Lost in the narrative: A case study on pathological digital fiction reading

INTRODUCTION

Reading has captivated readers for decades, allowing them to broaden their horizons and glimpse unknown worlds. Reading fiction kills boredom and, with an active imagination, takes readers to a fantasy world where they could be the protagonists and lead a much different and engaging life away from their real-life problems.¹ Thus, reading has always been a coping mechanism and a fun activity. Furthermore, reading fiction improves dispositional empathy and theory of mind,² alters mood, and develops intercultural competence and creativity.³ It has been considered one of the healthiest habits a person can cultivate, but can it be addictive?

Lately, with technological advancements and numerous social media platforms, the number of people who read has reduced tremendously.⁴ However, with digital interfaces designed solely for reading, providing access to unlimited free content to read, and thousands of fanfiction and novel fiction writers publishing content daily, there has been a further shift in reading habits. Behaviors that produce any form of short-term reward can become persistent despite the knowledge of adverse consequences, leading to diminished control over the behavior;⁵ when the behavior posits a significant direct functional impairment or distress, the behavior can be potentially addictive.⁶

Introducing a case with a shift in reading habits due to digital advancements. On average, Mr. P.K. reads for 16 hours a day and has trouble doing every other academic, social, and personal activity. He was engrossed in reading to curb his feelings of guilt and dissatisfaction with life, which worsened to the point where he decided to end his life.

CASE REPORT

A 21-year-old single male, in his final year of undergraduate study at a highly competitive technical university, presented for consultation reporting a pervasive low mood, an increased number of hours of reading, increased absenteeism coupled with a decline in academic performance, and suicidal ideation.

The client’s academic journey had been promising until 2020; he maintained a focused academic approach, primarily preparing for the entrance exams. Due to COVID-19, there was a shift to online classes; he initially coped with the monotony by engaging in fiction reading, starting with the Percy Jackson series. This leisure activity evolved into an obsession with fan fiction, initially consuming up to 2-3 hours and later becoming more than 10 hours a day. His reading habits affected his academic and social obligations. He missed exams, classes, assignments, and social activities. He felt guilty about his habits and felt inadequate due to not fulfilling his responsibilities. He reported that the stories would come to his mind when doing other activities, and seeing the laptop would ignite the desire to read. He was afraid of his parents’ reaction; thus, he lied to them about his academics and social life.

After the quarantine, moving to Delhi in 2022 for offline classes exacerbated client’s anxiety. Due to his reserved nature, he was apprehensive about meeting and interacting with new people. He continued his reading habits and would limit them only when his friends made him hang out with them. He believed he could compensate for the academics if he put in extra work once the third year started. However, the patient tested positive for COVID-19 on the very first day of the third year. The college followed COVID protocol, and he had to go into quarantine for a week, and by the end of it, classes had already started. He did not know where to go or start; he reported that he did not dare ask others where the class was or what he missed, as he felt ashamed for not knowing where the classes happened even after the 2^nd year. Thus, he would return to the hostel and read fanfiction. He would lie to his roommates and other friends, saying he attended classes from the previous year when they inquired about his absence.

A shift to a single room led to a cessation of social activities and a neglect of self-care. The pressure of parental expectations and disappointment in oneself fostered feelings of inadequacy. His social interactions dwindled, and lies about academic progress strained his relationship with his parents. He further read to avoid thinking about it and experiencing negative feelings. Fan fiction served as a coping mechanism, compensating for unmet needs and creating a fantasy world. Mr. P.K.’s lack of confidence in real-life situations found an outlet in literature, particularly those related to confidence in romance, socializing, life success, and exploring erotic fantasies. At this point, he would spend more than 16 hours a day reading.

The guilt over neglecting duties and a heightened fear of disappointing his parents became significant stressors. Suicidal thoughts emerged as he felt solely responsible for his perceived failure to manage academic and personal challenges. Isolation and an inability to communicate challenges contributed to Mr. P.K.’s distress. The guilt over perceived failure intensified, leading to a sense of hopelessness. On December 16, 2023, Mr. P.K. attempted suicide by jumping in front of a metro train. Emergency measures led to his hospitalization.

Psychological evaluation

A comprehensive interview and psychological evaluation were administered. Sack’s Sentence Completion Test,⁷ 16 personality factors,⁸ and Thematic Apperception Test⁹ revealed that the patient is an imaginative free thinker who prefers solitude and avoids conflicts. He feels guilty when distracted from academics, tends to withdraw in work settings, and often worries due to a strong sense of self-obligation. He is apprehensive, moody, avoidant of people, and is disturbed by his mood changes. He sees himself as relaxed but worries that over-satisfaction could affect his motivation. The patient is threat-sensitive, timid, and easily intimidated in relationships, with guilt linked to causing emotional pain to his father. He desires social connection and belonging but fears rejection and disapproval. This conflict suggests ambivalence towards relationships, a struggle to balance the need for connection with the fear of vulnerability, and the use of altruism and rationalization as coping mechanisms. The client is struggling with guilt and emotional distress due to perceived failures in academic and career pursuits. The recurring theme of external guidance influencing their actions suggests a potential reliance on validation from others. Overall, the findings highlight a complex interplay between self-reliance and external support. The clinical interview revealed that the patient has impaired control over reading behavior, with increasing priority given to behavior to the extent that reading takes precedence over other life interests or daily activities and continues despite negative consequences and significant functional impairment for a period of 2 years. The patient was diagnosed with 6B40 adjustment disorder and 6C5Z other specified disorder due to addictive behaviors.¹⁰

In the cognitive-behavioral model of pathological internet use by Davis (2005), the distant factors that make the patient vulnerable to addiction are his anxious-avoidant personality traits, social anxiety, and adjustment issues, coupled with the proximal factors like an escape from the monotony of online classes, a reduction in guilt feelings, reduced anxiety, and his social and erotic needs being met, which led to the pathological use of the internet for reading fiction [Figure 1].¹¹ The nonfunctional ruminative cognitions like “I am a worthy or capable person only when I am reading,” “I cannot solve my problems,” and “The only way I can deal with the issues is through reading” led the patient to repeat the problematic behavior, leading to an increase in cognitive and behavioral distress.¹² Complementing this, the compensatory model of addiction posits that individuals engage in addictive behaviors to avoid underlying stressors or make up for skill deficits and assert control over their lives.¹³ For the client, the behavior was likely reinforced by the experience of gratification or the avoidance of negative feelings associated with his real-world difficulties, thus compensating for perceived inadequacies in social connection, confidence, and academic success.

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Figure 1:

Cognitive-behavioral model of pathological Internet use by Davis (2005).¹¹

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Fourteen sessions of about 60 to 90 minutes were taken, along with two booster sessions on an outpatient basis. The therapist adopted a combination of supportive and cognitive behavioral therapy to address the patient’s concerns [Table 1]. Since the plan was for a short IP-Care, the initial psychotherapy plan was to start with supportive psychotherapy and orient to CBT. The patient was started on Tab. Escitalopram (5 mg), which was uptitrated to 15 mg per day, and Tab. Cloazepam (0.5 mg) sos.

Table 1: Psychotherapy plan and outcome summary

Phases of therapy	Goals	Work done and techniques used	Outcomes and progress
Initial phase 1-4 sessions	- Conduct a detailed intake, risk assessment, and clarification of history focusing on the reading pattern - Establish a therapeutic alliance - Develop and share case formulation to build insight; obtain feedback - Orient to the psychotherapy process and set goals	- Active listening & Unconditional Positive regard - Validation and Normalization - Facilitating emotional Ventilation - Functional Analysis of Reading Behavior - Comprehensive interview and Clarification of diagnosis (as per Griffith’s Behavioral Addiction Criteria) - Socratic dialogue - Socializing to CBT and Collaborative Goal Setting	- Strong therapeutic alliance and engagement - Understanding of antecedents of reading behavior - Greater understanding of the function and maintenance factors of excessive reading - Recognized and acknowledged counterproductive self-blame and began exploring healthier accountability - Developed readiness for behavioral change
Middle phase 5-12 sessions	- In-depth exploration of factors leading to excessive reading - Addressing compensatory reading and fantasy dependence - Addressing Coping Skills Deficits - Minimizing Procrastination towards academics and improving interpersonal skills - Addressing the difficult emotions associated with the shame/guilt related to the reading - Deficits in emotional awareness and healthy regulation skills - Addressing the conditional assumptions and core beliefs	- Semi-structured activity schedule (including both pleasurable and mastery activities) and graded task assignment - Craving management (Eg: Delay tactics and alternative behaviors) - Time management and Study skills (eg, Prioritization strategies and Pomodoro techniques) - Social Skills training (assertiveness training, non-verbal communication skills, dealing with criticism, cognitive restructuring) - Thought, Behavior, Emotion Linking - Emotion Identification exercises, Labelling of emotions, Emotion regulation skills (behavioral decentering, reframing, gradual exposure) - Cognitive restructuring of core beliefs and cognitive distortions - Cost benefit analysis, evidence for and against, challenging cognitive distortions, generating alternative solutions, Decatastrophizing, Behavioral experiments) - Downward arrow technique/Positive data log	- Behavioral activation and avoidance reduction, increased academic and social engagement - Reduced rigidity in thinking and flexibility in self-evaluation - Healthy coping skills - Greater confidence in social interactions and increased willingness in help seeking. - Improved self-efficacy - Reduced reading time - Improved identification and expression of emotions
Termination phase (13-14)	- Consolidation of therapy gains - Relapse prevention strategies for excessive reading - Increase help-seeking behavior - Activity scheduling and timetable for post discharge - Preparing the client for post-discharge	- Psychoeducation review and consolidation - Skill trainings were reviewed - Urge management strategies - High risk situation preparedness - Structured post-discharge plan integrating a balanced routine and follow-up after 1 month	- Increase in future-oriented thinking - Interest in the exploration of new activities in scheduled activities and reduced avoidance - Plan for managing urges and setbacks
Areas for future sessions	- Personality difficulties - Monitoring compensatory use of reading - Self-esteem	-	-

Sources: ​Synthesized from Judith S. Beck, Cognitive Behavior Therapy: Basics and Beyond, 3rd ed., The Guilford Press, 2021, https://www.guilford.com/books/Cognitive-Behavior-Therapy/Judith-Beck/9781462544196; Bruce S. Liese and Aaron T. Beck, Cognitive-Behavioral Therapy of Addictive Disorders, Guilford Press, 2022, https://www.guilford.com/books/Cognitive-Behavioral-Therapy-of-Addictive-Disorders/Liese-Beck/9781462548842; and Lewis R. Wolberg, The Technique of Psychotherapy, 4th ed., Jason Aronson, 1995, https://books.google.com/books?id=ebN9RAAACAAJ.

At a follow-up after a month, the patient showed improvement in his symptoms; he could limit his reading to 1 hour a day and participate actively in academic and social activities.

DISCUSSION

Integrating these perspectives within a broader bio-psycho-social framework,¹⁴ Mr. P.K.’s inherent reserved nature, anxious-avoidant traits, and fear of disapproval clashed with high academic and parental expectations, initially aggravated by the monotony of COVID-19 online classes. Excessive fanfiction reading emerged as a maladaptive coping mechanism for social anxiety and adjustment stress after moving to Delhi, providing a cognitive escape but paradoxically fueling guilt and avoidance of responsibilities. His quarantine due to COVID-19, isolation in a single room, and academic failures intensified this pattern, leading to strained relationships due to deception, increased psychological distress, chronic low mood, lack of support, and hopelessness, ultimately resulting in a life-threatening crisis.

A behavior like reading serves as positive reinforcement and even a coping mechanism to compensate for a lack of skills or distract from real-life stressors through immersion in the narrative world.¹⁵ It is positively encouraged by society, and people use reading to compensate for their emotional needs and escape distress; reading heightens, calms, or comforts them according to their needs. It may lead to avoidance of other pleasurable activities or behaviors as it gives a comfortable, flexible, and less risky alternative platform for experiencing the unmet needs. This further hinders their ability to solve real-life problems or engage in social relationships.¹⁵

The existing literature posits that technological advancements facilitate reading and provide information quickly and efficiently.¹⁶ The internet has made reading affordable, accessible, and readily available. The patient reads digital fiction for numerous hours; he copes with the shortcomings of his skills and life problems through reading. Irrespective of the quality of the material, he would spend hours devouring the available fiction and feel guilty afterward. Thus, reading became a maladaptive coping style for the patient; he prioritized it over every other activity, paving the path for addiction.^17,18 People who are addicted are more likely than non-addicts to experience anxiety and catastrophize. Avoiding the perceived and actual repercussions of catastrophizing is an essential factor contributing to addictive behavior.¹⁹ The patient avoided all other activities outside his comfort zone and shrank his world to fan fiction. Is it excessive behavior or a clinically identifiable addiction? To prevent pathologizing normal behaviors, the behavior was compared with the characteristics of other established behavioral addictions.²⁰ With respect to the component model of addictions, the behavior shares all the core components of addictions and thus can be clinically identified as one.²¹ Reading was a willful choice initially, but persistent and recurrent behavior led to impaired control, and behavior was prioritized over other activities or interests. The patient continued to use even after negative consequences, which resulted in significant impairments in personal, family, social, educational, occupational, and other areas of life.^10-22

CONCLUSION

Recent studies highlight the impact of technological advancements on reading habits. Due to the lack of studies, there is currently insufficient data to justify digital fiction reading as a behavioral addiction. The case exemplifies the potential for digital fiction reading to impair functioning and necessitates further research into diagnostic criteria and interventions for digital fiction reading addiction.