A Risk Factor for Problematic Pain Outcomes
Michael J. L. Sullivan, PhD, Whitney Scott, BA, and Zina Trost, PhD
Background: Emerging research suggests that perceptions of in-
justice after musculoskeletal injury can have a significant impact on
a number of pain-related outcomes.
Aims: The purpose of this paper is to review evidencelinking
perceptions of injustice to adverse pain outcomes. For the purposes
of this paper, perceived injustice is defined as an appraisal cogni-
tion comprising elements of the severity of loss consequent to in-
jury (“Most people don’t understand how severe my condition is”),
blame (“I am suffering because of someone else’s negligence”), a
sense of unfairness (“It all seems so unfair”), and irreparability of
loss (“My life will never be the same”).
Results: Cross-sectional studies show that high scores on percep-
tions of injustice are correlated with pain catastrophizing, fear of
movement, and depression. Prospective studies show that high
scores on perceived injustice are a prognostic indicator of poor
rehabilitation outcomes and prolonged work disability. Research
shows that perceptions of injustice interfere not only with physical
recovery after injury, but perceptions of injustice also impact
negatively on recovery of the mental health problems that might
arise subsequent to traumatic injury. Although research has yet to
address the process by which perceptions of injustice impact on
pain-related outcomes systematically; possible mechanisms include
attentional disengagement difficulties, emotional distress, malad-
aptive coping, heightened displays of pain behavior, anger, and
Conclusions: Perceived injustice appears to be associated with
problematic health and mental health recovery trajectories after the
onset of a pain condition. Future directions for research and
treatment are addressed.
Key Words: perceived injustice, pain catastrophizing, pain, pain
(Clin J Pain 2012;28:484–488)
uations that are characterized by a violation of basic human
rights, transgression of status or rank, or challenge to
equity norms and just world beliefs.1–3The experience of
esearch has shown that perceptions of injustice are
likely to arise when an individual is exposed to sit-
unnecessary suffering as a result of another’s actions and
appraisals of irreparable loss are also likely to give rise to
perceptions of injustice.4A case can be made that the sit-
uations or conditions that contribute to a sense of injustice
characterize the life situation of many individuals who have
sustained musculoskeletal injuries.
Particularly in situations where injury has occurred as
a result of another’s error or negligence, the injury victim
might experience postinjury life with a sense of injustice.4
Clinical anecdotes abound of people with persistent pain
who feel that they have been caused to suffer unjustly either
as a direct result of their injury, or indirectly by the se-
quellae of their injury.5,6Verbalizations such as “I wish he
could see what he has done to my life” or “Nothing will
ever make up for what I have gone through” reflect at once
elements of unfairness and the irreparability of loss.
Whether considered from philosophical, social, legal,
or psychological perspectives, writers have suggested that
injustice demands retribution.7,8Central to the process of
litigation within “tort”: systems is the determination of
fault and quantification of loss, and the exchange of fi-
nancial resources as a proxy for retribution.8The extant
literature of the deleterious effects of litigation on suffering
and recovery suggests that high levels of perceived injustice
might represent a risk factor for problematic recovery after
Although discussions of philosophical, social, and le-
gal issues related to injustice have a long history, only re-
cently have there been systematic efforts to study the
psychology of perceived injustice in the context of injury
and pain.4A few recent studies have examined the relation
between injury-related perceptions of injustice and pain-
related outcomes after musculoskeletal injury. Sullivan
et al13described the development of the Injustice Experi-
ence Questionnaire (IEQ). On this measure, perceived in-
justice is construed as an appraisal cognition comprising
elements of the severity of loss consequent to injury (“Most
people don’t understand how severe my condition is”),
blame (“I am suffering because of someone else’s negli-
gence”), a sense of unfairness (“It all seems so unfair”), and
irreparability of loss (“My life will never be the same”).
Factor analysis reveals that the IEQ yields 2 correlated
factors that have been labeled severity/irreparability of loss
In a prospective study of individuals with mixed
musculoskeletal injuries (ie, back sprain, whiplash), Sullivan
et al13reported that high scores on perceived injustice
predicted work disability at 1-year follow-up. Perceived
injustice predicted work disability even when controlling
for initial pain severity, postinjury functional limitations,
catastrophizing, depression, and pain-related fears. In the
latter study, perceived injustice was more strongly related to
disability than to pain severity. Prospective analyses
Received for publication September 29, 2011; accepted February 25,
From the Department of Psychology, McGill University, Montreal,
M.J.L.S. was supported by a Canada Research Chairs grant, and Z.T.
was supported by a postdoctoral fellowship from the Alan Edwards
Pain Research Foundation. None of the authors has any financial
interests in the findings of the present study. The authors declare no
conflict of interest.
Reprints: Michael J. L. Sullivan, PhD, Department of Psychology,
McGill University, 1205 Docteur Penfield, Montreal, QC H3A 1B1,
Canada (e-mail: email@example.com).
Copyrightr2012 by Lippincott Williams & Wilkins
SPECIAL TOPIC SERIES
484|www.clinicalpain.comClin J Pain?Volume 28, Number 6, July/August 2012
showed that perceived injustice was the best predictor of
follow-up occupational disability, whereas catastrophizing
was the best predictor of follow-up pain severity.
Sullivan et al13also reported on treatment-related
changes in perceived injustice in individuals enrolled in a
multidisciplinary pain rehabilitation program. Compared
with other psychosocial measures (eg, catastrophizing, fear
of movement, depression), perceived injustice showed the
least change through the course of treatment. The minimal
change in perceived injustice cannot be attributed to the
lack of sensitivity of the IEQ as treatment-related reduction
in perceived injustice was the only psychological variable
that was associated with increases in walking speed through
the course of the rehabilitation program. It is possible that,
for individuals with initially high scores on perceived in-
justice, reduction in perceived injustice might be a pre-
requisite for improvement in physical function.
In the research conducted to date, perceived injustice
has been highly correlated with catastrophizing. The mag-
nitude of the correlations between the IEQ and the pain
catastrophizing scale (PCS) (0.65 to 0.75) has been suffi-
ciently high to invite reflection about the degree of overlap
between these constructs. The “severity/irreparability of
loss” dimension of the IEQ likely overlaps to a substantive
degree with the exaggerated negative orientation toward
pain that characterizes catastrophizing. However, the “blame/
unfairness” dimension of the IEQ is neither reflected in the
conceptual framework that underlies catastrophizing or the
item content of the PCS.14,15
Despite the high correlation between the IEQ and the
PCS, there are also findings to support the distinctiveness of
the IEQ. Sullivan et al13reported that the IEQ and the PCS
each contributed significant unique variance to the pre-
diction of pain suggesting that perceived injustice might
impact on pain experience in a manner distinct from cata-
strophizing. The IEQ was also shown to prospectively
predict return to work even when controlling for scores on
the PCS (and other measures), whereas the PCS pro-
spectively predicted the persistence of pain independent of
the IEQ. Treatment-related changes in the IEQ were cor-
related with increased walking distance even when con-
trolling for catastrophizing (and other measures). In addition,
treatment-related changes in the IEQ were not correlated
with changes in pain, whereas treatment-related changes in
the PCS were significantly correlated with changes in pain.
These results argue for a conceptualization of perceived
injustice as a construct distinct from catastrophizing.
With respect to mechanisms of action, the high cor-
relation between perceived injustice and catastrophizing
suggests that perceived injustice might impact on pain
outcomes, at least in part, in a manner similar to cata-
strophizing. In other words, attentional disengagement
difficulties, emotional distress, and maladaptive coping
might also be vehicles through which perceived injustice
impacts on pain outcomes.16
Perceived injustice has also been associated with the
persistence of posttraumatic stress symptoms in individuals
who have sustained whiplash injuries. Sullivan et al17ex-
amined the predictors of recovery of posttraumatic stress
symptoms in a sample of individuals with recent onset
whiplash injuries who were participating in a multi-
disciplinary rehabilitation program. Individuals who scored
in the clinical range on a measure of posttraumatic stress
symptoms, and who scored high on a measure of perceived
injustice, were less likely to show recovery of their post-
traumatic stress symptoms than individuals with low scores
on perceived injustice. The latter findings suggest that
perceptions of injustice interfere not only with physical
recovery after injury, but perceptions of injustice also im-
pact negatively on recovery of the mental health problems
that might arise subsequent to traumatic injury.
A recent experimental study examined the relation
between perceived injustice and displays of pain behavior in
individuals who had sustained whiplash injuries.18Pain
behavior refers to movement alterations or expressive dis-
plays that are enacted during the experience of pain. Pain
behaviors can take varied forms including activity avoid-
ance, redistribution of weight to alleviate pressure on af-
fected limbs, holding or rubbing affected areas of the body,
facial grimaces, and vocalizations.19Research shows that
heightened expressions of pain behavior are associated with
a variety of adverse outcomes such as increased pain, de-
pression, functional disability, and prolonged work ab-
sence.20,21Research has supported a distinction between
communicative and protective pain behaviors. Communi-
cative pain behaviors might include facial expressions such
as grimacing or wincing, and verbal or paraverbal pain
expressions such as pain words, grunts, sighs, and moans.
The overt display of distress during pain experience conveys
information to observers about the internal state, pain-re-
lated limitations, and needs for assistance of the individual
who is experiencing pain.19,22–24Protective pain behaviors
might include any action that is intended to reduce the
probability of further injury, minimize the experience of
pain, or promote recovery from injury. For example, the
withdrawal of a limb from a hot surface serves to terminate
the action of a noxious stimulus and in turn, protects the
limb from further injury.25Protective pain behaviors might
also include movements such as guarding, holding, touch-
ing, or rubbing of the injured or affected area of the body.26
Sullivan et al18reported that perceived injustice was
associated with heightened levels of protective pain
behavior but was unrelated to communicative pain behav-
ior. The relation between perceived injustice and protective
pain behavior remained significant even when controlling
for variables known to be associated with pain behavior
such as pain severity, pain catastrophizing, and depression.
Mediation analyses revealed that protective pain behavior
might be one of the processes through which perceived in-
justice might impact on disability. These findings are con-
sistent with previous research showing that protective pain
behaviors are more strongly associated with disability than
communicative pain behaviors.21,27
Pain behavior is also one of the primary means by
which observers infer someone’s pain experience.19,28The
observation of heightened levels of pain behavior in an
injured patient might lead physicians to infer high levels of
pain and in turn, consider prescribing an extended period of
sick leave. The observation of heightened levels of pain
behavior might also lead an employer to consider that the
employee is unable to meet his or her occupational re-
sponsibilities. In addition to the communication value of
protective pain behaviors (eg, overt display of distress),
which might impact indirectly on the disability by influ-
encing observers’ judgments of an individuals’ potential
limitations, protective pain behaviors also engage the
musculature that would be required for task performance.
As such, pain behavior may not only be disruptive to ac-
tivity engagement, but the social response to pain behavior
might also contribute to prolonged disability.
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It has been suggested that revenge motives might be
elicited by perceptions of injustice.29The 12th century
philosopher, Anselm de Canterbury discussed injustice as a
state of mind that demanded retribution. He suggested that
individuals would only be liberated from the clutches of
injustice when suffering could be inflicted on the perpe-
trator of injustice that was equal in magnitude to that of the
experienced loss.30Under some circumstances, it is possible
that “disability” might represent the only “power” that an
individual possesses in efforts to bring about retribution for
losses sustained. In some cases, disability behavior might be
intentionally maintained to seek adequate retribution for
losses. Pain behavior might provide a useful vehicle for
publicly demonstrating the severity of one’s disability.
Challenges for future research will include the development
of paradigms that might elucidate the motives underlying
the expression of different forms of pain behavior and the
degree to which these motives are consciously represented.
It has been suggested that perceptions of injustice
might be one of the cognitive antecedents of anger reactions
associated with pain.29Anger reactions have been discussed
as central to the experience of perceived injustice.4,31Social
psychological research has shown that blame attributions
for negative outcomes are likely to trigger anger re-
sponses.32Emotional reactions to negative events persist
for longer periods of time when events are appraised as
unjust.33It has been suggested that a hostile attributional
style and beliefs in a just world might predispose anger
reactions to perceived injustice.3,34
Numerous investigations have shown significant rela-
tions between anger, pain, and disability in patients with
chronic pain.35–37Anger reactions that take the form
of nonadherence to treatment recommendations could im-
pact negatively on recovery trajectories after injury.37It
has been suggested that anger might contribute to height-
ened pain experience by increasing muscle reactivity.38
Burns et al39have proposed that anger might contribute to
dysfunction of the endogenous opioid system. Anger and
anger-related physiological changes might be one of the
vehicles through which perceptions of injustice impact on
Research on the prognostic value of perceived injustice
for recovery outcomes of individuals who have sustained
pain-inducing injuries is still in its infancy. Nevertheless, the
studies that have been conducted to date suggest that per-
ceived injustice might be a significant determinant of response
to rehabilitation interventions, and a powerful predictor of
prolonged occupational disability in individuals who have
sustained whiplash injuries. Although research has yet to
systematically address the mechanisms by which perceived
injustice might contribute to prolonged disability in in-
dividuals with whiplash injuries, there are grounds for sug-
gesting the potential contributions of catastrophizing, pain
behavior, and anger.
Regardless of the specific processes by which perceived
injustice might impact on disability, the results of recent
research suggest that perceptions of injustice might be an
important target of intervention for individuals recovering
from musculoskeletal injury. Although cognitive-behav-
ioral approaches are currently considered the preferred
treatment orientation to managing the persistent pain
conditions, treatment manuals on cognitive-behavioral
interventions for persistent pain do not specifically dis-
cuss how perceived injustice should be addressed in the
The impact that blame cognitions have on feelings of
anger and revenge motives suggests that interventions to
alter the injured individual’s perceptions of the offender
might be useful. Forgiveness interventions have been de-
scribed as potentially useful for accident or crime victims.41
Essentially, forgiveness is a method of dealing with an of-
fense or injustice that benefits victims through the reor-
ientation of their thoughts, emotions, and behaviors
towards the offender.41,42Reducing perceptions of blame
and revenge might serve to decrease an individual’s atten-
tional focus on his or her pain and disability, which may
have previously been seen as the only means to ensure ac-
curate retribution for one’s suffering.13One issue sur-
rounding forgiveness interventions, however, is that the
continuation of suffering, as is likely to occur for victims of
physical injury who have developed chronic pain, might
serve to impede the forgiveness process.43
Anger management interventions might also be of
benefit for individuals with high levels of perceived in-
justice.44–46Although techniques targeting anger might help
address injustice perceptions of blame and unfairness, other
interventions techniques might be needed to address ap-
praisal of severity and irreparability of loss. The growing
literature detailing the benefits of pain acceptance on pain-
related outcomes is suggestive of one such intervention.47–49
Essentially, acceptance entails continuing to pursue life
goals and valued activities even when pain is experienced
and the cessation of efforts to control or avoid pain,49and
has been shown to decrease pain, disability, and depression,
as well as to improve individuals’ work status.48On the
basis of the supposition that the appraisals of severity or
irreparability of loss and unfairness facets of injustice per-
ceptions are inherently linked,13acceptance-based treat-
ments aimed at reducing severity cognitions may also help
to inadvertently reduce perceptions of unfairness.
Mindfulness meditation has also been discussed as an
intervention that can promote acceptance and reduce dis-
tress associated with pain.50,51One of the objectives of
mindfulness meditation is to assist the client in reducing the
struggle to control aspects of one’s condition or situation
that are essentially uncontrollable. Acceptance without
judgment is considered to be one of the cognitive vehicles
through which the health and mental health benefits of
mindful meditation are achieved. There are indications that
the relation between catastrophizing and pain might be
moderated by mindfulness.52It has been shown that the
adverse impact of catastrophizing on pain might be more
pronounced in individuals who score low on measures of
mindfulness. These findings suggest that increases in
mindfulness might reduce the impact of risk factors such as
catastrophizing. It is possible that increases in mindfulness
might also reduce the negative impact of perceived injustice
on adverse pain outcomes.
It is important to note that the legal context within
which many pain conditions are treated might serve to
maintain perceptions of injustice, and in turn compromise
treatment effectiveness. When legal representation is sought to
obtain compensation for losses, or to challenge inadmissibility
decisions of insurers, legal procedures might actually augment
or prolong perceptions of injustice. Legal representatives have
a vested interest in ensuring that their clients’ perceptions of
injustice remain high. Interference with clients’ ability to re-
solve their perceptions of injustice might be one of the ave-
nues through which legal procedures contribute to poor
recovery outcomes in individuals with pain conditions.
Sullivan et al Clin J Pain?Volume 28, Number 6, July/August 2012
r2012 Lippincott Williams & Wilkins
In summary, recent research suggests that perceptions
of injustice can have a significant negative impact on health
and mental health outcomes associated with pain. Percep-
tions of injustice might impact on health and mental health
outcomes through several cognitive, affective, and physio-
logical processes. Cognitive influences might include ex-
cessive focus on loss and appraisals of irreparability of loss,
blame attributions, catastrophic thinking, and revenge
motives. Affective influences might include anger, depres-
sion, and posttraumatic emotional reactions. Physiological
influences might include sustained muscle reactivity and
dysfunctions of the endogenous opioid system. Research
linking perceptions of injustice to problematic recovery
outcomes has been sufficiently compelling to support the
use of measures of perceived injustice in the routine as-
sessment of individuals with pain conditions. Little is cur-
rently known about the intervention approaches that will
be most effective in reducing perceptions of injustice.
Identifying the mechanisms by which perceptions of in-
justice impact on pain outcomes, and the development of
techniques to reduce perceptions of injustice in pain suf-
ferers will be fruitful domains of future inquiry.
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