T H E T E R M I N O L O G I C A L R E L AT I V I S M O F DISSOCIATION: A LITERATURE REVIEW

HISTORY OF THE TERM

References to concepts similar to “dissociation” had been made before the term was actually coined. In 1791, Eberhardt Gmelin publishes the first case of double personality (1). The term itself is first mentioned in the field of psychopathology in 1812 by the American physician Benjamin Rush, although he refers to cases which were probably manic episodes and schizophrenic outbreaks. In Rush’s view, dissociation is based on the association of unconnected perceptions or ideas, and it originates in the mind’s inability to carry out tasks pertaining to judgment and reasoning (2).
Towards the end of the 18th century the main discussions revolve around the separation and splitting of consciousness. For instance, Marquis de Puységur, Anton Mesmer’s student, notices the special state of the subjects during “magnetization”: the subjects awoke with a total amnesia of the event.
Puységur and colleagues, studying the mechanisms of the above mentioned phenomenon, describe entities that today could be called dissociative (1,3).
The term dissociation, in the sense used today, was first employed by the French psychiatrist Moreau de Tours, in his 1845 work on the effects of hashish on the human psyche, through the weakening of mental associations (4).

In the mid-1800s, the emphasis is laid on the link between the splitting of the personality in hypnosis and phenomena pertaining to hysteria. With the presentation, in 1840, of the widely known Estelle case, a case of paraplegia with no traceable organic substratum, remitted by magnetization (hypnosis), Charles Despine asserts that hypnosis is linked to hysteria (1).
At the end of the 19th century (1878), in close connection to the phenomena of automatic writing during hypnosis, Hippolyte Taine describes ego splitting as a simultaneous existence within the same individual of “two thoughts, of two wills, of two distinctive actions, of one of which the subject is conscious, but the other of which he has no consciousness and which he attributes to invisible beings” (3).
Towards the end of the 19th century, the concept spreads. It is studied by Fredric Myers in England and by Charcot, Gilles de la Tourette, Pierre Janet in France. Later on, in 1940, observing the experience of World War I soldiers, Charles Samuel Myers notes a connection between dissociation and traumatic events. C.S. Myers argues that the failure to integrate the traumatic event leads to the splitting of the personality into what he calls the apparently normal one and what could be designated as the emotional one (5).

Also towards the end of the 19th century, the French philosopher and psychiatrist Pierre Janet turns his attention to dissociative manifestations. He is the first to describe dissociation (via somnambulism) as two or several states of consciousness dissociated through an amnesic episode which acted independently. Often using the term somnambulism, Janet does not employ it however in the sense referred to nowadays, but in a much broader sense. Basically, by influence somnambulique, Janet means any activity carried out in a dissociated state, so that hysteria, hypnosis, multiple personality and spiritism were for Janet types of somnambulism (6).
After this period, the term is taken over by Freudian psychoanalysts, but presented as a defense mechanism, a non-pathological phenomenon which, when used excessively, could lead to mental disorders.
Besides dissociation as a defense mechanism, at the end of the 1800s, two main theories are advanced: 1. dissociation seen as a splitting of the personality or as a splitting of consciousness, 2. dissociation as a phenomenon underlying hysterical symptoms (1).
Alfred Binet anticipates Hilgard’s theory of the hidden observer (a metaphor of the dissociative state experienced during hypnosis) almost a hundred years before its formulation. However, in his later works, he strays from the initial concept (which resembled the one described by Hillgard) (1). While Janet saw in dissociation a psychic failure, Binet talked about the duality of consciousness, more specifically, about a duality in which the instances function autonomously within the individual (7).
The study of dissociation then enters a stage of relative stagnation as the specialists turned towards psychoanalysis and behaviourism. The concept is re- brought into focus by the neo-dissociative theory of Ernest Hilgard (1977) who talks about the hidden observer (8). According to Hilgard’s theory, there is a series of super- and subordinate cognitive systems that control or influence an individual’s behaviour and inner processes. Hilgard describes an executive ego, which, under hypnotic influence, may be subject to splitting into two distinct entities, one of them remaining unconscious, like a hidden observer (9).
Presently, one of the major areas of study is the link between trauma and dissociative phenomena, starting from the interest in the dissociative identity disorder and the multiple personality controversy.

CURRENT MEANINGS, CIRCUMSCRIPTION AND CLASSIFICATIONS

Definitions of Dissociation
In what follows, we will provide some definitions of the term dissociation:
– Spiegel and Cardena (1991): “Separation of mental processes (e.g., thoughts, emotions, connotation, memory and identity) that are ordinarily integrated”(10).
– ICD-10 (1992): “A partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of body movements” (11).
– Putnam, Helmers and Trickett (1993): “Dissociation is a complex psychophysiological process that ranges along a continuum from minor, normal dissociation to Axis I psychopathology” (12).
– DSM IV – TR (2000): “The essential feature of the Dissociative Disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception. The disturbance may be sudden or gradual, transient or chronic” (13).
– Spiegel (2003): “A failure to integrate information and experiences in normally associated ways” (14).
– Dell, P. F. and O’Neil, J. A. (2009): “The essential manifestation of pathological dissociation is a partial or complete disruption of the normal integration of a person’s psychological functioning. Dissociative disruptions unexpectedly change the person’s usual functioning in ways that the person cannot easily explain. Any aspect of a parson’s conscious, psychological functioning can be disrupted by dissociation. Specifically, dissociation can unexpectedly disrupt, alter, or intrude upon a person’s consciousness and experience of body, world, self, mind, agency, intentionality, thinking, believing, knowing, recognizing, remembering, feeling, wanting, speaking, acting, seeing, hearing, smelling, tasting, touching, and so on” (1).
As it can be observed from the definitions above, the circumscription of the term is either extremely vague, or it encompasses such an array of phenomena (see the definition provided by Dell and O’Neil) that any delimitation based on a given definition becomes almost impossible. Additionally, differences can also be noted between the ways in which the same phenomenon was defined, at least from a theoretical point of view. Thus, we notice a qualitative inconsistency and insufficiency in defining the dissociative phenomenon.

Conceptual classifications
O n e t h e o r e t i c a l d i s t i n c t i o n r e g a r d i n g dissociation involves the quantitative and qualitative aspects.
According to what could hereby be designated as the quantitative model, the various dissociative phenomena and manifestations would be qualitatively similar or identical, but the quantity of dissociation would vary from one case to another (15). This perspective refers to the dissociative continuum. More specifically, a reduced quantity of dissociation would be at the basis of p h e n o m e n a s u c h a s a b s o r p t i o n , t r a n s i t o r y depersonalisation and hypnotic dissociation. A slightly higher level of dissociation would be responsible for dissociative amnesia, and, at the top end of the axis, there would be somatoform disorders and the dissociative identity disorder (16).
The dissociative continuum perspective constitutes the basis of one of the most frequently used clinical dissociation evaluation scales, the DES (Dissociative Experience Scale) (17).
A point of view that could be called qualitative refers to a bipartite model, which asserts the existence of two types or mechanisms of dissociation: detachment and compartmentalization. Richard J. Brown argues and j u s t i f i e s t h r o u g h r e s e a r c h , t h e r o l e o f t h e compartmentalization and detachment mechanisms in explaining dissociative phenomena (16).
Detachment refers to an altered state of consciousness characterised by a sense of separation from the daily aspects of life. This mechanism could be responsible for phenomena such as experiencing an inner void, depersonalization, derealisation, or out of body experiences.
In compartmentalization, the integrative functions defined as normal are divided or interrupted, and then, distributed into separate classes. This mechanism could underlie conversion disorders, hypnosis, dissociative amnesia and dissociative identity disorders (16).
Scholarly literature discusses the distinction between non-pathological and pathological dissociation. Non-pathological dissociation refers to daily dissociative experiences and defences (doubled by a good re- association capacity and, hence, it is transitory), while pathological dissociation involves concepts such as dissociative fugue or the dissociative identity disorder. This distinction is congruent with Prince’s dissociative continuum theory (15).
In an attempt to clarify the term’s polyvalence, Etzel Cardena classifies its meanings.
A range of subcategories are grouped into three main categories:
– “Dissociation as nonconscious or nonintegrated mental modules or systems”
– “Dissociation as an alteration in consciousness wherein disconnection/disengagement from the self or the environment is experienced”
– “Dissociation as defense mechanism” (18).

Another distinction, suggested by van der Hart, Nijenhuis and Steele emphasizes the difference between a psychoform dissociation, referring to phenomenologies involving the psyche in particular, such as dissociative amnesia or auditory hallucinations and a somatoform dissociation involving physical phenomena with no traceable organic substratum (pseudo-convulsions, hypnotic anaesthesia or paresis) (19).
Additionally, dissociation can also be considered from the point of view of its triggering element. For instance, dissociation can be provoked through hypnosis (8), by various narcotic substances (20), situations with a traumatic character (for acute dissociation) (21) or by neuropsychological exhaustion (22).

THE OMNIPRESENCE OF DISSOCIATIVE PHENOMENA
A literature review highlights the diversity of psychic fields and manifestations in which dissociative phenomena are involved in one way or another. Table 1 focuses exclusively on studies centred on the relation between dissociative manifestations and various psychic phenomena; studies that have obtained statistically significant results, without mentioning the type of analysis carried out.
In selecting the studies, the research in which the central variable was linked exclusively to trauma, narcotics or psychoactive substances consumption, hypnosis, dementia and psychosis was ignored, since the literature in these fields is so vast that it would require a special table for each. Nevertheless, many of the cited studies also take into account, among other variables, the previously mentioned ones.
The selection of studies was carried out from the EBSCO and Google Academic databases using keywords such as: dissociation and psychology, dissociation and p s y c h o p a t h o l o g y, d i s s o c i a t i o n a n d p s y c h i a t r y, dissociation.
Table 1 highlights the multitude of fields and variables with which dissociation relates besides those mentioned in the classical studies on this phenomenon. We do not claim to have carried out an exhaustive listing of all the fields which presented significant results.
This variety of fields in which dissociative phenomena occur can be due to a vague and incongruous definition of the concept. There are, however, also concurring hypotheses which may serve as an explanation, but these will be dealt with in the concluding remarks.
It can be noticed that many studies used the DES in order to assess dissociation. The DES approaches a wide range of dissociative conceptualisations and symptoms due to the fact that it claims to measure dissociation in terms of the dissociative continuum theory. On the other hand, some studies identified a set of three sub-factors: amnesia, absorption and derealization/ depersonalization (48). Thus, not even the frequently used DES offers the certainty of fidelity and validity.

CONCLUSIONS
The aim of this article was to draw attention to the issue of the semantic openness of the term dissociation. As it can be inferred from the above discussions, the term can designate an entire array of phenomenological entities. It can reflect a daily phenomenon, an ability, a defence mechanism, a temporary pathological state, or even the fragmentation of personality into its components. Dissociation can refer to the dissociation between reason and emotion, a mnesic information and the psyche in general, individual and context, individual and self, a part of the body and the rest of the body, or the dissociation of personality into several fragments.
The definitions and the taxonomy attempts have not succeeded in bringing a consensus among the s p e c i a l i s t s , w h i c h i s w h y t h i s t e r m i s u s e d heterogeneously.
The present paper is not the first to aim a review of the various meanings of the concept, or to underline the lack of semantic concordance. As a result of the demand to provide a definition of dissociation, Dell and O’Neil (1) noticing the difficulty of such a task, wrote an entire book which deals with this issue extensively. Their previously- awarded book, approaches (among others) the semantic openness of the term. Due to its conceptual polyvalence, Etzel Cardena (18) attempts to provide taxonomy of the term. Focusing on the theory of dissociation as a continuum, Brown (16) reviews the literature, yet clearly favours the qualitative explanation over the dissociative continuum theory.
Historically, it can be noticed that although the central theme of the concept remains somewhat the same, the term underwent a series of modifications and readjustments. Although the variations seem to revolve around the same theme, it is extremely difficult to identify the core that remained unchanged during the conceptual modifications of dissociation. It is equally difficult now to determine the common central element of the disorders classified as dissociative in DSM IV.
As far as the definition is concerned, as it was shown, a conclusive variant is necessary, since without a clear conceptual classification, each specialist can convey, and, even more so, study dissociation, in a different manner.

In the definitions provided as examples, it can be noticed that these are either highly relative, or they comprise a wide range of manifestations and phenomena. The result for both variants is the same, almost every phenomenon falls under the definition given for dissociation, which can be harmful both for diagnosis and research.
The research focused on terminological relativism leads to the impossibility to compare results. If a study focuses on a defense mechanism such as forgetting, while another study under the same name focuses on a hysterical paralysis or even a dissociative identity disorder, the results of those studies cannot be compared, and, in case they were compared, there is an increased risk of reaching wrong conclusions. The consequences of this problem revolve around the impossibility of acquiring objective, scientific knowledge on this phenomenon.
A possible solution to this would be to create a taxonomical classification of dissociations; more exactly, to establish classes or types of dissociation. Although scholarly literature mentions the distinction between somatoform and hysterical dissociation, or normal dissociation versus pathological dissociation, there is no unanimously accepted classification of the various types of dissociation. Using well-defined classifications has both the advantage of referring to the same concept when using the term, and it also gives the opportunity to carry out literature reviews and meta-analyses on dissociation subclasses.
Another issue directly related to the way in which a definition of dissociation is conceived refers to the means of classification. As shown above, there is no consensus regarding the classification of dissociative phenomena. Without good classification, it is difficult to formulate a definition that avoids the two aforementioned problems: mainly, relativism and covering all classes of possibility.
A possible starting point in solving this problem would be to elucidate the debate between the concept of dissociative continuum and other qualitative approaches; more precisely, to clarify the ratio between the quantitative aspects (dissociative continuum) and the qualitative ones (detachment and classification). A research direction worth exploring would address such questions as: Are these dimensions distinct or could they also be considered together from a phenomenological point of view? Is only one of the explanations correct (eliminating thus the other one) or are both theories correct and likely to overlap forming a clearer image?
As far as the omnipresence of the dissociative phenomenon is concerned, the table shown in this article does not present a concrete proof of the term’s relativity. Logically, a negative sentence is extremely difficult, even impossible to prove, so that the semantic openness does not constitute the only possible explanation for the diversity of fields in which dissociation occurs.
Dissociation could simply be a phenomenon accompanying many problems. For such a possibility, there could be several possible explanations, among which we can mention dissociation as a universal defence mechanism. In other words, in almost any unusual phenomenon, dissociation could occur as defence or as reaction. If dissociation as a specific phenomenon can occur as a reaction to a diffuse phenomenon, then it is possible to see dissociative manifestations within a broad range of psychical phenomena. Certainly, this view is only a theoretical one; there could also be other hypothetical explanations for the omnipresence of dissociation.
The variety of fields in which dissociation occurs could also be due to some faults in the measuring instruments. As it was shown above, not even the DES is infallible.
If the theory of the dissociative continuum is accurate, it could explain the omnipresence of dissociation in the specialized literature since we would be talking about the same phenomenon in radically different manifestations. Nevertheless, until the concept is solidly validated scientifically, this variant remains mere theorization.
On the other hand, if the reason for the diversity of the dissociative phenomena resides in the term’s polyvalence, then one cannot talk about scientific knowledge on this subject.
The present article aims to emphasize the necessity of approaching this issue and it suggests the semantic openness of the term as a subject for future research and debates.
Additionally, the article together with other texts in the literature on the conceptual incongruence of dissociation, aims to draw attention to the fact that, for the future editions of DSM and ICD, dissociation is a matter which requires further reviewing and reconceptualization.
Freud argues that at the basis of each symptom there is a conflict. Certainly, any conflict requires at least two sides. This theoretical presentation, which can remind us about concepts such as dissociation, can be found under one form or another in most schools of psychology, whether we talk about a conflict between conscious and unconscious, adult and child (transactional analysis) or emotion and reason. The risk of ignoring the present subject consists in the fact that, since dissociation is currently a permissive concept, any symptom can be considered a dissociative one, automatically thus eliminating the value of the term and of the class of dissociative disorders, by diluting its significance.

ACKNOWLEDGEMENT
This work was supported by the the European Social Fund in Romania, under the responsibility of the Managing Authority for the Sectoral Operational Programme for Human Resources Development 2007-2013 [grant POSDRU/CPP 107/DMI 1.5/S/78342]

Table 1. Studies in which dissociative manifestations are in statistically significant relation with other psychic phenomena and manifestations:
1.DES for adolescents.
2.Dissociative Experience Scale
3.Structured Clinical Interview for DSM-IV Dissociative Disorders.
4.Slightly adjusted variation of the DES, by the authors of the original test.
5.Dissociation questionnaire, self administered questionnaire.
6.Dissociative Disorders Interview Schedule.
7.Defence Style Questionnaire.
8.DES, adapted for non-clinical populations.
9.Cambridge Depersonalization Scale.

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