Maladaptive daydreaming as a distinct syndrome

Although pathological immersive fantasising is not a new clinical phenomenon,^{Reference Winnicott3} maladaptive daydreaming as a distinct concept has garnered recent popularity as individuals actively seek a label for their problem. The development of DSM-like criteria and a structured clinical interview^{Reference Somer, Soffer-Dudek, Ross and Halpern4} has enabled gathering of initial epidemiological evidence, resulting in a point-prevalence estimate of 2.5%, with higher rates in younger adults.^{Reference Soffer-Dudek and Theodor-Katz5} Associated distress and dysfunction include prevalent unemployment and suicide attempts.^{Reference Soffer-Dudek and Somer6,Reference Soffer-Dudek and Oh7} Clinical interview-based research suggests that individuals with maladaptive daydreaming tend to meet criteria for more than one existing disorder, commonly inattention, anxiety, obsessive–compulsive and related disorders, and depression;^{Reference Somer, Soffer-Dudek and Ross8} however, as we demonstrate below, none of these accounts for its presence or phenomenology. Many patients with maladaptive daydreaming report ineffective treatment when pursuing professional help.^{Reference Somer, Somer and Jopp2,Reference Bigelsen and Schupak9} Notably, targeted clinical interventions can reduce maladaptive daydreaming and substantially improve well-being;^{Reference Herscu, Somer, Federman and Soffer-Dudek10} this indicates the significance of recognising and addressing it.

Accumulated empirical evidence indicates that some individuals temporarily alleviate their distress by immersing themselves in fanciful, imaginative narratives, thereby disrupting their life goals.^{Reference Soffer-Dudek and Somer6–Reference Bigelsen and Schupak9,Reference Bigelsen, Lehrfeld, Jopp and Somer11} However, rather than representing a disorder, this could be construed as an excessive coping mechanism, providing short-term relief for those with well-established diagnoses (e.g. depression, anxiety). Nevertheless, we argue that there are compelling reasons to justify formalising maladaptive daydreaming as a disorder:

1. (a) Maladaptive daydreaming is addictive and structured, substituting other adaptive coping strategies, and additional symptoms are present (e.g. stereotypies, shame, failed attempts to reduce daydreaming, functional impairment), generating a complex clinical picture.

2. (b) Maladaptive daydreaming symptoms not only follow psychological distress but also generate and exacerbate it.^{Reference Soffer-Dudek and Somer6,Reference Bigelsen and Schupak9} They tend not to dissipate spontaneously, because maladaptive daydreaming is a stable condition, frequently becoming worse over time. For example, in a 1-year longitudinal study, maladaptive daydreaming was found to be highly stable and prospectively predicted an increase in anxiety and depression symptoms.^{Reference Musetti, Soffer-Dudek, Imperato, Schimmenti and Franceschini12}

3. (c) Other DSM or ICD diagnoses do not better explain the clinical picture. Despite significant impaired attention, the mental pattern underlying the distraction – absorptive emotional fantasising – is significantly differentiated from the typical mind-wandering of attention-deficit hyperactivity disorder.^{Reference Theodor-Katz, Somer, Hesseg and Soffer-Dudek13} In addition, although maladaptive daydreaming and obsessive–compulsive symptoms are associated,^{Reference Soffer-Dudek and Somer6,Reference Salomon-Small, Somer, Harel and Soffer-Dudek14} and maladaptive daydreaming could be considered to be compulsive, indulging in a daydream storyline is satisfying and enjoyable in the short term, unlike the distress caused by intrusive obsessions or compulsions. Although some individuals on the autism spectrum have maladaptive daydreaming,^{Reference West, Somer and Eigsti15} many individuals have maladaptive daydreaming without communication problems and thus do not meet the criteria for autism spectrum disorder. Maladaptive daydreaming could be viewed as a behavioural addiction, but there is no current addiction diagnosis suited for it. Moreover, maladaptive daydreaming does not necessarily include gradually increasing elements to reach the same effect (such as the criterion of increasing money spent in gambling disorder). Maladaptive daydreaming is not characterised by psychotic-spectrum delusions, hallucinations or thought impairments.

4. (d) Formally defining maladaptive daydreaming as a psychiatric disorder will increase awareness among clinicians and researchers and facilitate the development of specific intervention protocols.

DSM-like criteria for maladaptive daydreaming have been advanced previously,^{Reference Somer, Soffer-Dudek, Ross and Halpern4} but we propose updated criteria (Box 1) based on clinical and research developments of recent years. To avoid over-diagnosis, both the previous and the newly proposed criteria include the standard ‘clinically significant distress or impairment’ criterion of the DSM, ensuring that excessive fantasising is a core source of distress and dysfunction, as well as criteria concerning differential diagnoses and physiological effects. The proposed new criteria are more stringent to accurately pinpoint the unique characteristics of maladaptive daydreaming and avoid over-diagnosis.

A mandatory qualification in both sets of criteria is persistent and recurrent fantasy activity characterised by intense absorption or immersion with visual, auditory or affective properties. At least one more characteristic should have been met according to the previous criteria. By contrast, at least two more characteristics are required by the new criteria, and the list is shorter and worded more accurately to capture pathological rather than normal manifestations of daydreaming. As before, it includes stereotypical movement, using daydreaming to cope with distress, feeling annoyed when daydreaming is interrupted, repeated failed attempts to cut back on daydreaming and a preference for daydreaming over real life (e.g. social interactions). The criteria no longer include use of music, boredom, intensification of daydreaming when alone, or preferring daydreaming to daily chores or work, because these happen in the course of ordinary life and are less specific to maladaptive daydreaming. We also added an absolute criterion of time consumed, based on DSM criteria for obsessive–compulsive disorder, specifying at least 1 h per day devoted to immersive fantasising. In addition, a criterion of at least 30 min per daydreaming episode seeks to avoid diagnosing individuals who slip into daydreaming for a few minutes now and then – a normal manifestation of mind-wandering. In maladaptive daydreaming, significant periods of time are specifically devoted to the playing out of fantasy scripts. Individuals who meet all criteria except the duration qualifications may be diagnosed with ‘other specified’ maladaptive daydreaming.

The validity of psychiatric disorders is commonly judged according to five criteria originally set out by Robins and Guze and later Feighner and colleagues^{Reference Feighner, Robins, Guze, Woodruff, Winokur and Munoz16}; however, well-established psychiatric disorders meet up to three of those criteria. Maladaptive daydreaming meets four criteria: (a) a recognisable clinical presentation, (b) specific and reliable psychological tests for assessment, (c) reliable differentiation from other conditions, and (d) preliminary follow-up validity showing stability.^{Reference Musetti, Soffer-Dudek, Imperato, Schimmenti and Franceschini12} Research is needed on neurological markers and family studies (see table in the Supplementary material available at https://doi.org/10.1192/bjp.2024.279 for a summary of key studies supporting these assertions). Maladaptive daydreaming research also meets Blashfield’s guidelines for DSM inclusion.^{Reference Blashfield, Sprock and Fuller17} One criterion specifies that the topic be covered by at least 50 published papers in the past decade, including at least 25 empirical studies. Maladaptive daydreaming encompasses much more than that (see the Supplementary material for a list of peer-reviewed papers in the field of maladaptive daydreaming)Footnote ^a. Also, in accordance with Blashfield,^{Reference Blashfield, Sprock and Fuller17} diagnostic criteria were developed with solid interrater agreement,^{Reference Somer, Soffer-Dudek, Ross and Halpern4} and differentiation was demonstrated. Nonetheless, more research is needed on symptom co-occurrence.

Maladaptive daydreaming as a dissociative disorder

Although maladaptive daydreaming shares characteristics with various diagnostic categories, including behavioural addictions, obsessive–compulsive disorders, attention-deficit disorders and dissociative disorders,^{Reference Theodor-Katz, Somer, Hesseg and Soffer-Dudek13,Reference Salomon-Small, Somer, Harel and Soffer-Dudek14,Reference Pietkiewicz, Nęcki, Bańbura and Tomalski18,Reference Soffer-Dudek, Somer, Dorahy, Gold and O’Neil19} there are empirical and theoretical reasons for classifying it as a dissociative disorder. Empirically, studies have revealed high rates of maladaptive daydreaming among individuals with severe dissociation and strong associations between maladaptive daydreaming and dissociation.^{Reference Soffer-Dudek, Somer, Dorahy, Gold and O’Neil19,Reference Ross, Ridgway and George20} Furthermore, theoretical considerations highlight numerous dissociative characteristics. Individuals with maladaptive daydreaming experience themselves as leading two parallel lives. Internal events dissociate them from external reality, reducing responsiveness to their surroundings and their internal thoughts, feelings, memories, actions and sense of self, resulting in estrangement or disconnection from subjective experience; this is a hallmark of dissociation,^{Reference Chefetz, Soffer-Dudek and Somer21} as defined in the DSM-5-TR: ‘Dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior’ (p. 330). For example, the typical manifestation of immersion in fantasies while pacing in circles in one’s room represents a disconnect between perception and behaviour on one hand and consciousness and attention on the other. Maladaptive daydreaming may lead to experiential disconnectedness and self-incoherence,^{Reference Chefetz, Soffer-Dudek and Somer21} with individuals exploring different personas and characters in a complex inner world. Characters are imagined as having distinct personalities, desires and conflicts. The scripts in one’s fantasy world may be experienced with varying degrees of control and agency. This increases absorption in the daydream and disconnects from other perceptions, memories and sense of self, producing momentary relief and pleasure. An experience of playing out an ideal fantasy self in one’s mind is commonly reported to be at odds with one’s real-life self, leading to a discontinuity in one’s sense of identity.

Maladaptive daydreaming is both similar to and different from current dissociative disorders. Regarding depersonalisation/derealisation disorder (DP/DRD), vivid fantasisers often feel that their daydreams are more real than actual life, resulting in depersonalisation–derealisation or a detached sense of reality when not daydreaming.^{Reference Soffer-Dudek, Somer, Dorahy, Gold and O’Neil19} In a daily diary study, increased depersonalisation–derealisation experiences were reported on days of increased daydreaming and the following day but not the preceding day,^{Reference Soffer-Dudek and Somer6} supporting the directionality mentioned above. Both DP/DRD and maladaptive daydreaming may or may not follow trauma but are significantly associated with difficulties in regulating emotion (e.g.^{Reference Michal, Adler, Wiltink, Reiner, Tschan and Wölfling22–Reference Thomson and Jaque25}). However, a DP/DRD diagnosis does not necessarily imply daydreaming.

Regarding dissociative amnesia, individuals with maladaptive daydreaming are often lost in daydreams for several hours, and, when they ‘snap out of it’, they may experience a sense of lost time. However, they retain accessible memories of the fantasies they experienced and their autobiographical information. Regarding dissociative identity disorder (DID), both maladaptive daydreaming and DID imply mental and emotional engagement with different personas and characters with distinct personalities, desires and conflicts in a complex inner world. However, maladaptive daydreaming involves no division of personality or switching per se. Maladaptive daydreaming dramas occur in fantasy and are not acted out in the real world. This difference also applies to ‘subclinical’ DID, either the DSM’s ‘other specified dissociative disorder, example 1’, or the ICD’s partial DID. Finally, using the ‘unspecified’ or ‘other specified’ categories to diagnose maladaptive daydreaming is not ideal, as these are meant for rare or atypical presentations. By contrast, maladaptive daydreaming is a prevalent, specific, prototypical set of presenting symptoms. Its addition as a stand-alone disorder would enable accumulation of scientific and clinical knowledge on aetiology, phenomenology and efficient treatment courses.

Generally, the proposed classification of maladaptive daydreaming as a dissociative disorder aligns with its phenomenological characteristics, including ‘double consciousness’^{Reference Soffer-Dudek, Somer, Dorahy, Gold and O’Neil19} in the simultaneous experience of reality and fantasy, partial (phenomenologically experienced) dissociative intrusions,^{Reference Dell, Dell and O’Neil26} and concomitant disconnection from ordinary self-awareness and external perception. Therefore, including maladaptive daydreaming in the dissociative disorders sections of psychiatric manuals could advance research on shared mechanisms, such as alterations in the sense of agency, imagination, suggestibility, self-coherence and automaticity; thus, it could contribute to our understanding of a range of dissociative processes, including compartmentalisation of emotions, multiplicity, memory errors, disruptions in phenomenological and narrative self, differences between dissociated and non-dissociated psychological states, and complex DID presentations.

Additional considerations, limitations and a need for further research

The aetiological factors determining maladaptive daydreaming are not yet firmly established; however, several factors have been hypothesised to play a part in the development of this condition. First, it has been hypothesised that an innate ability for immersive daydreaming, which may not in itself be psychopathological, constitutes a risk factor or diathesis for maladaptive daydreaming.^{Reference Soffer-Dudek, Somer, Dorahy, Gold and O’Neil19} Reports of extensive immersive daydreaming starting at very early ages are the norm,^{Reference Bigelsen and Schupak9} whereas the problematic aspect of it may develop over time. Relatedly, some young children diagnosed with stereotypical movement disorder experience extensive imagery accompanying the stereotypies, and this may evolve into adult maladaptive daydreaming.^{Reference Hedderly, Somer, Eccles, Abdulsatar, Mitchell and Owen27} Genetic factors may play a part in these developmental tendencies, but this has not yet been empirically researched. Second, similarly to dissociation, stress or trauma may have a vital role, facilitating the metamorphosis of the heightened imagery tendency into an impairing psychopathology. Specifically, maladaptive daydreaming is often associated with past trauma (e.g.^{Reference Sándor, Bugán, Nagy, Nagy, Tóth-Merza and Molnár23–Reference Somer, Abu-Rayya and Brenner24,Reference Somer and Herscu28} , but see^{Reference Bigelsen and Schupak9,Reference Bigelsen, Lehrfeld, Jopp and Somer11} ) or with a current aversive or stressful reality such as strenuous relationships at home^{Reference Soffer-Dudek, Somer, Dorahy, Gold and O’Neil19} or social anxiety.^{Reference Somer and Herscu28} Shame and secrecy may also have roles in both maladaptive daydreaming and dissociation.^{Reference Chefetz, Soffer-Dudek and Somer21} In addition, several studies have shown that maladaptive daydreaming is associated with difficulties in emotion regulation (e.g.^{Reference Thomson and Jaque25}), which could play an aetiological part by strengthening the need for an alternative coping mechanism. Finally, personality dynamics also contribute to this condition. Specifically, there seems to be a central connection between maladaptive daydreaming and narcissism, with a majority of a clinical sample with narcissistic personality disorder exhibiting probable maladaptive daydreaming.^{Reference Pietkiewicz, Hełka, Barłóg and Tomalski29}

Some limitations of the current work should be acknowledged. First, despite the apparent evidence supporting the existence of maladaptive daydreaming as a clinical phenomenon, more research is needed to establish clearly the boundaries between normal and pathological daydreaming. In particular, the field will benefit most from neuropsychological research pinpointing the brain mechanisms involved, longitudinal research on children and teens to shed light on the typical developmental trajectory, and experimental work uncovering process dynamics in the maintenance of the condition. In addition, the diagnostic criteria suggested in this work, although based on clinical and research experience accumulated in recent years, are still somewhat arbitrary; further research is needed to quantify their ability to differentiate clinical from subclinical presentations. Importantly, interrater agreement rates exist for the previous criteria, but rates for the new criteria will also be required to determine adequate validity. Follow-up validity requires longitudinal research on interview-diagnosed individuals.

There is also concern that adding maladaptive daydreaming to psychiatric manuals would contribute to the general problem of increasing the number of diagnoses in those manuals. Notably, however, fugue as a separate disorder was omitted in the latest version of the DSM, so that may be less of a problem in the field of dissociative disorders. Finally, the dissociative nosology suggested here is not the only possible way to conceptualise maladaptive daydreaming. Despite its significant dissociative components, it could arguably be categorised as a behavioural addiction, an obsessive–compulsive spectrum disorder or a unique subtype of attention-deficit hyperactivity disorder. Indeed, some psychiatric disorders are hard to classify, even though they have distinct patterns and their definition is clinically useful,^{Reference Evans, Roberts, Guler, Keeley and Reed30} as they may have characteristics that overlap with more than one taxonomy dimension. The present position paper is a statement from a significant proportion of leaders in the field of dissociation who see the relevance and utility of adding maladaptive daydreaming to the spectrum of dissociative disorders.

To conclude, given that maladaptive daydreaming has substantial empirical support, a distinct clinical presentation and a significant impact on individuals’ lives, it warrants recognition as a dissociative disorder in diagnostic manuals. This would acknowledge the validity of maladaptive daydreaming, guide clinicians in accurate diagnosis, stimulate further research, and ensure that affected individuals who have long felt overlooked receive appropriate support and effective treatments.