tion and acting out result in deni al of reality and poor adaptation. Cognitive disconnection
schemata  reflect defectiveness and emotional inhibi tion and subsume themes of abuse, ne-
glect, and deprivation. Overconnection schemata  involve impaired autonomy with themes
of dependency, vulnerability, and incompetence.
Environmental. There is a clear association between the disorder and childhood interper-
sonal traumas in a substantial portion of individu als, although this association is not as prev-
alent or as extreme in the nature of the trau mas as in other dissociative disorders, such as
dissociative identity disorder. In particular, emotional abuse and emotional neglect have been
most strongly and consistently associated with  the disorder. Other st ressors can include phys-
ical abuse; witnessing domestic  violence; growing up with a se riously impaired, mentally ill
parent; or unexpected de ath or suicide of a family member or close friend. Sexual abuse is a
much less common antecedent but can be encountered. The most common proximal precipi-
tants of the disorder are severe stress (interpersonal, financ ial, occupational), depression, anx-
iety (particularly panic attacks), and illicit drug  use. Symptoms may be specifically induced by
substances such as tetrahydrocannabinol, ha llucinogens, ketamine, MDMA (3,4-methylene-
dioxymethamphetamine; “ecstasy ”) and salvia. Marijuana use may precipitate new-onset
panic attacks and depersonalization/derealization symptoms simultaneously.
Culture-Related Diagnostic Issues
Volitionally induced experiences of depersonalization/dereali zation can be a part of med-
itative practices that are prevalent in many religions and cult ures and should not be diag-