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TRASTORNO DE ENSOÑACIÓN EXCESIVA: CARACTERÍSTICAS CLÍNICAS Y NEUROPSICOLÓGICAS DEL PRIMER CASO DESCRITO EN ESPAÑA. MALADAPTIVE DAYDREAMING: CLINICAL AND NEUROPSYCHOLOGICAL FEATURES OF THE FIRST CASE REPORTED IN SPAIN
Abstract
El trastorno de Ensoñación Excesiva (TEE) constituye una condición psicopatológica recientemente definida y poco conocida, caracterizada por la presencia de fantasías diurnas complejas y recurrentes hasta extremos disfuncionales. Se desconoce la prevalencia del TEE a nivel mundial, destacando algunos autores su alta comorbilidad con otros trastornos mentales, especialmente con el Trastorno por Déficit de Atención/Hiperactividad (TDAH). En este trabajo presentamos el primer caso de TEE descrito en España, en una paciente joven que acude a los Servicios de Salud Mental por otros motivos. La evaluación clínica constata varios trastornos mentales comórbidos, entre ellos TEE, pero no TDAH ni alteraciones neuropsicológicas llamativas. Se discute el caso en el contexto de la investigación sobre efectos cognitivos de la ensoñación y la divagación mental, sugiriéndose la hipótesis de distintas variantes del TEE dependiendo de la afectación (o no) atencional-ejecutiva. Se discuten también algunas cuestiones relativas al tratamiento psicológico del TEE. La detección de este primer caso en España subraya la conveniencia de explorar síntomas compatibles con TEE en entornos clínicos y contribuye a sumar evidencia sobre esta patología, siendo necesario adaptar a diversas poblaciones los instrumentos de medida existentes y depurar su caracterización sindrómica antes de que pueda plantearse como un nuevo trastorno dentro de los sistemas clasificatorios
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Maladaptive daydreaming (MD) is a newly identified condition characterized by absorption in fantasy, which appears to progress into psychological dependence, associated with substantial distress and maladaptation. This study determines, for the first time, the psychometric properties of the 16-item Maladaptive Daydreaming Scale (MDS-16), an updated version of the MDS-14 (Somer, Lehrfeld, Bigelsen, & Jopp, 2016), originally designed to identify maladaptive daydreaming experiences. The MDS-16 was administered in a multicountry Arab sample composed of 180 respondents aged 18 to 58 years (M = 26.28, SD = 8.14). Our analyses indicated 2 strongly related factors underlying the MDS-16, capturing immersive daydreaming and the distress and impairment associated with it. The MDS-16 demonstrated sound psychometric properties and differentiated well between self-identified individuals with and without MD on a range of psychosocial indicators. The instrument had high sensitivity and specificity, implying that the MDS-16 can confidently be deployed in future investigations of MD in the Arab world. Our findings shed light on the potential value of the MDS-16 for international inquiry of this newly defined condition.
Background and aims: Maladaptive daydreaming (MD) has many features of behavioural
addiction but research exploring this syndrome is limited. This case study provides a
qualitative exploration of MD.
Method: A structured clinical interview and mental state examination of a patient with MD
was video-recorded and transcribed verbatim. Transcripts were subjected to the interpretative phenomenological analysis.
Results: MD 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 behavioural addictions.
Background: Maladaptive Daydreaming (MD) characterizes individuals who engage in vivid, fanciful daydreaming for hours on end, neglecting real-life relationships and responsibilities, resulting in clinical distress and functional impairment. Sufferers have embraced the term MD in cyber-communities devoted to this problem because it seemed to uniquely fit their experience and since existing diagnostic labels and their therapies seemed inadequate. However, scientific research in the field has been scarce, relying on cross-sectional or case study designs. Existing knowledge on MD suggests the involvement of dissociative and obsessive-compulsive symptoms, as well as positive reinforcement comparable to processes in addiction disorders. The present study aimed to rigorously explore factors that accompany MD employing a longitudinal daily-diary design, hypothesizing that temporal increases in MD will associate concurrently with, and will temporally precede, other symptoms and emotional changes. In addition, we aimed to explore which symptoms may act as precursors to increases in MD, in order to identify possible mechanisms bringing about daydreaming in these individuals.
Methods: In a sample of 77 self-diagnosed individuals with MD we assessed relevant daily symptoms for 14 days, including MD, depression, general anxiety, social anxiety, obsessive-compulsive symptoms, and dissociation, as well as positive and negative emotion.
Results: Increases in MD were strongly related to concurrent increases in all other symptoms and negative emotion, and to decreased positive emotion. Obsessive-compulsive symptoms, dissociation, and negative emotion also temporally followed MD. Obsessive-compulsive symptoms were the only consistent temporal antecedent of MD.
Conclusions: MD and obsessive-compulsive symptoms coincided in what seems to be a vicious cycle; understanding possible shared mechanisms between these symptoms may inform our understanding of the etiology of MD. For example, Serotonin levels may possibly be involved in the development or maintenance of this condition. The findings may also provide clues as to potentially beneficial interventions for treating MD. For example, perhaps utilizing response prevention techniques may be useful for curbing or intercepting unwanted daydreaming. Future studies on MD should address its compulsory nature.
This study explored the relationships of childhood trauma, social anxiety absorption and fantasy dependence with maladaptive daydreaming (MD), a newly discovered behavioral addiction involving pervasive immersive, fanciful daydreaming that creates distress and dysfunction. Based on the responses of 315 university students, our data showed that MD correlated significantly with childhood trauma and social anxiety, with moderate effect sizes for both correlations. MD also significantly correlated with absorption and fantasy addiction with large effect sizes. After controlling for the relationships between the independent variables, childhood trauma and social anxiety no longer significantly correlated with MD, implying mediation. Although absorption did not mediate the relationship between social anxiety and MD, our mediation model suggested that childhood trauma and social anxiety may be independent risk factors for MD and that addiction to fantasy was an important mediating variable, explaining 65% of MD variance.
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 daydreaming , consumed many hours of his day and produced distress, dysfunc-tion, and excessive Internet use. Ontological analysis resulted in classifying 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 modalities 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 daydreaming scale score and his self-assessed pleasure derived from daydreaming showed more modest gains. I discuss this discrepancy and suggest future research directions.
In order to determine the comorbidity profile of individuals meeting criteria for a proposed new disorder, Daydreaming Disorder (more commonly known as Maladaptive Daydreaming, MD), the Structured Clinical Interview for DSM-5 and the Structured Clinical Interview for DSM-IV Dissociative Disorders were administered to 39 participants who met criteria for MD on a structured interview. We determined high rates of comorbidity: 74.4% met criteria for more than three additional disorders and 41.1% met criteria for more than four. The most frequent comorbid disorder was attention deficit hyperactivity disorder (76.9%); 71.8% met criteria for an anxiety disorder; 66.7% for a depressive disorder; and 53.9% for an obsessive-compulsive or related disorder. Notably, 28.2% have attempted suicide. Individuals meeting criteria for MD suffer from complex psychiatric problems spanning a range of DSM-5 disorders. This finding provides evidence that MD is different than normal daydreaming, and that these individuals experience considerable distress and impairment.
Daydreaming, a common mental activity, can be excessive and accompanied by distress and impaired functioning in daily life. Although currently not formally identified by diagnostic manuals, daydreaming disorder (maladaptive daydreaming-MD) is a clinically well-defined phenomenon. However, research is lacking regarding the diagnostic reliability of MD. Our aims were: (1) to develop diagnostic criteria and a structured interview for MD, (2) to examine the reliability of this measure for distinguishing individuals with and without MD, and (3) to establish an optimal cutoff score for identifying clinical-level MD using an existing self-report measure. Thirty-one individuals who met screening criteria for MD and 31 matched controls completed the self-report measure and participated in two structured clinical interviews. Each participant was interviewed independently by two clinicians blind to the participant’s group membership. Cohen’s kappa values for the agreement rate between each interviewer and the screening criterion, and between the two interviewers, ranged from good to excellent (k=.63-.84). A cutoff score of 50 on the self-report measure yielded nearly perfect sensitivity and specificity and good-to- excellent agreement between the self-report measure and the interview (k=.68-.81). Our interviews were conducted over the Internet, rather than in person; results might have been influenced by self-selection; and interviewing wider samples is warranted. We found that MD can be diagnosed reliably using a structured interview developed for that purpose. The new diagnostic interview showed excellent agreement with a self- report measure for the disorder. Additionally, we identified a useful cutoff score identified for future self-report research.
Both theoretical and empirical findings have demonstrated similarities across diagnoses, leading to a growing interest in transdiagnostic interventions. Most of the evidence supporting transdiagnostic treatment has accumulated for depression, anxiety, and eating disorders, with minimal attention given to posttraumatic stress disorder and other reactions to traumatic stressors. Although single-diagnosis protocols are effective for posttraumatic stress disorder (PTSD) and other trauma-related disorders, in principle, transdiagnostic approaches may have beneficial applications within a traumatized population. This paper defines different types of transdiagnostic treatments, reviews transdiagnostic approaches used in related disorders, and discusses their applicability to PTSD. Examples are drawn from existing transdiagnostic treatments in order to provide a framework for the application of such interventions to the field of traumatic stress. Implications for implementation and dissemination are also discussed.
Conscious experience is fluid; it rarely remains on one topic for an extended period without deviation. Its dynamic nature is illustrated by the experience of mind wandering, in which attention switches from a current task to unrelated thoughts and feelings. Studies exploring the phenomenology of mind wandering highlight the importance of its content and relation to meta-cognition in determining its functional outcomes. Examination of the information-processing demands of the mind-wandering state suggests that it involves perceptual decoupling to escape the constraints of the moment, its content arises from episodic and affective processes, and its regulation relies on executive control. Mind wandering also involves a complex balance of costs and benefits: Its association with various kinds of error underlines its cost, whereas its relationship to creativity and future planning suggest its potential value. Although essential to the stream of consciousness, various strategies may minimize the downsides of mind wandering while maintaining its productive aspects. Expected final online publication date for the Annual Review of Psychology Volume 66 is November 30, 2014. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
Human minds often engage in thoughts and feelings that are self-generated rather than stimulus-dependent, such as daydreaming. Recent research suggests that under certain circumstances, daydreaming is associated with adverse effects on cognition and affect. Based on recent literature about the influence of resting mind in relation to rumination and depression, this questionnaire study investigated mechanisms linking daydreaming to depressive symptoms. Specifically, an indirect effect model was tested in which daydreaming influences depressive symptoms through enhancing self-focus and ruminative thought. Results were in line with the hypothesis and several alternative pathways were ruled out. The results provide initial supportive evidence that daydreaming can influence depressive symptoms through influences on self-focus and rumination. Further research should use prospective or experimental designs to further validate and strengthen these conclusions.
Maladaptive daydreaming (MD) is extensive fantasy activity that replaces human interaction and/or interferes with academic, interpersonal, or vocational functioning. This qualitative inquiry explored the nature and experience of MD. Six patients in a trauma practice were identified as displaying MD. Four participants were diagnosed as suffering from a dissociative disorder; two were given the diagnosis of narcissistic personality disorder. Cross-sectional analysis of respondents' verbatim transcripts yielded nine themes clustered into three categories (Functions, Themes, and Dynamics) that best captured the fantasizing experience. Identified MD functions included Disengagement from Stress and Pain by Mood Enhancement and Wish Fulfillment Fantasies; and Companionship, Intimacy, and Soothing. Recurrent MD themes were Violence; Idealized Self; Power and Control; Captivity; Rescue and Escape; and Sexual Arousal. Motifs that were classified as describing MD dynamics were Onset and Kinesthetic elements. Although MD seemed to have been preceded by a normal childhood propensity for creative imagination, aversive circumstances were seen to have contributed to the development of MD. Theoretical explanations for the development and function of MD are discussed.
The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inner-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
The experiences of 90 individuals who self-identify as "excessive" or "maladaptive" fantasizers are summarized in this report. Our sample consisted of 75 female and 15 male participants, ranging in age from 18 to 63 who responded to online announcements. Participants completed a 14-question emailed survey requesting descriptions of their fantasy habits and causes of potential distress regarding fantasy. Results demonstrated that participants shared a number of remarkably specific behaviors and concerns regarding their engagement in extensive periods of highly-structured, immersive imaginative experiences, including the use of kinesthetic activity which accompanies the fantasies of 79% of participants. Participants reported distress stemming from three factors: difficulty in controlling the need or desire to engage in fantasizing; concern that the quantity of fantasizing interfered with actual relationships and endeavors; and intense shame and exhaustive efforts to keep this behavior hidden from others. It is hoped that this report will encourage interest in this elusive syndrome.
Importance
Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments.
Objective
To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders.
Design, Setting, and Participants
From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat.
Interventions
The UP or SDPs.
Main Outcomes and Measures
Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs.
Results
Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, −0.93; 95% CI, −1.29 to −0.57) and SDPs (Cohen d, −1.08; 95% CI, −1.43 to −0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (β, 0.25; 95% CI, −0.26 to 0.75) and from baseline to the 6-month follow-up (β, 0.16; 95% CI, −0.39 to 0.70) indicated statistical equivalence between the UP and SDPs.
Conclusions and Relevance
The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders.
Trial Registration
clinicaltrials.gov Identifier: NCT01243606
Traducción de: Wechsler Adult Intelligence Scale-III Tr. de la 3a ed. en inglés
This case study describes a patient presenting with a long history of excessive daydreaming which has caused her distress but is not incident to any other apparent clinical psychiatric disorders. We have treated this patient for over 10 years, and she has responded favorably to fluvoxamine therapy, stating that it helps to control her daydreaming. Our patient, and other psychotherpists, have brought to our attention other possible cases of excessive daydreaming. We examine the available literature regarding daydreaming, mind wandering, and fantasy proneness relative to current cognitive and neuroanatomical models of executive attention.
The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
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