Comorbidities of Maladaptive Daydreaming (MD): A Systematic Review

1. INTRODUCTION

Maladaptive Daydreaming (MD) is characterized by imaginary and vivid thoughts which interfere with daily life functioning. Research has reported its prevalence, such as 34.3 percent of medical students reported to be a maladaptive day dreamer (Bashir, 2021). In another study, 25 percent of 67 clients diagnosed with dissociative identity disorder reported that they suffered through MD (Soffer-Dudek & Theodor, 2022). Thus, the phenomenon is prevalent in both general and clinical populations. People spend ample time in drifting away mentally rather than focusing on what they are doing. MD is a proposed mental disorder as it involves addictive absorption in daydreaming, it is found to be associated with maladaptive outcomes. A person indulging in it loses the track of time resulting into excessive waste of time in maladaptive random thoughts. It consumes several hours, causes significant distress and interferes with daily life functioning including social as well as occupational functioning (Marcusson et al., 2019).  Moreover, as MD is a proposed mental disorder, its assessment often involves clinical interviews. This criterion has been mentioned and utilized in numerous researches (Somer et al., 2017). Moreover, maladaptive daydreaming has also been frequently measured by a standardized tool namely Maladaptive Daydreaming Scale (Somer et al., 2016).

Individuals engaging in MD report a strong urge to engage in day dreaming whenever possible and feel annoyed if they are not able to do so. They also report repeated and unsuccessful efforts to control or stop day dreaming just like other addictive behaviors. This supports the validity of MD as a psychological disorder (Soffer & Theodor, 2022). MD is found to be associated with restricted emotion regulation (Greene et al., 2020), symptoms of dissociative disorder (Ross et al., 2020) and Generalized Anxiety Disorder (GAD) (Alenizi et al., 2020). It may also function as a coping mechanism to escape hurtful memories (Somer et al., 2020).

According to recent research, MD has several detrimental effects on a person’s social life, academic performance, and overall mental and physical health. The vivid imagination of maladaptive daydreamers may distort their perception of reality, making it difficult to achieve personal goals (Brenner et al., 2022). Compared to their peers who are typically developing, children with ASD make fewer imaginary friends (Davis et al., 2018). This infers that one of the side effects of maladaptive daydreaming is that it may lead individuals to construct imaginary figures that do not exist in reality. Moreover, adults with ASD tend to participate in fewer social activities and struggle to establish and maintain social relationships, which can lead to feelings of social isolation and loneliness when compared to their typically developing peers (Müller et al., 2008; Stice & Lavner, 2019).

According to Somer et al. (2016), MD fantasies are pleasurable and evoke strong emotional and sensory reactions. Since these individuals frequently feel ashamed or embarrassed about their daydreaming and habitually experience functional impairment due to time spent in fantasy, daydreaming is reinforced as an escape from an increasingly stressful reality. Therefore, even though these individuals are able to discriminate between reality and fiction and are capable of intentionally entering into states of daydreaming, MD has an addictive, compulsive component that may be viewed as involuntary (Somer & Herscu, 2017).

A growing body of research has started to look into the connection between mind wandering and ADHD. Mind wandering predicted the intensity of ADHD symptoms in adults with ADHD (Helfer et al., 2019). Soffer-Dudek (2019) demonstrated that items from the Mind Wandering Questionnaire and ADHD Self-Report Scale (ASRS) loaded onto a similar factor they named "Mind Wandering/Distraction," indicating a connection between mind wandering and ADHD symptoms.

Researchers found that certain characteristics of daydreaming are less adaptive. The term "fantasy proneness," for instance, was first used by Wilson and Barber (1981) to characterize individuals who have a propensity for engaging in frequent, elaborate, and intensely vivid fantasy activities. These individuals are also characterized by unusual perceptual experiences (such as difficulty telling the difference between reality and fantasy, psychosomatic experiences), which they concluded may occasionally be a coping mechanism for feelings of loneliness, isolation, or exposure to stressful situations. Subsequent research on the connection between psychopathology and fantasy proneness showed that fantasizers had far higher levels of dissociative and depressive symptoms than controls (Duarte et. al., 2022).

In particular, it's possible that daydreaming is comparable to other mental states (like worry) that can be categorized along a range between normal and unhealthy. Daydreaming appears to have the same potential to create discomfort as other mental phenomena when it occurs excessively in terms of intensity, frequency, and length, and when it interferes with important areas of functioning (Soffer-Dudek & Somer, 2018). Maladaptive daydreaming (MD) is a term used to describe compulsive fantasy activity that is marked by a rich inner world and deep imagination while ignoring social, professional, and academic responsibilities (Fischera, 2024).

According to Pietkiewicz et al. (2018) Maladaptive daydreaming is a type of behavioral addiction characterized by a persistent desire to daydream and immerse oneself in a self-directed fantasy world. Numerous times, this behavior is triggered or enhanced by exposure to music and repeated motions (Somer, 2017). Thus, Maladaptive daydreaming could result into dysfunctionality of individuals, rendering them unfocused on the task they are doing. Moreover, it may drag the thought pattern away from the task at hand to other distal thoughts that may be irrelevant at that time.

Daydreaming is referred to as an adaptive consciousness state by a number of researches. For instance, developing a platform for processing everyday experiences and solving problems in a manner that defies conventional, goal-oriented, logical thinking (Butler, 2016). Additionally, it has been proposed that daydreaming helps with creative thinking, attention decoupling, achieving a variety of objectives, and possibly acting as a resting mechanism for assimilation (Lawson & Thompson, 2024).

The objective of the current study is to provide a systematic review of the relationship between maladaptive daydreaming and other mental health disorders. The current systematic review was vital doing as it summarized the comorbidities of a newly discovered abnormality in thought pattern. As earlier researches have quoted MD resulting into dysfunctionality of an individual (Mansuklal et al., 2025), it is important to understand which are the prominent disorders that have been found associated with it. In other words, the current systematic review outlined the psychological disorders that may lead to MD. The findings are significant for clinical diagnosis of MD as well.

Method

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidance was followed during the systematic review, and the protocol was created and registered on PROSPERO (CRD42024548037) (Page et al., 2021).

To begin, a scoping review was conducted to assist in locating relevant search terms. Following this, three databases namely Science Direct, PubMed, PsycINFO were searched from beginning to May 2024, to identify relevant published researches for full text review. PhD published theses were not included in the selection of full text articles. The following search terms were used: (a) Mind wandering* OR Maladaptive fantasy* OR fantasy proneness* OR Excessive daydreaming* OR Meta Cognition* OR Divergent thinking* OR Self-generated Thoughts*

OR Idle Thoughts* and (b) Normal individuals* OR Psychotic patients* OR neurotic patients *OR Healthcare patients* OR Medical patients* OR Hospital patients*.

At first stage, all five researchers independently screened abstracts and titles of the identified studies. This step was carried out manually by each researcher. In the second stage, the shortlisted articles' complete texts were reviewed during multiple group discussions, where all authors examined the articles to ascertain eligibility for inclusion criteria. Moreover, inter-rater agreement was established using Cohen’s Kappa. The statistic revealed that there was a moderate to good agreement (0.78) between authors.

If any article that is published but not available on the selected three databases, we requested the authors via email to send us the complete article in PDF format. This screening process was carried out by all five researchers independently, and discrepancies were addressed through discussion and consensus. 

The following inclusion criteria had to be fulfilled by the studies that were part of the review: 1) clinical studies, 2) comorbidities, 3) correlational studies, 4) Adult clinical population, 5) studies conducted in last five years (2019-2024), because literature has suggested the emergence of Maladaptive Daydreaming as a distinct construct especially in clinical studies post 2019, 6) Studies published in English language. 

Similarly, studies were excluded if they were based on 1) interventions, 2) normal adult population, 3) written in languages other than English.

Utilizing the Joanna Briggs Institute (JBI) (2021) Critical Appraisal Checklist for Analytical Cross-sectional studies, the included correlational studies were systematically assessed for risk of bias. The checklist consists of eight structured appraisal questions, organized to guide the reviewers through key methodological domains including sampling, measurement validity, identification of confounding factors, and appropriateness of statistical analysis. Each question requires the assessor to judge methodological quality by marking ‘yes’, ‘No’, ‘unclear’ or ‘not applicable’.

The appraisal process began by screening all included studies using eight-item checklist. Each item prompted reviewers to critically reflect on potential threats to validity such as biased sample recruitment, unreliable measurement tools, lack of confounder control, or inappropriate statistical procedures. The structured nature of the tool facilitated consistent evaluation across studies.

To ensure rigor, five independent reviewers evaluated each study separately. After completing the checklist, reviewers compared their ratings, discussed discrepancies, and reached consensus through deliberation. This collaborative process minimized individual bias and enhanced the credibility of the appraisal. The final ratings were then synthesized to identify recurring methodological strengths and weaknesses across the included literature, such as common sources of bias, typical limitations, and areas of strong methodological execution.

Extracted data included details of journal, author, year, participants’ country, tool used to measure construct, aim of study, study design, publishing date, sampling technique, sample, comorbidities and other useful information. Data extraction was undertaken independently after dividing researches by research team members. Then reviewed by each member, in case of any discrepancies, it was resolved through discussion. 

The current systematic review aimed to identify the existing literature on the comorbidities of maladaptive daydreaming. A total of 10 studies conducted in last five years (2019-2024) were included provided data on 1541 participants. Studies were conducted around the world. The overall quality of evidence was rated as satisfactory as all studies used validated assessment tools. Systematic review highlights the prevalence of comorbid mental health conditions among individuals with maladaptive daydreaming. Studies consistently reported a significant association between maladaptive daydreaming and

Comorbid mental health disorders include schizophrenia, obsessive compulsive disorder attention deficit hyperactivity disorder, anxiety and depression among others. The strength of the association varied across studies, some reported moderate to high correlations.

Results

For the systematic review on the comorbidities of maladaptive daydreaming, ten research papers were found to be eligible. Fig. 1 shows a flow diagram of the screening procedure from study identification to inclusion criteria. Table 1 of the final screening of excluded articles is presented in Appendices. Of the 153 studies, 95 were excluded at the title stage, and 58 full-text articles were excluded with reasons such as no relevant outcomes (N=34), no relevant population (N=27), and no relevant association (N=5).

Figure 1

Flow Diagram of Studies

The included studies originated from all over the world which provided cross- sectional data on the maladaptive daydreaming with other mental health conditions (such as schizophrenia, obsessive compulsive disorder attention deficit hyperactivity disorder, anxiety and depression) is presented in table 2. The shortlisted articles on the comorbidities of maladaptive daydreaming for the period of last five years, reveal that there are a number of comorbidities associated with MD.

Theodor‐Katz et al. (2022) reported that around 20 percent of the sample of their study who had ADHD, also met with the criteria of MD. Moreover, in people who had both of these i.e. ADHD and MD were way too vulnerable to depression, low self-esteem and loneliness. The researchers were of the view that maladaptive daydreamers were immersed in their thoughts, and could not perform their daily routine tasks with due consideration, there is a chance that they may also be diagnosed with ADHD. MD’s cooccurrence have found to be associated with ADHD, revealing that if an individual suffers through one, he is likely to go through the other problem as well. 

Furthermore, the studies conducted by Figueiredo et al. (2020) and Biederman et al. (2019) also assessed the relationship between MD and inattention. Their study found out that the two are significantly positively correlated. Moreover, MD was also found to be positively correlated with depression in this study. Later study even reported MD to be associated with hyperactivity as well. It also reported that people who were high on MD reported to have worse executive functioning. 

Chen et al. (2021) revealed that when MD is overwhelmed with negative beliefs, it may lead a person towards depression. In other words, abnormally daydreaming and that too about negative thoughts correlates with depressive symptoms. Patients of MD also reported to be intolerable to uncertainty. MD is also found to be significantly correlated with severe anxiety in this study. Salomon-Small et al. (2021) explored the relationship between MD and Obsessive Compulsive Disorder. Their study found out that MD is significantly associated with obsessions but not with compulsions. This could also be understood in the context that obsessions are mainly recurring thoughts that may be distressful for an individual, and MD is also composed of thoughts, hence the two disorders are very close to each other. 

The study conducted by West et al. (2022) revealed that Maladaptive daydreaming (MD) is common among adults having autism spectrum disorder (ASD), adults with experiences of MD associate with the high level of emotion regulation difficulties and loneliness. It also revealed that comorbidity of MD and ASD associates with high scores on repetitive and restricted behaviors. 

Ross et al. (2020) study findings reported that MD is having comorbidity in patients of dissociative disorders and there is an association of MD with Dissociative Identity Disorder (DID) and other disorders. It also revealed that DID shared common features with maladaptive daydreaming. The study conducted by Gau et al. (2022) also revealed that MD correlates with impulsive response style and ADHD symptoms. ADHD symptoms Severity is linked with MD. 

The findings by Kolavarambath et al. (2020) found no correlation of metacognition and emotion regulation in schizophrenia patients, whereas the social functioning is associated with negative symptoms. Overall schizophrenia patients have shown more deficits in emotion recognition. The study conducted by Iglesias-Parro et al. (2020) reported that schizophrenia patients do more MW and also revealed that patients have different EEG patterns of complexity and MW in schizophrenia is not linked to cognitive deficits.

The findings of the studies that are included revealed the comorbidity of MD with schizophrenia, ADHD, Depression, ASD, anxiety symptoms, dissociative disorders, obsessions, dissociative identity disorder (DID), emotion regulation difficulties and loneliness, impulsive response style, inattention, repetitive and restricted behaviors. 

Discussion

Maladaptive daydreaming is a newly recognized disorder (Somer et al., 2017). This is the reason that research is still trying to figure out its comorbidities and other such information. The current systematic review provides a comprehensive summary of the most pertinent researches conducted on the construct to understand it. Researches conducted on maladaptive daydreaming over last five years were carefully sifted through three databases, and the most relevant articles were shortlisted. Consequently, a table was made outlining the key points of the researches on the comorbidities of maladaptive daydreaming.

A number of researches have shown that maladaptive daydreaming is significantly associated with attention deficit hyperactivity disorder (ADHD) symptoms (Biederman et al., 2019). People who daydream a lot are mostly diagnosed with inattention. Their concentration is distracted by the thoughts that come and go in their mind, and as a result they are unable to pay due attention to daily life matters. This could be the reason that also leads to ineffective executive functioning as reported in research (Biederman et al., 2019). Thus, MD does not only disturb a person’s concentration but also his decisions because of lack of attention.

Researches have also pointed that Maladaptive Daydreaming is most closely associated with obsessive compulsive disorder (OCD), specifically with obsessions (Salomon-Small et al., 2021). The recurrent obsessive thoughts that distract and distress an individual in OCD could be thought of as similar to those thoughts that recur in MD. Thus, they both cooccur and could be associated with either MD or OCD, or even both. However, these two can be thought of as distinctive for the reason that obsessions often lead to compulsive, repetitive behavior, whereas MD makes a person inattentive and lost in thoughts for most of the time of his day.

The findings (West et al., 2022) are in line with the findings of the study conducted by Duarte et al. (2022) that MDD associate with less imaginative ability among ASD patients. The findings are also consistent with the findings that emotion regulation and loneliness are linked with ASD and MDD (Cai et al., 2018).  The conclusions of the study conducted by Gau et al. (2022) is consistent with the findings of the studies by Alali-Morlevy and Goldfarb (2020) that reports about ADHD symptoms positive association with MW and adults with ADHD showed weak performance on tasks that were been conducted on vigilance. The findings by Kolavarambath et al. (2020) are Contrary to findings by Brewer et al. (2022) that emotion recognition, emotion awareness, or metacognition does not associate with social functioning.

The studies have reported that MD is found to be associated with anxiety and depression (Chen et al., 2021; Figueiredo et al., 2020). This could be understood in the way that recurring thoughts could lead to Negative Automatic Thoughts (NATs), which result in depressive symptoms. NATs are also a common reason for a person’s malfunctioning and ill-adjustment. Thus, thinking too much and that too about pessimistic and negative thoughts is bound to lead a person to anxiety. This anxiety and depression could even sometimes rise to the level of being diagnosed a disorder itself.

Another significant finding of the research was that MW is unintentional (Gau, 2022). It happens without the doer knowing consciously that they are being engaged in it. More like NATs, mind-wandering starts occurring randomly and could become dysfunctional and distressful for a person during his daily life. The findings of this study also hint that although MD is not a recognized disorder as per the latest version of DSM, it is still a widely reported symptom of many notable disorders (Chen et al., 2021; Figueiredo et al., 2020; Gau et al., 2022). The occurrence of MS thus should be specifically noted by practitioners like clinical psychologists in the process of diagnosis. The findings of current research are helpful in presenting a summary for such practitioners which they could refer to while drawing inferences regarding the diagnosis of patients reported MD.

Moreover, the co-occurrence of MD with disorders like OCD (Salomon-Small et al., 2021), and anxiety (Chen et al., 2021) also infer that MD could possibly contribute to negative thoughts and consequently associating with serious disorders. In other words, MD is a specific characteristic leading to problematic thought pattern that could harm a person’s psychological health. The findings of current systematic review also direct towards the necessity of catering such problematic thought pattern while charting out other relevant things in the management plan of clients suffering through disorders like OCD and anxiety.

The study has great implications as the findings are useful in understanding the newly identified disorder. This research provides all useful information to understand the comorbidities of MD in a single paper. These findings could be utilized in clinical settings for better understanding and treatment of people identified with MD. However, there are also a number of limitations of the study. This research identified researches on MD that were available on three databases only namely Science Direct, PubMed and PsycINFO. There is a possibility that there might be other useful information available on a different platform that could not be included in the current research. Moreover, as researches on MD are growing, there is still an ambiguity on the terminology. Some call it maladaptive daydreaming, others call it mind wandering, meta-cognition, etc. Although the current research has searched for researches of many symptoms, but still there is a chance that a crucial synonym prevalent in the research language might have been missed out. This is also the reason that some of the articles that have been finally included in this review have measured the construct through Mind Wandering Scale. Although maladaptive daydreaming and mind-wandering are overlapping constructs, yet they could be distinct because former is impairing whereas latter is not. To overcome this limitation, only those studies have been finally included which although utilized MW scale, but did also present some comorbidity linked to the synonymous construct.

The current study also points out towards a wide gap that mut be covered by future researches. They may focus on longitudinal research design, devising a sound psychometric measure for MD, as well as devising a clinical diagnostic criterion for the variable. Moreover, one significant recommendation of this study is Maladaptive Daydreaming must be screened along in the patients diagnosed with OCD, ADHD, ASD. This paper outlines the significance of the newly discovered phenomenon of MD, creating a need for researches on this construct. This variable could hence be seen with other notable psychological disorders, other than those mentioned in this review, in order to verify the prevalence of MD with them. Further studies could verify the relation between MD and other significant disorders. The current paper also identifies the need for more researches in this regard.

To conclude, MD is a newly identified disorder. The research on this construct is developing. The current paper is a humble attempt to identify the comorbidities of MD. It has found out that MD is closely associated with ADHD, OCD, ASD, dissociative disorders, schizophrenia depression and anxiety symptoms. The findings of this systematic review can be utilized for the better understanding of the disorder.

Author Contribution

Muhammad Safi Aslam: conceptualization, data curation, methodology, formal analysis, and writing – original draft. Faiza Abdul Khaliq: data curation, methodology, formal analysis. Ushna Seher: data curation, methodology, formal analysis. Qudsia Nashee: data curation, formal analysis.  Amber Tasleem: data curation, formal analysis. Haziq Mehmood: supervision, writing – review & editing. 

Conflict of Interest

The authors of the manuscript have no financial or non-financial conflict of interest in the subject matter or materials discussed in this manuscript.

Data Availability Statement

The data associated with this study will be provided by the corresponding author upon request.

Funding Details

No funding has been received for this research.

Generative AI Disclosure Statement

The authors did not used any type of generative artificial intelligence software for this research.