, socio-demographical, clinical and travel-related variables of 106
tourists who were admitted to hospital in Florence between 1977 and 1986. She
described cases in which a small detail in a famous painting or sculpture
evoked an outburst of anxiety, reaching psychotic dimensions. According to
her, such reactions are usually associated with a latent mental or psychiatric
disturbance that manifests itself as a reaction to paintings of battles or
other masterpieces and culminates in the full-blown Florence or Stendhal
syndrome.
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TOWARDS THE MILLENNIUM |
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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 data obtained by systematic empirical research were thwarted by the reluctance of ex-patients to cooperate. A more detailed investigation would therefore be needed in order to arrive at a better understanding of the Jerusalem syndrome in general, and in particular its most intriguing version, the pure, unconfounded type III version.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Bar-El, Kalian, M. & Eisenberg, B. (1991b) Tourists and psychiatric hospitalization with reference to ethical aspects concerning management and treatment. Psychiatry, 10, 487 -492.
Cohen, E. (1979) A phenomenology of tourist experience. Sociology, 13, 179 -201.
Flinn, D. B. (1962) Transient psychotic reactions during travel. American Journal of Psychiatry, 119, 173 -174.
Freud, S. (1936) A disturbance of memory on the Acropolis. Reprinted (1953-1974) in the Standard Edition of the Complete Psychological Works of Sigmund Freud (trans. and ed. J. Strachey), vol. 22, p. 239. London: Hogarth Press.
Magherini, G. (1992) Syndrome di Stendhal. Milan: Fettrinelli.
Nabokov, V. (1971) Gogol. Reprinted in Hebrew (1997) (trans. D. Frenz). Tel Aviv: Yedioth Ahronoth.
Shapiro, S. (1982) Airport wandering as a psychotic symptom. Psychiatria Clinica, 15, 173 -176.[Medline]
Singh, H. A. (1961) A case of psychosis precipitated by confinement in long distance travel by train. American Journal of Psychiatry, 117, 936 -937.
Received for publication September 7, 1998. Revision received August 31, 1999. Accepted for publication August 31, 1999.