When imagination turns into disorder: the case of maladaptive daydreaming

Maladaptive daydreaming (MD) is defined as a psychological condition characterized by immersive, narrative-based fantasies that dominate waking consciousness and interfere with daily functioning. While daydreaming is an adaptive cognitive activity, above all in adolescents, MD represents an extreme and compulsive variant associated with significant emotional distress, social withdrawal, academic and occupational impairment. This narrative review offers a comprehensive synthesis of the current literature on MD, with particular emphasis on its clinical manifestations, neurobiological underpinnings, epidemiology, comorbidities, differential diagnosis, and therapeutic perspectives. The review highlights the role of dissociation, trauma history, attention dysregulation, and obsessive-compulsive traits in the pathogenesis of MD, while also distinguishing it from normative mind-wandering, fantasy-prone personality, and psychotic disorders. Despite increasing evidence, MD is not included in the diagnostic systems, and this leads to underdiagnosis and a lack of targeted treatments. Assessment tools such as the Maladaptive Daydreaming Scale (MDS) and the Structured Clinical Interview for Maladaptive Daydreaming (SCIMD) will be explored as useful tools for clinical identification. Finally, treatment options will be discussed even if still not validated. We aim to underscore the nosological significance of this clinical entity, advocating for its recognition in the future landscape of psychiatric classification.