Dear Editor, Maladaptive Daydreaming (MD) is a behavioral condition characterized by persistent, vivid, and highly immersive daydreaming that replaces real-life social, academic, or occupational activities. First described by Somer in 2002, it features elaborate, often narrative-driven fantasies that are emotionally absorbing, frequently prompted by stimuli such as music, books, or visual media.1 These narratives often feature idealized versions of the self and can become compulsive. Despite growing awareness, MD is not formally included in diagnostic systems like DSM-5 or ICD-11. Adolescents may be especially vulnerable to MD due to heightened emotional reactivity and identity development. MD has been linked to trauma, internet addiction, and even memory distortion in individuals with sensory impairments.2–5 Though epidemiological data remain sparse, community-based studies suggest a prevalence of around 2%–3%.6 This case report adds to existing literature by describing an adolescent female diagnosed with MD, and treated with a combination of psychotherapy and off-label use of modafinil. Ms. A, a 15-year-old schoolgirl, was referred for academic decline, inattention, and social withdrawal over 1 year. Previously high-achieving, she had failed two subjects. Teachers found her disengaged, and parents noted she spent hours alone, pacing or lying down with headphones. She engaged in complex, vivid daydreams that involved fictional characters and alternate versions of herself in heroic or emotionally satisfying scenarios. These episodes, triggered by books or music, lasted 6–8 hours daily. She described them as “more comforting than real life,” retained insight but was distressed by her inability to stop. There was no history of trauma, psychosis, or substance use. Developmental and family history was unremarkable. On the Maladaptive Daydreaming Scale (MDS-16), she scored 65, indicating probable MD.5 Screening for Attention Deficit Hyperactivity Disorder (ADHD) and mood and anxiety disorders was unremarkable. A provisional diagnosis of MD was made. Psychoeducation was offered to the family, and CBT was initiated, emphasizing emotion regulation, activity scheduling, and use of a “daydream diary.” Modafinil up to 200 mg/day was introduced off-label with parental consent for its wakefulness-promoting effects. By 8 weeks, she reported improved alertness, greater control over her daydreams, improved academics, and resumed social interaction. No adverse effects of modafinil were observed. Maladaptive Daydreaming is a clinical construct that lies at the intersection of imagination, attention dysregulation, and emotional escapism. In this case, MD led to significant academic impairment and social isolation, despite preserved insight. Differential diagnoses considered included ADHD, dissociative disorder, and obsessive imagery. Unlike ADHD, where inattention is stimulus-driven, MD involves deliberate, structured fantasy. Dissociative disorder shares deep mental absorption but lacks the organized narrative and emotional gratification seen in MD. Obsessive imagery tends to be intrusive and distressing, whereas MD is often ego-syntonic and comforting. Treatment required more than just behavioral redirection; it needed acknowledgment of her emotional attachment to fantasy. The observed benefit of modafinil may relate to its dopaminergic and noradrenergic effects on cortical arousal and executive networks. By strengthening prefrontal regulation and reducing default-mode network overactivity, modafinil may attenuate the cognitive immersion that sustains maladaptive fantasy, though controlled trials are needed to substantiate this. This case highlights the need for greater awareness of MD in adolescent populations. Early identification, psychoeducation, and structured behavioral therapy form the cornerstone of treatment. In select cases with attentional deficits, wakefulness-promoting agents like modafinil may offer additional benefit. This report is limited by its single-case design, absence of standardized post-treatment assessments, and the off-label nature of pharmacologic intervention. Findings should therefore be interpreted cautiously, emphasizing the need for longitudinal and controlled studies to validate these preliminary observations. Clinicians should actively consider MD in adolescents presenting with inattention, emotional withdrawal, and compulsive fantasizing, especially when traditional diagnoses fall short. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sengupta et al. (Wed,) studied this question.