Primary and secondary gain

Primary morbid gain or secondary morbid gain are used in medicine to describe the significant subconscious psychological motivators patients may have when presenting with symptoms. It is important to note that if these motivators are recognized by the patient, and especially if symptoms are fabricated or exaggerated for personal gain, then this is instead considered malingering.

Primary morbid gain produces positive internal motivations. For example, a patient might feel guilty about being unable to perform some task. If a medical condition justifying an inability is present, it may lead to decreased psychological stress. Primary gain can be a component of any disease, but is most typically demonstrated in conversion disorder – a psychiatric disorder in which stressors manifest themselves as physical symptoms without organic causes, such as a person who becomes blind after seeing a murder. The "gain" may not be particularly evident to an outside observer.

Secondary morbid gain can also be a component of any disease, but is an external motivator. If a patient's disease allows him/her to miss work, avoid military duty, obtain financial compensation, obtain drugs, or avoid a jail sentence, these would be examples of a secondary gain. An example would be an individual having stomach cramps when household chores are completed by a family member. In the context of a person with a significant mental or psychiatric disability, this effect is sometimes called secondary handicap.[1]

Tertiary morbid gain, a less well-studied process, is the benefit that a third party receives from the patient's symptoms.[2] It includes gaslighting, in which a family member or healthcare worker, for financial or other reasons, manipulates a patient into believing he or she is mentally ill. A pharmaceutical company has tertiary gain when it runs ads to convince viewers they have symptoms which require treatment with the company's drug.

The difference between Primary morbid gain and Secondary morbid gain is that in primary gain the reason the patient cannot go to work is because he or she is injured, whereas with secondary gain the reason the patient is injured is so he or she can't go to work.