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IMPOSTER PHENOMENON

Martin R. Huecker; Jacob Shreffler; Patrick T. McKeny; David Davis.

Author Information and Affiliations

AUTHORS

Martin R. Huecker1; Jacob Shreffler2; Patrick T. McKeny3; David Davis4.



AFFILIATIONS

1 University of Louisville
2 University of Louisville School of Medicine
3 Orange Park Medical Center
4 Orange Park Medical Center

Last Update: July 31, 2023.

Go to:


CONTINUING EDUCATION ACTIVITY

Imposter syndrome is a commonly reported and experienced phenomenon that affects
high-functioning, high-achieving individuals, particularly in medicine and
healthcare. Due to the many potential detrimental effects of this syndrome on
these individuals, in addition to the multiple associated co-morbidities,
including depression, anxiety, and other behavioral health issues, the
identification, and treatment of those affected with this syndrome are
imperative. This activity reviews the identification and evaluation and
highlights the interprofessional team's role in managing patients with imposter
syndrome.

Objectives:

 * Review the six most commonly reported characteristics of imposter syndrome.
 * Describe the manifestations and/or symptoms of the most commonly reported
   characteristics of imposter syndrome.
 * Identify common behavioral health co-morbidities that are associated with
   imposter syndrome.
 * Explain the importance of identifying and treating imposter syndrome to
   improve healthcare team outcomes.

Access free multiple choice questions on this topic.



Go to:


INTRODUCTION

Imposter syndrome (IS) is a behavioral health phenomenon
described as self-doubt of intellect, skills, or accomplishments among
high-achieving individuals. These individuals cannot internalize their success
and subsequently experience pervasive feelings of self-doubt, anxiety,
depression, and/or apprehension of being exposed as a fraud in
their work, despite verifiable and objective evidence of their
successfulness.[1] The terms imposter syndrome and imposter phenomenon (IP) are
used interchangeably, with IP gaining more frequent use in recent literature. 

Imposter syndrome (also commonly-termed imposter phenomenon, fraud
syndrome, impostorism, and perceived fraudulence) was first described in 1978
by Suzanne Imes, Ph.D., and Pauline Rose Clance, Ph.D. as an observation first
among successful women and other marginalized groups.[1] 

In the interim, since the original publication by Clance Et. Al., imposter
syndrome has expanded significantly in scientific literature and formal and
informal media. The most commonly linked groups to imposter syndrome are
typically comprised of high-achieving individuals and appear disproportionately
prevalent in academics, particularly in the healthcare field. There is a
particular interest in studying this phenomenon in medicine, as there is an
established relationship between IS and other behavioral health disorders,
including burnout, depression, anxiety, and exacerbation of other behavioral
health issues.[2]

While imposter syndrome is a commonly researched, experienced, and pervasive
phenomenon, there is an unknown true prevalence. Currently, no formal or widely
accepted medical definition exists (e.g., DSM-V criteria). Despite a lack of a
formal definition, the original six criteria identified by Clance have been
expanded upon since its inception and can be summarized as the following
constellation of interrelated characteristics that may or may not be present in
an individual with IS: the imposter cycle, perfectionism, super-heroism,
atychiphobia (fear of failure), denial of competence, and achievemephobia.[1][3]

I mposter Cycle  

An essentially pathognomonic characteristic of imposter syndrome, the imposter
cycle occurs when individuals with IS face an assignment, obstacle, duty, or
other achievement-related tasks. In those with IS, the response to this
achievement-related task is generalizable into two broad categories:
over-preparation and procrastination. 

In over-preparation, those with IS feel they must work harder than others to
achieve the same goal, and because of this objectively false perception that one
must put in more effort, they are an imposter. In cases of procrastination,
those with IS feel that they are an imposter due to hurried
'last-minute' preparation and will eventually be exposed as a fraud.

Upon completion of the task, there is a brief sense of success or triumph in
each scenario. Despite this sense of accomplishment, possibly due to one of the
other five interrelated characteristics of IS (discussed below), the perceived
brevity of the sense of success, or another poorly understood neurobiological
mechanism of IS, there is a failure to internalize this sense of success. This
leads to those with IS experiencing a spectrum of fear, anxiety, fraudulence,
and other pathology leading into the next task, effectively repeating
the aforementioned cycle.[4]

Perfectionism 

Perfectionism was originally described by Clance et al. as the 'need to be the
best,' this category is a continuum of hyper-competitive and perfectionist
behaviors that occurs when practically unattainable standards and goals are
self-imposed by those with IS. These impossible-to-reach benchmarks continually
drive a detrimental positive feedback loop in those needing to 'be the best.'

This aspect of IS can exacerbate phenomena such as work martyrdom (sacrifice of
self-interests for a falsely perceived 'greater good'), over-generalizing
mistakes that are perceived as a 'lack of ability,' and overly critical
non-constructive self-feedback. These behaviors, among others, can lead to
the super-heroism aspects of IS.[2]

Super-H eroism

A commonly reported component of the imposter cycle, super-heroism is
intrinsically related to the need to be the best. It often presents in IS as a
tendency to over-prepare for tasks to appear more than capable of completing
them. The central manifestation in this component of IS is over-preparation,
which is secondary to the above-mentioned unattainable self-imposed standards.
This additional workload is detrimental to mental health.[5]

Atychiphobia (Fear of Failure) 

Fear of failure manifests when facing externally or internally
imposed achievement-related tasks. Individuals with IS experience anxiety, the
fear of being shamed and /or humiliated if they fail or do worse than a peer on
a particular task; thus, they are exposed as an imposter if they were to
fail.[6]

Denial of Competence and Capability 

Closely tied to perfectionism, individuals with imposter syndrome tend to
discount their intelligence, experience, skills, and natural talents. There is a
propensity to internalize failure and relate success to external influence or
random chance, despite evidence that the individual accomplished a particular
task without these factors.

Achievemephobia (Fear of Success) 

Describes the internalization of failures as a positive feedback loop and
difficulty in internalizing or recognizing their successes, as succeeding may
lead to higher expectations or increase pre-existing workload.[7] These
characteristics are not completely inclusive of all manifestations of IS,
and the lack of any or all of these classically accepted characteristics does
not exclude an individual from being affected by imposter syndrome.

Go to:


ETIOLOGY

Like many other behavioral health disorders, the etiology of imposter syndrome
is likely multifactorial. Despite numerous case reports, and scientific and
non-scientific studies in psychology, psychiatry, and sociology, there is no
formal consensus on the etiology of IS. 

Better delineation of the etiology will require more formal definitions, the
study of the prevalence and etiology of the syndrome, and investigation into the
spectrum of behavioral health co-morbidities. Currently, the proposed etiologies
can be broken down into the following:

 * As a standalone syndrome, imposter syndrome may result from any of the
   previously mentioned six factors, which all relate to broken meta-cognitive
   processes. Imposter syndrome is increasingly reported and recognized in
   high-pressure academic and workplace settings. Academic settings,
   including undergraduate, graduate, post-graduate, and professional education,
   create social constructs with multiple levels of internal and external
   attributions. While IS can occur in any person, a disproportionate amount of
   high-functioning individuals in healthcare are burdened with IS.[8]

 * As a manifestation of other comorbid mental health disorders, imposter
   syndrome may, in part, be a complex presentation of various mood and
   personality disorders.[9]

Go to:


EPIDEMIOLOGY

Reports regarding the epidemiology of imposter syndrome exist but are not
significant enough in breadth or depth to make meaningful statements on
biostatistical factors regarding imposter syndrome (incidence, prevalence,
demographic information, etc.) on the scale of the U.S. or worldwide. Despite
this knowledge gap, based on existing studies and reports, imposter syndrome
tends to be more common in females than males and in marginalized groups
(minority racial and ethnic groups, socioeconomic status).[1] Groups with a
reportedly high prevalence of IS include students, minority groups, and select
workforce members in high-pressure, high-stakes settings. 

Imposter syndrome is highly prevalent among students in healthcare professions.
For instance, one study of medical students found more than one-quarter of male
students and half of the female students experienced IS. In that same study,
there was a statistically significant association between IS and burnout
syndrome, as determined by the Maslach Burnout Inventory.[10] Imposter syndrome
reliably affects the well-being and quality of life of students and
professionals. 

In a study of pharmacy students, higher Clance Imposter Phenomenon Scale (CIPS)
scores correlated with the number of hours worked per week and prior mental
health treatment.[11] This supports the conjecture that the high-pressure,
high-stakes environments of undergraduate and graduate medical education (and
healthcare in general) are environmental factors that exacerbate or uncover IS
in susceptible individuals. This is further supported by other studies regarding
medical, dental, veterinary, and pharmacy students, nurses, and graduate medical
education level trainees that likely demonstrate the relationship between IS and
high-stakes academic and healthcare settings.[12][13][14][15]

Go to:


HISTORY AND PHYSICAL

Historical and physical examination features of those with imposter syndrome may
be challenging. Many historical features obtained during an examination or
evaluation are also part of a psychologic/psychiatric assessment. 

Historical and Physical features:

 * Imposter cycle
 * Intellectual self-doubt
 * Low self-esteem
 * Feelings of fraudulence and/or inadequacy 
 * Denial and/or failure to internalize competencies, accolades, achievements,
   or successes
 * Fear of the success
 * Fear of failure
 * Super-heroism
 * Anxiety
 * Depression
 * Burnout
 * In professional settings: excessive comparison to peers
 * Personality disorder(s): maladaptive personality

Go to:


EVALUATION

A thorough history and physical, including pertinent questioning of social,
environmental, and psychologic factors, are needed to identify imposter
syndrome. A holistic approach to identifying and understanding the constellation
of factors is critical because no standardized or externally validated
diagnostic criteria exist.

The Clance Imposter Phenomenon Scale is the most commonly utilized diagnostic
tool; it consists of 20 Likert-Scaled questions which have not been externally
validated. Additional scales have been created, including the Harvey Impostor
Phenomenon Scale, Young Imposter Scale, Leary Imposter Scale, and the Perceived
Fradulance Scale.[16]

Laboratory, radiographic, and other diagnostic testing is subject to a
case-by-case basis by the evaluating clinician; these evaluations will likely
have no clinical significance unless another condition is present concurrently.

Informal evaluation involves individual self-assessment and peers/mentors
assessing one another. A detailed physical examination can rule out physical
conditions with psychiatric manifestations. Additionally, some individuals with
imposter syndrome could have psychosomatic symptoms, and a physical exam can
address these symptoms.

Go to:


TREATMENT / MANAGEMENT

Treatment and management of imposter syndrome will vary depending on the level
of detriment IS has on an individual's life. Medical and behavioral health
treatments should be determined case-by-case in suspected or diagnosed imposter
syndrome, with attention to concomitant behavioral health conditions. 

 * Self-reflection for metacognition
 * Counseling
 * Cognitive behavioral therapy (CBT)
 * Psychotherapy
 * Pharmacologic therapy for co-morbid behavioral health conditions; possibly
   for imposter syndrome, depending on future research into the neurobiology and
   pathophysiology of IS
 * Gratitude exercises to focus on what one has accomplished

Go to:


DIFFERENTIAL DIAGNOSIS

Given that imposter syndrome does not have a formal DSM-V definition or another
formal set of consensus criteria, the differential diagnoses, which are also
likely to be comorbidities in those with IS, include both formal and informal
'diagnoses':

 * Anxiety: generalized anxiety disorder, social anxiety disorder, anxiety
   disorder due to another medical condition, unspecified anxiety disorder,
   phobia, OCD, PTSD
 * Depression
 * Other mood disorders
 * Burnout
 * Low self-esteem
 * Personality disorders

Go to:


PROGNOSIS

Given the absence of formal diagnostic criteria or established treatments or
management plans, we cannot comment on the prognostication of imposter syndrome.

Go to:


COMPLICATIONS

Complications of imposter syndrome can include worsening of concomitant
behavioral health conditions and the emergence of behavioral health conditions.

Go to:


DETERRENCE AND PATIENT EDUCATION

Educators have the potential to prevent imposter syndrome by reassuring students
that they have earned their place in the professional school they attend.
Potential patients should address insecurities promptly to prevent the positive
feedback cycle that can lead to imposter syndrome. This may be especially
important for individuals who are underrepresented in medicine and other
professional fields.[17]

Go to:


ENHANCING HEALTHCARE TEAM OUTCOMES

The importance of identification and management of imposter syndrome ranges from
the individual to the societal level. Prevention, early intervention, and
management of IS would likely ameliorate the detrimental effects imposter
syndrome has on individuals, patients, teams, and families.

Given the existence of multiple definitions and diagnostic criteria for IS, a
formally validated diagnostic tool and/or a DSM definition would further
research into the diagnosis, management, and prognostication.

Improving diagnosis and management will likely enhance the healthcare team's
performance and enhance team performance. Improving team performance in
healthcare settings reduces costs and burdens on the healthcare system and
improves patient outcomes. Additionally, improved diagnostics and interventions
for IS will likely lead to decreased disparities in minority groups in these
high-pressure academic and clinical settings.

Current research and literature are at the Oxford CEBM Level 4 and 5
evidence. Potential future research exists in further identifying the etiology,
pathophysiology, epidemiology, identification, and management of imposter
syndrome/phenomenon.

Go to:


REVIEW QUESTIONS

 * Access free multiple choice questions on this topic.
 * Comment on this article.

Go to:


REFERENCES

1.
Bravata DM, Watts SA, Keefer AL, Madhusudhan DK, Taylor KT, Clark DM, Nelson RS,
Cokley KO, Hagg HK. Prevalence, Predictors, and Treatment of Impostor Syndrome:
a Systematic Review. J Gen Intern Med. 2020 Apr;35(4):1252-1275. [PMC free
article: PMC7174434] [PubMed: 31848865]
2.
Thomas M, Bigatti S. Perfectionism, impostor phenomenon, and mental health in
medicine: a literature review. Int J Med Educ. 2020 Sep 28;11:201-213. [PMC free
article: PMC7882132] [PubMed: 32996466]
3.
Mak KKL, Kleitman S, Abbott MJ. Impostor Phenomenon Measurement Scales: A
Systematic Review. Front Psychol. 2019;10:671. [PMC free article: PMC6463809]
[PubMed: 31024375]
4.
Jaremka LM, Ackerman JM, Gawronski B, Rule NO, Sweeny K, Tropp LR, Metz MA,
Molina L, Ryan WS, Vick SB. Common Academic Experiences No One Talks About:
Repeated Rejection, Impostor Syndrome, and Burnout. Perspect Psychol Sci. 2020
May;15(3):519-543. [PubMed: 32316839]
5.
Sukhera J, Poleksic J, Zaheer J, Pack R. Normalising disclosure or reinforcing
heroism? An exploratory critical discourse analysis of mental health stigma in
medical education. Med Educ. 2022 Aug;56(8):823-833. [PubMed: 35246993]
6.
Giel LIS, Noordzij G, Noordegraaf-Eelens L, Denktaş S. Fear of failure: a
polynomial regression analysis of the joint impact of the perceived learning
environment and personal achievement goal orientation. Anxiety Stress Coping.
2020 Mar;33(2):123-139. [PubMed: 31762323]
7.
Cavenar JO, Werman DS. Origins of the fear of success. Am J Psychiatry. 1981
Jan;138(1):95-8. [PubMed: 7446791]
8.
Chrousos GP, Mentis AA, Dardiotis E. Focusing on the Neuro-Psycho-Biological and
Evolutionary Underpinnings of the Imposter Syndrome. Front Psychol.
2020;11:1553. [PMC free article: PMC7396514] [PubMed: 32848987]
9.
Feenstra S, Begeny CT, Ryan MK, Rink FA, Stoker JI, Jordan J. Contextualizing
the Impostor "Syndrome". Front Psychol. 2020;11:575024. [PMC free article:
PMC7703426] [PubMed: 33312149]
10.
Villwock JA, Sobin LB, Koester LA, Harris TM. Impostor syndrome and burnout
among American medical students: a pilot study. Int J Med Educ. 2016 Oct
31;7:364-369. [PMC free article: PMC5116369] [PubMed: 27802178]
11.
Sullivan JB, Ryba NL. Prevalence of impostor phenomenon and assessment of
well-being in pharmacy residents. Am J Health Syst Pharm. 2020 Apr
27;77(9):690-696. [PubMed: 32201891]
12.
Kogan LR, Schoenfeld-Tacher R, Hellyer P, Grigg EK, Kramer E. Veterinarians and
impostor syndrome: an exploratory study. Vet Rec. 2020 Oct 03;187(7):271.
[PubMed: 32571984]
13.
Haney TS, Birkholz L, Rutledge C. A Workshop for Addressing the Impact of the
Imposter Syndrome on Clinical Nurse Specialists. Clin Nurse Spec. 2018
Jul/Aug;32(4):189-194. [PubMed: 29878930]
14.
Holliday AM, Gheihman G, Cooper C, Sullivan A, Ohyama H, Leaf DE, Leaf RK. High
Prevalence of Imposterism Among Female Harvard Medical and Dental Students. J
Gen Intern Med. 2020 Aug;35(8):2499-2501. [PMC free article: PMC7403282]
[PubMed: 31654355]
15.
Gottlieb M, Chung A, Battaglioli N, Sebok-Syer SS, Kalantari A. Impostor
syndrome among physicians and physicians in training: A scoping review. Med
Educ. 2020 Feb;54(2):116-124. [PubMed: 31692028]
16.
Freeman KJ, Houghton S, Carr SE, Nestel D. Measuring impostor phenomenon in
healthcare simulation educators: a validation of the clance impostor phenomenon
scale and leary impostorism scale. BMC Med Educ. 2022 Mar 03;22(1):139. [PMC
free article: PMC8892706] [PubMed: 35236357]
17.
Owusu-Akyaw K. The Forward Movement: Amplifying Black Voices on Race and
Orthopaedics-Who is the Imposter? Clin Orthop Relat Res. 2022 Feb
01;480(2):244-245. [PMC free article: PMC8747599] [PubMed: 34985851]

Disclosure: Martin Huecker declares no relevant financial relationships with
ineligible companies.

Disclosure: Jacob Shreffler declares no relevant financial relationships with
ineligible companies.

Disclosure: Patrick McKeny declares no relevant financial relationships with
ineligible companies.

Disclosure: David Davis declares no relevant financial relationships with
ineligible companies.

 * Continuing Education Activity
 * Introduction
 * Etiology
 * Epidemiology
 * History and Physical
 * Evaluation
 * Treatment / Management
 * Differential Diagnosis
 * Prognosis
 * Complications
 * Deterrence and Patient Education
 * Enhancing Healthcare Team Outcomes
 * Review Questions
 * References

Copyright © 2023, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) (
http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to
distribute the work, provided that the article is not altered or used
commercially. You are not required to obtain permission to distribute this
article, provided that you credit the author and journal.

Bookshelf ID: NBK585058PMID: 36251839


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 * Introduction
 * Etiology
 * Epidemiology
 * History and Physical
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 * Treatment / Management
 * Differential Diagnosis
 * Prognosis
 * Complications
 * Deterrence and Patient Education
 * Enhancing Healthcare Team Outcomes
 * Review Questions
 * References


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Huecker MR, Shreffler J, McKeny PT, et al. Imposter Phenomenon. [Updated 2023
Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK585058/
Making content easier to read in Bookshelf Close

We are experimenting with display styles that make it easier to read books and
documents in Bookshelf. Our first effort uses ebook readers, which have several
"ease of reading" features already built in.

The content is best viewed in the iBooks reader. You may notice problems with
the display of some features of books or documents in other eReaders.

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