Frontiers in the Psychotherapy of Trauma and Dissociation, 1(2):1–22, 2018
Copyright ©Int. Society for the Study of Trauma and Dissociation
ISSN: 2523-5125 print /2523-5125 online
Ontological Analysis, Treatment Rationale;
a Pilot Case Report
ELI SOMER, Ph.D.1
University of Haifa, Israel
This paper describes the course of psychotherapeutic treatment of a 25-
year-old man presenting with maladaptive daydreaming (MD), from
analysis of the underlying rationale through the treatment process to
the outcomes. MD, a condition marked by highly absorptive daydream-
ing, consumed many hours of his day and produced distress, dysfunc-
tion, and excessive Internet use. Ontological analysis resulted in clas-
sifying MD characteristics under several categories: as a dissociative
disorder of absorption, as a behavioral addiction, and as an obsessive-
compulsive spectrum disorder producing signiﬁcant attention deﬁcits.
The therapy plan was derived from evidence-based treatment modali-
ties for conditions elucidated in the ontological analysis and included
cognitive behavioral interventions as well as mindfulness meditation.
Therapy was provided for a predetermined period of six months. MD
and relevant indices were measured before and after therapy, as well as
at a two-month follow-up. The data show that the client was able to
reduce his daydreaming time by over 50% and his time spent on the
Internet by over 70%. He reported an improvement of over 70% in his
work and social adjustment. Nevertheless, his maladaptive daydream-
ing scale score and his self-assessed pleasure derived from daydreaming
showed more modest gains. I discuss this discrepancy and suggest future
KEYWORDS maladaptive daydreaming; absorption; psychotherapy;
1Address correspondence to: School of Social Work, University of Haifa, 199 Abba
Khoushy Ave. Haifa 3498838, Israel. Email: firstname.lastname@example.org.
In this paper I describe the rationale, process and outcome of psy-
chotherapy for maladaptive daydreaming (MD). MD is a newly identiﬁed
disorder marked by absorption in fantasy. In some cases, this condition
seems to evolve into psychological dependence that is manifested in the
compulsion to daydream extensively, sometimes for several hours every
day, causing distress and impaired functioning (Somer, 2002). Internet users
around the world have adopted this relatively new term to facilitate com-
munication between them, confer themselves a collective identity and give
meaning to their mutually distressing condition (Bigelsen, Lehrfeld, Jopp,
& Somer, 2016). Still, the existence of MD has yet to be recognized, let alone
understood, by mental health professionals. Suﬀerers recently reported
being embarrassed by their unusual disorder, often believing no one else
suﬀered from similar symptoms. Others described how their MD symptoms
had been summarily dismissed or contested by practitioners who treated
them unsuccessfully for more common diagnoses ranging from anxiety to
schizophrenia (Somer, Somer, & Jopp, 2016a).
The MD experience
Recently published phenomenological data (Somer, Somer, & Jopp, 2016a,b)
point to a number of features marking MD: a) Individuals with MD dis-
covered their ability to activate fanciful fantasies during childhood. b) They
need privacy to engage in this mental activity, and movement (e.g., pac-
ing) and exposure to music are important facilitators. c) Some maladaptive
daydreamers (MDers) report constantly struggling with the outcomes of
adverse childhood experiences or ongoing social and emotional diﬃculties.
d) This rewarding and soothing experience can develop into a detrimental
mental habit. Daydreaming scenarios often are intertwined with emotion-
ally compensatory themes involving fantasized emotional support, compe-
tency, and social recognition. This leads to the development of a vicious
cycle in which they use MD to seek comfort from their stressors only to
experience further distress about their time-wasting, which they ease with
more daydreaming (Somer, Somer, & Jopp, 2016b).
Is MD a Psychopathology?
There is ample evidence to suggest that MD is a reliable clinical construct
(e.g., Somer, Lehrfeld, Jopp, & Bigelsen, 2016; Somer, Soﬀer-Dudek, Ross, &
Halpern, 2017). MDers report feelings of distress and intense shame stem-
ming from their diﬃculty in controlling their MD yearnings and behavior
that interference with social and daily functioning (Bigelsen & Schupak,
2011). A separate study by Bigelsen et al. (2016) conﬁrmed that MD dif-
fers signiﬁcantly from normative daydreaming in terms of quantity, con-
tent, experience, distress, degree of perceived control, and interference with
life functioning. Results also demonstrated that MDers exhibit signiﬁcantly
Psychotherapy for Maladaptive Daydreaming 3
higher rates of attention deﬁcit, obsessive-compulsive, and dissociative
symptoms than controls.
Comorbidity—the concomitance of two or more psychiatric diagno-
ses—is a hallmark of DSM diagnoses. For instance, in the US National
Comorbidity Survey (Kessler et al., 1994), 51% of patients with a DSM–
III–R/DSM–IV (American Psychiatric Association, 1987, 1994) diagnosis
of major depression had at least one concomitant (comorbid) anxiety dis-
order, and only 26% had no concomitant (comorbid) mental disorder. In
the Early Developmental Stages of Psychopathology Study (Wittchen, Nel-
son, & Lachner, 1998) the corresponding ﬁgures were 48.6% and 34.8%.
A recent systematic assessment of psychiatric comorbidity in MD revealed
that individuals meeting criteria for MD exhibit complex psychiatric prob-
lems spanning a range of DSM-5 disorders; 74.4% met criteria for more
than three additional disorders and 41.1% met criteria for more than four.
Attention-deﬁcit hyperactivity disorder was the most frequent comorbid
disorder (76.9%), followed by anxiety disorder (71.8%), depressive disorder
(66.7%) and obsessive-compulsive or related disorders (53.9%). A notable
28.2% of MDers have attempted suicide (Somer, Soﬀer-Dudek, & Ross,
2017). Recently, my colleagues and I provided evidence showing that not
only is MD a distinct clinical construct but that based on our proposed diag-
nostic criteria MD can be diagnosed reliably using a structured interview
developed for that purpose. The new diagnostic interview demonstrated
excellent agreement with a self-report measure for the disorder. Addi-
tionally, we identiﬁed a useful cutoﬀscore for future self-report research
(Somer, Soﬀer-Dudek, Ross, & Halpern, 2017). Nevertheless, despite the
importance of identifying MD correctly, the main challenge in this nascent
clinical ﬁeld is to understand the essence of MD and its derivative
An Ontological Analysis of MD
MD is a multifaceted clinical entity that is diﬃcult to pigeonhole. In this
section I attempt to determine the ontological status of this condition. In
other words, I try to conceptualize the nature of this "thing" known as
maladaptive daydreaming. The many MDers I have spoken with in recent
years have invariably informed me that their MD began with their child-
hood discovery of a capacity to immerse themselves in gratifying vivid
imagery. Some of my interviewees believe this trait may have a genetic
component, as close family members also seem to possess it. I begin with
the assumption that MD starts with and is based on a trait that facilitates
a powerful sense of presence during daydreaming. This trait is probably
what ontologists would term a "natural kind" (Devitt, 2008). To say that a
kind is natural is to say that it corresponds to a grouping that reﬂects the
structure of the natural world rather than the actions of human beings or
their interpretations. In our case the reference is to a mental module. Onto-
logical functionalists deﬁne natural mental kinds by their functional roles
(Fodor, 1983). Although a thorough discussion of the evolutionary function
of human fantasy is beyond the scope of this paper, Somer, Somer, & Jopp,
(2016a) have described the defensive and restorative functions of this trait.
Some of these functions will become apparent in the following analysis.
MD as a Dissociative Disorder
MDers report that their fantasizing activity entails intense, absorptive focus-
ing on spontaneous but maintained and elaborated “private worlds” of fan-
tasy, which is referred to in the literature as “paracosms” (MacKeith, 1983).
Indeed, daydreaming and absorption experiences have long been identiﬁed
as dissociative in nature. The absorption-imaginative involvement factor of
the Dissociative Experiences Scale (DES) is composed of common, benign
experiences, such as being engrossed in a movie or missing part of a con-
versation (Carlson & Putnam, 1993). DES factor studies (e.g., Ross, Joshi
& Currie, 1991) show that the absorption/imaginative involvement items
are much more common than those of the other factors in the scale. This
is primarily because DES items seeking to address absorption/imaginative
involvement do not represent inherently pathological experiences. This is
true even when the score on an individual item is high.
Evidence shows that absorption is associated with hypnotizability
(Smyser & Baron, 1993). The absence of a psychopathological version of
absorption has led to the claim that absorption is a non-trauma-related,
nonclinical form of dissociation. It is a personality trait associated with nor-
mal, benign experiences related to the ability to be immersed in a single
stimulus, either external (e.g., a book) or internal (e.g., daydreaming), while
neglecting other stimuli in the environment (Kihlstrom, 2005).
Maladaptive daydreaming may represent the pathological end of ab-
sorption spectrum experiences. Recently, Somer, Lehrfeld, Jopp, & Bigelsen
(2016) have provided further evidence about the relationship between the
Maladaptive Daydreaming Scale (MDS) and dissociation.
The signiﬁcant correlation between the DES total score and the MDS
score (r⇤.55,p<.01) demonstrated that maladaptive daydreaming activ-
ity was akin to the more general phenomenon of dissociation. A more care-
ful examination of the subscale scores revealed that the absorption items
of the DES were more responsible for this relationship (r⇤.63,p<.01)
than either amnesia (r⇤.24,p<.01) or depersonalization items (r⇤.39,
p<.01). This pattern of associations corresponds with our understanding
that MD is ﬁrst and foremost a process of full absorption in one’s inner
world. MD seems to have strong dissociative properties characterized pri-
marily by a propensity toward absorption.
Psychotherapy for Maladaptive Daydreaming 5
Nevertheless, these data are not very helpful in devising a dissociation-
informed treatment strategy. Absorption experiences do not represent post-
traumatic structural dissociation. Available data indicate that only 27% of
MDers report experiencing either some sort of childhood physical, emo-
tional, or sexual abuse or other forms of trauma. Most report uneventful or
happy childhoods (Bigelsen & Schupak, 2011). Therefore, treatment guide-
lines designed for severe trauma-related dissociative psychopathology such
as the DID (International Society for the Study of Trauma and Dissociation,
2011) may not be pertinent.
MD as a Disturbance of Attention
Several interrelated constructs associated with diﬃculties in remaining
focused on external tasks have been described in the literature as involving
daydreaming. Diagnostic criterion A1c (relating to inattention) for attention
deﬁcit disorder/hyperactivity (ADHD) describes a symptom that alludes to
daydreaming: “Often does not seem to listen when spoken to directly” (e.g.,
mind seems to be elsewhere, even in the absence of any obvious distraction)
(American Psychiatric Association, 2013). Indeed, daydreaming has often
been described as characteristic of ADHD (e.g., Bokor & Anderson, 2014).
“Mind wandering”—another associated concept deﬁned as a shift of atten-
tion from a task to unrelated concerns—has also been associated with day-
dreaming (Marcusson-Clavertz, Cardeña, & Terhune, 2016) and with ensu-
ing impaired performance (Mrazek et al., 2012). “Sluggish cognitive tempo”
(SCT) is another related construct. SCT was hypothesized to describe a
constellation of behaviors that includes daydreaming, lethargy, drowsiness,
diﬃculty sustaining attention and underactivity. Measures of SCT have
shown associations with symptoms of attention-deﬁcit/hyperactivity dis-
order (ADHD), particularly inattention (Jacobson et al., 2012).
MD research data conﬁrm the existence of attention deﬁcits among
MDers. For example, items measuring ADHD inattention symptoms de-
monstrated larger eﬀects for diﬀerences between MDers and non-MDers
(Bigelsen et al., 2016). However, in a recent study on MD comorbidity,
Somer, Soﬀer-Dudek, & Ross (2017) showed that MDers suﬀer from perva-
sive inattention psychopathology. No less than 76.9% of diagnosed MDers
also met diagnostic criteria for ADHD. Twenty-seven of the 30 intervie-
wees diagnosed with ADHD were identiﬁed as Inattentive Type (69% of the
entire sample). Research participants have unvaryingly attributed their dis-
turbed attention functions to MD and claimed that their MD preceded their
ADHD. The researchers concluded that MD cannot be better accounted for
by a comorbid attention disorder. Further evidence for the above assertion
is found in the fact that 23.1% of diagnosed MDers did not meet criteria
for attention deﬁcit/hyperactivity disorder, showing that ADHD cannot
fully account for MD. Although the nature of the relationship between
these comorbid disorders is not yet resolved, treatment for MD must clearly
include assessment of attention dysfunction and derivative treatment com-
MD as a Behavioral Addiction
Several behaviors can produce short-term rewards that are suﬃciently
potent to reinforce perseverance despite concerns about unfavorable eﬀects
such as compromised functioning and weakened behavior regulation. This
similarity to substance addiction has given rise to the concept of non-
substance or “behavioral” addictions. Although the notion of behavioral
addictions has some scientiﬁc and clinical heuristic value, it remains con-
troversial. Behavioral addictions, identiﬁed in the DSM-IV-TR (American
Psychiatric Association, 1987) as impulse control disorders, are now a sep-
arate category in the DSM-5 (American Psychiatric Association, 2013).
A core characteristic of MD is its lure. A review of the MD literature
based on the participation of hundreds of respondents consistently indi-
cated that MD is so rewarding that MDers feel compelled to extend and
repeat their experience as long and as often as they can. For example, an
analysis of 90 self-identiﬁed MDers revealed that most participants were
distressed by what they described as an uncontrollable need to engage in
fantasy, with 79% of the sample reporting unsuccessful attempts to limit
their fantasizing (Bigelsen & Schupak, 2011). A qualitative analysis of in-
depth interviews with 16 MDers conﬁrmed that they struggled with an
insatiable yearning for daydreaming (Somer, Somer, & Jopp, 2016a). In
another study, Bigelsen, Lehrfeld, Jopp & Somer (2016) reported that over
half the MDers described a strong urge to begin daydreaming immedi-
ately upon awakening or to return to a daydream immediately after being
interrupted by a real-world event. MDers seemed able to suppress their
daydreaming when they absolutely had to (i.e., when in public), but expe-
rienced diﬃculty ﬁghting the urge to daydream in other circumstances
(Biegelsen et al. 2016). Recently Somer et. al., (2016) showed that craving (for
daydreaming) is a salient feature of MD. In a conﬁrmatory factor analysis
of the maladaptive daydreaming scale (MDS), the authors showed that the
three-factor construct of MD includes “yearning,” a cluster of symptoms
that reﬂect the appeal of daydreaming, and intense craving to engage in
this activity. Together, these ﬁndings seem to correspond with the DSM-
5, which lists craving as an important symptom of any addiction. In this
case, MD is best classiﬁed as a nonsubstance addictive behavior or a behav-
ioral addiction, similar to gambling, Internet use, video-game playing, sex,
exercise, and shopping addictions. These disorders bear some resemblance
to alcohol and drug dependence despite the fact that no substances are
ingested. Hence, I conclude that informed treatment of MD should share
elements from evidence-based treatments for nonsubstance or behavioral
Psychotherapy for Maladaptive Daydreaming 7
The case report that is the focus of the current paper addresses another
noteworthy form of mental escapism: excessive Internet use. Internet addic-
tion disorder (IAD, Pies, 2009). IAD was identiﬁed as a signiﬁcant modern
public health problem (Weinstein & Lejoyeux, 2010) and has been con-
sidered for inclusion in the DSM-5. Like MD, IAD was conceptualized
as a behavioral addiction, with features resembling those of obsessive-
compulsive spectrum and impulse-control disorders (Cash, Rae, Steel, &
MD as an Obsessive-Compulsive Spectrum Disorder
In this section I discuss what some scholars have argued—that behavioral
addictions are best classiﬁed as obsessive-compulsive spectrum disorders
(e.g., Allen, King, & Hollander, 2003).
MD is characterized by chronic diﬃculties in controlling the impulse
for recurrent and extensive daydreaming. From this perspective, MD shares
some characteristics with the DSM-5 classiﬁcation of impulse-control disor-
ders such as gambling, kleptomania and pyromania in that individuals with
these disorders have lost control, have an irresistible impulse to perform
dysfunctional acts, and may consequently harm themselves. As in disor-
ders that were previously known as “impulse-control disorders,” MDers
report a pre-act arousal and/or tension. Moreover, engaging in this men-
tal behavior results in relief or gratiﬁcation that is sometimes followed by
guilt. MD is characterized by an inability to resist the urge to daydream
and is often progressive. Gambling disorder (GD), the only nonsubstance
use disorder currently listed in the DSM-5, has also been hypothesized
to represent an obsessive-compulsive-spectrum disorder (Blanco, Moreyra,
Nunes, Sáiz-Ruiz, & Ibañez, 2001; Hollander & Wong, 1995). Whether GD
and MD should be construed as “compulsive,” “impulsive,” or “impulsive-
compulsive” remains an unanswered question. There may be some overlap
in the underlying psychobiology of obsessive-compulsive disorder (OCD)
and that of certain behavioral addictions (Chamberlain, Blackwell, Fineberg,
Robbins & Sahakian, 2005), although a review of pertinent research sug-
gests more diﬀerences than similarities between these disorders and OCD
(Phillips et al., 2010).
The disagreement concerning the theoretical classiﬁcation of behav-
ioral addictions notwithstanding, there is some evidence that both GD
and MD responded to medication believed to inﬂuence obsessiveness
and/or compulsiveness. For example, Allen, King and Hollander (2003)
demonstrated the possible eﬃcacy of selective serotonin reuptake inhibitors
(SSRIs) in GD. Their studies assessed the eﬃcacy and tolerability of the
SSRI ﬂuvoxamine in GD without comorbidities and found that ﬂuvoxam-
ine reduced gambling urges and behavior. Similarly, Schupak and Rosen-
thal (2009) reported the successful treatment of a patient presenting with
chronic MD. The patient reportedly responded favorably to ﬂuvoxamine
therapy, stating that it helped control her daydreaming. The fact that this
patient responded to a medication that inﬂuences serotonergic tone might
imply neurochemical irregularity. Further research is needed before more
robust inferences could be made about the possibility that at least some
compulsive daydreaming may be related to obsessive-compulsive spectrum
Client Background Information
Ben is a 25-year-old single Israeli, undergraduate history student, at a major
university who lives in student housing. He has a sister who is three years
younger than he. He described his parents as loving and supportive and
portrayed his childhood as safe, fairly happy, and characterized by a pen-
chant for daydreaming. Ben has been an avid guitar player since childhood.
He indicated that during adolescence he wasted many hours imagining
himself on stage performing in front of big crowds that included attractive,
admiring female classmates.
Ben wrote to me after reading an outdated call for research participants
posted on a Facebook community of individuals struggling with MD. In
his email, Ben indicated he was willing to participate in any MD study and
that he was particularly eager to help promote knowledge about MD and
its treatment . He reported daydreaming intensely and extensively since
early childhood. He enjoyed daydreaming immensely despite the fact that
this mental activity resulted in dreadful compromises in his daily function-
ing. A year before he contacted me, Ben had begun psychotherapy at his
university student counseling center. His presenting problems were con-
centration problems and depression. He informed his therapist at that time
about his daydreaming. She understood his MD as a symptom of atten-
tion deﬁcit/hyperactivity disorder (ADHD), the diagnosis she assigned to
him and, as a regressive mode of coping with stress. The clinic’s consult-
ing psychiatrist prescribed the psychostimulant Methylphenidate (Ritalin),
the medication most commonly prescribed for ADHD. Methylphenidate
was titrated gradually to 20 mg orally twice a day as a maintenance dose.
Although the medication improved his ability to concentrate in class and
sporadically improved his ability to work at the university library, it also
enhanced his concentration on daydreaming, particularly when he was
alone in his apartment, resulting in a 50% increase in daydreaming time.
Ben discontinued taking his medication after two weeks because of its para-
doxical eﬀect on his daydreaming and his realization that it resulted in
daily bouts of depression occurring four to ﬁve hours following ingestion.
Because he felt his gains were negligible, Ben terminated his psychotherapy
after six months.
Psychotherapy for Maladaptive Daydreaming 9
When Ben presented himself for treatment, he complained of day-
dreaming several hours every day. He stated that his MD had compromised
his studies, his ability to practice guitar and to take part in proﬁtable gigs
as well as his dating and social life. He reported having no close friends
on campus and stated he had not been in a serious romantic relationship
in ﬁve years. He reported his concern that he might be missing the “right”
match for him while he was dating his current partner. Ben tended to drift
into daydreaming to envision an idealized future with a “perfect” girlfriend
and to see himself as a successful scholar or an accomplished musician. He
used daydreaming as an antidote to boredom, to contemplate the mean-
ing and purpose of his life, to elaborate and embellish on book and movie
plots, to “revise and improve” subjectively unsatisfactory interactions and
to escape depressive guilt associated with his MD-related procrastination.
Listening to music, watching music videos, jogging and pacing were strong
MD triggers and facilitators. Ben was also concerned about his tendency to
spend considerable time surﬁng the Internet.
During the initial evaluation, Ben was administered a screening question,
several self-report questionnaires, and a structured diagnostic interview, as
described in the following.
•Screening question. Ben ﬁrst responded to an MD classiﬁcation ques-
tion that during our initial correspondence helped identify him as
someone potentially suﬀering from MD (see Somer et al., 2017). Based
on the screening question, Ben conﬁrmed his daydreaming as mal-
•The 16-item Maladaptive Daydreaming Scale (MDS; Somer et al.
2016). The MDS is a 14-item self-report MD questionnaire. Based on
evidence about the important role of music in MD (Somer, Somer, &
Jopp, 2016b), two additional items were added to the previously pub-
lished MDS that gauge the relevance of music in the respondent’s
MD experience. In this case report the revised 16-item MDS (MDS-
16; Somer et al., 2017) was used. This measure was administered two
additional times: initially at the end of therapy, and later during a two-
month follow-up session.
The structured clinical interview for maladaptive daydreaming
(SCIMD, Somer et al., 2017). The SCIMD was developed based on pro-
posed diagnostic criteria for MD. It consists of a 10-question probe (and
subsequent additional follow-up questions) for inclusion criteria and
one probe (and its follow-up questions) for an exclusion criterion. The
SCIMD has demonstrated both good interrater reliability and excellent
10 Eli Somer
Cohen’s kappa values for the agreement rate between the SCIMD diag-
nosis and a self-report measure for the disorder. Ben’s SCIMD inter-
view yielded a diagnosis of “maladaptive daydreaming—severe”—a
diagnosis that met the inclusion criteria for this case study.
•Average daily daydreaming time. Ben was instructed to monitor his
daily daydreaming time for a period of one week. The data indicated
that Ben spent an average of 169 minutes per day daydreaming. This
measure was administered two more times: at the end of therapy and
during the two-month follow-up session.
•Average daily Internet use time. Ben was instructed to monitor his
daily time spent using the Internet for a period of one week. The data
indicated that Ben spent an average of 150 minutes per day using the
Internet. This measure was administered two more times: at the end of
therapy and during the two-month follow-up session.
•Average daily MD pleasure. Ben was asked to rate the level of plea-
sure he derived from his daily daydreaming. His weekly average level
of daily enjoyment was 43 on a scale ranging 1-100, indicating a low-
moderate level of pleasure. This measure was administered two more
times: at the end of therapy and during the two-month follow-up ses-
•The Obsessive–Compulsive Inventory-Revised (OCI-R; Foa et al.,
2002) is an 18-item self-report measure assessing symptoms of
obsessive–compulsive disorder. Recommended cutoﬀscore is 21, with
scores at or above this level indicating the likely presence of OCD (Foa
et al., 2002). Ben’s score on the OCI-R was 7, well below the clinical
cutoﬀfor the disorder. His score exclusively resulted from his endorse-
ment of items describing obsessions. A debrieﬁng of Ben’s endorsed
items clariﬁed that he was mostly distressed about his current life
and obsesses about desired future developments. His obsessions were
usually followed by immersive daydreaming about the fantasized out-
comes. This measure was administered two more times: at the end of
therapy and during the two-month follow-up session.
•The Work and Social Adjustment Scale (WASAS; Marks, 1986) is a
simple 5-item self-report scale of functional impairment attributable to
an identiﬁed problem. The WASAS is rated on a 9-point scale (0–8). It is
a reliable and valid measure of impaired functioning (Mundt, Marks,
Shear, & Greist, 2002). A sample item is: “Because of my maladaptive
daydreaming, my ability to work is impaired.” A score of 0 indicates
“not at all impaired,” whereas an 8 indicates “very severely impaired
to the point I can’t work.” WASAS scores between 10 and 20 are associ-
ated with signiﬁcant functional impairment (Mundt et al., 2002). Ben’s
Psychotherapy for Maladaptive Daydreaming 11
score was 19, well above the clinical cutoﬀ, indicating substantial mal-
adaptation. This measure was administered two more times: at the end
of therapy and during the two-month follow-up session.
Ben reported a life-long, probably innate, capacity for immersive daydream-
ing characterized by an intense sense of presence. He had developed his
intense dissociative absorption not only into a freestanding source of daily
pleasure, but also into a rewarding distraction from daily boredom and
worries. The client’s habit had developed into a time-consuming addictive
behavior with a detrimental impact on his social life, his studies and his
music career. Ben’s problems were exacerbated by two additional processes:
1) time-consuming obsessive thoughts, mainly about a desired future, and
2) excessive Internet use serving as an additional escapist activity. The objec-
tive assessment (SCIMD, Somer, et al. 2017) showed that he met the sug-
gested diagnostic criteria for MD. Daydreaming and Internet use, respec-
tively, consumed 169 and 150 minutes of each day. His escapist activities
deprived him of more than ﬁve of his daily waking hours, signiﬁcantly com-
promising his functioning. As is typical of addictive patterns, Ben resorted
to more daydreaming and Internet use to soothe his distress associated with
wasting time. In the absence of any guidelines for the treatment of patho-
logical absorption such as MD, it was decided to explore existing treatment
modalities shown to be eﬀective for behavioral addictions such as Internet-
use disorder, OCD, and ADHD/mind wandering.
Studies on cognitive behavior therapy (CBT) for substance-use disorder
demonstrate that length of treatment can vary greatly. However, some cor-
relational studies indicate a positive relationship between longer duration
and positive outcome (Simpson, Joe, & Brown, 1997). Without existing
guidelines for the treatment of MD, and given the pioneering nature of the
planned treatment, a relatively longer CBT duration was chosen. In consid-
eration of budgetary constraints, Ben’s experimental therapy was limited
from the onset to a treatment of duration of six months or less. Neither
Ben nor the therapist received any monetary compensation for the treat-
ment. The therapist and Ben developed the treatment modalities together
by consulting and revising various coping strategies and tailoring them to
Ben’s own needs and preferences. Despite several setbacks and occasional
relapses, Ben monitored his MD/Internet use on a daily basis and reported
the results in writing every week. After six months, Ben’s therapy was ter-
minated because the designated treatment time ran out. Because Ben lived
far from the treating therapist’s oﬃce, the decision was made to conduct the
therapy via a secure video conference service. Remote and Internet-based
12 Eli Somer
therapy has long been demonstrated to be as eﬀective as face-to-face therapy
(e.g., Barak, Hen, Boniel-Nissim & Shapira, 2008).
As discussed above, no treatment modalities have been developed for
non-trauma-related, benign, extensive absorption (Carlson & Putnam, 1993;
Kihlsrom, 2005). In creating a treatment plan for Ben’s MD, interventions
pertinent to the treatment OCD-spectrum and attention deﬁcit disorders
Motivational interviewing (MI). Addictions are often regarded as dis-
orders of motivation (Heather, 1992). A person with an addiction disorder
exhibits an inclination for self-defeating behavior that is obviously con-
trary to the individual’s long-term welfare. Persons suﬀering from addictive
disorders are often puzzled by, disapprove of, and wish to change their
own self-destructive behavior (Heather, 1998). One of the most important
challenges in addiction psychotherapy is the fostering of suﬃcient moti-
vation to oﬀset the rewarding characteristics of the addictive substance or
behavior. Motivational interviewing (MI) has repeatedly demonstrated its
eﬀectiveness in addiction psychotherapy (Heather, 2004). The ﬁrst element
included in Ben’s treatment was MI, a client-centered yet directive method
for enhancing intrinsic motivation to change by exploring and resolving
client ambivalence (Miller & Rolnick, 2002). MI was used to help Ben relin-
quish his MD and excessive Internet use behaviors. By using techniques
such as openended questions, reﬂective listening, aﬃrmation, and sum-
marization that help individuals express their concerns about change, Ben
was able to develop new behavioral skills (Miller, 2010). MI allowed Ben
to become more aware of the impending complications, consequences and
jeopardies resulting from his escapist absorption. In addition, he was able
to visualize a better future, contemplate what might be gained through
change, and become increasingly motivated to commit himself to the ardu-
ous work involved in controlling his MD (Brodie, Inoue & Shaw, 2008;
Cummings, Cooper & Cassie, 2009). This strategy helped Ben to think dif-
ferently about his behavior and ultimately consider changing it. The initial
phase of therapy focused on Ben’s motivation to change his MD and his
excessive Internet use. The therapeutic rationale was that his addiction was
inconsistent with his stated personal values, desired self-image, and goals
Cognitive-behavior therapy. Typically, traditional substance depen-
dency treatment aims for total abstinence from maladaptive behaviors.
However, in Ben’s case, total abstinence was not the goal, primarily because
daydreaming is a universal experience comprising much of normal mental
activity (Klinger, 2009). Instead, it was decided to help him curb his exten-
sive uncontrolled bouts of daydreaming, abstain from problematic appli-
cations (such as Facebook), and engage in scheduled rather than impul-
sive Internet usage (Petersen, Weymann, Schelb, Thiel & Thomasius, 2009).
Psychotherapy for Maladaptive Daydreaming 13
Inspired by Young’s work with Internet use disorder (2007) and by the
work of Solanto and her colleagues with ADHD (Solanto, Marks, Mitchell,
Wasserstein, & Kofman, 2008), CBT interventions were included to teach
Ben contingent self-reward, time- and task-management, implementation of
learned relaxation and mindfulness skills, problem solving, and planning
for future academic and work-related goals. Following are speciﬁc examples
of the CBT component of his treatment:
•Throughout the treatment, Ben self-monitored his target behaviors and
maintained a diary in which he noted the circumstances surrounding
his MD and Internet use as well as his associated thoughts and feelings.
•Every evening Ben prepared a detailed schedule for the next day’s
activities in which he designated a single, late evening hour for recre-
ational Internet use.
•Ben read the day’s plan in the mornings and reread a printed copy of
the schedule several times a day.
•To suppress the reinforcing pleasure of his MD, Ben strove to inter-
cept his developing MD plots as early as possible and to terminate
these plots with negative or aversive endings (e.g., a distressful twist
to the fantasized plot, a reminder from his MI that daydreaming is a
detestable, self-destructive act).
•Ben was instructed to reinforce himself with self-praise for successful
interceptions of MD.
•Ben maintained accountability by texting reports of self-monitored
MD/Internet time and coping measures. Intermittent feedback was
provided in the form of encouraging text messages or brief phone
coaching sessions to remind him of the skills and resources available
to him (e.g., calling his girlfriend).
•Ben is an avid jogger, and kinesthesia is a known trigger for MD
(Somer, 2002; Somer, et al. 2016a). Indeed, Ben tended to get lost in
his daydreaming while jogging, sometimes extending his exercise time
to three times his originally allocated time. Ben controlled his day-
dreaming while jogging by running mindfully, as per the mindfulness
training described below.
•Ben learned to employ a number of coping statements he found very
convincing and helpful: “Daydreaming is detrimental to me—it is a
harmful addiction”; “I will mindfully deal with my distress in the
present rather than escape into a future fantasy”; “I will recognize
obsessive worries as OCD symptoms rather than as real concerns and
will deal with them mindfully rather than daydream about solutions”;
“Problems in life can only be addressed in the present.”
14 Eli Somer
•Despite his yearning for a meaningful romantic relationship, Ben was
tormented by perfectionistic and obsessive doubts that hampered his
ability to maintain a satisfactory durable relationship. Ben responded
to cognitive and acceptance- and commitment-informed therapy (ACT;
Hayes, Strosahl & Wilson, 2012) interventions. He learned to recognize
his doubts as obsessions rather than as reality-based concerns, to accept
that his “ideal match” is an unattainable fantasy and to acknowledge
that it was better to be mindful of his experience with his current
partner than to daydream about a coveted “ultimate lady.”
Mindfulness training. Mindfulness is a psychological process of Bud-
dhist origins. It involves shifting one’s attention to experiences occurring in
the present moment. Mindfulness can be developed by practicing medita-
tion training (Kabat-Zinn, 2013). Converging scientiﬁc evidence has begun
to corroborate the positive impact of mindfulness meditation on a vari-
ety of psychological conditions. The inclusion of mindfulness training in
Ben’s treatment is based on evidence that it enhances attention (MacLean
et al., 2010), decreases mind wandering and improves cognitive perfor-
mance (Mrazek, Franklin, Phillips, Baird, & Schooler, 2013). Mindfulness
meditation has been associated with signiﬁcant reductions in alcohol, mar-
ĳuana, and crack cocaine use (Bowen et al., 2006) and with reduced relapse
risk in substance-use disorders (Bowen et al., 2014). Therefore, it may be an
important modality in the treatment of MD.
Ben became an enthusiastic mindfulness disciple. He practiced it as
a morning routine and as a versatile mode of coping with a variety of
Ben’s more grounded life experience in response to therapy had several
manifestations elucidated below. One poignant modiﬁcation he introduced
into his life involved a stable romantic relationship. Three months into ther-
apy Ben met a female student on campus whom he consciously decided to
“tolerate” for the sake of his therapy. As time progressed, he developed a
meaningful, tender attachment to her and reported enjoying her wit and her
caring behaviors. This relationship, the longest since he was in high school,
was still going strong during the follow-up session. This, however, was a
positive side eﬀect of the main goals of this treatment. Based on an ontolog-
ical analysis of MD, the aim was to discover whether derivative treatment
modules can help alleviate MD behaviors and distress.
Data collected at termination of therapy and at a two-month follow-
up showed a 53% and 57% reduction in daydreaming time, respectively,
and a 79% and 73% reduction in Internet use time, respectively (See Fig-
ure 1). According to Global Web Index, a technology company that provides
audience proﬁling data, digital consumers claim to be spending an average
Psychotherapy for Maladaptive Daydreaming 15
FIGURE 1 Average daily duration of daydreaming and Internet use (in minutes)
of almost two hours per day on social networks and messaging (Mandler,
2016). Ben’s total daily time spent on the Internet at follow-up was 41 min-
utes. Compared to 2016 global ﬁgures, his rate of Internet consumption was
relatively low. Therefore, complete abstinence from either activity may not
be a reasonable expectation.
Figure 2 shows repeated measurement of Ben’s work and social adjust-
ment index as evaluated before treatment, immediately after the end
of treatment, and at two-month follow-up. The results demonstrated an
improvement of 86% and 71%, respectively (lower WASAS scores reﬂect
In light of these favorable objective ﬁndings, it was important to gauge
the reﬂected changes in Ben’s self-reported MD experiences. Ben’s MDS-16
score was 65.6 before therapy, 54.4 at the end of therapy and 58.8 at follow-
up, reﬂecting a 17% and 10% subjective decrease, a considerably smaller
diﬀerence than in his objective measures. Reported changes in Ben’s daily
pleasure levels experienced during daydreaming may shed some light on
the discrepancy between the objective and the subjective MD measures.
Ben’s daydreaming pleasure appraisals rated on a 1–100 scale measured at
therapy onset, termination, and follow up were 43, 34, and 35, respectively.
These changes reﬂect modest post-therapy reductions in daydreaming grat-
iﬁcation of 20% and 19% respectively, demonstrating the continued lure of
this mental activity.
16 Eli Somer
FIGURE 2 Work and Social Adjustment Scale (WASAS) scores*
Note. *Lower scores reﬂect better adjustment
Finally, in light of Ben’s obsessional habits, his mean OCI obses-
sion symptoms were examined. His obsession scores across the three
measurements—before, after, and at follow-up—were 5, 1, and 2, respec-
tively, reﬂecting an 80% and 60% improvement post-therapy and at fol-
This paper represents the ﬁrst known documented attempt to treat an indi-
vidual presenting with MD. An ontological analysis of MD portrayed this
absorption disorder as emanating from a mental capacity, possibly an innate
characteristic. This mental process is invariably experienced at ﬁrst as highly
rewarding, leading some individuals to indulgence that can go awry and
develop into an addictive habit. It is proposed that MD be considered a
dissociative absorption disorder and as either an OCD-spectrum disorder
or a behavioral addiction. Unlike other dissociative disorders, no evidence
has yet shown that childhood trauma is either suﬃcient or necessary for
the development of MD. This strongly suggests that treatment guidelines
developed to help dissociative survivors of childhood abuse may not be
pertinent for many, if not most, MD cases.
Psychotherapy for Maladaptive Daydreaming 17
Ben’s case study demonstrates the integration of several treatment
modalities that have exhibited eﬃcacy in the treatment of substance use
and OCD-spectrum disorders as well as behavioral addictions. This integra-
tive approach contributed to a stable decrease in target behaviors (duration
of daydreaming and Internet use), underlying obsessions, and also work
and social dysfunction. It is known, however, that several etiological path-
ways may contribute to the development of MD. For example, my own
research identiﬁed a subpopulation of MDers with a background of child-
hood trauma (Somer, 2002; Somer, Somer & Jopp 2016a). Other research
established childhood abuse (Somer, 2003; Somer, Altus & Ginzburg, 2010)
and disordered attachment styles (e.g., Flores, 2001; Zapf, Greiner & Car-
oll, 2008) as contributors to later life addictions. It is recommended that a
careful assessment for a history of childhood trauma and attachment styles
for MD clients be taken as some individuals may beneﬁt from transference-
aware psychodynamic psychotherapy strategies.
One unresolved issue is the discrepancy between the encouraging
objective outcomes and the MDS-16 data. Although changes in the self-
report measure were consistent with actual behavioral changes, the scale
reﬂected an apparently smaller improvement. Several factors may account
for this diﬀerence. First, Ben’s perfectionism, often a prime instigator of
compensatory daydreaming themes, left him constantly unsatisﬁed with
his gains in therapy. Unavoidable lapses were very discouraging to him
and occasional setbacks were very painful for him, particularly as the ther-
apy approached its predetermined end. A second explanation for this gap
relates to the nature of the MDS-16 items. Most of them address essential
qualities of the phenomenon rather than quantitative measures. For exam-
ple, if music and movement are still experienced as potential triggers for
daydreaming, these items may still be highly endorsed even if the respon-
dent shows improved control over his actual daydreaming. Future revisions
of the MDS-16 should perhaps consider adding measures of the target
behaviors. Finally, subjective changes in Ben’s MD behavior were experi-
enced as relatively small because the level of pleasure associated with MD
showed only a slight decrease following treatment. In other words, day-
dreaming subjectively remained as alluring post-therapy as it was in the
pretreatment measurement, leaving Ben with a subjective sense that he is
still at risk of addiction. This experience has been recognized by a 12-step
fellowship of individuals who are recovering from addiction to fantasy and
other escapist behaviors (EFAA—Escapism and Fantasy Addicts Anony-
mous, 2017). The 12-step process involves admitting that one cannot control
one’s addiction or compulsion and that only a higher power can help (Van-
denBos, 2007). Incidentally, among other positive ﬁndings, reviews of the
12-step literature (e.g., Krentzman et al., 2010) noted that participation in
such groups is associated with a greater likelihood of prolonged abstinence,
improved psychosocial functioning and greater levels of self-eﬃcacy. Future
18 Eli Somer
studies should therefore assess the eﬀectiveness of structured mutual sup-
port groups similar to EFAA for the treatment of MD, either as primary or
This paper describes a pioneering eﬀort, or, as I aﬀectionately told Ben:
“You are MD’s patient 001.” In an embryonic ﬁeld such as MD, case studies
are essential both as initial hypodeductive processes that can help formulate
early treatment ideas and as a reciprocal inductive theory-building process.
Clearly, this is only the ﬁrst step. A more thorough study of online discourse
in MD peer-support communities and focus-group research is warranted to
yield valuable information from experts by experience (the suﬀerers) and
derivative intervention ideas. Another limitation of this case report is the
possible confounding variable of conﬁrmation bias. The author, a leading
researcher in the ﬁeld of MD, took on the roles of both the therapist and
the primary instrument of data collection and analysis. Future case replica-
tion studies by other clinicians and controlled psychotherapy research are
necessary to shed further light on the treatment needs of this population.
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