A second strategy involves the reduction of stress. Here relationships become more complex. Stress takes many forms. Reducing stress requires changes in the physical and social environment. Environmental stress situations involve a whole complex of interacting variables. Some
Freud defined primary gain as a decrease in anxiety from a defensive operation which caused a symptom. Secondary gain was defined as interpersonal or social advantage attained by the patient because of the illness. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-R) de fined primary gain as the gain achieved from a conversion symptom which in turn keeps a conflict out of awareness. Secondary gain was defined as the gain achieved from the conversion symptom in avoiding a noxious activity or enabling support from the environment. Secondary gain is not a DSM-III-R diagnosis. Primary and secondary gains are thought to occur by unconscious mechanisms. The following is a list of possible secondary gains: gratification of dependency needs; gratification of revengeful strivings; fulfillment of need for attachment; desire of patient to prove entitlement for disability; fulfillment of need for oversolic-itousness from others; avoidance of hazardous work conditions; fulfillment of need for sympathy and concern; permission to withdraw from unsatisfactory life role; need for sick role; financial rewards; acquisition of drugs; manipulation of spouse; maintenance of family status; maintenance of family love; domination of family; freedom from given socioemotional role; and contraception.
Tertiary gains are attained from a patient's illness by someone other than the patient. It is not known whether these occur at a conscious or unconscious level. The following is a list of possible tertiary gains: Collusion on the part of the significant other to focus on patient's somatic complaints; diversion of attention from existential issues (cancer/death); enjoyment of change in role for significant other; financial gain; sympathy from social network; decreased family tension; and resolution of marital difficulties.
It is not clear whether secondary gains are the same as reinforcers. It appears that operationally some are the same; the gain may be the reinforcer. Secondary gains, however, are a more unconscious motivation for the observed behaviors.
Abnormal illness-affirming states include the following DSM-IV-R diagnoses: somatoform disorders (Conversion Disorder, Hypochondriasis, Somatization Disorder, Pain Disorder); factitious disorders (including Munchausen Syndrome); and malingering. In all these diagnoses, secondary gain is thought to be responsible for the production of some or all of the patient's signs and symptoms.
Secondary losses may also result from a patient's disability. The following is a list of possible secondary losses: economic loss, loss of opportunity to relate to others through work, loss of family life, loss of recreational activities, loss of comfortable and clearly defined role, loss of respect and attention from those in helping roles, loss of community approval, social stigma of being chronically disabled, guilt over disability, negative sanctions from family, and loss of social support. Patients act in spite of these losses even though the secondary losses far outweigh the secondary gains. This problem with the economy of secondary gains and losses is a direct challenge to the integrity of the secondary gain concept.
Secondary gain is often incorrectly equated with malingering. The term has also been equated with financial rewards associated with disability, which in turn is equated with malingering. Suspicion of malingering usually interferes with treatment and development of empathy. Moreover, secondary gain issues are often used as an excuse for treatment failure. Treating professionals often ignore the concept of secondary loss and focus only on secondary gain. If all patients in a medical facility were examined for alleged secondary gains, most would be found to have one or more secondary gains; however, the identification of an apparent secondary gain does not necessarily mean that this gain has had an etiological or reinforcing effect on the illness.
David A. Fishbain
University of Miami
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