A systematic analysis of symptom formation reveals that the ego's defensive efforts against instinctual impulses entails simultaneous changes in the relationship between self and the environment. Thus primary gain has both an intrapsychic and external component, and adaptive propositions must be included in a metapsychological analysis of symptom formation.

Once symptom formation has led to illness, attention has traditionally been focused on the gains derived from the patient's interaction with his environment. Such an analysis has rarely gone beyond the descriptive level. Also, the dynamic, economic, structural, and genetic aspects of the gain from illness as well as its relationship to the underlying conflict which led to symptom formation have been insufficiently studied. Moreover, little attention has been paid to intrapsychic changes subsequent to symptom formation, e.g., the "secondary revision" of symptom and the constant interplay between internal and external adaptations. Thus secondary gain too has an intrapsychic and external component.