Invited commentaries on: Roast breadfruit psychosis: a consequence of disturbed racial identification in African-Caribbeans1

adhere with home norms and resisting going native, leading to conflict. At times, the pressures of social isolation, sexual frustration and alcohol would lead to outbursts of aggression, brooding, depression and increasing suspiciousness cul minating into running amok like the natives (Littlewood, 1985). The analogy with breadfruit psychosis is inescapable. Hickling & Hutchinson (1999) rehash a rather dated debate within cultural psychiatry (Mannoni, 1956) and argue for a diagnostic category that takes into account the historical and political relationship between colonisers and colonised, and between racism and psychosis. Their provocative and articulate essay is more rhetoric than a substantial and compelling case that establishes 'disturbed racial classification' as contributory to the


Tropical fruits or jungle madness?
This defunct popular colonial folk category referred to the White expatriate's attempt to adhere with home norms and resisting going native, leading to conflict.At times, the pressures of social isolation, sexual frustration and alcohol would lead to outbursts of aggression, brooding, depression and increasing suspiciousness cul minating into running amok like the natives (Littlewood, 1985).The analogy with breadfruit psychosis is inescapable.Hickling & Hutchinson (1999) rehash a rather dated debate within cultural psychiatry (Mannoni, 1956) and argue for a diagnostic category that takes into account the historical and political relationship between colonisers and colonised, and between racism and psychosis.Their provocative and articulate essay is more rhetoric than a substantial and compelling case that establishes 'disturbed racial classification' as contributory to the psychosis they postulate.It lacks depth and falls short of hypothesising intermediary factors which could make explicit the link between a cultural conflict and psychosis.There is nothing new in their essay.
It is a truism within medical anthropology worth restating: rhetoric reflects, guides and shapes biomÃ©dical epistemology, psychiatry in cluded (Kirk & Kutchins. 1992: Jadhav & Littlewood, 1994).That does not in itself take away the merit of enquiry nor does it invalidate ensuing research.But it does reveal how prevailing cultural concerns guide the direction of science.The authors of this essay too, have expressed popular consciousness (Morrison, 1994) about the unhealthy consequences of racism to victims as well as perpetrators, and effectivelyargue how skewed and imposed psychological norms in any society could scar growth and development.However to then extrapolate this to a psychosis (a term with fairly rigorous empirical criteria) in the absence of clearer links between 'conflicts' or  this issue 'symptoms' (resulting from racist experience) and individual psychopathology, is tenuous but not any more impractical nor socially inconsequen tial (on both methodological and fiscal grounds), than for example, researching genetic contribu tion to psychoses.
To argue for a diagnosis in the absence of documented, rigorous and systematic 'thick' case description that detail lived experiences of racism and how these relate to psychopathology, violate the fundamental premise of psychiatric nosology.It invites the same denunciation that the authors levy against the "dubious succour of standardised diagnostic instruments and inter national classification systems, generated by Euro-American perspectives".An a priori conclu sion, 'a roast breadfruit psychosis' merely adds to the rapidly expanding and meaningless diag nostic labels derived from tropical fruits and risk imitating existing culturally flawed classificatory systems such as DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health Organization, 1992) (The term coconut syndrome is popular among British-Asians in a manner analogous to breadfruit syndrome; while banana and mangoe psychosis are terms overheard by this author at transcultural psychiatry confer ence dinners, and refer to 'atypical psychoses' in South Asia observed by Western psychiatrists.While the fruits chosen are from tropical' regions or ex-colonies, they are popular despised meta phors denoting a camouflaged core self: a marker of cultural inauthenticity).There is an additional danger here: although legitimising the experi ence of racism through psychiatric diagnosis, it could further pathologise the victim, while absolving the perpetrators.And this has been substantiated more recently with ethnographic studies on post-traumatic stress disorder (Young, 1995).
Until recently, the field has been hampered by paucity of appropriate methods that bridged personal experience and psychiatric categories.But emerging paradigms such as ethnopsychiatry that demonstrates the case for multiple psychia tries (Gaines, 1992), and innovative frameworks such as the Explanatory Model Interview Cata logue (Weiss, 1997), which seek to validate cultural experience and psychopathology on its own terms, provide just that.They tease out the relationship between experience near (racism) and experience distant (psychiatric diagnoses) vocabularies, and help establish causal links between the two.This is the subject matter of medical anthropology and indeed a major re search agenda for cultural psychiatry in the twenty-first century (Bibeau, 1997).

On racism and mental illness
Racism is an attractive explanation for the increased rates of psychotic illness in African-Caribbeans in the UK.It has effects on physical, social and psychological environment (Williams, 1998).Its effects cross generations (Laviest, 1993: David & Collins, 1997).It compounds the effects of gender and social class (Lillie-Blanton & Laviest, 1996).
The experience of racism has been shown to produce pathophysiological changes acutely and is linked to a number of chronic physical illnesses (Laviest, 1996).Its influence on the perception of self and the perception of com munity may affect an individual's self-esteem, their ability to live a healthy lifestyle and to support others in a health promoting life-style.It may have a deleterious effect on the structures of minority communities and society as a whole (Wallace et al, 1996: Kennedy et al. 1998).
The US literature on the effects of racism on mental health is more robust than that of the UK.Studies there have not linked racism aetiologically to psychotic illness.Parker & Kleiner (1996) have demonstrated a relationship between thwarted aspirations and psychological stress in African-Americans.More recently, the persist ent, prolonged struggle and failure to overcome difficulties of blocked opportunities (John Henryism), has been linked to a decrease in psycho logical well-being -though not as yet to operationally defined mental ill-health (James, 1994).A discrepancy between occupational status and an ability to maintain the appear ances of a successful lifestyle has been linked to depression in young African-Americans and a link between internalised racial stereotypes and depression and alcohol misuse has been described (Neighbors et al 1996;Williams-Morris, 1996).
Racism has community and societal meanings and correlates.Frustration and disillusionment of individuals could lead to alternative economies and lifestyles which undermine the family and are associated with low social cohesion (Wallace et al, 1996).Reduced social buffers and social disorganisation are linked to poorer mental health (Taylor et al 1991).
The links between racism, identity and psycho logical development in children is a current area of interest but associations between these factors and physical and mental illness have yet to be assessed (Williams-Morris, 1996).
So what of roast breadfruit psychosis (Hickling & Hutchinson, 1999)?There is little doubt that racism is an important stress producing factor in the UK.However, that the identity problems it fosters could not only produce psychosis but would be reflected in psychotic symptomatology remains to be proved.Why identity problems would be linked to affective disorders and substance misuse in victims of racism in the US (Neighbors, 1996) but psychosis in only one ethnic minority group in the UK would need to be explained.
Detailed study and documentation is needed if such an illness category is to be entertained, and a proper evaluation of any treatment modality would need to be undertaken before it is made widely available.