Abstract
Background and aims
Maladaptive daydreaming (MD) has many features of behavioral addiction, but research exploring this syndrome is limited. This case study provides a qualitative exploration of MD.
Methods
A structured clinical interview and mental state examination of a patient with MD were video-recorded and transcribed verbatim. Transcripts were subjected to the interpretative phenomenological analysis.
Results
MD was developed as a strategy to cope with distress but led to uncontrollable absorption in fantasy, social withdrawal, and neglecting aspects of everyday life. It was coupled with excessive Internet use and viewing porn.
Discussion and conclusions
Patients should be questioned about MD during clinical assessment. Further studies are necessary to determine whether MD constitutes a separate syndrome or is a part of other behavioral addictions.
Introduction
While the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) only lists the gambling disorder in the behavioral addictions chapter, authors also consider additional forms, such as Internet gaming disorder, and recommend further research into excessive use of social media or viewing pornography (American Psychiatric Association [APA], 2013). Internet gaming may involve role-playing games (RPGs) or live action RPG in which participants are identified with their characters and co-create imagined scenarios (Tychsen, Brolund, & Kavakli, 2006; Vorobyeva, 2016). Some people use paid services allowing participants to create avatars and virtual environments in which they interact with others, for example, World of Warcraft or Second Life (Messinger, Stroulia, & Lyons, 2008). Studies show that users often develop idealized versions of themselves, with personality traits or preferences similar to their own, and engage in normal actions, such as socializing or shopping or express forbidden, conflicting desires (Gottschalk, 2010; Linares, Subrahmanyam, Cheng, & Guan, 2011). RPGs, which are in significant imaginative involvement, compared with other types (e.g., shooters or strategic games), have been associated with the highest risk of generating behavioral addiction (Lee et al., 2007; Lemmens & Hendriks, 2016).
There is a growing body of evidence identifying dysfunctional forms of imaginative involvement, defined as maladaptive daydreaming (MD), which may be expressed through extensive book-reading, watching films, or gaming. MD refers to extensive, often compulsive, absorption in fantasy for several hours a day, which replaces human interaction and impairs functioning in various domains: academic, interpersonal, or vocational (Somer, 2002, 2018). This syndrome was found in patients with a wide range of DSM-5 disorders, including attention-deficit hyperactivity disorder, anxiety disorder, depressive disorder, and obsessive–compulsive or related disorders (Somer, Soffer-Dudek, & Ross, 2017). Somer (2002) initially associated MD with dissociative pathology and personality disorders. More recently, however, he described this behavior in relation to four categories: a dissociative disorder, disturbance of attention, obsessive–compulsive spectrum disorder, or behavioral addiction (Somer, 2018). Maladaptive daydreamers may share certain similarities with problematic Internet gamers who play games to avoid real-life difficulties (escapism), and use fantasy to experience things that are not workable in real life or live out alternative identities through the game (Ballabio et al., 2017). Escapism, according to Demetrovics et al. (2011), should be distinguished from coping (i.e., improvement of mood or channeling of aggression), which has no clear relationship with problematic gaming. MD could be considered a behavioral addiction, because it is so rewarding that people experience intense yearning for it or feel compelled to extend and repeat this action (Somer, Somer, & Jopp, 2016b). Some report an irresistible urge to immerse themselves in a fantasy world immediately on waking or want to continue fantasizing when interrupted (Bigelsen, Lehrfeld, Jopp, & Somer, 2016). Bigelsen and Schupak (2011), however, note that daydreamers are also distressed about losing control over fantasizing and unsuccessful attempts to limit it.
There are only a few studies on MD, and its symptoms are often unacknowledged or dismissed during clinical assessment (Somer, Somer, & Jopp, 2016a). Because this may lead to unsuccessful treatment, further research is required (Somer, 2018; Somer et al., 2016b). There is also an ongoing dispute among researchers whether or not to classify certain problematic behaviors as “new” behavioral addictions. To avoid overpathologizing the daily life activities, Billieux, Schimmenti, Khazaal, Maurage, and Heeren (2015) suggest that preliminary qualitative studies should precede quantitative research and explore underlying psychological processes and how certain behaviors are experienced, instead of merely comparing behavior against diagnostic criteria. This paper is in line with this approach. It presents a case study of a patient having MD with features of behavioral addiction, whose narrative was explored adhering to rigorous diagnostic and methodological procedures of the interpretative phenomenological analysis (IPA).
Methods
This study took place in Poland in 2018 as part of the project exploring alterations in consciousness. IPA was used for data analysis. IPA generates rich and detailed descriptions of how individuals experience phenomena under investigation and synthesizes concepts derived from phenomenology, hermeneutics, and idiography. Detailed exploration of how participants make meaning of their world is combined with researchers’ attempts to make sense of the participants’ meaning (Pietkiewicz & Smith, 2014).
Participants
Peter (his real name has been changed to ensure confidentiality), aged 25 years, is a single Caucasian male who has moved out of the family home and lives with a flatmate. He is about to complete an IT degree. He uses alcohol rarely and in small doses and has never used drugs or other psychoactive substances. He meets the DSM-5 criteria of the 301.82 avoidant personality disorder (he avoids interpersonal contacts fearing disapproval, criticism, and rejection; he has never had an intimate relationship or sexual initiation because of shame and fear; he is preoccupied about being socially ashamed or mocked and feels inadequate, inhibited, and socially inept; he has poor self-esteem and feels inferior; and he is reluctant to engage in activities potentially associated with being embarrassed). He also reported multiple symptoms indicating non-substance behavioral addiction associated with daydreaming and excessive Internet use for watching videos, pornography, playing games, and reading news. He has become increasingly involved in these activities to achieve desired excitement, experienced irritation when unable to continue that behavior, stayed preoccupied with it, and made repeated and unsuccessful attempts to control his mental and physical actions. He used that behavior to regulate affect but was ashamed and tried to conceal it, experiencing distress as a result. However, he reported neither posttraumatic stress disorder symptoms and somatoform or psychoform dissociation, nor symptoms indicating the existence of dissociative personality parts.
Procedure
The study was approved by the local university research committee. Our participant had been screened for dissociative experiences by a local psychiatrist who referred him to the Research Centre for Trauma & Dissociation for an in-depth diagnostic examination, where he was subjected to the Trauma and Dissociation Symptoms Interview – TADS-I (Boon & Matthess, 2017) to explore his medical history, substance use, and various aspects of everyday functioning (including sleep, eating, self-image, mood regulation, inter-personal relationships, and alterations in consciousness). TADS-I is a comprehensive tool for a differential diagnosis of dissociative disorders, thoroughly examining alterations in consciousness (including depersonalization, derealization, absorption, and daydreaming) and symptoms indicating structural dissociation of the personality. The interview was held in two sessions and lasted approximately 4 hr in total. A psychiatrist also performed a standard mental health assessment and informed the participant about his results and recommended treatment. All interviews were video recorded.
Data analysis
A detailed, verbatim transcript of the video recording was separately analyzed by all authors in Nvivo11 (computer-assisted qualitative data analysis software), using the consecutive analytical steps recommended for IPA (Pietkiewicz & Smith, 2014). First, the transcript was carefully read several times and researchers made their interpretative comments about the content and language use. They registered repetitive phrases, similes, and similarities in how the participant described various experiences at different points of the interview. The “hermeneutic circle” was applied in the analysis, meaning researchers tried to understand each individual part by reference to the whole and vice versa. Then, they categorized the notes into emergent themes by allocating descriptive labels (nodes) and discussed their coding and interpretations of data with each other. They analyzed the connections between themes and grouped themes according to conceptual similarities into superordinate ones and subthemes. This article presents an elaboration of salient themes relating to the experience of excessive daydreaming and the participant’s associations and interpretations.
Ethics
The study procedures were carried out in accordance with the Declaration of Helsinki. The institutional review board of the SWPS University of Social Sciences & Humanities approved the study. The participant was informed about the study and provided informed consent.
Results
Theme 1: Facing social rejection was unbearable
I think I didn’t realise that I pushed too hard and they [classmates] didn’t like it. I wasn’t arrogant, selfish or unfriendly, I simply bragged about how fortunate I was. I craved the spotlight.
They mocked me all the time, and avoided me. I sat alone at the back in class and had no one to talk to. Everyone knew I was a figure of fun.
This led him to feel weak, inferior, and socially excluded. He felt especially ashamed and humiliated when teased or mocked in the presence of girls he found attractive.
Theme 2: Seeking distraction and release of tension
I spend about 14 hours a day surfing on my computer, watching pictures of cars, YouTube, and wanking. Political news, for example, may trigger delusional fantasies in which I am a multimillionaire who would never let that situation happen. If nothing stops my fantasizing – like going swimming or to the library – then I crave music, which gets me even more hopped up. I walk around the flat, imagining how it would be in that world. When I have had too much, I need to watch some porn and masturbate.
When I felt this pain as a child, I started imagining how things could be different. I created stories which never happened. To suppress that pain I would hug my pillow or quilt, thinking I was being comforted by someone else.
Theme 3: Intense imaginative involvement
Time goes by and I am not really able to control it. I sit at my PC and daydream day by day. I start in the morning and realise it is already night. It started by the second grade but did not bother me then so much. Now I fear that I have wasted my life and opportunities.
Although daydreaming is pleasurable, he says he has developed a “delusional personality” and lost control over fantasizing, becoming afraid of losing touch with reality or that the “alter” will take over.
Triggers for excessive daydreaming
My main problem is that I was too traumatised to express my feelings and needs. No life, women, hobbies throughout these years … only fear and shame about saying what I wanted. This is what they did to me at school.
Thinking about something, I automatically create a scenario. For instance, I become this multimillionaire, giving an interview. People admire my wisdom, respect me and make way for me. I move around my flat, listening to music and getting really high. I live these delusions for a few hours, daydreaming about that life: driving cars, car racing, sex.
Experimenting with alters
I created this delusional personality of a multimillionaire by building digital systems that allow mankind to conquer death and cure all mental or physical problems. Sometimes I am the king of Poland, a guardian of values, ideals, social order, or a hero who can do things that other people are unable to do. I rescue them. I am an FBI agent with a photographic memory, an Iron Man who kills Muslim terrorists, or I destroy villains like a Robocop. I am the best.
As a multimillionaire I visit my old school and share my story with the pupils. I tell them how I managed to conquer my own weakness and that this was the best lesson I received from life… not giving in to my hatred.
Fantasies are private experiences
I don’t want people to see my emotions, whether I am angry, happy, or sad. I want them to see nothing but my unimpressed attitude, my poker face.
Talking about his fantasy world evokes tension and extreme shame; thus, he has never spoken about daydreaming to any healthcare provider before and neither has anyone asked about absorption in earlier interviews.
Theme 4: Regret for lost opportunities
I love my addiction and know I can escape unpleasant situations with porn and daydreaming. But when I do that, I miss something more valuable – the chance to attract the love of a woman. I had no social life at school, missed parties and other chances to get to know girls. Later on, my peers would wake up in bed with women, have relationships, work and reach maturity. I never grew up. I could have learnt the taste of love, kisses, walks, hugging, sex.
Discussion
Literature acknowledges that many people engage in daydreaming as a strategy to cope with distress (Winnicott, 1971). This may become maladaptive when used excessively, causing social withdrawal (Somer, 2002). MD has been considered in terms of four psychopathological categories: as a symptom of dissociation, disturbance of attention, obsessive–compulsive, or behavioral addiction (Somer, 2018). This case study illustrates the last category.
Several distinct components of behavioral addiction are commonly identified as: (a) salience – the activity becomes more important than anything else and dominates thinking, (b) mood modification – experiencing the activity leads to an arousing “buzz” or a “high,” (c) tolerance – ability to do increasing amounts of the particular activity, (d) withdrawal – unpleasant states when activity is discontinued or suddenly reduced, (e) conflict (inter- or intrapersonal), and (f) relapse – addictive patterns are easily and quickly restored even after a long time of abstinence or control (Griffiths, 2005). Although the DSM-5 only describes symptoms of gambling disorder, the Appendix lists additional forms of behavioral addiction that should be explored (e.g., excessive use of social media or watching porn), and proposes criteria for Internet gaming disorders (APA, 2013). Various authors note that this form of entertainment can lead to preoccupation (obsessive thinking about online games), overuse, neglecting areas of everyday life, social isolation, inter- and intrapersonal conflicts, and escape from painful reality (Demetrovics et al., 2012; King, Herd, & Delfabbro, 2017, 2018; Király et al., 2017; Kuss, 2013; Kuss & Griffiths, 2012). Such people risk substituting real life with virtual reality (Smahel, Blinka, & Ledabyl, 2008).
While our subject has all these characteristics in relation to Internet use and viewing porn, he also reports MD as his main area of concern and difficulty. His MD alone involves seeking opportunities to indulge himself in fantasies and elaborate his scenarios (preoccupation), feeling very excited (mood modification), excessive and increasing use (tolerance), feeling irritated when something or someone disturbs his daydreaming (withdrawal), and inner frustration associated with avoiding confrontation with problems (conflict). Fantasy, which is normally a natural coping strategy to regulate affect, apparently becomes dysfunctional in MD and leads to escapism, causing impairment of functioning in school, work, and social life.
Our subject initially used daydreaming to distract his attention from problems at school or aid emotional regulation. Only later he discovered that daydreaming can be triggered using the Internet or viewing porn. Although he identified MD as his main problem for which he sought help, there were few days when fantasy dominated his functioning but did not involve using the Internet. This shows that further quantitative studies are necessary to distinguish whether MD is merely a component of other disorders or compulsive behaviors (e.g., personality disorder or porn/Internet addiction) or is an isolated symptom that justifies creating its own separate diagnostic category. Interestingly, our entire subject’s compulsive behaviors (excessive Internet use, watching porn, and MD) required being absorbed. This justifies further studies into alterations in consciousness in people with behavioral addictions. It could be rewarding to analyze the function of imaginative involvement and its impact on daily life in people excessively using RPG (Tychsen et al., 2006; Vorobyeva, 2016) or virtual reality (Messinger et al., 2008).
Literature shows that adverse childhood experiences can lead to the structural dissociation of the personality (Nijenhuis, 2015; van der Hart, Nijenhuis, & Steele, 2006). Our subject felt neglected at home and bullied at school, which resulted in alterations in consciousness (immersion in his inner world) and compulsive behavior. He also developed symptoms of avoidant personality and revealed narcissistic conflicts associated with shame and fragile self-esteem. However, he reported no symptoms of pathological dissociation. This supports the observation that some cases of MD do not involve dissociative pathology at all. Although MD may involve a disordered form of absorption, many researchers disregard these alterations in consciousness as dissociative in nature. This, however, relates to the ongoing theoretical dispute, what is dissociation per se, and will not be explained here.
Finally, it is interesting that our subject had never revealed his MD symptoms to any healthcare professional. This can be attributed to intense shame associated with the contents of his fantasies, limited control over imaginative involvement, and perceived consequences. This, however, justifies the need to openly ask questions about potential signs of MD during clinical interviews.
Authors’ contribution
All authors made substantial contribution to acquisition, analysis, or interpretation of data.
Conflict of interest
The authors declare no conflict of interest.
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