A pharmacotherapeutic and neuroimaging case study of maladaptive daydreaming

Abstract

Background

Maladaptive daydreaming (MD) is an underreported mental health condition involving prolonged, vivid fantasizing, associated with significant functional impairment or disability. The underlying neurobiology of MD is unknown, and there have been no prior neuroimaging studies in affected individuals.

Case presentation

A twenty-year-old woman with a history of depression and obsessive-compulsive disorder reported experiencing intense and highly distracting daydreams, exacerbated by stress and resulting in an inability to complete her studies. We describe her clinical presentation, treatment and symptom response over 120 weeks. Depression was largely treatment-resistant with antidepressants, and improvement with lamotrigine (Lamictal) augmentation was limited by poor tolerance. Antipsychotic medications (lurasidone, risperidone (Risperdal) and aripiprazole) resulted in a rapid reduction or cessation of daydreaming, and dopaminergic medications (lisdexamfetamine and bupropion) resulted in substantially increased time spent daydreaming. The patient underwent Magnetic Resonance Imaging (MRI) using a 3 Tesla scanner, and the brain's cortical thickness and functional connectivity networks were assessed and compared to a matched population of healthy individuals. We found regions of cortical thinning in the left hemisphere, primarily in the middle temporal cortex. The left default mode and cingulo-opercular networks, and the salience network bilaterally, were enlarged compared to the general population. In contrast, the left frontoparietal network was smaller.

Conclusion

A hyperdopaminergic state may be involved in some cases of MD. Altered development of the left brain may underlie the capacity for prolonged, vivid daydreaming. Future studies in larger patient populations are needed to validate findings.