Sometimes persistent stress symptoms are knowingly (consciously) or unknowingly (unconsciously) used by us to get sympathy, support, love, attention, money, etc. This phenomenon is known as secondary gain. Since the sufferer gets some type of benefit because of his symptoms, he is not very motivated to receiving treatment or getting better. So, if I am collecting disability payments from an insurance company due to anxiety symptoms, I would report no improvement of my symptoms regardless what treatment I get, as this would mean losing my monetary benefits, and having to return to my job that I hate. Here are two interesting cases.
A 58 year old woman who had been receiving disability payments for over twenty years on the grounds of some vague physical complaints, received a letter from the Social Security Disability Department to undergo routine evaluation to assess her current health status. After examining her, the naive physician said, ‘Congratulations! You are in robust health. There is not a thing wrong with you!’ As he left the room, he heard a thud. When he turned to see what happened, he saw the patient on the floor.
Apparently she had fainted. The physician was forced to hospitalize her for ‘further investigation.’ She stayed in the hospital for over two weeks costing Medicare several thousand dollars. No matter what the doctor did, the patient kept telling him she was not feeling any better. She agreed to leave the hospital only after the doctor assured her that he was going to pass on to the Social Security office her three inch thick chart showing how sick she was!
Here is another true story: A 55 year old truck driver received a minor injury to his neck as a result of a damaged side mirror of his truck. The injury missed his carotid artery by a millimeter. After the skin laceration healed, the patient continued to have a number of physical symptoms such as blurred vision, numbness of face, weakness of tongue, etc. He did not respond to any of the treatment, including ‘nerve medications’, offered by his neurologist. Unable to find a physical cause, his neurologist finally referred him to me.
In the interview I found out that the patient had worked for a local truck company for over thirty years. This truck company was now in the process of laying off truck drivers one by one. He was certain that if he returned to work, he would lose his job and he would not find another job at his age. As long as he stayed sick, he was guaranteed his full salary. So, regardless what treatment I gave him, he came back to report, ‘I am worse than ever.’
Then, one day he walked into my office looking very cheerful. He said he was doing just fine. Surprised by this wonderful change in his demeanor I asked him what happened. He replied smiling that he had been diagnosed as having cancer of the stomach, and that the Social Security office had declared him as totally and permanently disabled. Now that he was guaranteed a paycheck, he felt great. The fact that his stomach cancer would kill him in six months seemed far from his insecure mind!
People who are injured at work often do not feel better until they receive adequate compensation. This type of secondary gain is called compensation neurosis. These people invariably have a list of grievances against their employers. They have nurtured ill will toward their employer or supervisor for real or perceived injustice done to them. Very often these people give history of someone higher-up having made a derogatory remark just before or after the accident. They also report that they did not get proper attention or sympathy from the supervisor at the time of the accident; did not get a ‘Get Well Card’ while recovering, and whatnot.
By the time they see a psychiatrist, they have already retained a lawyer. In treatment, they usually do not take medications as prescribed; do not keep their appointment for physical or talking therapy; and they report no response to medications or therapy given for their main symptom, which usually has to do with pain or inability to move their limbs. Once they have received a compensatory payment, their symptoms improve dramatically.
Sometimes, people who are insecure in their relationship with significant others, keep hanging on to their stress symptoms to curry sympathy, support and pity. A 35 year old woman who suspected her husband of infidelity started having severe panic attacks. Her husband suspected that her panic attacks had something to do with their strained relationship. He became very solicitous and supportive in response to her suffering. In spite of high doses of medications and regular psychotherapy, the patient reported little improvement. It became clear to me soon enough that the patient was scared to declare improvement as that might jeopardize her improved relationship with her husband