Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Primary vs. Secondary Gain

Most involved in case management and patient care are familiar with secondary gain. It occurs when a patient_s symptoms are maintained because of the impact of attention, affection, remuneration, access to medication and other incentives. Sometimes the patient is aware of these sources of secondary gain, but often they lack insight that it is occurring and need to be shown the ways in which they are gaining from their injury.

Primary gain is quite different. It occurs when the injury solves an internal conflict for the individual. For example, the patient may have a fear or aversion to something at work (or at home) and their symptoms prevent them from having to be exposed to it. These may range avoiding intimate contact with their spouse to avoiding work tasks over which they are phobic (heights, closed spaces, etc).

Quite often there are elements of both primary and secondary gain occurring at the same time. In a recent case, a patient with a minor injury was able to use his injury to: a. manipulate his girlfriend into marrying him (secondary gain), b. avoid a physical relationship with her (primary gain), c. gain access to narcotics (secondary gain) and d. avoid competing in the workforce (primary gain).

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