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Received: 2025/01/20 | Accepted: 2025/02/24 | Published: 2025/03/5
Received: 2025/01/20 | Accepted: 2025/02/24 | Published: 2025/03/5
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Amani M, Kazemi S, Nazari F. Relationship between Maladaptive Daydreaming and Psychological Distress in Nurses; The Moderating Role of Emotion Regulation. J Clinic Care Skill 2025; 6 (1) :11-16
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1- Department of Psychology, Faculty of Educational Sciences and Psychology, University of Mohaghegh Ardabili, Ardabil, Iran
2- Department of Psychology, Faculty of Human Sciences, University of Bojnord, Bojnord, Iran
2- Department of Psychology, Faculty of Human Sciences, University of Bojnord, Bojnord, Iran
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Introduction
Psychological distress is generally defined as a state of emotional distress characterized by symptoms of depression, anxiety, and physical problems [1]. Nurses face high levels of psychological distress because their job demands include dealing with the suffering and death of patients, meeting high job expectations, continuously increasing work pressure, and adapting to changing work environments, all while receiving limited professional support [2]. In a study conducted in Iran, 43.7%, 73%, and 24% of nurses reported moderate to severe levels of depression, anxiety, and stress, respectively [3].
In the context of psychological distress, there is often a problem with emotion and emotion regulation. Difficulty in emotion regulation can be identified as a vulnerability factor for many mental disorders [4]. Gratz and Roemer [5] proposed an integrated conceptualization of emotion regulation that assumes it includes not only the moderation of emotional arousal but also the awareness, clarity, and acceptance of emotions, as well as the ability to control emotional impulses and act in an appropriate manner. The lack of these abilities may lead to impaired emotion regulation. Studies indicate that people who suppress their emotions tend to have poor emotional clarity and are less successful in recovering their mood [4]. Thus, expressive suppression is usually considered a maladaptive strategy that can lead to overwhelming emotions and, in turn, to experiences of psychological distress, such as depression [4, 6]. Several studies have shown that while adaptive emotion regulation strategies play a protective role against negative emotions and help individuals cope with stressful life events [7], failures in emotion regulation can lead to a multitude of physical and psychological problems, including psychological distress, anxiety disorders, and depression [8-11].
Nurses may resort to psychological mechanisms, such as daydreaming to escape from the stressful conditions in their work environment. Daydreaming is not necessarily associated with psychological distress, especially if individuals are aware of their situations [12]; however, intense immersion in daydreaming can be considered maladaptive [13-14]. Maladaptive daydreaming (MD) is a condition in which individuals feel a strong compulsion to engage in daydreaming so frequently and intensely that it interferes with their functioning and/or causes distress [15]. MD is characterized by a persistent craving for daydreaming, a high level of experienced presence, stereotyped movements (e.g., rocking, walking, shaking hands), and the use of music to facilitate and maintain involvement in fantasy [16]. Bigelsen et al. [17] assessing a sample of clinicians, reported that this daydreaming world provides an endless source of comfort and emotional satisfaction, but at the same time causes distress through three factors, including difficulty controlling the need or desire to daydream, concern that the amount of time spent daydreaming interferes with real-life performance, and intense embarrassment about daydreaming, which leads to significant efforts to keep the behavior hidden [17]. Empirical evidence on MD has shown that it is positively associated with a range of psychopathological domains, including attention deficit hyperactivity disorder, anxiety, and depressive disorders [18-20]. In a study among Iranian nurses, Jahangiri et al. [21] found that MD and social loneliness are related to the psychological distress of nurses. MD and loneliness explain 45% of the variance in psychological distress and 65.8% of the variance in job performance. Hashemi et al. [22] found that nurses with a high level of MD have more psychological problems (high scores in anxiety, obsessive-compulsive disorder, and attention deficit hyperactivity disorder) and lower job performance.
While it has been shown that individuals experience positive emotions when daydreaming [23], MD is also associated with emotional relationship problems, particularly engaging in impulsive behaviors when distressed, as well as low levels of emotional clarity and weak emotional regulation abilities [24]. A cross-cultural study based on a multi-country survey found that MD predicts low levels of emotional regulation abilities [24].
One study indicates that individuals with MD have difficulties in separating thoughts and refocusing due to deficits in cognitive control, thus failing to utilize adaptive emotion regulation strategies [13]. Compared to normal daydreamers, individuals with MD have greater difficulty accepting emotional responses, greater difficulty engaging in goal-directed behavior, lower emotional awareness, limited access to emotion regulation strategies, and lower emotional clarity [25]. The results of Chirico et al.’s [26] study showed that individuals with a high level of MD have higher levels of expressive suppression.
The present study examined the simultaneous relationships between MD, difficulty in emotion regulation, and psychological distress, focusing on the moderating role of emotion regulation in the relationships between MD and psychological distress—an aspect that has not been assessed in previous studies. Therefore, this study aimed to investigate the moderating role of emotion regulation in the relationships between MD and psychological distress among nurses.
Instrument and Methods
This descriptive correlational study was conducted with 186 nurses in hospitals in Mashhad, Iran in 2023. According to the G*Power 3.1 program, a sample size of 100 individuals is estimated for correlation studies, with a test power of 0.95 and an alpha of 0.05. To account for potential sample loss and to increase test power, 200 nurses were initially considered; ultimately, after eliminating incomplete questionnaires, the final sample size was 186 nurses. Cluster sampling was also employed. Two hospitals were randomly selected, and then all nurses in these two hospitals were invited to participate in the study. The inclusion criteria for the sample included having a bachelor’s degree or higher in nursing and employment in hospitals in Mashhad. The exclusion criteria consisted of incomplete completion of the questionnaires and unwillingness to participate in the study. To comply with ethical considerations, participants were assured of confidentiality and signed a consent form to participate in the study.
Research tools
Nurses who were willing to participate completed the following questionnaires.
Maladaptive Daydreaming Scale: A self-report instrument consisting of 16 items was designed by Somer et al. [27] to identify MD. Respondents are asked to rate the 16 MDS items on a ten-point scale (from never to very much). Scores range from 0 to 160, with a higher score indicating a higher level of MD. A score of 50 is recommended as a cutoff for diagnosing MD. The psychometric properties of the Maladaptive Daydreaming Scale were investigated in an Italian sample, where the MDS-16 scores demonstrated good internal consistency. Exploratory factor analysis extracted a 2-factor solution (disruption in life and isolation and sensory-motor regression). In Iran, Ahmadi et al. [28], through exploratory factor analysis, revealed three factors in the Iranian student population, including intrusive daydreaming, persistent daydreaming, and dependent daydreaming. The Cronbach’s alpha for the first factor was 0.90, for the second factor it was 0.86, for the third factor it was 0.79, and for the entire questionnaire, it was 0.93. There is also a direct and significant relationship between the three questionnaire factors and the total MD score with the components of dissociative amnesia, depersonalization and derealization, and absorption and imagination, which indicates the convergent validity of the instrument.
Kessler Psychological Distress Scale: This questionnaire was developed by Kessler et al. [29] to screen and identify mental health problems in two forms: the 6-item and the 10-item versions. In this study, the ten-item form was used. The ten-item version is not intended to identify a specific disorder but rather to determine the level of anxiety and depression that the individual has experienced in the past few weeks. The questions are scored on a five-point Likert scale (never, rarely, sometimes, most of the time, and all of the time). The range of scores is between 0 and 40, with a higher score indicating psychological distress and mental health problems. Furukawa et al. [30] reported favorable reliability and validity for this questionnaire. In Iran, Yaghubi [31] also examined the psychometric properties of this questionnaire. Using confirmatory factor analysis, a single factor was reported for the questionnaire, with factor loadings ranging between 0.65 and 0.84. The sensitivity and specificity of the scale were found to be 81% and 80.5%, respectively, with the best cutoff score being 8, and Cronbach’s alpha was reported to be 0.93.
Difficulty in Emotion Regulation Questionnaire: Bjureberg et al. [32] designed and validated the Difficulty in Emotion Regulation Scale - Short Form. This scale consists of 16 questions, and its scoring method uses a five-point Likert scale (almost never=1, rarely=2, sometimes=3, often=4, almost always=5). Scores range from 1 to 80, with higher scores indicating greater difficulty in emotion regulation. The scale includes six dimensions, including lack of acceptance of negative emotions, difficulties controlling impulsive behaviors, limited access to effective emotion regulation strategies, difficulties engaging in goal-directed behaviors, lack of emotional clarity, and lack of emotional awareness [5]. Additionally, in Iran, the reliability of Cronbach’s alpha was reported to be 0.84, and the test-retest coefficient was 0.72 [33].
Data analysis
After collecting the questionnaires and removing incomplete ones, data analysis was performed using the Pearson correlation coefficient and moderator regression analysis at a significance level of p < 0.05 using SPSS software version 27.
Findings
The number of participants was 186. Of the sample, 46.7% were male and 53.3% were female. Additionally, 26.1% of the sample was single, while 73.9% were married. The average age of the participants was 37.08±9.17 years and the average work experience of the subjects was 12.20±8.07 years.
There was a significant correlation coefficient of 0.396 between the total score of MD and psychological distress. In addition, there was a significant correlation coefficient of 0.331 between the total score of MD and difficulty in emotion regulation and a correlation coefficient of 0.588 between the total score of difficulty in emotion regulation and psychological distress (p<0.01; Table 1).
Table 1. Descriptive indices and correlation coefficients between parameters
To examine the roles of the parameters of MD, difficulty in emotion regulation, age, and job experience in psychological distress, regression analysis using the enter method was employed and the predictor parameters explained 40% of the variance related to psychological distress, and the analysis of variance related to this regression analysis was statistically significant (F=25.98, p<0.0001).
Because both the independent and moderator parameters were of interval scale types, Hayes regression was utilized. Psychological distress was considered the dependent parameter, while MD and difficulty in emotion regulation served as the predictor parameters, and the interaction of daydreaming and difficulty in emotion regulation acted as the moderator. Given the significant role of age in predicting psychological distress, the effect of age was controlled and the main effect of daydreaming on psychological distress was not significant, whereas the main effect of difficulty in emotional regulation was significant in predicting psychological distress. The interactive effect of MD and difficulty in emotional regulation on psychological distress was also significant (R² change=0.019, p<0.027). In other words, difficulty in emotional regulation played a moderating role in the relationship between MD and psychological distress. Specifically, the negative effect of MD on psychological distress was exacerbated by difficulty in emotional regulation. When the level of difficulty in emotional regulation was high, the effect of MD on increasing psychological distress was greater (Table 2).
Table 2. Interactive effect of maladaptive daydreaming and difficulty in emotional regulation on psychological distress
Discussion
The present study investigated the moderating role of emotion regulation in the relationship between MD and psychological distress while controlling for the age of nurses. Difficulty in emotion regulation was significantly correlated with psychological distress. This finding is consistent with previous studies [8-11]. In a review study, Cutuli [8] confirmed the correlation of emotion regulation components, namely cognitive reappraisal and expressive suppression, with psychological distress. Using meta-analysis and review studies, Cisler and Olatunji [9] and Aldao et al. [10] demonstrated that emotion regulation is significantly correlated with psychological distress. According to Khakpoor et al. [11], there is a relationship between emotional regulation and psychopathological stress in a clinical sample. Previous studies have established that in cases of psychological distress, there is often a problem with emotion and emotion regulation; difficulty in emotion regulation can increase vulnerability to many mental disorders [4]. Due to the pressures of work and the challenges of working in a hospital, nurses experience additional psychological pressures and stress, which heightens the likelihood of psychological distress and unpleasant mental states. Difficulty in emotional regulation or the use of maladaptive strategies for regulating emotions may prevent nurses from managing unpleasant mental and emotional states, which, in the long term, can increase the likelihood of developing psychological distress such as depression and anxiety.
There was also a positive and significant correlation coefficient between the total score of MD and psychological distress. This finding is consistent with previous studies [18-22]. Mariani et al. [18] and Zsila et al. [20], using a general population sample, demonstrated that MD is associated with psychological distress, although their tools for measuring psychological distress differ from those used in the present study. Soffer-Dudek and Somer [19] confirm the same relationship in a clinical sample using a different instrument to measure emotional regulation. Jahangiri et al. [21] and Hashemi et al. [22] also confirm the relationship between MD and psychological stress in a sample of nurses, although their tools for measuring psychological stress were different from those used in the present study.
In MD, the individual is repeatedly and intensely immersed in their daydreams, which prevents them from accurately and effectively assessing their problems. Some researchers consider MD to be an avoidance-based strategy because individuals use this escape approach to distance themselves from life’s experiences and emotions [34]. Therefore, when an individual employs avoidance strategies to deal with problems, these strategies not only fail to resolve the issues but can also lead to increased psychological distress.
MD was significantly associated with difficulty in regulating emotions. These results are similar to the studies by West and Somer [24], Greene et al. [13], Chirico et al. [26], and Mancinelli et al. [35]. The difference between the present study and these aforementioned studies lies in the study sample. While the sample in the present study consisted of nurses, the other studies were conducted on the general population. Individuals who have difficulty in processing negative emotions tend to have less control over their thoughts, feelings, and behaviors, and this self-control deficit is associated with a lower ability to self-regulate [13]. It appears that MD can be considered a form of maladaptive self-regulation. Studies have also confirmed that individuals with MD perceive themselves as less skilled in self-regulation and experience more difficulty in separating from negative emotions, which intensifies their tendency to engage in daydreaming [13]. Therefore, it can be stated that individuals who struggle to divert their attention from negative emotions are more likely to engage in MD and have a reduced ability to select and employ effective emotion regulation strategies.
Regarding age, younger individuals exhibited significantly higher levels of MD and psychological distress, while the level of difficulty in emotional regulation was also higher, although this difference was not statistically significant. In other words, as self-control ability increases in individuals, they are less likely to use MD as an immature strategy. Therefore, due to the significant effect of age, this parameter was controlled for in relation to the moderating role of emotional regulation in the relationship between MD and psychological distress. After controlling for age, difficulty in emotion regulation played a moderating role in the relationship between MD and psychological distress. Specifically, difficulty in emotion regulation exacerbated the negative effect of MD on psychological distress. If the level of difficulty in emotional regulation was high, the effect of MD on increasing psychological distress was greater. According to previous research, individuals with MD struggle to separate thoughts from emotions and to shift their attention to emotions due to deficits in cognitive control [13, 26]. Researchers also note that when a person experiences emotional arousal and cannot reduce this arousal using emotion regulation strategies, they may resort to MD [13, 15]. Therefore, it can be concluded that if a person possesses the ability to regulate emotions, MD is less likely to occur, ultimately leading to reduced psychological distress. In other words, the ability to regulate emotions can prevent the use of MD through emotional awareness, impulse control, engagement in purposeful behavior, and access to effective emotion regulation strategies.
In general, nurses who have difficulty regulating their emotions often resort to negative strategies such as MD in various situations, including stressful ones, which in turn exacerbates their psychological distress. Therefore, enhancing nurses’ emotional regulation skills can mitigate the negative effects of MD on psychological stress. It is recommended that nurses receive training in emotion regulation strategies. These skills can help prevent nurses from becoming lost in fantasies while at work, thereby improving the accuracy and quality of patient care. Additionally, training and interventions focused on emotion regulation can assist nurses in managing negative emotions more effectively during stressful situations, ultimately helping to prevent mental health problems in the long term.
The present study had several limitations. First, questionnaires were used to collect data, which may be affected by issues of social desirability. Second, the sampling was limited to two hospitals in the city of Mashhad, thus; generalization of the findings should be approached with caution. The third limitation was the lack of control for issues related to the work environment. Given these limitations, it is suggested that future research evaluate this topic using other research tools, such as interviews and additional reporting checklists. It is also recommended that this research area be examined concerning occupational, organizational, and interpersonal parameters.
Conclusion
Difficulty in emotion regulation has a moderating role in the relationship between maladaptive daydreaming and psychological distress.
Acknowledgments: The authors express their gratitude to the managers and nurses of Mashhad hospitals for their sincere cooperation.
Ethical Permissions: In this study, all ethical considerations were observed, including maintaining trust and honesty, obtaining informed consent from participants, and ensuring the confidentiality of participants’ identity information. Individuals were permitted to withdraw from the study at any stage of the research without facing any harm or loss.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors' Contribution: Amani M (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (50%); Kazemi SS (Second Author), Assistant Researcher/Discussion Writer/Statistical Analyst (25%); Nazari F (Third Author), Introduction Writer/Methodologist/Assistant Researcher (25%)
Funding/Support: This study received no financial support.
Psychological distress is generally defined as a state of emotional distress characterized by symptoms of depression, anxiety, and physical problems [1]. Nurses face high levels of psychological distress because their job demands include dealing with the suffering and death of patients, meeting high job expectations, continuously increasing work pressure, and adapting to changing work environments, all while receiving limited professional support [2]. In a study conducted in Iran, 43.7%, 73%, and 24% of nurses reported moderate to severe levels of depression, anxiety, and stress, respectively [3].
In the context of psychological distress, there is often a problem with emotion and emotion regulation. Difficulty in emotion regulation can be identified as a vulnerability factor for many mental disorders [4]. Gratz and Roemer [5] proposed an integrated conceptualization of emotion regulation that assumes it includes not only the moderation of emotional arousal but also the awareness, clarity, and acceptance of emotions, as well as the ability to control emotional impulses and act in an appropriate manner. The lack of these abilities may lead to impaired emotion regulation. Studies indicate that people who suppress their emotions tend to have poor emotional clarity and are less successful in recovering their mood [4]. Thus, expressive suppression is usually considered a maladaptive strategy that can lead to overwhelming emotions and, in turn, to experiences of psychological distress, such as depression [4, 6]. Several studies have shown that while adaptive emotion regulation strategies play a protective role against negative emotions and help individuals cope with stressful life events [7], failures in emotion regulation can lead to a multitude of physical and psychological problems, including psychological distress, anxiety disorders, and depression [8-11].
Nurses may resort to psychological mechanisms, such as daydreaming to escape from the stressful conditions in their work environment. Daydreaming is not necessarily associated with psychological distress, especially if individuals are aware of their situations [12]; however, intense immersion in daydreaming can be considered maladaptive [13-14]. Maladaptive daydreaming (MD) is a condition in which individuals feel a strong compulsion to engage in daydreaming so frequently and intensely that it interferes with their functioning and/or causes distress [15]. MD is characterized by a persistent craving for daydreaming, a high level of experienced presence, stereotyped movements (e.g., rocking, walking, shaking hands), and the use of music to facilitate and maintain involvement in fantasy [16]. Bigelsen et al. [17] assessing a sample of clinicians, reported that this daydreaming world provides an endless source of comfort and emotional satisfaction, but at the same time causes distress through three factors, including difficulty controlling the need or desire to daydream, concern that the amount of time spent daydreaming interferes with real-life performance, and intense embarrassment about daydreaming, which leads to significant efforts to keep the behavior hidden [17]. Empirical evidence on MD has shown that it is positively associated with a range of psychopathological domains, including attention deficit hyperactivity disorder, anxiety, and depressive disorders [18-20]. In a study among Iranian nurses, Jahangiri et al. [21] found that MD and social loneliness are related to the psychological distress of nurses. MD and loneliness explain 45% of the variance in psychological distress and 65.8% of the variance in job performance. Hashemi et al. [22] found that nurses with a high level of MD have more psychological problems (high scores in anxiety, obsessive-compulsive disorder, and attention deficit hyperactivity disorder) and lower job performance.
While it has been shown that individuals experience positive emotions when daydreaming [23], MD is also associated with emotional relationship problems, particularly engaging in impulsive behaviors when distressed, as well as low levels of emotional clarity and weak emotional regulation abilities [24]. A cross-cultural study based on a multi-country survey found that MD predicts low levels of emotional regulation abilities [24].
One study indicates that individuals with MD have difficulties in separating thoughts and refocusing due to deficits in cognitive control, thus failing to utilize adaptive emotion regulation strategies [13]. Compared to normal daydreamers, individuals with MD have greater difficulty accepting emotional responses, greater difficulty engaging in goal-directed behavior, lower emotional awareness, limited access to emotion regulation strategies, and lower emotional clarity [25]. The results of Chirico et al.’s [26] study showed that individuals with a high level of MD have higher levels of expressive suppression.
The present study examined the simultaneous relationships between MD, difficulty in emotion regulation, and psychological distress, focusing on the moderating role of emotion regulation in the relationships between MD and psychological distress—an aspect that has not been assessed in previous studies. Therefore, this study aimed to investigate the moderating role of emotion regulation in the relationships between MD and psychological distress among nurses.
Instrument and Methods
This descriptive correlational study was conducted with 186 nurses in hospitals in Mashhad, Iran in 2023. According to the G*Power 3.1 program, a sample size of 100 individuals is estimated for correlation studies, with a test power of 0.95 and an alpha of 0.05. To account for potential sample loss and to increase test power, 200 nurses were initially considered; ultimately, after eliminating incomplete questionnaires, the final sample size was 186 nurses. Cluster sampling was also employed. Two hospitals were randomly selected, and then all nurses in these two hospitals were invited to participate in the study. The inclusion criteria for the sample included having a bachelor’s degree or higher in nursing and employment in hospitals in Mashhad. The exclusion criteria consisted of incomplete completion of the questionnaires and unwillingness to participate in the study. To comply with ethical considerations, participants were assured of confidentiality and signed a consent form to participate in the study.
Research tools
Nurses who were willing to participate completed the following questionnaires.
Maladaptive Daydreaming Scale: A self-report instrument consisting of 16 items was designed by Somer et al. [27] to identify MD. Respondents are asked to rate the 16 MDS items on a ten-point scale (from never to very much). Scores range from 0 to 160, with a higher score indicating a higher level of MD. A score of 50 is recommended as a cutoff for diagnosing MD. The psychometric properties of the Maladaptive Daydreaming Scale were investigated in an Italian sample, where the MDS-16 scores demonstrated good internal consistency. Exploratory factor analysis extracted a 2-factor solution (disruption in life and isolation and sensory-motor regression). In Iran, Ahmadi et al. [28], through exploratory factor analysis, revealed three factors in the Iranian student population, including intrusive daydreaming, persistent daydreaming, and dependent daydreaming. The Cronbach’s alpha for the first factor was 0.90, for the second factor it was 0.86, for the third factor it was 0.79, and for the entire questionnaire, it was 0.93. There is also a direct and significant relationship between the three questionnaire factors and the total MD score with the components of dissociative amnesia, depersonalization and derealization, and absorption and imagination, which indicates the convergent validity of the instrument.
Kessler Psychological Distress Scale: This questionnaire was developed by Kessler et al. [29] to screen and identify mental health problems in two forms: the 6-item and the 10-item versions. In this study, the ten-item form was used. The ten-item version is not intended to identify a specific disorder but rather to determine the level of anxiety and depression that the individual has experienced in the past few weeks. The questions are scored on a five-point Likert scale (never, rarely, sometimes, most of the time, and all of the time). The range of scores is between 0 and 40, with a higher score indicating psychological distress and mental health problems. Furukawa et al. [30] reported favorable reliability and validity for this questionnaire. In Iran, Yaghubi [31] also examined the psychometric properties of this questionnaire. Using confirmatory factor analysis, a single factor was reported for the questionnaire, with factor loadings ranging between 0.65 and 0.84. The sensitivity and specificity of the scale were found to be 81% and 80.5%, respectively, with the best cutoff score being 8, and Cronbach’s alpha was reported to be 0.93.
Difficulty in Emotion Regulation Questionnaire: Bjureberg et al. [32] designed and validated the Difficulty in Emotion Regulation Scale - Short Form. This scale consists of 16 questions, and its scoring method uses a five-point Likert scale (almost never=1, rarely=2, sometimes=3, often=4, almost always=5). Scores range from 1 to 80, with higher scores indicating greater difficulty in emotion regulation. The scale includes six dimensions, including lack of acceptance of negative emotions, difficulties controlling impulsive behaviors, limited access to effective emotion regulation strategies, difficulties engaging in goal-directed behaviors, lack of emotional clarity, and lack of emotional awareness [5]. Additionally, in Iran, the reliability of Cronbach’s alpha was reported to be 0.84, and the test-retest coefficient was 0.72 [33].
Data analysis
After collecting the questionnaires and removing incomplete ones, data analysis was performed using the Pearson correlation coefficient and moderator regression analysis at a significance level of p < 0.05 using SPSS software version 27.
Findings
The number of participants was 186. Of the sample, 46.7% were male and 53.3% were female. Additionally, 26.1% of the sample was single, while 73.9% were married. The average age of the participants was 37.08±9.17 years and the average work experience of the subjects was 12.20±8.07 years.
There was a significant correlation coefficient of 0.396 between the total score of MD and psychological distress. In addition, there was a significant correlation coefficient of 0.331 between the total score of MD and difficulty in emotion regulation and a correlation coefficient of 0.588 between the total score of difficulty in emotion regulation and psychological distress (p<0.01; Table 1).
Table 1. Descriptive indices and correlation coefficients between parameters
To examine the roles of the parameters of MD, difficulty in emotion regulation, age, and job experience in psychological distress, regression analysis using the enter method was employed and the predictor parameters explained 40% of the variance related to psychological distress, and the analysis of variance related to this regression analysis was statistically significant (F=25.98, p<0.0001).
Because both the independent and moderator parameters were of interval scale types, Hayes regression was utilized. Psychological distress was considered the dependent parameter, while MD and difficulty in emotion regulation served as the predictor parameters, and the interaction of daydreaming and difficulty in emotion regulation acted as the moderator. Given the significant role of age in predicting psychological distress, the effect of age was controlled and the main effect of daydreaming on psychological distress was not significant, whereas the main effect of difficulty in emotional regulation was significant in predicting psychological distress. The interactive effect of MD and difficulty in emotional regulation on psychological distress was also significant (R² change=0.019, p<0.027). In other words, difficulty in emotional regulation played a moderating role in the relationship between MD and psychological distress. Specifically, the negative effect of MD on psychological distress was exacerbated by difficulty in emotional regulation. When the level of difficulty in emotional regulation was high, the effect of MD on increasing psychological distress was greater (Table 2).
Table 2. Interactive effect of maladaptive daydreaming and difficulty in emotional regulation on psychological distress
Discussion
The present study investigated the moderating role of emotion regulation in the relationship between MD and psychological distress while controlling for the age of nurses. Difficulty in emotion regulation was significantly correlated with psychological distress. This finding is consistent with previous studies [8-11]. In a review study, Cutuli [8] confirmed the correlation of emotion regulation components, namely cognitive reappraisal and expressive suppression, with psychological distress. Using meta-analysis and review studies, Cisler and Olatunji [9] and Aldao et al. [10] demonstrated that emotion regulation is significantly correlated with psychological distress. According to Khakpoor et al. [11], there is a relationship between emotional regulation and psychopathological stress in a clinical sample. Previous studies have established that in cases of psychological distress, there is often a problem with emotion and emotion regulation; difficulty in emotion regulation can increase vulnerability to many mental disorders [4]. Due to the pressures of work and the challenges of working in a hospital, nurses experience additional psychological pressures and stress, which heightens the likelihood of psychological distress and unpleasant mental states. Difficulty in emotional regulation or the use of maladaptive strategies for regulating emotions may prevent nurses from managing unpleasant mental and emotional states, which, in the long term, can increase the likelihood of developing psychological distress such as depression and anxiety.
There was also a positive and significant correlation coefficient between the total score of MD and psychological distress. This finding is consistent with previous studies [18-22]. Mariani et al. [18] and Zsila et al. [20], using a general population sample, demonstrated that MD is associated with psychological distress, although their tools for measuring psychological distress differ from those used in the present study. Soffer-Dudek and Somer [19] confirm the same relationship in a clinical sample using a different instrument to measure emotional regulation. Jahangiri et al. [21] and Hashemi et al. [22] also confirm the relationship between MD and psychological stress in a sample of nurses, although their tools for measuring psychological stress were different from those used in the present study.
In MD, the individual is repeatedly and intensely immersed in their daydreams, which prevents them from accurately and effectively assessing their problems. Some researchers consider MD to be an avoidance-based strategy because individuals use this escape approach to distance themselves from life’s experiences and emotions [34]. Therefore, when an individual employs avoidance strategies to deal with problems, these strategies not only fail to resolve the issues but can also lead to increased psychological distress.
MD was significantly associated with difficulty in regulating emotions. These results are similar to the studies by West and Somer [24], Greene et al. [13], Chirico et al. [26], and Mancinelli et al. [35]. The difference between the present study and these aforementioned studies lies in the study sample. While the sample in the present study consisted of nurses, the other studies were conducted on the general population. Individuals who have difficulty in processing negative emotions tend to have less control over their thoughts, feelings, and behaviors, and this self-control deficit is associated with a lower ability to self-regulate [13]. It appears that MD can be considered a form of maladaptive self-regulation. Studies have also confirmed that individuals with MD perceive themselves as less skilled in self-regulation and experience more difficulty in separating from negative emotions, which intensifies their tendency to engage in daydreaming [13]. Therefore, it can be stated that individuals who struggle to divert their attention from negative emotions are more likely to engage in MD and have a reduced ability to select and employ effective emotion regulation strategies.
Regarding age, younger individuals exhibited significantly higher levels of MD and psychological distress, while the level of difficulty in emotional regulation was also higher, although this difference was not statistically significant. In other words, as self-control ability increases in individuals, they are less likely to use MD as an immature strategy. Therefore, due to the significant effect of age, this parameter was controlled for in relation to the moderating role of emotional regulation in the relationship between MD and psychological distress. After controlling for age, difficulty in emotion regulation played a moderating role in the relationship between MD and psychological distress. Specifically, difficulty in emotion regulation exacerbated the negative effect of MD on psychological distress. If the level of difficulty in emotional regulation was high, the effect of MD on increasing psychological distress was greater. According to previous research, individuals with MD struggle to separate thoughts from emotions and to shift their attention to emotions due to deficits in cognitive control [13, 26]. Researchers also note that when a person experiences emotional arousal and cannot reduce this arousal using emotion regulation strategies, they may resort to MD [13, 15]. Therefore, it can be concluded that if a person possesses the ability to regulate emotions, MD is less likely to occur, ultimately leading to reduced psychological distress. In other words, the ability to regulate emotions can prevent the use of MD through emotional awareness, impulse control, engagement in purposeful behavior, and access to effective emotion regulation strategies.
In general, nurses who have difficulty regulating their emotions often resort to negative strategies such as MD in various situations, including stressful ones, which in turn exacerbates their psychological distress. Therefore, enhancing nurses’ emotional regulation skills can mitigate the negative effects of MD on psychological stress. It is recommended that nurses receive training in emotion regulation strategies. These skills can help prevent nurses from becoming lost in fantasies while at work, thereby improving the accuracy and quality of patient care. Additionally, training and interventions focused on emotion regulation can assist nurses in managing negative emotions more effectively during stressful situations, ultimately helping to prevent mental health problems in the long term.
The present study had several limitations. First, questionnaires were used to collect data, which may be affected by issues of social desirability. Second, the sampling was limited to two hospitals in the city of Mashhad, thus; generalization of the findings should be approached with caution. The third limitation was the lack of control for issues related to the work environment. Given these limitations, it is suggested that future research evaluate this topic using other research tools, such as interviews and additional reporting checklists. It is also recommended that this research area be examined concerning occupational, organizational, and interpersonal parameters.
Conclusion
Difficulty in emotion regulation has a moderating role in the relationship between maladaptive daydreaming and psychological distress.
Acknowledgments: The authors express their gratitude to the managers and nurses of Mashhad hospitals for their sincere cooperation.
Ethical Permissions: In this study, all ethical considerations were observed, including maintaining trust and honesty, obtaining informed consent from participants, and ensuring the confidentiality of participants’ identity information. Individuals were permitted to withdraw from the study at any stage of the research without facing any harm or loss.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors' Contribution: Amani M (First Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (50%); Kazemi SS (Second Author), Assistant Researcher/Discussion Writer/Statistical Analyst (25%); Nazari F (Third Author), Introduction Writer/Methodologist/Assistant Researcher (25%)
Funding/Support: This study received no financial support.
Keywords:
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