Background Background Jerusalem'spsychiatrists Jerusalem'spsychiatrists expecttoencounter,asthemillennium expecttoencounter,asthemillennium approaches,anever-increasingnumberof approaches,anever-increasingnumberof touristswho,uponarrivinginJerusalem, touristswho,uponarrivinginJerusalem, maysufferpsychoticdecompensation. maysufferpsychoticdecompensation. Aims Aims TodescribetheJerusalem TodescribetheJerusalem syndromeasauniqueacutepsychotic syndromeasauniqueacutepsychotic state. state. Method Method Thisanalysisisbasedon Thisanalysisisbasedon accumulatedclinicalexperienceand accumulatedclinicalexperienceand phenomenologicaldataconsistingof phenomenologicaldataconsistingof culturalandreligiousperspectives. culturalandreligiousperspectives. Results Results Threemaincategoriesofthe Threemaincategoriesofthe syndromeareidentifiedanddescribed, syndromeareidentifiedanddescribed, withspecialfocusonthecategory withspecialfocusonthecategory pertainingtospontaneousmanifestations, pertainingtospontaneousmanifestations, unconfoundedbypreviouspsychotic unconfoundedbypreviouspsychotic historyorpsychopathology. historyorpsychopathology. Conclusions Conclusions Thediscreteformofthe Thediscreteformofthe Jerusalemsyndromeisrelatedtoreligious Jerusalemsyndromeisrelatedtoreligious excitementinducedbyproximitytothe excitementinducedbyproximitytothe holyplacesofJerusalem,andisindicatedby holyplacesofJerusalem,andisindicatedby sevencharacteristicsequentialstages. sevencharacteristicsequentialstages. Declarationof interest Declarationofinterest None. None. Jerusalem, a city that conjures up a sense of Jerusalem, a city that conjures up a sense of the holy, the historical and the heavenly, it the holy, the historical and the heavenly, it holds a unique attraction for people of sev- holds a unique attraction for people of sev- eral of the world's faiths and religions ± eral of the world's faiths and religions ± especially Jews, Christians and Muslims. especially Jews, Christians and Muslims. When people dream of Jerusalem, they do When people dream of Jerusalem, they do not see the modern, politically controversial not see the modern, politically controversial Jerusalem, but rather the holy biblical and re- Jerusalem, but rather the holy biblical and re- ligious city. Since 1980, Jerusalem's psychia- ligious city. Since 1980, Jerusalem's psychia- trists have encountered an ever-increasing trists have encountered an ever-increasing number of tourists who, upon arriving in number of tourists who, upon arriving in Jerusalem, suffer psychotic decompensation. Jerusalem, suffer psychotic decompensation. In view of the consistently high incidence of In view of the consistently high incidence of this phenomenon, it was decided to channel this phenomenon, it was decided to channel all such cases to one central facility ± the all such cases to one central facility ± the Kfar Shaul Mental Health Centre (Bar-El Kfar Shaul Mental Health Centre (Bar-El et et al al, 1991 , 1991a) ± for psychological counselling, ) ± for psychological counselling, psychiatric intervention and, if deemed ne- psychiatric intervention and, if deemed ne- cessary, admission to hospital. Over the cessary, admission to hospital. Over the course of 13 years (1980±1993), 1200 tour- course of 13 years (1980±1993), 1200 tour- ists with severe, Jerusalem-generated mental ists with severe, Jerusalem-generated mental problems have been referred to this facility. problems have been referred to this facility. Of these, 470 were admitted to hospital. Of these, 470 were admitted to hospital. On average, 100 such tourists are seen On average, 100 such tourists are seen annually, 40 of them requiring admission to annually, 40 of them requiring admission to hospital. hospital. On the basis of clinical experience, we On the basis of clinical experience, we have identified three main types of patient have identified three main types of patient with Jerusalem syndrome (see Table 1). with Jerusalem syndrome (see Table 1). TYPEI:JERUSALEM TYPEI:JERUSALEM SYNDROMESUPERIMPOSED SYNDROMESUPERIMPOSED ONPREVIOUSPSYCHOTIC ONPREVIOUSPSYCHOTIC ILLNESS ILLNESS Type I refers to individuals already diag- Type I refers to individuals already diag- nosed as having a psychosis before their nosed as having a psychosis before their visit to Israel. Their motivation in coming visit to Israel. Their motivation in coming to Israel is directly related to their mental to Israel is directly related to their mental condition and to the influence of religious condition and to the influence of religious ideas, often reaching delusional levels, ideas, often reaching delusional levels, compelling them to come to Jerusalem compelling them to come to Jerusalem and do `something' there. Type I can be and do `something' there. Type I can be divided into the following four subtypes. divided into the following four subtypes. Subtype I(i): psychotic Subtype I(i): psychotic identification with biblical identification with biblical characters characters Individuals from this subtype strongly iden- Individuals from this subtype strongly iden- tify with characters from the Old or New tify with characters from the Old or New Testament or are convinced that they them- Testament or are convinced that they them- selves are one of these characters. Their selves are one of these characters. Their conviction reaches psychotic dimensions. conviction reaches psychotic dimensions. Jewish tourists generally identify with char- Jewish tourists generally identify with char- acters from the Old Testament, and Chris- acters from the Old Testament, and Chris- tian tourists with characters from the New tian tourists with characters from the New Testament; in the same vein, men and Testament; in the same vein, men and women generally identify with male and women generally identify with male and female personalities respectively. female personalities respectively. Example Example An American tourist aged in his 40s, suf- An American tourist aged in his 40s, suf- fering from paranoid schizophrenia, had fering from paranoid schizophrenia, had been admitted to hospital and treated over been admitted to hospital and treated over the years in the USA. He began working on the years in the USA. He began working on his body image, by exercising and weight- his body image, by exercising and weight- lifting, in the framework of a rehabilitation lifting, in the framework of a rehabilitation programme. Over time, he started to iden- programme. Over time, he started to iden- tify with the biblical character Samson. tify with the biblical character Samson. Eventually, he was overcome by a compul- Eventually, he was overcome by a compul- sion to come to Israel in order to move one sion to come to Israel in order to move one of the giant stone blocks forming the Wes- of the giant stone blocks forming the Wes- tern (Wailing) Wall which, in his opinion, tern (Wailing) Wall which, in his opinion, was not in the right place. On arriving at was not in the right place. On arriving at the Western Wall, he attempted to move the Western Wall, he attempted to move one of the stones. His actions instigated a one of the stones. His actions instigated a terrible commotion, culminating in police terrible commotion, culminating in police intervention and his placement in the intervention and his placement in the hospital of the Kfar Shaul Mental Health hospital of the Kfar Shaul Mental Health Centre. Centre. Contrary to accepted practice, the duty Contrary to accepted practice, the duty psychiatrist challenged the patient's delu- psychiatrist challenged the patient's delu- sional ideas, telling him that he could not sional ideas, telling him that he could not possibly be Samson and that, according possibly be Samson and that, according to the Bible, Samson had never been in to the Bible, Samson had never been in Jerusalem. The patient reacted to this with Jerusalem. The patient reacted to this with rage, became aggressive, broke a window, rage, became aggressive, broke a window, and escaped through it. A team was sent and escaped through it. A team was sent out to look for him, and a student nurse out to look for him, and a student nurse found him standing at a bus stop. Demon- found him standing at a bus stop. Demon- strating commendable wisdom, she told strating commendable wisdom, she told him that he had proved that he possessed him that he had proved that he possessed qualities similar to Samson's and that he qualities similar to Samson's and that he could now return to the hospital, which could now return to the hospital, which he did of his own volition. A hospital ex- he did of his own volition. A hospital ex- amination showed him to be in an acute amination showed him to be in an acute psychotic state: he was convinced that he psychotic state: he was convinced that he was Samson and that he had a mission was Samson and that he had a mission to accomplish. After receiving anti- to accomplish. After receiving anti- psychotic medication, he calmed down psychotic medication, he calmed down and was able to fly back home, escorted and was able to fly back home, escorted by his father. by his father. 86 86 BRITISH JOURNALOF PSYCHIATRY BRITISH JOURNALOF PSYCHIATRY (2000),176, 86^90 (2000),176, 86^90 Jerusalem syndrome Jerusalem syndrome YAIR BAR-EL, RIMONA DURST, GREGORY KATZ, JOSEF ZISLIN, YAIR BAR-EL, RIMONA DURST, GREGORY KATZ, JOSEF ZISLIN, ZIVA STRAUSS and HAIM Y. KNOBLER ZIVA STRAUSS and HAIM Y. KNOBLER
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.
