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Feeling like a fraud

Posted by Leigh MacMillan on Friday, March 19, 2021 in Features, Homepage Highlights, Spring 2021 .

Illustration by iStock

“They must not know I’m from Queens.”

Maureen Gannon, PhD, was in a hotel room in Sweden, talking on the phone with her sister in New York. At the time, Gannon was a new faculty member at Vanderbilt University School of Medicine, and she had been invited to give a presentation at an international conference about her research on the development of the pancreas.

She was anxious.

“I felt like who am I? I don’t mean this as an insult to Queens — there are lots of wonderful people from Queens — but I’m from this very regular, very blue-collar world, and here I was invited to give a talk in Sweden,” Gannon says. “I had these fears that someone was going to discover that it was all a big mistake, that I wasn’t qualified and really didn’t belong there.”

Some years would pass before Gannon, professor of Medicine, learned that her feelings had a name, that she was experiencing what is known as imposter syndrome.

The realization came at a 2011 AAMC women’s leadership training conference that Gannon attended after she was appointed vice chair for Faculty Development in the Department of Medicine.

Maureen Gannon, PhD. Photo by Erin O. Smith.

“I read the description for a breakout workshop called ‘Recognizing and Overcoming the Imposter Syndrome,’ and I thought, ‘oh my gosh, this is what I’ve been feeling for all these years,’” Gannon says.

At the imposter syndrome workshop, she was surprised to find in attendance some of the women who had seemed to be the most accomplished at the conference.

“That’s when it hit me that there are probably a lot of people who look like they’ve got it all together, but they’re having these same feelings.”

After she returned from the conference, Gannon began giving presentations about imposter syndrome to fellow faculty members and trainees at all levels.

“I’ve presented to high school students doing summer research, undergraduates, MD-PhD students, Meharry-Vanderbilt Alliance students, junior faculty and departmental grand rounds,” says Gannon, who was appointed associate dean for Faculty Development for VUSM in 2019. “I’m trying to talk to as many people as possible about this, not only to help people who are having imposter syndrome feelings, but to raise awareness among mentors so they can recognize this syndrome in individuals they are training and help them overcome it.”

Imposter syndrome susceptibility

The term “impostor phenomenon” was coined by two psychologists, Pauline Clance and Suzanne Imes, who had noticed a common set of feelings among high-achieving women they encountered in individual psychotherapy sessions, group interactions and college classes.

“Despite their earned degrees, scholastic honors, high achievement on standardized tests, praise and professional recognition from colleagues and respected authorities, these women do not experience an internal sense of success. They consider themselves to be ‘impostors,’” they wrote in a 1978 paper in the journal Psychotherapy: Theory, Research and Practice. (Clance and Imes used the spelling impostor in their 1978 publication.)

Their study included more than 150 women — undergraduate, graduate and medical students, faculty members and professionals.

They defined the imposter phenomenon as “an internal experience of intellectual phoniness,” and noted that women who experience it “persist in believing that they are really not bright and have fooled anyone who thinks otherwise.”­

Gannon adds that people experiencing the imposter syndrome tend to attribute their successes to external factors out of their control, rather than to their own skills, talents or expertise. She recalls thinking that she received scholarships based only on economic need, not because of her excellent grades and test scores, or that she had been invited to speak at a conference because the organizers needed to include a woman speaker, not because she was an expert islet cell biologist.

“Objectively, I know they’re not rational feelings, but they’re the feelings I had,” Gannon says.

Although Clance and Imes defined the imposter phenomenon based on their findings in women, it is now clear that both women and men experience such feelings, says Jennifer Blackford, PhD, professor of Psychiatry & Behavioral Sciences and Psychology at Vanderbilt.

“There are many different factors that can make someone vulnerable to imposter syndrome,” Blackford says. “Fifty years ago, being a woman was probably more of a factor than it is now because there were fewer women in academic and professional roles. Now, the factors might include having parents who are immigrants or being a first-generation college student or being a member of any group that our country discriminates against.”

Imposter syndrome happens in people who are perfectionists and have trouble continuing to be perfect as life gets more complex. Also, people whose career goals differ from their parents appear to be more susceptible to imposter syndrome, Gannon says.

“It doesn’t have to be having blue-collar parents and pursuing a PhD, it could be that your parents are lawyers, and you want to be a dancer. You have the sense that you don’t fit; you don’t belong.”


Microaggressions add fuel

Kevin Mitchell, MD, PharmD, has spent a lifetime feeling that he doesn’t belong.

“I remember when I was 4 or 5, my mom telling me that I would encounter people in the world who think less of me, who do not value me, because of the color of my skin,” Mitchell says. “I think that’s a common story for Black boys — hearing the message that you will have to be really good at everything in order to make it in the world, that you will need to work twice as hard to get half as much.”

Imposter syndrome feelings initially kept Kevin Mitchell, MD, PharmD, from pursuing his interest in medicine. Photo by Susan Urmy.

Coupled with experiences of people calling him racial slurs or classmates discriminating against him, Mitchell says, “it’s easy to get into a mindset that you’re not doing enough. If you were, why would people be treating you this way?”

But Mitchell’s mother and teachers recognized his potential and encouraged him to participate in opportunities like a youth leadership conference in Washington, D.C., while he was in high school and to continue his education.

Imposter syndrome feelings initially kept Mitchell from pursuing his interest in medicine.

“I didn’t think I was ‘good enough’ to go to medical school because even now, you don’t see a lot of doctors who look like me,” he says. “I didn’t apply for scholarships or take opportunities because I was afraid of failing.”

Mitchell found support again from family, friends and professors at Florida A&M University, the historically Black college he attended as a first-generation college student, which he says was a formative experience.

“I was surrounded by people like me who were achieving their educational goals, and that allowed me to see myself in a different light.”

He changed his major and earned his Doctor of Pharmacy degree, then went to medical school at the University of South Florida. Mitchell completed his residency at Vanderbilt University School of Medicine and is now on the faculty as an assistant professor of Medicine and Pediatrics.

Microaggressions — statements or actions of subtle discrimination — have continued to fuel imposter syndrome feelings for Mitchell.

He commonly gets the question, “Are you the doctor?” when he walks into a clinic or hospital room, despite introducing himself as “Dr. Mitchell” and wearing a white coat embroidered with his name, a badge and a stethoscope.

“When I say, ‘Yes, I am,’ I often get met with an incredulous look, as if I couldn’t be,” he says.

“Microaggressions add an external component to the internal worry that people will find out you’re not qualified, that you’re not supposed to be wherever you are. They solidify those irrational thoughts that you’re not good enough.”


Neurobiological roots of anxiety

Imposter syndrome is not a clinical or psychological diagnosis, but it shares symptoms with social anxiety disorder and generalized anxiety disorder.

“People with social anxiety have a real dread or fear of other people evaluating them, and that fear of evaluation is a core part of imposter syndrome,” Blackford says. “Generalized anxiety disorder is a pervasive worry that bad things will happen. For people with imposter syndrome, fears of failure, of not being perfect, of being found out as a fraud look like generalized anxiety.”

Jennifer Blackford, PhD. Photo by John Russell.

Blackford and her colleagues have studied the neurobiology of anxiety, shedding light on brain pathways that may be involved in imposter syndrome.

It has been known for decades that a central brain region called the amygdala is involved in responses to fear — the short-term ‘fight or flight’ reaction to something life-threatening, like a tornado tracking toward your home, Blackford says.

But anxiety in humans is different from fear, she notes. “It’s a sustained long-term response to something that might potentially be threatening.”

Blackford and her team have used functional magnetic resonance imaging (fMRI) to study the fear and anxiety brain networks triggered by scary images, in their case “fear faces” — a standardized set of photographs of actors showing fear.

The researchers first train participants that when they see a certain colored shape cue, it will be followed be a neutral face (predictable safe); another cue will be followed by a fear face (predictable threat); and a third cue will be followed by an unknown image (unpredictable: safe or threat).

The unpredictable cue turned out to engage a tiny brain region near the amygdala called the BNST, the bed nucleus of the stria terminalis. Blackford’s group was the first to identify the BNST using neuroimaging methods in humans, and they have since mapped the neural network of the BNST and shown that BNST activity to unpredictable threat cues is higher in people with social anxiety.

“The fear signal comes from the eyes to the visual cortex and then to the amygdala, which evaluates the threat. If the amygdala decides the signal might be threatening, we think it does a sort of lateral pass to the BNST, which now runs with that football of anxiety,” Blackford says. “It’s likely that part of the neural circuitry of the imposter syndrome is an increased BNST response to things that are not truly threatening.”

Connections between the BNST and the prefrontal cortex are important for therapies such as cognitive behavioral therapy, Blackford notes.

“The prefrontal cortex is critical for inhibiting anxiety. Someone who has weaker connections from the prefrontal cortex to the BNST is going to feel that anxiety every time their BNST is engaged, whereas someone with a stronger prefrontal cortex connection might be able to shut down the signal before there’s a physiological response,” Blackford says. “With behavioral therapy treatments, we can teach someone to strengthen those connections and to use thinking and planning to counter the anxiety.”


Managing imposter syndrome

In her presentations, Gannon discusses strategies for overcoming imposter syndrome feelings, which she notes can impede educational or career progress.

“I think a little bit of these feelings are OK; they keep you humble,” Gannon says. “But when you don’t feel that you deserve an opportunity or an appointment or a position, then you don’t advocate for yourself and push for the things you’ve earned.”

Sara Horst, MD, MPH, a gastroenterologist at Vanderbilt who became aware of imposter syndrome at one of Gannon’s presentations, realized that feeling like she didn’t belong quieted her voice.

“When I’m in a meeting surrounded by successful people and I wonder why I’m there, I don’t talk,” Horst says. “I feel like a lot of people do that, and then their voice, which may have a different tone or a different experience because they are a minority or a woman, doesn’t get heard.”

Gannon suggests that people experiencing imposter syndrome make and review factual lists of their accomplishments, talk to others about the feelings, and get honest feedback from people they trust. She advises mentors to use similar strategies with trainees and to tell their own stories of failure, so that it becomes clear that success does not follow a perfect linear path.

She also notes that imposter syndrome symptoms may worsen or reappear during life or career transitions and shows evidence of this by sharing her scores on the “Clance Impostor Phenomenon Scale” — a questionnaire developed by Pauline Clance to help individuals assess their imposter feelings.

“I periodically complete the assessment and my score goes down when I’m comfortable in a given role and up when I’m in a new role,” Gannon says. “Imposter syndrome is not something that you get rid of, but that you learn how to manage.”

Imposter syndrome was discussed on the new VUMC podcast, Vanderbilt Health DNA: Discoveries in Action. This episode and others are available on all podcast platforms.