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.

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.

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]

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]

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

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.

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

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

Prognosis

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

Complications

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

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]

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.

Review Questions

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

References

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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.