Beguiling Daydreams: A Case of Maladaptive Daydreaming

Daydreaming is a stream of consciousness that detaches from current external tasks when attention drifts to a more personal and internal direction. Although it has been linked to creativity and introspection, excessive daydreaming can interfere with an individual’s normal functioning, work, or relationships.¹ This faulty adaptation in behavior gave rise to the clinical entity of maladaptive daydreaming, which is understood as an immersive and addictive imaginative activity that is distressing and causes social, occupational, and academic impairment.² Childhood trauma and social anxiety may contribute as independent risk factors for maladaptive daydreaming, and addiction to fantasy is an important mediating variable.³ Here, we discuss the case of a young man with maladaptive daydreaming treated with fluvoxamine and cognitive-behavioral therapy (CBT).

Case Report

A 27-year-old single man presented with a 9-year history of immersion into a pattern of chain of thoughts related to day-to-day activities. He described these thoughts as “stories” running continuously through his mind for most of the day. These stories mostly entailed having a girlfriend, enjoying a romantic relationship, and having sexual intercourse with her. Sometimes the stories were related to mundane activities. Initially, however, they were less time-consuming and enjoyable, and the frequency and intensity gradually increased so much that it hampered his occupational, social, and personal life. He was unable to concentrate during his classes in college and later at work, leading to frequent dismissals from jobs. He reported that these stories became clearer and vivid while listening to music or watching television and were not under his control. He reported enjoying being engrossed in his stories, and he only felt distressed later over the wasted time and not being productive. There were frequent outbursts of anger and abusiveness against family members when confronted for not pursuing a job and sitting idle at home, for which he was brought to hospital services. On further exploration of childhood experiences, it was found that being frequently mocked for not having a girlfriend inculcated a sense of inadequacy in him. Resultantly, he started fantasizing about his relationship with women. He also pretended to talk to the women on calls in front of others to make them believe the same.

A complete general physical and systemic examination, routine blood investigations, hormonal profile, and magnetic resonance imaging of the brain found no abnormalities. His intelligence quotient was 84. Rorschach Inkblot Test⁴ revealed mediational dysfunction due to preoccupations leading to proneness to unconventional behavior, inability to deal with stress or regulate emotions effectively, use of fantasy and avoidance as a coping style, and poor self-image. The International Personality Disorder Examination⁵ showed emotionally unstable personality traits. He scored 59 on the 16-point Maladaptive Daydreaming Scale⁶ (≥ 40 indicates probability of maladaptive daydreaming).

Clinically, as there was no evidence of thought alienation, false firm fixed beliefs, hallucinatory behavior, increased psychomotor activity, elevated mood or grandiose talks, or obsessive ruminations, the treatment team faced considerable difficulty in understanding the nature and intricacies of the patient’s thought process. Hence, these possibilities were ruled out, and a consensus on the diagnosis of maladaptive daydreaming was reached. He reported improvement on treatment with CBT and fluvoxamine up to 200 mg over a duration of 1 month. Management also included psychoeducation, activity scheduling, and thought record and distraction techniques. He is now able to follow a routine and has started looking for a suitable job.

Discussion

The nosologic status of maladaptive daydreaming is still unclear, with no specific guidelines or criteria in any current classification systems. Existing knowledge on maladaptive daydreaming suggests the involvement of dissociative and obsessive-compulsive symptoms, as well as positive reinforcement comparable to processes in addiction disorders.⁷ Various mediators between maladaptive daydreaming and obsessive-compulsive disorder (OCD) have been hypothesized, such as sense of control, mind wandering, trauma, and dissociation.

There are no guidelines for the management of maladaptive daydreaming; however, the literature suggests a role of fluvoxamine and CBT.² Fluvoxamine was used due to the link between maladaptive daydreaming and OCD as mentioned above. The patient in the case presented here improved on this combination of treatment.

This case is unique in that although many people engage in daydreaming as a strategy to cope with distress, it may become maladaptive when used excessively, leading to socio-occupational impairment. There is a growing body of evidence identifying dysfunctional forms of imaginative involvement defined as maladaptive daydreaming, which has been under study for quite some time. However, the need for further research remains.

Article Information

Published Online: June 8, 2023.
https://doi.org/10.4088/PCC.22cr03355
© 2023 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord. 2023;25(3):22cr03355
To Cite: Chauhan N. Beguiling daydreams: a case of maladaptive daydreaming. Prim Care Companion CNS Disord. 2023;25(3):22cr03355.
Author Affiliations: Postgraduate Institute of Medical Education and Research, Chandigarh, Nehru Hospital, Chandigarh, India (Chauhan); Department of Psychiatry, Government Medical College and Hospital, Chandigarh (Sharma and Mahajan).
Corresponding Author: Nidhi Chauhan, MD, DM, Chandigarh, Nehru Hospital, Cobalt Block, 3rd Fl, Chandigarh, India 160012 ([email protected]).
Relevant Financial Relationships: None.
Funding/Support: None.
Patient Consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect anonymity.