Jerusalem Syndrome

What Is Jerusalem Syndrome?

The city of Jerusalem has been a major magnet for pilgrim from some of the largest religions in the world, namely Christianity, Judaism and Islam. When traveling, many people can start to feel overwhelmed, but in rare cases, a person can experience a rare psychosis called Jerusalem syndrome.

This usually happens to people without a prior history of mental illness, who get to overwhelmed by their sensations and emotions they experience while visiting the city. Some specialists say, that this condition belongs to a group of psychotic diseases and is not unique to Jerusalem, for example, people experience similar psychosis upon visiting Florence or Paris (e.g. Florence syndrome and Paris syndrome) ^[1]. Also read about psychosis in Wernicke-Kossakoff syndrome.

Causes

The exact cause of Jerusalem syndrome is not known. In some cases, it is caused by an already existing psychiatric condition.

Jerusalem syndrome mostly affects Protestants- almost 97% of all cases. Researchers believe, that it is due to orthodox upbringing and good knowledge of the Bible. Catholics also have other sacred places and intermediaries, like the Vatican and Saints. But for Protestants, Jerusalem is the only place where they can follow the life of Jesus ^[2].

Types

Type 1

In type 1 Jerusalem syndrome, there is already an underlying psychiatric disorder, which has been diagnosed before going to Jerusalem. In some cases, visiting Jerusalem is directly related to their mental condition. There are 4 subtypes for type 1 Jerusalem syndrome:

Subtype 1

psychotic identification with characters from the bible

Individuals from this subtype identify themselves with a character from the bible. In some cases, they believe that they themselves are one of the characters. Usually men identify with male characters, and women- with female. Christians are mostly seen reliving a character’s life from New Testament, while Jewish people- the Old Testament

Subtype 2

identification with an idea

In this case, individual identifies themselves with an idea of a religious, sometimes political nature. These individuals go to Jerusalem to act on their idea.

Subtype 3

magical ideas about connection of holy places and health

In this subtype, patients have magical ideas about their health. They believe that by being in Jerusalem and doing certain rituals will heal them. For example, the famous writer Gogol believed that if he visits Jerusalem and recites special prayers at the holy burial sites, he will be healed.

Subtype 4

psychosis as culmination of family problems in Jerusalem

This subtype includes individuals, whose mental problems are expressed as family problems. It is not easy to distinguish this subtype and understand the meaning of Jerusalem to the patient. Usually these people repeatedly go to Jerusalem and over there develop psychosis ^[3,4]. Also read about psychotic behavior in Kluver-Bucy syndrome.

Type 2

Type 2 Jerusalem syndrome is superimposed on and complicated by idiosyncratic ideations. In this type, an individual already has a mental disorder, like personality disorders or obsessive disorder, but they do not have a clear mental illness. Read about obsessive compulsory disorder in Tourette syndrome. There are two subtypes- subtype 1 affecting and individuals belonging to a group and subtype 2 applies to individuals.

Individuals in groups usually follow one certain idea, like wearing clothing similar to what Jesus wore. These people usually do not get admitted into hospitals, since their actions usually do not disturb peace and they do not harm anyone. In some cases individuals from such group can get violent.

Individuals might get obsessed with a certain idea, for example, finding the “true religion” or preaching to others. In mild cases these people are generally seen as strange and they do not receive any treatment, but they might also develop a full psychosis ^{[3,4, 6]}.

Type 3

Type 3 Jerusalem syndrome is also known as the real Jerusalem syndrome. In this case, there is no prior history of mental illness and the individual gets affected by the psychotic episode while they are in Jerusalem. These patients also usually recover spontaneously, after leaving the country. The main diagnostic criteria for Type 3 Jerusalem syndrome are:

• No prior history of psychiatric illness
• No history of psychotic episodes, significant problems at work or with family (see Battered Woman syndrome)
• No recent history of drug use
• Individual has arrived to Jerusalem as a tourist, with no specific purpose. Usually these people arrive together with friends or family, or with a larger group
• Individual develops a psychotic reaction upon arrival in Jerusalem ^[3,4].

Clinical Stages

There are usually seven main clinical stages present in people affected with Jerusalem syndrome. These clinical stages apply to type 3 Jerusalem syndrome.

1. Anxiety, agitation or nervousness. There might also different reactions accompanying these symptoms
2. Desire to split from the group and see Jerusalem alone. Tour guides are aware of this stage, and usually refer the tourist to a mental institution.
3. Need to be clean. This stage can start with talking about it, and later obsessively washing themselves and cutting fingernails and toenails
4. Preparation, mostly with white, ling bed-linen.
5. Need for screaming or loudly singing verses from Bible or religious hymns.
6. Procession to one or multiple holy places of Jerusalem
7. When getting to a holy place, the subject will deliver a religious, confusing and unrealistic sermon. Usually they plea others to adopt a more moral and simpler way of life. Read more about confusion and agitation in elderly- Sundown syndrome.

In this type of Jerusalem syndrome, the patient knows who they are and they do not experience visual, auditory or other types of hallucinations. Although they know who they are, they ask not to be disturbed on their quest ^[3,4].

Treatment

Type 1 and 2 can be seen as an acute exacerbation of an already existing condition therefore it should be treated depending on what the underlying cause is. Treatment might require hospitalization, psychotherapy and antipsychotic, as well as other kinds of medication.

Type 3 Jerusalem syndrome usually resolves on its own. Patients might require hospitalization to prevent them hurting themselves. After 5 to 7 days, the symptoms resolve and patients usually go back to their lives. Leaving the country is also a good way to recover more quickly.

Very often minor use of tranquillizers or melatonin is used. Melatonin is effective in patients who might have a jet-lag caused psychosis. Melatonin is also used in treatment of Smith-Magenis syndrome. Patients can also be offered to talk to a priest to perhaps resolve their issues and get answers to their questions.

Patients who have experienced Jerusalem syndrome usually feel embarrassed about their actions, since they can remember everything that happened. They should be encouraged to talk to a specialist about their feelings and experience ^[4].

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References

1. What is Jerusalem syndrome: http://science.howstuffworks.com/life/inside-the-mind/human-brain/jerusalem-syndrome.htm
2. Causes: https://www.psychologytoday.com/blog/life-is-trip/201203/mental-illness-youve-never-heard-1
3. Types of Jerusalem syndrome: http://www.livescience.com/50373-jerusalem-syndrome.html
4. Clinical presentation and treatment: http://bjp.rcpsych.org/content/176/1/86
5. Type 1 case report: http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.51.8.1052-a
6. Type 2 case report: http://journals.sagepub.com/doi/pdf/10.1177/136346150203900208