Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (16 page)

Visitors in the second category lack a psychiatric diagnosis but have what the authors call “idiosyncratic ideations.” These are groups or individuals with “unusual ideas” who are “outside the mainstream of the established churches.” They settle in Jerusalem believing, for instance, that doing so will bring about the resurrection of Christ. They may “wear distinctive clothing which, according to them, is similar to that worn in the days of Christ.” At some point these patients shift from merely harboring extreme religious beliefs to engaging in behavior that becomes more problematic. Bar-El and his coauthors give the example of a man who set out to preach his message of “true religion” to the people of Jerusalem and eventually, in the Church of the Holy Sepulcher, “succumbed to an attack of psychomotor agitation and started shouting at the priests, accusing them of being pagans and barbarians and of worshipping graven images.” Eventually the altercation became physical, and the man began destroying paintings and statues in the church, resulting in his psychiatric evaluation. He was found to have no identifiable mental illness beyond his extreme religious beliefs, even three years after the episode.

It is, however, the third category of tourists afflicted by Jerusalem syndrome that is the most mind-boggling. This category is described as a “pure” form of the syndrome, because its sufferers have no history of mental illness. These tourists experience an acute psychotic event while in Jerusalem; they recover “fairly spontaneously, and then, after leaving the country, apparently enjoy normality.” As a result they are considered to be mentally well, but for these isolated episodes. However, what episodes they are!

Tourists with the third subtype of Jerusalem syndrome succumb to a sequence of identifiable stages that are consistent, characteristic, and highly specific.

First, such sufferers exhibit “anxiety, agitation, nervousness and tension.” They then announce that they wish to split off from their tour group or family and explore Jerusalem on their own. The authors write, “Tourist guides aware of the Jerusalem syndrome and of the significance of such declarations may at this point [preemptively] refer the tourist . . . for psychiatric evaluation.” They add ominously, “If unattended, [the following] stages are usually unavoidable.”

People afflicted by Jerusalem syndrome will then demonstrate a “need to be clean and pure,” becoming obsessed with bathing or compulsively cutting their finger- and toenails. Next is my favorite step in the sequence: the “preparation, often with the aid of hotel bed-linen, of a long, ankle-length, toga-like gown, which is always white.”

Once appropriately clad, the person in question will proceed to “scream, shout, or sing out loud psalms, verses from the Bible, religious hymns or spirituals.” He or she will then proceed to a holy place within the city and deliver a sermon, which the authors describe as “usually very confused and based on an unrealistic plea to humankind to adopt a more wholesome, moral, simple way of life.”

The affected person typically returns to normal within five to seven days, feels ashamed about his behavior, and recovers completely. Between 1980 and 1993, the authors report that forty-two cases met all the diagnostic criteria for this third subtype.

Similar syndromes have been reported in Paris and Florence, each with its own odd specificities. Paris syndrome strikes Japanese tourists, sixty-three of whom were hospitalized with the condition between 1988 and 2004, according to a paper in the French psychiatric journal
Nervure.
Apparently the condition was common enough—and severe enough—that the Japanese embassy arranged for a Japanese psychiatrist to assist in treating cases at the Parisian psychiatric institution Hôpital Sainte-Anne. The Canadian philosopher Nadia Halim notes in her paper “Mad Tourists” that “Paris holds a ‘quasi-magical’ attraction for many Japanese tourists, being symbolic of all the aspects of European culture that are admired in Japan.” Tourists who fall victim to Paris syndrome “arrive in Paris with high, romanticized expectations, sometimes after years of anticipation, . . . unprepared for the reality of the city. The language barrier, the pronounced cultural differences in communication styles and public manners, and the quotidian banalities of contemporary Paris—the ways in which it is like any other 21st-century Western city—induce a profound culture shock” that results in symptoms ranging “from anxiety attacks accompanied by feelings of ‘strangeness’ and disassociation, to psychomotor issues, outbursts of violence, suicidal ideation and actions, and psychotic delusions.”

In the 1980s Graziella Magherini, an Italian psychiatrist and psychoanalyst, identified a syndrome in Florence in which visitors to the city become emotionally unmoored by their encounters with its art and architecture. Magherini reports on 106 cases from Santa Maria Nuova Hospital over ten years. Symptoms include breathlessness, palpitations, panic attacks, and fainting or collapsing to the floor. Severe cases have involved persecutory delusions and paranoia.

Nadia Halim writes in “Mad Tourists” that in many of Magherini’s case studies “patients report some sense of disintegration” or feel themselves breaking apart. After becoming transfixed by Caravaggio’s
Bacchus,
a fifty-three-year-old man felt “there was no longer any precise definition” in his life. The
New York Times
reports an event in front of the same painting, in which a man “collapsed onto the floor of the Uffizi, thrashing about madly. He was carried out on a stretcher, raving and disoriented.”

Also according to the
New York Times,
a twenty-five-year-old woman named Martha “became ‘delirious’ after standing for a long time before the Fra Angelico paintings in San Marco. She returned to her hotel,” the
Times
reports, “and stood for a long time in a corner, mute and withdrawn.” A twenty-year-old woman was seized by terror in the Uffizi and screamed for help, believing that she felt “the anguish of breaking into a thousand pieces.” Halim writes that she was “so agitated she had to be physically restrained.”

A 2009 paper in the
British Medical Journal
describes a seventy-two-year-old artist who went to Florence “to fulfill a lifelong wish to see the art and culture that so inspired him. He described some works of art as ‘like seeing old friends.’” The Ponte Vecchio apparently had a particular allure for him, being “the part of Florence he was most eager to visit.” Once he was standing upon it, he had a panic attack, became “disoriented in time,” and became floridly paranoid, believing, among other things, that his hotel room was bugged and that he was being monitored by international airlines. His symptoms resolved in three weeks.

Magherini dubbed the condition Stendhal syndrome after the French author of that name who became overwhelmed as a result of viewing the frescoes in the Church of Santa Croce. Stendhal wrote that as he exited the church, the sight of Brunelleschi’s dome on the Florence Cathedral nearly led him to madness. “I felt a pulsating in my heart,” he wrote about the experience. “Life was draining out of me. I walked with the fear of falling.” He was cured only by sitting down to read the poetry of Ugo Foscolo, who had written about Florence and hence was “a friendly voice to share my anguish.”

The mere existence of these “city syndromes,” as Nadia Halim dubs them, is controversial. Many voices have weighed in to argue that these episodes are merely exacerbations of preexisting psychiatric disease or the initial onsets of mental illnesses that happen to occur in foreign cities. Still others have chalked up the circumstances to jet lag or some other mundane variety of travel-related disorientation. At this point no one knows.

I didn’t meet Colin before he traveled with Amma across the American West. Which came first, the symptoms of his illness or the experience and promise of his transformation? He might have begun to exhibit subtle signs of mental dysregulation before he left to follow Amma, and then the stress and stimuli of travel caused his symptoms to explode. Or he might have been completely healthy before his trip and then gone to the mountains and taken some hallucinogens, at which point his bizarre beliefs and behavior began to emerge and his illness was unmasked. I got to see Colin only when he was already ill, without the benefit of knowing whether holiness, or place, or beauty had anything to do with the mental illness that had derailed him.

•   •   •

O
ne morning a woman named Nancy was admitted to my inpatient service. “Why do we look alike?” she asked me suspiciously, though she was twice my size and a different race. Before I could answer that I wasn’t sure we did, she demanded I recite the Fourth Amendment. I couldn’t. “Will you kindly get the fuck out of my room, then, and send in an American?” she asked. I left and looked it up. Ah, search and seizure. Needing a warrant. Now I know.

Nancy was in filthy clothes, and because she held a paranoid belief about the city’s having poisoned the water supply, she had not bathed or brushed her teeth in weeks. I knew from reading the report from her physical exam that she had a fungal infection beneath her breasts where they lay against her abdomen because it had been so long since she had washed herself there.

I treated Nancy for the first two days of her admission, but while she remained hospitalized, my clinical assignment switched and I began covering a different unit. When my schedule shifted back to her unit three weeks later, I saw Nancy’s name on the board and remembered our encounter. I was curious about her progress and went out on the ward to talk with her. I scanned the whole unit twice and could not find her. Alarmed, I finally approached the nurse in charge of the unit.

“I can’t find a patient. I’ve looked everywhere,” I announced, flustered.

“Which one?” asked the nurse.

“Nancy,” I replied. “Nancy, with paranoid schizophrenia.”

The nurse looked at me quizzically. “She’s right there,” she said, and gestured to a well-groomed and neatly dressed woman ten feet away from me in plain view, drinking coffee and reading the
Providence Journal.

I went over to Nancy. “Excuse me,” I said. “I’m Dr. Montross, Nancy. We’ve actually met once before.”

“I’m sorry, Doctor, I don’t remember,” Nancy responded, smiling politely at me. “It’s been a bit of a rough patch for me lately. Would you like to sit down?” I did, and we proceeded to have a perfectly lovely conversation about how she was feeling (“Oh, much better, thank you”) whether she was having any problems with her medications (“They always make me a little drowsy at first, but that’s passing now”) and her plans for the future (“My husband’s been taking care of our dog, so I’m anxious to get back home to our apartment. He doesn’t spoil that dog the way I do”).

When I left Nancy, I went to the computer and read sequentially through her progress notes since I’d seen her last. My evaluation was first, documenting how she’d been out of treatment for four years prior to her admission, that she’d also accused the emergency-room physicians of violating her Fourth Amendment rights, and that she’d claimed to be homeless despite living with her husband of twenty years. She had, at the time of her admission, said that she had three children, all of whom had died of AIDS. In fact, her three grown children were alive and well and, according to the nurses, had been in to visit her several times during her hospitalization.

Subsequent physician notes revealed that Nancy had been paranoid and agitated for nearly a week after she was first admitted and that she had refused to shower or eat, convinced that the water and food were poisoned. Eventually the primary psychiatrist who was treating her took her to mental-health court. In certain circumstances, which vary from state to state, a clinician can use the same rationale that provides for hospitalizing a person against her will (danger to self or others or “grave disability”) to make a petition for court-ordered treatment. In cases such as these, which go beyond an initial involuntary hospitalization, a judge may rule that the patient must remain hospitalized, even if she does not wish to do so, and must also take the psychiatric medication she is prescribed.

The judge ruled with the psychiatrist in Nancy’s case, and Nancy remained in the hospital and was treated with antipsychotic medication. Relatively quickly her symptoms abated, and she improved.

Taking away someone’s autonomy is an uneasy balance. In Nancy’s case, with the benefit of hindsight, we now know that it was the right thing to do. As a psychiatrist, I find it immensely rewarding to see a patient delivered from fear. And this trajectory is shared by many patients, because for all the vagaries of psychiatric medications, correctly prescribed antipsychotics frequently
do
treat psychosis in precisely this way.

Our psychiatric diagnoses are not always as clear as we would like or as well defined as we may believe. We can’t be sure whether a person feels his life disintegrating because of Caravaggio’s puissance or because of jet lag and an underlying predisposition to mental fragility. We must weigh whether a young man has the right to fast and adopt bizarre—potentially dangerous—behaviors if he believes himself to be the devout disciple of a saint. Surely we should tread with extraordinary caution when we infringe upon our patients’ freedoms. And yet, as Nancy and many other patients have taught me, that doesn’t mean we aren’t sometimes obliged to do so.

We all long, at some point, for a profound awakening. We travel with the expectation that the places we see and the encounters we have will transform us. We go to theaters and museums and holy sites in the hope of discovering something that will have a new and permanent resonance in our lives. It’s a human hunger. We
want
transformative things and places and people to exist in the world, and we want to be able to tap into their power, to use them to see our lives with a new and greater clarity.

The truth is that these transformations—these awakenings—exist. Their power is experienced in galleries and on mountaintops, in libraries and in temples, at rock concerts, on psychotherapists’ couches, and in scientific laboratories. They may be subtle or life-changing, as when the young Alexander Calder, working as a fireman on a ship, reportedly woke from sleep on the deck to a sky that held both a full moon and a dazzling sunrise. The sight inspired him to become an artist.