Sunday 18 March 2018

The beauty and power of certain iconic places can lead to holiday psychosis

Aerial view of Paris at night, France. Photo: Deposit
Aerial view of Paris at night, France. Photo: Deposit

Patricia Casey

It's the time of year when we flock to foreign parts for holidays. Most of these spots are emotionally neutral like beach resorts in the South of France or Spain, or cottages in the West of Ireland or the Yorkshire Dales. Some will head for places that have a particular emotional power. These may have profound religious connotations or simply be beautiful cities like Paris or Florence, with a rich history.

There is now a small but definite scientific literature on the power of place to cause psychosis. The best-known is Jerusalem Syndrome but others include Stendhal Syndrome and Paris Syndrome. Stendhal (or Florence) Syndrome was described in the early 19th century in a book by the writer Stendhal (Marie-Henri Beyle), Naples and Florence: A Journey from Milan to Reggio. This disorder can lead to spontaneous fainting, confusion and hallucinations. It is reported to occur in art-loving tourists who become overwhelmed by the beauty and splendour of the city of Florence. Psychoanalyst Graziella Magherini in her book La sindrome di Stendhal wrote a clinical description of the features of 106 tourists admitted to hospital in Florence between 1977 and 1986. In her series she reported that these particular patients became preoccupied by a detail in a painting that culminated in hallucinations and delusions.

Paris Syndrome, first described in 1986, is characterised by acute delusions in visitors to the City of Light. For some reason, it seems to have a predilection for Japanese tourists.

Jerusalem Syndrome was first described in the 1930s by Heinz Herman, a psychiatrist working in Jerusalem, although cases had been described in the Middle Ages by travel writers. Jerusalem Syndrome affects about 50-100 tourists each year and, unsurprisingly, Easter, Passover and Christmas are the most likely periods. During these times, hospitals are on high alert for new Messiahs to emerge.

In 2001, Dr Yair Bar El from the Kfar Shaul Medical Centre in Jerusalem, which treats all of these cases, published a case series in The British Journal of Psychiatry. Over a 13-year period from 1980 to 1993, 1,200 tourists with a Jerusalem-generated mental disorder were assessed in that centre. Of these, 470 required psychiatric admission, or 40 annually. Three groups emerged: those with previous psychotic illness travelling alone (this group identify with specific biblical characters or with specific religious ideas, such as replacing Muslim monuments with Christian ones, and arrived to implement this, while others developed magical ideas about health and holy places or came in order to repair family problems); the second group is those without any prior psychotic illness but with other psychological problems such as personality disorder or eccentric religious ideas; the third group is those with no prior psychiatric illness, who were functionally normal. This group develops the psychosis in Jerusalem and after a brief period of hospitalisation and treatment returns home and has no further episodes. This illness-free group is small - amounting to 42 cases in the 13-year study.

This group arrives in the city, often as part of a tour group and with no 'agenda' apart from visiting the sights. They often present initially with anxiety and a desire to split off from the tour group; they become preoccupied by purity and cleanliness and they have a compulsion to shout and or sing psalms. They often deliver a 'sermon' from one of the holy places. This is of very acute onset and recovery is often spontaneous. Most are deeply ashamed about the incident when they return home.

Although most clearly described in relation to Jerusalem, similar episodes have been described in Mecca, at holy places in India and at shrines to the Blessed Virgin Mary as well as evangelical rallies.

The things these locations have in common are their beauty, their personal significance, religiously or historically, and the emotion of reverence or awe that they inspire. These are cities that, to the person involved, are more than bricks and mortar.

To try and understand what is happening in the group with no prior psychiatric disorder, Andrew Newberg, a neuroscientist at Thomas Jefferson University in Philadelphia, has conducted several brain-imaging studies of people in moments of extreme devotion. The limbic system, which is concerned with our emotions, shows high levels of activity during prayer. On the other hand, the frontal lobes, which ordinarily regulate extreme emotion, start to shut down, leading to hallucinations and abnormal behaviours. Other factors like jet lag, suggestibility and language or cultural barriers may also play a role.

These unusual conditions are not named specifically in the standard textbooks of psychiatry or in the classifications such as the Diagnostic and Statistical Manual of Mental Disorders from the US. However, all of the psychiatric texts and manuals recognise that brief psychotic episodes, with and without a stressor, do occur and resolve rapidly, often without treatment.

Jerusalem Syndrome, and other such place-related syndromes, demonstrate the interplay between place, history and personal significance.

Most of us can visit these wonderful, awe-inspiring places without any psychological difficulties. We will continue to do so and be enriched by our experience.

Health & Living

Life Newsletter

Our digest of the week's juiciest lifestyle titbits.

Editors Choice

Also in Life