Imposter Phenomenon

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.