Jerusalem syndrome

Overview
The Jerusalem syndrome is the name given to a group of mental phenomena involving the presence of either religiously themed obsessive ideas, delusions or other psychosis-like experiences, that are triggered by, or lead to, a visit to the city of Jerusalem. It is not endemic to one single religion or denomination, but has affected Jews and Christians of many different backgrounds.

The best known, although not the most prevalent manifestation of the Jerusalem syndrome, is the phenomenon whereby a person who seems previously balanced and devoid of any signs of psychopathology, becomes psychotic after arriving in Jerusalem. The psychosis is characterised by an intense religious theme and typically resolves to full recovery after a few weeks, or after being removed from the area.

Dr. Yair Bar El et al. claimed that there is a specific syndrome which emerges in tourists who had no previous psychiatric history. However this has been disputed, especially by Dr. Moshe Kalian and Prof. Eliezer Witztum. They stressed that nearly all of the tourists who demonstrated the described behaviours were already mentally ill prior to their arrival to Jerusalem. Further, of the small proportion alleged to have exhibited spontaneous psychosis after arrival in Jerusalem, there was no evidence presented that they had previously been well.

History
The syndrome was first clinically described in the 1930s by Jerusalem psychiatrist Heinz Herman and pertains to behaviors exhibited by some visitors to Jerusalem. Whether or not these behaviors specifically arise from visiting Jerusalem is debated, as similar behaviors have been noted at other places of religious and historical importance such as Mecca and Rome (see Stendhal syndrome). It is known that cases of the syndrome had already been observed during the Middle Ages, since it was described in the itinerary of Felix Fabri and the biography of Margery Kempe. Other cases were described in the vast literature of visitors to Jerusalem during the 19th century.

One case often mentioned in relation to the syndrome occurred in 1969, when an Australian tourist, Michael Rohan, overwhelmed with a feeling of divine mission, set fire to the al-Aqsa Mosque. His act was followed by citywide rioting. These events helped form the premise of a movie called The Jerusalem Syndrome.

Bar-El et al. suggested that at the approach of the year 2000, large numbers of otherwise normal visitors might be affected by a combination of their presence in Jerusalem and the religious significance of the millennium, causing a massive increase in the numbers of Jerusalem syndrome admissions to hospital. Despite a slight increase in tourist hospitalisations with the rise in total tourism to Jerusalem during the year 2000, the feared epidemic of Jerusalem syndrome never materialised.

Types
The 'classic' Jerusalem syndrome, where a visit to Jerusalem seems to trigger an intense religious psychosis that resolves quickly or on departure, has been a subject of debate in the medical literature. Most of the discussion has centred on whether this definition of the Jerusalem syndrome is a distinct form of psychosis, or simply a re-expression of a previously existing psychotic illness that was not picked up by the medical authorities in Israel.

In response to this, Bar-El et al. classified the syndrome into three major types to reflect the different types of interactions between a visit to Jerusalem and unusual or psychosis-related thought processes. However Kalian and Witztum have objected that Bar-El et al. presented no evidence to justify the detailed typology and prognosis presented, and that the types in fact seem to be unrelated rather than different aspects of a syndrome.

Type I
Jerusalem syndrome imposed on a previous psychotic illness. This refers to individuals already diagnosed as having a psychotic illness before their visit to Jerusalem. They have typically gone to the city because of the influence of delusional religious ideas, often with a goal or mission in mind which they believe needs to be completed on arrival or during their stay. For example, an affected person may believe himself to be an important historical religious figure, or may be influenced by important religious ideas or concepts (such as causing the coming of the Messiah or the second coming of Christ).

Type II
Jerusalem syndrome superimposed on and complicated by idiosyncratic ideas. This does not necessarily take the form of mental illness, and may simply be a culturally anomalous obsession with the significance of Jerusalem, either as an individual, or as part of a small religious group with idiosyncratic spiritual beliefs.

Type III
Jerusalem syndrome as a discrete form, uncompounded by previous mental illness. This describes the best known type, whereby a previously mentally balanced person becomes psychotic after arriving in Jerusalem. The psychosis is characterised by an intense religious character and typically resolves to full recovery after a few weeks, or after being removed from the locality. It shares some features with the diagnostic category of a 'brief psychotic episode', although a distinct pattern of behaviours has been noted: Bar-El et al. reported 42 such cases over a period of 13 years, but in no case were they able to actually confirm that the condition was temporary.
 * 1) Anxiety, agitation, nervousness and tension, plus other unspecified reactions.
 * 2) Declaration of the desire to split away from the group or the family and to tour Jerusalem alone. Tourist guides aware of the Jerusalem syndrome and of the significance of such declarations may at this point refer the tourist to an institution for psychiatric evaluation in an attempt to preempt the subsequent stages of the syndrome. If unattended, these stages are usually unavoidable.
 * 3) A need to be clean and pure: obsession with taking baths and showers; compulsive fingernail and toenail cutting.
 * 4) Preparation, often with the aid of hotel bed-linen, of a long, ankle-length, toga-like gown, which is always white.
 * 5) The need to scream, shout, or sing out loud psalms, verses from the Bible, religious hymns or spirituals. Manifestations of this type serve as a warning to hotel personnel and tourist guides, who should then attempt to have the tourist taken for professional treatment. Failing this, the two last stages will develop.
 * 6) A procession or march to one of Jerusalem's holy places.
 * 7) Delivery of a ‘sermon’ in a holy place. The sermon is usually very confused and based on an unrealistic plea to humankind to adopt a more wholesome, moral, simple way of life.

Prevalence
During a period of 13 years (1980-1993) for which admissions to the Kfar Shaul Mental Health Centre in Jerusalem were analysed, it was reported that 1,200 tourists with severe, Jerusalem-themed mental problems were referred to this clinic. Of these, 470 were admitted to hospital. On average, 100 such tourists have been seen annually, 40 of them requiring admission to hospital. About 2 million tourists visit Jerusalem each year. Kalian and Witztum note that as a proportion of the total numbers of tourists visiting the city, this is not significantly different from any other city.

References in popular culture

 * Artist Nathan Coley exhibited a piece of video artwork entitled 'Jerusalem Syndrome' which included two films shot in Jerusalem. The films are played simultaneously and contrast an interview with Dr Moshe Kalian, the current District Psychiatrist of Jerusalem discussing the syndrome and affected individuals, with shots of worshippers at the Western Wall, the Church of the Holy Sepulchre and the Temple Mount.
 * The syndrome figures in the plot of critically noted author Robert Stone's 1998 novel Damascus Gate.
 * The television show The X-Files referenced the Jerusalem syndrome in its third season on the episode "Revelations," which aired in 1995.
 * A film named Jerusalem Syndrome, directed by Erin Sax, depicted a fictionalised version of events which led Michael Rohan, an Australian tourist, to set fire to the al-Aqsa Mosque in 1969.
 * On Hillel Street in Jerusalem there is a music pub named 'The Syndrome'.


 * Journalist Louis Theroux did a segment about the syndrome on Michael Moore's TV Nation.