The below is an excerpt from the book "The Myth of Mental Illness: Foundations of a Theory of Personal Conduct" by Thomas Szasz. Chapter 14 Impersonation and Illness pages 243 thru 245

The book can be downloaded as a pdf file here: http://allthatstreaming.com/pdf/the-myth-of-mental-illness-by-thomas-szasz-1974.pdf

In the case of malingering, hysteria, and the Ganser syndrome—and, indeed, in all cases of so-called mental illness—psychiatrists actually confirm the patient's self-definition as ill and so help to shape his illness. This psychiatric authentication and legitimization of the sick role for those who claim to be ill,  or about whom others make such claims, has the most profound implications for the whole field of psychiatry, and beyond it, for all of society. When physicians and psychiatrists began to treat those who impersonated the sick role as genuinely ill patients, they acted much as an audience would if it treated Raymond Massey or Ralph Bellamy as Presidents of the United States. This sort of feedback to the actor means not only that he can no longer rely on his audience for a corrective definition of reality and his own identity in it, but also that, because of the audience's response, he must doubt his own perceptions about who he really is. In this way, he is encouraged to acquiesce in the role which in part he wants to  play, and which his audience wants him to play. While actors are sophisticated about the risks of typecasting, persons playing on the metaphorical stage of real life are usually quite unsuspecting of this danger.

Hence, few persons who launch themselves on a career of impersonating the sick role reckon with the danger of being authenticated in this role by their families and by the medical profession. On the contrary, they usually expect that their impersonated roles will be opposed or rejected by their audience. Just as swindlers expect skepticism and opposition from their intended victims, so malingerers have traditionally expected skepticism and oppositions from physicians. However, as on the stage so also in real life, an audience's resistance to an actor's impersonated role is strongest when the play is first put on stage. After a run of initial performances, the actor is either accepted in his role— and the play goes on for a longer run; or he is rejected in it—and the play closes down. Moreover, the longer the actor plays his role, the less will his critics and audience scrutinize his performance: he is now "in." This is a familiar process in many phases of life. For example, if a student does well early in his courses and becomes defined as a good student, his teachers will scrutinize his subsequent performance much less Impersonation and Illness closely-than they will that of a bad student. In the same way, actors, athletes, financiers, and others of proven ability tend to be much more immune to criticism than those who are notyet so accepted.

The distinction between genuine and impersonated roles may be described in still another way, by making use of the concepts of instrumental and institutional groups and the criteria for membership in them." Instrumental groups are based on shared skills. Membership in them, say in a Davis Cup team, implies that the person possesses a special skill. We consider this role genuine because such a person really knows how to play tennis. Institutional groups, on the other hand, are based on kinship, status, and other nonfunctional criteria. Membership in a family, say in a royal family, is an example. When the king dies, the crown prince becomes the new king. This transformation from nonking to king requires no new knowledge or skills; it requires only being the son of a dead king.

Impersonation may be summed up in one sentence; it is a strategy of behavior based on the model of hereditary monarchies. Implicit in this strategy is a deep-seated belief that instrumental skills are unimportant. All that is needed to succeed in the game of life is to "play a role" and gain social approval for it. Parents often hold up this model for their children to follow. When they do follow it, they soon end up with an empty life. When the child or young adult then tries to fill the void, his efforts to do so are often labeled as some form of "mental illness." However, being mentally ill or psychotic —or killing someone else or himself—may be the only games left for such a person to play.

From:  rod@disroot.org