1.

5 Causes and Reasons

As used in medicine and psychiatry. The concept of causality (aetiology) is derivative upon
that studied in the philosophy of science. The Latin term causa meant: reason, motive,
inducement, occasion (and even ‘opportunity’). It translated the Greek words 
and  (stems of 'aetiology') whose original meaning was 'origin', 'ground', and 'the
occasion of something bad'. In the event, and with little change, the Latin causa was
imported into the main European vernaculars.
Tal como se utiliza en medicina y psiquiatría. El concepto de causalidad (etiología) deriva del estudiado
en la filosofía de la ciencia. El término latino causa significaba: razón, motivo, inducción, ocasión (e
incluso "oportunidad"). Traducía las palabras griegas  y  (raíces de 'etiología') cuyo
significado original era 'origen', 'fundamento' y 'ocasión de algo malo'. Al final, y sin apenas cambios, el
latín causa se importó a las principales lenguas vernáculas europeas.
Since Greek times 'cause' has been used as a relational concept, i.e. that 'without which
another thing (called effect) cannot be'; but it was Aristotle who established its lasting
meaning:
Desde la época griega, "causa" se ha utilizado como concepto relacional, es decir, aquello "sin lo
cual otra cosa (llamada efecto) no puede ser"; pero fue Aristóteles quien estableció su significado
duradero:
“we call a cause (1) that from which (as immanent material) a thing comes into
being, e.g. the bronze of the statue and the silver of the saucer, and the classes
which include these. (2) The form or pattern, i.e. the formula of the essence, and the
classes which include this (e.g. the ratio 2:1 and number in general are causes of the
octave) and the parts of the formula. (3) That from which the change or the freedom
from change first begins, e.g. the man who has deliberated is a cause, and the father
a cause of the child, and in general the maker a cause of the thing made and the
change-producing of the change. (4) The end, i.e. that for the sake of which a thing
is. e.g. health is the cause of walking. For why does one walk? We say ‘in order that
one may be healthy’, and in speaking thus we think we have given the cause. The
same is true of all the means that intervene before the end, when something else
has put the process in motion (as e.g. thinning or purging or drugs or instruments
intervene before health is reached); for all these are for the sake of the end, though
they differ from one another in that some are instruments and others are
actions...”.

Ever since Aristotle, four types of cause have been recognized: (1) material, (2) formal, (3)
efficient and (4) final but not all are used in current medical parlance: indeed, the debate in
Western culture has been on whether: a) the four meanings are ‘really’ different, b) might
work better when combined, and c) one is more important than the others. Since the
scientific revolution of the 17 C and the development of 'mechanicist models' of the world,
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causation type (3) (efficient) has been considered as the core definition.
Desde Aristóteles se han reconocido cuatro tipos de causa: (1) material, (2) formal, (3) eficiente
y (4) final, pero no todos se utilizan en el lenguaje médico actual: de hecho, el debate en la
cultura occidental ha girado en torno a si: a) los cuatro significados son "realmente" diferentes,
b) podrían funcionar mejor combinados y c) uno es más importante que los otros. Desde la
revolución científica del siglo XVII y el desarrollo de los "modelos mecanicistas" del mundo, el
tipo de causalidad (3) (eficiente) se considera la definición básica.
Aetiology as Medical Narrative
Since the Medieval period medical men have endeavoured to compose explanatory
narratives for the ailments affecting their charges. Such narratives tend to reflect ongoing
metaphysical beliefs and hence are intelligible and persuasive. This was not the case earlier
on: for example, the Hippocratic case-notes (Epidemics I and III) include a descriptio
subjecti (a personal history) and a cursus morbi (history of the disease) but lack accounts of
the origo morbi (the cause of the disease). Be that as it may causal explanations began to
be incorporated in case-reports in the medieval concilia.
Written by experienced medical men for the benefit of neophytes, a concilium (advice)
contained information on the causes of disease ranging from commentaries on
'constitutions' to lists of specific ‘causal events’. The choice of the latter was dictated more
by tradition and theory than by 'observation and experience' (in the sense given to these
terms by Sydenham during the 17 C).th

The 16 C saw the initiation of the great medical tradition of inspectio cadaveris (post-
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mortem), and this generated correlational data which, in the event, allowed Morgagni and
Bichat to place disease within the frame of the body. This is the origin of the 'anatomo-
clinical' model of disease and of modern medicine. By the middle of the 19 C, case-histories
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had become full narratives comprising: descriptio subjecti, praegressa remota, origo morbi,
praegressa proxima, status praesens, and cursus morbi. This influenced the way in which
medical ‘causality’ was conceived (see below).
Aetiological Models & Mental Disorder
Current views on the aetiology of mental disorders were first developed during the 19 C. th

Both 'efficient causes' and 'internal mechanism' were considered but the latter were the
preferred focus of research after the 1850s. ‘Efficient causes’ were not abandoned and
psychiatric textbooks continued listing ‘efficient causes’ (as 'Antecedents' - events preceding
the onset of the disease) but they soon became stereotyped and uninformative.
The fact that alienists continued writing about efficient causes needs epistemological
explanation. In this regard the influence of Hume, the growth of historicist thinking, and the
impact of evolutionary theory will be briefly discussed.
Hume's legacy
Hume’s attack on the epistemological validity of 'efficient causes' did set two logical
requirements to future applications of the model: 1) that cause and effect were different
entities and 2) that the former occurred before the latter: ‘a cause is an object precedent
and contiguous to another, and so united with it, that the idea of the one determines the
mind to form the idea of the other, and the impression of the one to form a more lively idea
of the other’. This ‘seriatim view’ of causality was popular amongst 19 C alienists such as
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Pinel, Heinroth, Bayle, Prichard, Esquirol, Georget, Feuchtersleben, Morel and Griesinger.
Historicism
Historicism is first and foremost an epistemological attitude. It grew during the 19 C out of
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an 'awareness of the past', of the fact that things before that period had been different from
what they are now. This led to searching both for commonalities or continuities (the search
for stability) and also for differences, singularities and the uniqueness of specific events.
Historicism can be said to be more akin to the search for differences. To understand how
historicism affected the conceptualization of efficient causes, we first need to distinguish
between 'anthropological historicism' (‘historicity’ (Geschichtlichkeit) as a trait of all human
beings) and 'cosmological historicism' (according to which nature and the entire cosmos
have a specific history). The latter in turn has been interpreted in two ways: as history as a
conceptual frame (or episteme) in relation to which everything is interpreted (i.e.
'epistemological historicism') and history as a creative force ('ontological historicism'). 19 C
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alienists made use of both ‘anthropological’ and ‘epistemological’ historicism in their re-
analysis of 'efficient causes'.
Evolutionism
Mannheim believed that ‘evolutionism was the first manifestation of modern historicism’.
Evolutionism has changed meaning since the 18 C. At the beginning 'evolution' did not
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imply development in ‘time’. It was only during the first half of the 19 C that Lyell first
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linked 'evolution' to ‘time’. Although not the first men to suggest that organisms could
‘change’ (evolve) from generation to generation, Wallace and Darwin were the first to
propose a mechanism by means of which such changes occur. Thus Lamarck accepted the
idea of ‘species variation’ which he conceived as the realization of an idealized ‘principle of
perfection’ expressed piecemeal in the habits and ‘willingness’ of the organisms
themselves.
By emphasizing what had taken place before as directly relevant to the present, both 19 C th

historicism and evolutionism offered new conceptual props to 'efficient causes'. This in turn
supported clinicians in their belief that antecedents had real causal power and had been
feeling threatened by Humean scepticism.
The fact that internal mechanisms were nonetheless preferred to 'efficient causes' needs
explanation. Historical data suggest that alienists were under two kinds of pressure. On the
one hand, the Humean view dictated that 'evidence' linking 'causal' event and disease had
to be considered as probabilistic and inductive in nature. In practice, this meant that large
patient groups needed to be observed before any life event (remote event) could become a
candidate. Analysis of such data, however, required methodological and statistical
techniques which were not yet fully available during the 19 C. Indeed, alienists during this
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period were far better equipped to investigate brains (i.e. internal mechanisms).
On the other hand, anthropological and ontological historicism suggested that what linked
events and disease was meanings, symbols and the rest of deeper structures that governed
social life. Ascertaining these links required tools other than statistics and larger groups: it
required the development of cultural and psychodynamic models to link the generalities of
history to individual experience. In the event, these needs gave rise to both the 'Erlebnis &
Verstehen' models of historicism (e.g. Dilthey) and the psychodynamic models (e.g. Freud
and followers).
'Internal mechanisms' in the 19 C
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The predominance of interest in 'internal mechanisms' resulted from positive factors (i.e.
that contributed to its expansion), and negative factors (that played down the value of
efficient causes). Amongst the positive factors, the following must be listed: 1) the rapid
increase during the 19 C of knowledge about the structure and organization of the brain; 2)
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the development of new theories on the relationship between brain and mind, and 3) the
predominance in academic psychiatry of disease-related concepts over person-related
concepts of mental illness.
Important amongst the negative factors were:1) the challenge to probabilistic causality
(e.g. by Claude Bernard). 2) the absence of multivariate models to handle interactions
between efficient causes, and 3) the general shift from history to structure (from diachrony
to synchrony) which occurred towards the very end of the century. This shift was not, of
course, unique to psychiatry. Similar changes were occurring in other fields, for example, in
Linguistics where historical (diachronic) accounts of the origin of language had become
discredited and were being rapidly replaced by (synchronic) analyses of the structure of
language.
It goes without saying that the changes listed above did not cause alienists to disown
diachronic causality altogether but led them to show an increasing interest in ‘internal
structure or mechanisms’. This is very much the case with opinion-makers such as Meynert,
Jackson, Wernicke and von Monakow. In general, academic psychiatrists were keener on the
internal mechanisms whilst asylum psychiatrists remained interested in antecedent.
Because there is no evidence that 21 C aetiological models are epistemologically more
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advanced than the ones discussed during the 19 C, nothing will be said about current
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aetiological theory in psychiatry.

'Internal mechanisms' as causes (synchronic causality)
The concept of mechanism
During the second half of the 19 C the concept of 'mechanism' was rapidly changing,
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particularly in the context of biology and medicine where it was defined as 'the mode in
which an act or a series of acts is performed, as the mechanism of respiration or of
parturition'. The decline of vitalism, i.e. of the view that life resulted from the interaction
between organic mechanisms plus the presence of some ineffable organizational principle,
also led thinkers to viewing 'mechanisms' as the final object of research: 'mechanism is the
view that every biological event is a pattern of non-biological occurrences'. This attitude was
reinforced by the establishment of anatomy and physiology as the fundamental explanatory
sciences in brain research. This is one of the reasons why at the time, the terms
'mechanism' and 'process' were used as synonyms.
The concept of ‘chronogenetic’ localization
Borrowed from Semon, this concept introduces 'time' as a crucial parameter for all
neuropsychiatric phenomena. Functions (e.g. movement) are processes which like music
unfold in time and according to a specific 'kinetic melody'. Hence, it would be a mistake to
attempt to localize processes (i.e. brain functions) in terms of specific brain sites (i.e., space
alone). Now, since most mental symptoms are considered as resulting from disordered brain
function, it follows that it would be equally erroneous to try and localize symptoms on
specific brain addresses. Influenced by Jackson, Von Monakow and Mourgue believed that
chronogenetic localization was a late acquisition in evolutionary time, and hence regarded it
as a complex but unstable mechanism.
One of the implications of the concept of chronogenetic localization is that both cross-
sectional studies and traditional longitudinal studies (as collections of cross-sectional
snapshots) are inadequate for the capture of neuropsychiatric symptoms. The latter, Von
Monakow and Mourgue insisted, have to be observed as they unfold in time according to
their own kinetic melody; for example, a hallucination is fully understood only when an
entire 'token' or hallucinatory episode, which may last minutes or hours, has been studied.
In addition to its conventional 'cross-sectional features' such an episode includes real
longitudinal information such as, for example, modulations in intensity, changes in imagery,
and accompanying emotions can only make sense when integrated along a time dimension.
From an aetiological view point, knowledge of these longitudinal variables may in fact
provide more information on the brain-localization of the symptom than traditional static
snapshots.
Diaschisis
'Diaschisis' ( = I separate at the distance) refers to a variety of sudden and
reversible clinical (usually negative) phenomena seen in the wake of 'shock' caused by
localized lesions of the central nervous system. The defining element of all these symptoms
being that they cannot be explained in terms of the extension and localization of the brain
lesion: e.g. in a hemiplegia, there are more functional deficits and other symptoms than the
lesion can explain. Inhibition differs from Diaschisis in that the former results from the
activity of known nervous connection.
When applied to psychiatry, diaschisis raises two important issues: one is that some mental
symptoms at last may not have a direct anatomical localization; the other, that more such
symptoms may appear when there is a disorder of functions that are chronogenetically
localized (because in evolutionary terms such functions are more recently acquired and
hence more unstable).
Epistemology of Causes and Reasons in Psychiatry
‘Causes’ and ‘reasons’ are forms of accounting for the existence and / or origin of objects,
tokens, episodes, processes, and behaviours. Although etymologically different, they have
overlapping semantic fields (i.e. are used by people as synonyms) and similar epistemic
power (capacity to explain actions). Causes are used in the natural sciences; reasons in the
social sciences (which in the past included psychology). What about psychiatry?
What has been said above suggests that to ask for the ‘cause’ of a mental disorder is
already to opt for a particular model of explanation as equally cogent would be to ask for a
‘reason’, based on the view that that people may do things, including ‘talking and behaving
crazy’, for reasons better known to themselves. Reason in this sense needs not be
construed in material or mechanical terms but may remain expressed in the language of folk
psychology. Even more radically, it could be said that mental disorders are not effects at all,
that they do not follow either causes or reasons, that they are just ‘givens’, that is they
have been there from the beginning of time. In a world keen on looking for the causes of all
things, this latter view may sound strange but it is not unintelligible and it simply reflects
the ontology of preformationism, a view of biology predominant in the 18 C. th

It could be argued that reasons are just a ‘subtype’ of cause. Although in common parlance
it is widely accepted that ‘reasons’ provide adequate accounts for a range of human
behaviours, the semantic engine that makes these explanations possible is unclear. Cicero
used ratio to translate the Greek for ‘account, calculations’, etc., and soon enough, it also
translated the Greek for cognition, thinking, discourse, understanding, etc. This combination
of meanings has plagued the term ever since. In most European vernacular languages,
‘reason’ refers to the illative rather than the creative or imaginative aspects of the intellect.
Since ancient times, reasons have been used to justify actions (post facto) or explain their
origin. To say that “I did x because of y” remains a good way of accounting for my
behaviour as long as: 1) there is a cultural or semantic frame within which “y mostly leads
to x”; and 2) there is no reason to believe that I am cheating.
To some, however, accounts of behaviour by means of ‘reasons’ are considered as ‘after the
event’ and hence not to constitute ‘proper’ causal accounts. Two factors (inter alia) can
explain this disenfranchisement: a) causality is currently understood in terms of general
laws (not idiosyncratic explanations); b) the neurobiology of ‘reasons’ remains obscure and
hence there is no material or organic handle with which to ‘convert’ reasons into ‘real’
physical causes. There is also the question of whether reasons (as it is mostly believed in
medicine, jurisprudence and moral theory) entail ‘intentionality’ and conscious awareness;
in other words, whether in order for person p to claim that “he had reason x for behaviour
y” he must have been aware pre-facto of x and taken then a decision that “y is the best
course of action”. This view is considered by others as narrow: for example, according to
psychoanalysis it would be sensical to claim that “John gives so many presents to Mary
because he is in love with her although he is not aware of it” (and also sensical for John to
say likewise post-facto as an explanation of his generous behaviour).
The application of the language of reasons to psychopathology makes things complex.
However, a claim by a clinician that a patient has a ‘reason’ to report “I am hearing voices
when there is no one around” should not be dismissed tout court: at a superficial level, it
may mean that the patient is believed to be ‘entertaining an image’ (i.e. experiencing
something in terms of the old, ‘passive’ recipient model); or it may mean that the clinician
believes that the patient is actually participating (consciously or unconsciously) in the
‘construction’ of his experience and that this participation is far more important to the fact
that he is having such an experience than whatever signal might be flashing in his brain.
This claim by the clinician would be based on a model of symptom formation in which
formatting codes are essential to the constitution of the experience itself and its report (see
3.4).
In order to experience it, handle it cognitively, remember it, and talk about it, he/she needs
to configure the primordial soup. This he/she does by means of formats (personal, familiar,
cultural) and in negotiation with his clinician (all these factors are extrinsic to the primordial
soup). Once this process has been completed the formatted product will be reported as a
voice, a strange belief, sadness, anxiety, a physical sensation, etc., etc. It follows that the
fact that the primordial soup is always the result of a brain signal (related to a lesion or
dysfunction) is not sufficient (and on occasions not necessary) to explain the utterance. This
because what the utterance is about is not the primordial soup as such (or it is but in the
remotest of ways) but about a final product that is the result of a formatting cascade
integrated by many ‘reasons and decisions’. In other words, the conceptual distance
between brain signal, primordial soup and (reported) mental symptom is so wide that to say
that the brain signal is the ‘cause’ of the mental symptom (for it might correlate with it) has
little explanatory meaning.
The above claim about the depth of the formatting process must not be confused with the
conventional view (which most biological psychiatrists would be happy to accept) that the
‘form’ of the symptom is determined by the brain site from which it ‘originates’ (e.g.
symptoms ‘related’ to the occipital cortex are visual or those related to Broca’s area are
linguistic). The model of symptom formation explicated above states that not only the
‘content’ but also the ‘form’ of the mental symptom is determined by the formatting
process. This has interesting consequences, for example, that if the formatting process can
override the influence of the site of origin then correlations between blood flow (as a proxy
for site) and mental symptoms have little meaning.
To recapitulate: 1) brain site and lesion can only provide a jejune and nonspecific causality;
2) the fact that a proxy marker of a brain state (e.g. ‘change in blood flow’) ‘correlates’ with
a mental symptom cannot be considered as meaningful; 3) the formatting (i.e.
construction) of the mental symptom (i.e. the ‘cause’ of its form and content) has been
governed by reasons; 4) personal factors seem essential to the formation of mental
symptoms; and 5) what makes tokens of symptoms (say ‘hallucinations’ as reported by
different patients) the ‘same’ symptom is not that all those ‘hallucinations’ originate from
the same location in the brain but that the patients in question have formatted a variety of
primordial soups (probably originating in different parts of the brain) by means of the same
formatting routines.

For references see:

Berrios G.E. (2000) Historical Development of ideas about psychiatric aetiology. In Gelder et
al (eds) New Oxford Textbook of Psychiatry, Vol. 1, Oxford, Oxford University Press, pp147-
153.