A Narrative Review on Jerusalem Syndrome: Exploring Diagnosis, Treatment and Cultural Impacts

1. Undergraduate Student, Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 2. Undergraduate Student, Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 3. Professor, Department of Biochemistry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 4. Assistant Professor, Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.

Abstract

Visitors to Jerusalem who are not religious may experience “Jerusalem Syndrome,” characterised by obsessive religious ideas and delusions that can lead to psychosis. There are three varieties of this disorder. However, it is not officially recognised: Type-I affects individuals who have already experienced psychosis; Type-II affects persons who held unusual ideas before travelling to Jerusalem; and Type-III affects people who were initially mentally stable but developed psychosis while in Jerusalem. The review explores the effects of Jerusalem Syndrome on mental health, drawing comparisons with “Paris Syndrome.” Notable similarities with schizophrenia point to different initiators related to Jerusalem’s significance. Jerusalem Syndrome is treated with individualised mental care that combines medication and psychotherapy.

Paris syndrome, Psychotherapy, Religious delusions

A visit to Jerusalem might cause a person to experience a range of mental health issues known as “Jerusalem syndrome,” which includes delusions, obsessive thoughts with a religious theme and other symptoms similar to psychosis. It has impacted Jews, Christians and Muslims from a wide range of backgrounds and is not exclusive to any one religion or denomination (1). It is not listed as a medical condition in the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders (2). The discrete type of Jerusalem syndrome, which has distinct sequential stages, is associated with religious excitement brought on by being close to Jerusalem’s sacred sites (3). Anxiety, agitation, nervousness and tension are some of the initial signs (4). Declaring one wants to go solo and see Jerusalem instead of travelling with the group is a sign of this syndrome (5). If the syndrome is not treated in its early phases, stages such as an overwhelming demand for cleanliness, getting ready for a white gown, verbal outbursts of religious content, ending in a procession to a holy location and giving a confused sermon may ensue (6). The phenomenon wherein an individual who appeared to be regular and free of psychopathology suddenly developed psychosis after moving to Jerusalem is the most well-known, if not the most common, form of Jerusalem syndrome (7). The severe religious theme that characterises the psychosis usually disappears after a few weeks or after the person is taken out of the environment (8). Due to its religious orientation, Jerusalem syndrome differs from other phenomena, such as Florence’s Stendhal or Paris’s syndrome (9). Formerly known as fièvre Jérusalemienne, Jerusalem syndrome was thought to be a type of hysteria (10). The prevalence of Jerusalem syndrome is difficult to determine precisely due to its complex nature and the lack of formal recognition in diagnostic manuals (2). On average, around 100 patients are seen annually suffering from Jerusalem syndrome (1). Additionally, the phenomenon may manifest differently among individuals and may not always result in clinical attention or diagnosis (2),(3). The rationale for the present review of Jerusalem syndrome is to provide a comprehensive examination of a complex and relatively obscure psychological phenomenon that is not officially recognised in standard diagnostic manuals. Overall, the present narrative review enhances understanding among clinicians, researchers and educators and promotes a more nuanced approach to diagnosing and treating culture-bound syndromes. The epidemiology of Jerusalem syndrome is characterised by its rarity, diversity in affected individuals and variability in presentation. Despite these challenges, understanding the syndrome’s prevalence, demographic patterns and types is crucial for developing effective preventive and treatment strategies, especially in a city as culturally and religiously significant as Jerusalem. A person visiting Jerusalem may develop a variety of mental health conditions known as “Jerusalem syndrome,” which includes psychotic-like symptoms, delusions and obsessive thoughts with a religious theme (11). Heinz Hermann, a psychiatrist from Jerusalem and one of the pioneers of contemporary psychiatric study in Israel, wrote the first clinical description of it in the 1930s (12). The medical literature has debated the existence of the typical Jerusalem syndrome, which is characterised by an extreme religious mania that appears to be triggered by a journey to Jerusalem and dissipates immediately after or on departure (13). It is debatable if these actions are mainly related to visiting Jerusalem because comparable actions have been observed in other significant religious and historical locations like Mecca and Rome, as in Stendhal syndrome (14).

Three Distinct Types of Jerusalem Syndrome

To represent the various ways in which a visit to Jerusalem may interact with odd or psychotic-like cognitive processes, the Jerusalem syndrome is divided into three main categories (15). Patients with an already present psychotic disease who experience Jerusalem syndrome are considered to have Type-I Jerusalem syndrome (16). These people frequently travel to the city with preconceived notions about religion. They see themselves as influential religious leaders from history or as having a purpose or objective connected to their hallucinations (3). Instead of being clearly diagnosed with a mental disorder, Type-II Jerusalem syndrome affects people with peculiar beliefs. It frequently takes the form of an unusual fixation with Jerusalem’s cultural significance. This can happen personally or in tiny religious communities with unusual spiritual practices, resulting in a sophisticated and enhanced bond with the city (17). The most common kind, known as Type-III Jerusalem syndrome, is defined by the sudden onset of psychosis in mentally stable individuals upon their arrival in Jerusalem. This is frequently accompanied by paranoid beliefs, such as the idea that they are being targeted by an agency that will poison or drug them to induce symptoms (18). Types of Jerusalem syndrome and its manifestations are represented in (Table/Fig 1). This table classifies three types of Jerusalem syndrome:

Symptoms of Jerusalem syndrome include anxiety, a desire to distance oneself from the group and an obsession with cleanliness, which is frequently manifested in over-grooming and bathing (19). This progresses to wearing an improvised white robe, reciting prayers, making a pilgrimage to a sacred location and finally giving a sermon encouraging others to live a more moral life, clearly showing a precise sequence of actions linked to the condition (20).

Type-I Jerusalem syndrome affects individuals who have a pre-existing psychotic disorder. These individuals often come to Jerusalem with entrenched religious delusions, seeing themselves as significant religious figures or having a divine mission (16). The intense religious environment of Jerusalem can exacerbate these pre-existing conditions (16).

Type-II Jerusalem syndrome involves individuals with peculiar beliefs but no formal psychotic disorder. These beliefs often include an unusual obsession with Jerusalem’s spiritual significance, which can intensify upon arrival in the city (3),(16),(17).

Type-III Jerusalem syndrome occurs in individuals without prior mental health issues. The sudden onset of psychosis in these cases suggests that the intense spiritual and cultural atmosphere of Jerusalem can trigger latent psychological vulnerabilities (16),(18).

Cognitive Dissonance

The experience of being in Jerusalem can create a significant psychological conflict in individuals, especially those with deeply held but unexamined religious beliefs (2). The actual experience of the holy sites may clash with their expectations, leading to cognitive dissonance and, eventually, psychosis as a way to resolve the internal conflict (4).

Psychological and Environmental Triggers

Pilgrims often feel immense pressure to have a transformative spiritual experience in Jerusalem (19). This societal and self-imposed expectation can lead to heightened emotional states and, in vulnerable individuals, trigger psychotic episodes (3),(20). The collective environment of religious fervor and the presence of other pilgrims experiencing similar intense emotions can create a feedback loop, intensifying the individual’s symptoms (7),(20). Travel-related stress, including jet lag, unfamiliar surroundings and cultural differences, can contribute to the onset of Jerusalem syndrome (10). The isolation from familiar support systems can also exacerbate the condition, especially if the individual starts exhibiting unusual behaviour that alienates them from their group (11),(14). The decision to explore Jerusalem alone, which is often an early sign of the syndrome, further isolates the individual and may lead to an increase in stress and anxiety (16),(18).

Paris Syndrome and its Parallel Symptoms in Jerusalem Syndrome

When someone visits Paris, they may experience “Paris syndrome,” which is an intense feeling of disappointment because they feel that the city does not meet their expectations (21). Most people consider the illness to be a severe case of culture shock, as in Jerusalem syndrome. Acute delusional states, hallucinations, feelings of persecution, perceptions of being the victim of prejudice, aggression, hostility from others, derealisation, depersonalisation, anxiety and psychosomatic manifestations like dizziness, tachycardia and sweating are among the psychiatric symptoms that define the Paris syndrome, which shares similarities with the Jerusalem syndrome except for the religious aspect (22). Although visitors from Japan have been the target of the Paris syndrome more than any other country in East and Southeast Asia, including China, South Korea and Singapore, it has also afflicted these visitors (23). The term was first used in the 1980s by Hiroaki Ota, a Japanese psychiatrist at the Sainte-Anne Hospital Centre in France (24). In 1991, Ota wrote a book with the same name. In 1998, a Japanese patient suffering from manic depression and experiencing Paris syndrome was described by Katada Tamami of Nissei Hospital (25).

Contrasting Symptoms of Schizophrenia and Jerusalem Syndrome

A variety of symptoms distinguish schizophrenia as a distinct mental illness within a group of associated illnesses involving psychosis, like Jerusalem syndrome (26). People with schizophrenia frequently suffer from delusions and hallucinations, seeing and believing things that are not based on reality (27). Disorganised or incomprehensible speech and conduct can also be symptoms of the illness, disrupting daily functioning and mental processes. Schizophrenia is a complicated mental illness with many facets and negative symptoms, including social disengagement and decreased emotional expressiveness, add to this complexity. The cultural and religious significance of Jerusalem distinguishes Jerusalem syndrome from schizophrenia (28). A comparison of Jerusalem syndrome and schizophrenia is presented in (Table/Fig 2).

Treatment Approaches for Jerusalem Syndrome

Jerusalem syndrome is treated mainly with psychiatric treatments because it is regarded as a type of psychosis. A professional mental assessment and, if required, hospitalisation may be recommended for those displaying symptoms (1). Antipsychotic drugs are frequently used in combination with psychotherapy to address underlying psychological issues and control symptoms (29). It’s crucial to remember that medicine is only one part of treatment; a thorough strategy may also involve counselling, psychotherapy and assistance from mental health specialists (30). The objective is to treat the underlying psychological issues that are causing the syndrome and to offer comprehensive care to the afflicted individuals. The therapeutic strategy must be customised to meet the unique requirements and circumstances of the person suffering from Jerusalem syndrome.

Conclusion

A rare combination of psychological, spiritual and cultural factors can come together in the phenomenon known as Jerusalem syndrome and it can manifest in various ways during pilgrimages to the holy city. Jerusalem syndrome is characterised by its cultural and religious background, although psychiatric interventions, a combination of medication and psychotherapy, are the mainstay of treatment. Therapy approaches must be customised to the individual’s situation for comprehensive care. The present review sheds light on the complex interactions between the mind and external stimuli during significant travel experiences, emphasising the importance of understanding how cultural, religious and environmental factors can impact mental health when navigating the complexities of Jerusalem syndrome.

DOI and Others

DOI: 10.7860/JCDR/2024/70465.19737

Date of Submission: Mar 02, 2024
Date of Peer Review: May 01, 2024
Date of Acceptance: Jun 12, 2024
Date of Publishing: Aug 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
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ETYMOLOGY: Author Origin

EMENDATIONS: 5