Primary and secondary gain

Primary 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 gain can also be a component of any disease, but is an external motivator. If a patient's disease allows them to miss work, avoid military duty, obtain financial compensation, obtain drugs, avoid a jail sentence, etc., these would be examples of a secondary gain. For instance, an individual having household chores completed by someone else because they have stomach cramps would be a secondary gain. In the context of a person with a significant psychiatric disability, this effect is sometimes called "secondary handicap".[2]

Tertiary gain, a less well-studied process, is the benefit that a third-party receives from the patient's symptoms.[3] It includes gaslighting wherein a person, such as a family member or healthcare worker for financial or other reasons, manipulates a patient into believing that they are ill. Tertiary gain can also be received when, for example, a pharmaceutical company runs advertisements to convince viewers they have symptoms which require treatment with the company's drug.