Wholly holy: A beginner’s guide to Jerusalem syndrome

In a previous blog I examined Stendhal Syndrome where some people when exposed to the concentrated works of art, experience a wide range of symptoms including physical and emotional anxiety (rapid heart rate and intense dizziness, that often results in panic attacks and/or fainting), feelings of confusion and disorientation, nausea, dissociative episodes, temporary amnesia, paranoia, and – in extreme cases – hallucinations and temporary ‘madness’. While researching that article, I also came across another condition that would appear to be related to Stendhal Syndrome, namely ‘Jerusalem Syndrome’ – a condition that I have some empathy with.

One of the things I love about my job is all the wonderful places I have been able to travel to and visit as part of my work. Back in 2010, I did some consultancy on social responsibility practices for the online gambling company 888 and was flown to Tel Aviv to speak to various departments about my work. Once my talks and meeting were over, I experienced one of the best days of my life when I given a personal guide around the whole of Jerusalem. I am not religious but I found myself totally overcome with emotion as I visited one tourist attraction after another.

I say all this by way of introduction to what has been reported in the psychological literature as the aforementioned ‘Jerusalem Syndrome’ where visitors to the holy city are totally overcome by the weight of its history. The condition was first described (perhaps unsurprisingly) by an Israeli psychiatrist – Haim Herman – in the 1930s. However, psychiatrists did not begin keeping comprehensive clinical and statistical information on these cases until the late 1970s. One of the most infamous cases often cited in relation to Jerusalem Syndrome occurred in 1969, when a male Australian tourist (Denis Michael Rohan) set alight the al-Asqa Mosque following an overwhelming feeling of divine mission.

In 1999, Dr. Eliezer Witzum and Dr. Moshe Kalian wrote the first paper on Jerusalem Syndrome in an issue of the Israelian Journal of Psychiatry and Related Sciences. The condition became more widely known in 2000, when Dr. Yair Bar-El and colleagues published a paper in it in the British Journal of Psychiatry (BJP). Since 1980, Dr. Bar-El and his colleagues reported that Jerusalem’s psychiatric services had encountered over 1000 tourists with Jerusalem Syndrome (approximately 100 a year and overwhelmingly evangelical Christians). All cases were sent to one central facility (the Kfar Shaul Mental Health Centre [KSMHC]) for psychological counselling, psychiatric intervention, and/or admission to hospital. Between 1980 and 1993 approximately 1200 tourists with severe, Jerusalem-generated mental problems were referred to the KSMHC (with 470 being admitted to hospital). Based on those requiring treatment, the 2000 BJP paper outlined what the authors believed were the three main categories of the syndrome.

• Type I: Comprises individuals that have already been diagnosed as having a psychosis (e.g., schizophrenia, bipolar illness) prior to visiting Israel. They usually travel alone and come to Israel for psychiatric religious ideation.
• Type II: Comprises individuals with mental disorders (e.g., personality disorders, obsessions) but don’t have a clear mental illness and whose strange thoughts would not be classified as delusional or psychotic. They usually travel in groups (but sometimes alone) and come to Israel for curiosity reasons.
• Type III: Comprises individuals that have no previous history of mental illness, but who become victim to a psychotic episode while in Israel (particularly Jerusalem). Type III individuals are said to recover spontaneously, and enjoy normality on their return to their home country. They usually travel with friends or family (often as part of an organized tour) and come to Israel as regular tourists (and have a religious home background).

The authors reported that the third type was the most was “perhaps the most fascinating” because it included individuals with no prior history of mental illness and whose symptoms were context-specific and recover spontaneously with little psychological intervention. Therefore, the authors noted that Type III Jerusalem Syndrome is not associated with other psychopathologies, and is this is a “pure” or “unconfounded” form of the syndrome. Of the 1200 or so cases, only 42 were classified as Type III.

Despite the many reported case of Jerusalem Syndrome, in subsequent responses to the BJP paper, Kalian and Witzum then disputed its existence and claimed it is just a variant of schizophrenic illness. They wrote in a letter that:

“Our accumulated data indicate that Jerusalem should not be regarded as a pathogenic factor, because the morbid ideation of the affected travelers started elsewhere. Jerusalem syndrome should be viewed as an aggravation of a chronic mental illness and not a transient psychotic episode. The eccentric conduct and bizarre behavior of these colorful but mainly psychotic travelers become dramatically overt once they reach the Holy City – a geographical locus containing the axis mundi of their religious beliefs”.

The authors of the original paper then responded with yet another letter and pointed out that:

“Our initial account of Jerusalem syndrome clearly distinguished between patients with Jerusalem syndrome who also have a history of psychotic illness – Jerusalem syndrome superimposed on a previous psychotic illness – and those with no previous psychopathology, whom we referred to as having the discrete form of the syndrome. In either case, the symptoms of the syndrome appear on arrival in Jerusalem and exposure to the holy places”.

There have been a number of explanations as to why Jerusalem Syndrome occurs. Some authors suggest that mental state changes can occur as a result of a significant change in routine and circumstances  (e.g., culture clash, geographical isolation, unfamiliar surroundings, proximity to strangers and/or foreigners). These factors compounded with the religious significance to many different faiths (Christians, Jews and Muslims), may be the stimuli that to trigger acute psychotic episodes. Such ‘spiritual’ travel may represent a modern-day version of a pilgrimage. There are of course limitations of the work by Bar-El and colleagues that the authors duly acknowledge including the fact that the study (i) was based on a phenomenological description and was not a research study, (jj) lacked follow-up information, and (iii) did not taken into account changes in circumstances associated with the expected influx of tourists in the millennial year.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bar-El, Y., Durst, R., Katz, G., Zislin, J., Strauss, Z. & Knobler, H.Y. (2000) Jerusalem syndrome. British Journal of Psychiatry, 176, 86-90.

Bar-El, Y., Kalian, M. & Eisenberg, B. (1991) Tourists and psychiatric hospitalization with reference to ethical aspects concerning management and treatment. Psychiatry, 10, 487 -492.

Bar-El, I., Witztum, E., Kalian, M., et al (1991) Psychiatric hospitalization of tourists in Jerusalem. Comprehensive Psychiatry, 32, 238 -244.

Fastovsky N, Teitelbaum A, Zislin J, et al (2000). The Jerusalem syndrome. Psychiatric Services, 5, 1052.

Gordon, H., Kingham, M. & Goodwin, T. (2004). Air travel by passengers with mental disorder. The Psychiatrist, 28, 295-297.

Halim, N. (2009). Mad tourists: The “vectors” and meanings of city-syndromes. In K. White (Ed.), Configuring Madness. Oxford: Inter-Disciplinary Press.

Kalian, M. & Witzum, E. (2000) Comments on Jerusalem syndrome. British Journal of Psychiatry, 176, 492.

Kalian M. & Witzum, E. (2002) Jerusalem syndrome as reflected in the pilgrimage and biographies of four extraordinary women from the 14th century to the end of the second millennium. Mental Health, Religion and Culture, 5, 1-16.

Monden, C. (2005). Development of psychopathology in international tourists. In van Tilburg, M. & Vingerhoets, A. (Eds.), Psychological Aspects of Geographical Moves: Homesickness and Acculturation Stress (pp. 213-226). Amsterdam: Amsterdam Academic Archive.

Witztum, E., & Kalian, M. (1999). The “Jerusalem syndrome” – fantasy and reality. A survey of accounts from the 19th century to the end of the second millennium. Israelian Journal of Psychiatry and Related Sciences, 36, 260-271.