In Reply: The issue raised in our communication to Psychiatric Servicesis not whether the Jerusalem syndrome is a "distinct clinical entity" or whether the city of Jerusalem should be regarded as a "pathogenic factor," as implied in Dr. Kalian and Dr. Witztum's letter. Rather, our letter described a case in which an objectively verifiable syndrome simultaneously served as a paranoid delusional object—the "Jerusalem syndrome organization."
Our initial account of Jerusalem syndrome (1) 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. The patient described in our communication suffered from Jerusalem syndrome superimposed on paranoid schizophrenia. Proximity to the holy places of Jerusalem clearly triggered the full sequence of his symptoms.
Dr. Kalian and Dr. Witztum, who have previously expressed their objections to our description of Jerusalem syndrome (2), wrote elsewhere (3) that "the study of the psychopathology of those who do suffer mental breakdowns in a particular place has yielded important observations and deductions." They described travelers who "had a psychotic episode while visiting Jerusalem" and argued that "there is clearly a correlation between the meaning of Jerusalem as a place central to religious experience and the nature of the psychotic episode." They have also stated, as they do in their letter, that "the eccentric conduct and bizarre performance of these colorful yet psychotic visitors became dramatically overt once they reached the Holy City—a geographical locus containing the 'axis mundi' of their religious belief" (4).
We have no quarrel with Dr. Kalian and Dr. Witztum about the strong cultural-religious background of Jerusalem syndrome, and we have argued elsewhere for the importance of taking such factors into account (1).
As a syndrome rather than as a distinct nosological entity, Jerusalem syndrome may appear in the context of other major psychiatric disorders or as a de novo psychotic condition. We are confronted by such patients regularly in our mental health center in Jerusalem, the psychiatric facility to which virtually all tourists suffering psychotic breakdowns while in the Jerusalem area are referred for treatment.
The authors are psychiatrists in the Kfar Shaul Mental Health Center in Jerusalem, which is affiliated with the Hadassah Medical School of Hebrew University.