The more detailed wholistic view of lifelong complex multiple problems of personality-functioning and psychological syndromes can be diagrammatically presented as a developmental line in Fig. 14.2. For instance, when there has been an initial intersubjective cause, and across time there is the chaining of both biological cause and further intersubjective ‘causes’, this produces deterioration in mood, self-esteem and the ability to interact with others, these effect close relationships , the ability to work and provide child care. The link to eidetic imaginative variation below is creating a formal means of representing current and future-possible changes in the meaningful objects that are called syndromes. Because the notation is formal then other specific meanings can be substituted. The next step is to use clinical experience or research findings to discuss with clients as to what will help them. When it comes to understanding sub-syndromal latencies, tendencies or sensitivities, then they can be understood as semi-permanent aspects of personality, at a biopsychosocial level that are comprised of biological predispositions plus social learning of sub-optimal attachment styles due to dysfunctional parenting, family and social contexts. Distress can get triggered by small meanings in the current social contexts of work and home by meanings that might, at another time, have no effect whatsoever. The sensitivity that people have to distress-inducing meanings is variable and related to the whole set of events happening in a person’s life at any one time.

The biopsychosocial perspective means that intentional implication is happening in three different ways. Firstly, in biological cause there are biological drives that seek expression and these make some tendencies and abilities much easier than others, merely through genetic predisposition. Secondly, in the intersubjective sphere, intentional implication between persons and cultural objects are linked to learning that accrues across time. The learned meaningful links are the understanding of the meaning of objects and these are related to numerous social contexts , where these meanings have appeared ever since their first occurrence in childhood (I, 141). Thirdly, there is psychological cause in how the individual construes their situation and accepts distress as part of themselves, so defending themselves and making their own intentional links and conditioning associations. The syndromes produced could be in personality functioning or in the clinical syndromes of the general aspects of a person’s life. In the biopsychosocial view there may be cases where biological factors and intersubjective ones are in interplay in complex ways that are hard to differentiate. The therapeutic need is for persons to look after themselves, manage their distress and tendency to become excessively self-focused in a negative way, through genuinely understanding what is happening for them. Effective self-care is the remedy for a lack of self-care through self-neglect, lack of compassion to self and the inaccurate valuing of self by self, which are frequent causes of problems in relation to the mounting complexity of beliefs and habits of distress and accepting its presence across decades of the prior lifespan.

In other situations where it is unclear what causation is for the individual, it is possible to amalgamate the three multifactorial causes and state that: biopsychosocial cause → syndrome 1, a summated cause produces difficulties of distress, defence , impairment and how to cope and respond. In other cases, it is possible to conclude with certainty that a traumatic, neglectful or general accumulation of stressful experiences have overwhelmed the ability to maintain well being , openness and functioning composure. It is possible to conclude that the biological constituent can be ignored in terms of its cause, when it is possible to identify ‘cause’ in poor parenting and social relationships. It is inevitable that meanings create their own temporary, long-term or more permanent changes in biochemistry and the neurological concomitants of distress, written as “‘cause’ → syndrome 1”, as a short hand for what is really an interplay of different types of cause. An example of this is when persons have had stressful experiences over childhood and teenage years, and were able to cope until having a first panic attack in a crowded place. At which point they refuse to go out thereafter. Such a defensive strategy is an avoidant choice of the ego as a way of managing the possibility of future panic attacks. In this case, syndrome 1 is panic and syndrome 2 is agoraphobia written as egoic ‘cause’ → syndrome 1 → syndrome 2.

Let’s consider the conditions of possibility of the causes of syndromes. In reference to the introductory comments above, the first point is to note what to include in the consideration of a whole. Given that what is constant is the possibility of interactions between parts of the whole of consciousness, there is always the possibility of both better and worse accuracy of understanding of clients themselves as well as changes in the context. When it comes to the precise details of how the pieces of the whole of any individual fit together, then that is the job of formulating to help clients in the empirical testing of the ideas of ‘cause’. The task for therapists is to work out how noesis-noema pieces of sense get summated to form identifiable patterns of meaning that are the referents of the definitive textbooks in the professional discourse . The role of universal a priori concepts is to identify the connections between what is manifest, before being able to identify the connection between those parts that control and those that are controlled. The first case is where there are variations of the level of syndromes that do not entirely remit. This can be formalised as: sub-syndromal biopsychosocial vulnerability → subsyndrome 1 → sub-syndromal vulnerability remains. What this expresses is the case where some aspects of a syndrome are constantly present across time, with slight increases, with or without treatment. The changes are due to the person’s own ability to cope without medication or help.

Let’s consider another condition of possibility of the causes of syndromes one step up in distress from the last case. The next case is where there is one problem and it does not interact with any other syndrome and varies in strength due to stressors in the social context. This can be formally represented as: Sub-syndromal psychosocial vulnerability → syndrome 1 → sub-syndromal vulnerability. This situation is where there are intermittent changes in how to adapt to pressure on self where sometimes there is distress and a short period of impairment that qualifies as a syndrome.

Another situation is one comprised of the simplest case of accounting for simultaneously acting forms of cause across the three registers. Biological cause → syndrome 1, for instance, how to cope with a bipolar illness that is inherited from parents and grandparents. Psychological ‘cause’ → inaccurate understanding of changes in mood leading to ineffective defending in the context of mis-understanding self in relation to others and cultural objects , sub-syndrome 2. While in social life, intersubjective ‘cause’→ sub-syndrome 3, e.g. occasional experiences of social anxiety and low self-esteem due to bullying at work, an intersubjective event, occurs when there are current conflicts and tensions in the social contexts of home, work and play. This example permits three types of cause to be current and discussible with the person who has them and can act as a means of presenting research findings.

In a wholistic view, Angélique Cramer et al. (2010) notes that there can be shared intentional processes between any two syndromes. For example, there are similar intentionalities between social anxiety and worry. For instance, the shared aspects might be imagining that things will go wrong, that people will notice that self is anxious and self believes that others will think bad things about socially nervous, worried people. The most general case expressed in formulation by intentionality is that ‘causes’ can be expressed as motivations for constituting meanings of various sorts. When it comes to being pragmatic in gaining leverage on how to get changes, the point of getting an accurate picture of individuals’ personal development is for the purposes of making it plain to them how the learnings of the meanings of various objects have been created over time in relation to intentionalities and other relevant causative factors. The most general biopsychosocial formulation is as follows, in the specific case of vulnerability to social anxiety and worry. Because of the biological heritability of temperament there is a predisposition towards a set of intentionalities 1 → that produces negative meanings about cultural objects, sub-syndrome 1. Psychologically, the ego is actively choosing, willing and rationalising with a common set of intentionalities → and places an excessively negative focus on itself, to create the belief that itself, a cultural object for all to see, is damaged, inadequate and socially inept. This meaningful object of the sense of self as inadequate is common to sub-syndromes 1 and 2. Socially around the person, there are interpersonal conflicts and situations that need careful handling. So looking out towards the mass of society, there is a set of intentionalities 2 → concerning the negative meanings of cultural objects , now being maintained in social contexts, sub-syndrome 2.

Let’s consider another condition of possibility of the causes of a different constellation of syndromes. The first case is where there are gradual accumulations of syndromes between two end-states. The type of imaginative variation being requested is merely to think about how some psychological syndromes have been constituted across the lifespan of consciousness in general. If one syndrome diminishes and another remains the same, then they are not connected. And vice versa, if one syndrome diminishes and so does another, then they are interdependent in an ontological sense (XIX/1, 240–241). The progression, sub-syndromal biopsychosocial vulnerability → syndromes 1 and 2 → producing sub-syndromal vulnerability of two syndromes simultaneously concerns variability between two interdependent forms of distress. But, in the case where sub-syndromal biopsychosocial vulnerability → syndromes 1 and 2 → syndrome 1, shows that syndrome 1 persists and is not connected to syndrome 2.

The word “psychological” stands for the worldview of the individual ego that is mediated by intentionality with respect to their sense of self and volition in the world about what can be chosen, valued and willed to exist. Specifically, psychological ‘cause’ is the domain of the personal. The personal lifestyle is comprised of the very many choices and values that people wish to express in relation to their personality, the social contexts which they inhabit and the values they make manifest. The ego possesses many forms of intentionality, the ways of feeling, thinking and imagining the world and every cultural object’s place in it. The experiences that people have are not always the most helpful ones and could be inaccurately understood in relation to what they could be. There are always several potential views at stake about the same scenario. A fundamental difference is what clients experience and how they could experience the same, meta-representationally. The extended presence of one type of distress then ‘causes’, leads to a choice to self-medicate with recreational drugs and alcohol, for instance, which actually leads to further negative consequences. The unforeseen consequences of the prolonged usage of substances to manage mood could be addiction, impaired functioning whilst intoxicated, and having the hangover and come-down experiences with further associated changes in mood and how that affects their relationships . Three formal statements about natural-biological, individual-psychological and social-intersubjective causes are made in the eidetic sphere across the remaining sections below. They can be written as: Intersubjective ‘cause’ → leads to subsyndrome 1, (a vulnerability for syndrome 1) → subsyndromal vulnerability of type 2 → syndromes 1 and 2 → syndromes 1, 2 and 3 → syndromes 1, 2, 3 and 4. In one example, syndrome 1 could be worry. Syndrome 2 could be anxiety and depression. Syndrome 3 could be alcohol and drug abuse, defined as impairment of roles at home or work. And syndrome 4 would be addiction to drugs and alcohol, with an even greater impairment to the performance of roles at work and home. Worry and low self-esteem are linked to the neurotic personality factor. However, the phenomenological thinking involved is to take clinical observations about how distress and impairments of roles at home and work occur across the lifespan and to represent them in the eidetic way. Because in any possible set of difficulties certain forms of increase in distress and decrease in functioning are observable when there is no self correction. Diagrammatically, a general case of distress across the lifespan can be represented as: