Why isn’t maladaptive daydreaming in the DSM?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association. It’s widely accepted as the “dictionary” of mental health diagnoses. Many psychiatrists acknowledge that the DSM isn’t perfect, and that not all mental health problems fit neatly into diagnostic categories. However, it’s still the case that if your problem isn’t listed in the DSM, it can be harder to get a diagnosis, or even convince a psychiatrist or mental health professional that your problem is “real”.

Currently, maladaptive daydreaming disorder is not listed in the DSM. Psychiatrists are largely unaware of it, there are no universally recognised diagnostic criteria, and there is no standard treatment. But why is it so hard to get recognition for a condition that could affect as much as 2.5% of the population?

The main reason maladaptive daydreaming disorder isn’t in the DSM is that it’s simply too new. The current edition of the DSM is known as the DSM-5 and was published in 2013. There was a revision of the DSM in March 2022, but this was a “text revision” of the DSM-5 (referred to as DSM-5-TR), rather than a new edition. In a text revision, the emphasis is on clarifying and updating the criteria and categorisation of existing diagnoses, rather than adding new ones. The only new condition added to the DSM-5-TR was prolonged grief disorder.

All of the diagnoses currently listed in the DSM already had enough scientific research to justify their inclusion by 2013. And therein lies the problem. Although maladaptive daydreaming was first described in 2002, very little research was done in the following decade. A quick look at the list of publications on the ICMDR website reveals that by 2013, only two papers in addition to the original 2002 study had been published in English-language journals. It wasn’t until 2016 that research really started to take off.

So when psychiatrists were compiling the DSM-5 in the years leading up to 2013, maladaptive daydreaming was still unknown. No-one knew what it was, how to define it, what caused it, or how it could be treated. That’s why maladaptive daydreaming disorder isn’t in the DSM-5. But could it be included in the future?

Maladaptive daydreaming has many of the features of a behavioural addiction. One behavioural addiction, gambling disorder, is listed in the DSM-5. Gambling disorder was listed in the previous edition of the DSM under the name “pathological gambling”, but in the DSM-5 it was reclassified from an impulse-control disorder to an addictive disorder. This gave greater recognition to the idea that a behaviour can be addictive, and opens the door for other addictive behaviours to be included in future editions of the DSM.

But research into maladaptive daydreaming is a long way behind research into gambling addiction. Researchers still don’t know what causes someone’s daydreaming to become maladaptive. They aren’t even sure how many people have it. And to be included in a future edition of the DSM it would also be necessary to show that maladaptive daydreaming is a distinct condition and not a symptom of something else. A lot more research needs to happen in all these areas.

Science moves slowly. It can take several years to plan, execute and publish a single research project. It could be decades before enough research has been done into maladaptive daydreaming for scientists to consider including it in the DSM. Equally, the DSM moves slowly. Only one new diagnosis has been added since the DSM-5 was published in 2013 and there are currently no plans for a DSM-6. Although it’s not impossible that new diagnoses could be added in future revisions of the DSM-5, it’s unlikely that large numbers of new conditions will be added.

So, for the foreseeable future, maladaptive daydreaming disorder will remain an unofficial diagnosis, not accepted by many psychiatrists. That doesn’t mean, however, that it won’t be possible to get treatment for maladaptive daydreaming. Increasing awareness of the condition means that increasing numbers of mental health professionals do believe it’s a real disorder, despite its absence from the DSM. Many of the techniques that have been shown to help in other behavioural addictions may be helpful in managing maladaptive daydreaming. And treatments specifically targeting maladaptive daydreaming are under investigation. Maladaptive daydreaming disorder won’t be appearing in the DSM any time soon, but the outlook for those struggling with maladaptive daydreaming has never been brighter.

[Image by Rebecca Tregear from Pixabay]