The Astounding True Case Of Jerusalem Syndrome

By Ilan Preskovsky

In Neil Gaiman’s latest short story collection, Trigger Warning: Short Fictions and Disturbances, among the master fantasist’s usual assortment of tales of werewolves, hellhounds, and Time Lords, there is a singularly disturbing story about a middle-aged British couple who, on their first visit to Jerusalem, come face-to-face with a particularly strange kind of insanity; an intensely religious, messianic delusional state that is caused by nothing less than the city itself. Unlike the rest of the stories around it, though, the “monster” at the centre of the aptly titled Jerusalem is, in fact, a very real phenomenon.

Jerusalem Syndrome, as it is called, has courted a fair amount of controversy in psychiatric circles, but, regardless of the specific nature and classification of the phenomenon, it is a very well-documented disorder that affects in the region of 100 tourists to the Holy City each year.

Once classified as a sub-order of the catch-all psychiatric disorder known as “hysteria” – which once included things such as dissociative identity disorder – the now very much improved fields of psychiatry and psychology still aren’t entirely sure what to do with this strange disorder. Still not included in the latest Diagnostic and Statistical Manual of Mental Disorders (the DSM V), psychiatrists aren’t sure if it isn’t just a variation of schizophrenia or if the phenomenon really has anything to do with Jerusalem at all, as something similar has manifested in smaller quantities in various other cities.

Regardless, Jerusalem Syndrome demonstrably exists and, for something this peculiar, it’s also relatively common. Three different types of the syndrome have even been identified, each with its own set of criteria and symptoms, so for all of its controversy and all of its mysteriousness, it has clearly been the subject of a not insignificant amount of study.

Dissecting a phenomenon

The first type of Jerusalem Syndrome applies to those who already have an existing psychosis, upon which an additional psychosis related to Jerusalem is added. Such people might believe themselves to be Biblical figures or obsessed with preaching particular religious ideas and they usually travel to Jerusalem in the first place as a way of fulfilling their existing delusions. This is the most obvious case of Jerusalem Syndrome not being a disorder in and of itself but a suborder of a larger diagnosis.

As, for example, in a particular case study, an American man in his forties diagnosed with paranoid schizophrenia started to identify more and more with the Biblical figure Samson (Shimshon), becoming increasingly obsessed with traveling to Jerusalem to “fix” the Kotel by moving one of its stones. Israeli doctors could not dissuade the man of his delusions and it was only after a nurse, who found him alone at a bus stop, convinced him that he surely was Samson and that he has completed his mission, were they able to get him to a nearby hospital to give him the medication he needed.

The second type, on the other hand, are those who had not been diagnosed with a specific psychosis, but either have non-psychotic personality disorders or, more intriguingly, higher-than-average cultural or religious obsessions with Jerusalem. This second type can be your typical loner but more often actually applies to groups of people who share the same, almost obsessive, draw to Jerusalem. Considering just how central Jerusalem is to all three Abrahamic faiths, this no more surprising than the fact that religion, in certain unguarded, extreme iterations, can be easily mistaken for a form of obsession, even psychosis.

The line between mental illness and religious belief is particularly interesting here when you consider that some of the most well-documented cases of Type II Jerusalem Syndrome involved a group of Christians, who relocated to Jerusalem in the firm belief that by doing so they could bring about the resurrection of their saviour. Not to be outdone, there is also the case of three small Jewish groups who similarly relocated to Jerusalem in the belief that, once there, they would be able to discover a Red Heifer – a purely red cow that was used in the Temple for “purification” purposes. These groups are usually left alone and tend not to undergo psychiatric testing, as they are, by their very nature, utterly peaceful, keeping very much to themselves, doing neither themselves nor other any physical harm.

Most intriguing of all, though, is the third type; the kind that is usually identified with the syndrome but is actually by far the least common – only forty-two Type III cases were clearly identified out of the 1200 cases of Jerusalem Syndrome recorded between 1980 and 1993. Though, considering that it seems to be a temporary condition, apparently cured simply by leaving the city, that number could be far lower than the reality – especially as those who suffer from “temporary madness” presumably wouldn’t want to talk about something that is usually a source of some embarrassment for them.

Unlike Type I, or even Type II, this form of Jerusalem Syndrome is preceded by no form of serious psychiatric disorder, no religious obsession, and no specific mission to visit Jerusalem as anything but a regular tourist. In other words, this person shares none of the specific symptoms and behavioural patterns that are common in the other two types.

Once he enters Jerusalem, however, a clearly identified seven-step process towards an “acute psychotic episode” begins quite rapidly. It starts off with general anxiety and nervousness and is followed by the person breaking away from his family/tour group/traveling companions. Forty-two documented cases in a decade or not, these symptoms are common enough that apparently many tour guides in Jerusalem are trained to look out for these symptoms and they often step-in and get the person the psychiatric help they need.

Should this not happen, however, the other five stages occur in fairly rapid succession. First, the person is driven by a compulsive need for cleanliness, including thorough baths or showers and fingernail and toenail cutting. This is followed by the sufferer draping themselves in a white cloth or toga; always white and often made from their hotel linen, and shouting, at the top of their voices, Biblical verses, Psalms, or hymns. Again, at this stage it is often possible for others to step in, as this sort of behaviour is rather noticeable – especially for fellow hotel guests or hotel management.

Left to their own devices, however, those with Type III Jerusalem Syndrome will head off towards a particular holy place in Jerusalem and start preaching usually incoherent, utopian religious pleas to all passers-by. Intriguingly, though some two-thirds of those with Jerusalem Syndrome are Jewish, the forty-two Type III cases were overwhelmingly Christian, with only one Jew among them.

Again, though, this is hardly conclusive. The fact that these incredibly specific seven stages were observable in all forty-two subjects is astounding enough, but the “cure” is no less so. While those with the third type of Jerusalem Syndrome act in these most peculiar ways, they don’t apparently suffer from typical schizophrenic symptoms as auditory hallucinations and tend to still know who they are. As such, major psychiatric intervention is not required and, along with minor tranquilisers or relaxants, the best cure usually is just to remove the patients from Jerusalem, or at least its holiest places, where the person soon returns to “normal”, especially if met by family, close friends, or a religious confidant like a priest or rabbi. Usually, the person does, however, remember every last detail of his behaviour and usually treats it with great shame and embarrassment, so he may need some additional therapeutic help to deal with this specific side effect. It also explains why this third type of Jerusalem Syndrome might go largely undocumented.

What’s in a city?

Regardless of type, it’s pretty crazy stuff (no pun or political incorrectness intended) and major credit to the British Journal of Psychiatry’s website (bjp.rcpsych.org) for all the actual, meticulous research that served as the source material for this article. Jerusalem Syndrome is so mind-bogglingly strange, in fact, that had I not worked so closely off such thoroughly detailed scientific research, you probably wouldn’t believe that I’m not making at least a good portion of it up.

And yet, here we are. The human mind never fails to fascinate and astound, but does this astounding syndrome tell us anything else about our holiest of cities and our relationship to it? To be honest, probably not. Like all so-called religious proofs, this can no doubt at all be viewed purely as a psychological phenomenon, with no paranormal or spiritual dimension to it at all. And yet, quite aside for the fact that there is something deeply religious about the mind in and of itself, doesn’t this only confirm something that anyone even remotely familiar with Jerusalem knows in their gut – at least those who are open enough to admit it?

Jerusalem is a beautiful, wholly unique and wondrous city but, whether it’s its sheer sense of history, a shared religious consciousness spanning three major religions, or even its very spiritual makeup, there’s also something quite overwhelming, even unsettling about it. Frankly, I may only have ever visited there for three weeks of my life (with no signs of my inner Samson breaking out or compulsive needs to chant “Blessed are the Cheesemakers”, as near as I could tell) but incredible as the city so obviously is, I have no earthly idea how anyone actually lives there as, apparently, sometimes even visiting can be overpowering enough!