Jerusalem Syndrome or Paranoid Schizophrenia?

To the Editor: We were intrigued to read the case report by Dr. Fastovsky and her colleagues in the August 2000 issue (1). As the authors of several articles on Jerusalem syndrome, we would like to add our comments. Contrary to the opening statements in Dr. Fastovsky's letter, attempts to present the so-called Jerusalem syndrome as a distinct clinical entity have been severely criticized (2). In our view, Jerusalem syndrome should perhaps be regarded as a unique cultural phenomenon because of its overwhelming theatrical characteristics (3). Dramatic cases have been reported by various biographers since the establishment of pilgrimages to the Holy City and tourism (4), and such cases are appealing to today's media.

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 (5). 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 case presented by Dr. Fastovsky and colleagues demonstrates our basic assumptions. In our view, their patient was experiencing an aggravation of paranoid schizophrenia. The content of the patient's delusions and his overt behavior were colored by his cultural-religious background.

Dr. Kalian is the district psychiatrist in the Ministry of Health in the Central District of Israel in Ramle. Dr. Witztum is professor of psychiatry at the Negev Faculty of Health Sciences at the Mental Health Center in Beer Sheva.