Injustice Perception in Chronic Pain: Shaped Through Expectation and Experience

A tendency to perceive pain as an irreparable or unjust experience may vary widely between people and across situations. Sullivan and colleagues have termed this pattern of thinking “injustice perception”, and have proposed that it is comprised of two, related ways of viewing pain: perceiving inequity or unfairness inherent within the experience of an unwanted medical problem (e.g., pain, injury), and feeling as though one has irreparably lost something precious or important [1]. Unsurprisingly, the presence of injustice perception correlates with more intense pain, worse disability, poorer physical and mental health, and worse response to treatment [2].

In many cases, injustice appraisal can be attributed to external factors or agents. For people whose pain occurred in the context of an injury, these beliefs have been attributed in part to interactions with the medicolegal system (as in the case of injury litigation), which may reinforce the nature of trauma and slow down the process of healthy adjustment to a major injury [3]. Even in the absence of an obvious external cause for chronic pain, the intensity of pain and pain-related changes in function may also appear to contribute to injustice perceptions [4]. My colleagues and I have found preliminary evidence that people who report more experiences of previous racial or ethnic discrimination are more likely to endorse stronger perceptions of injustice related to pain [5]. We believe these findings illustrate that injustice perception and (likely) other patterns of cognitive appraisal are not static, and instead are shaped through personal experience.

In our recent publication in Pain Management [6], we take a popular model from computational neuroscience (predictive processing) and apply it to the concept of injustice perception. Put simply, predictive processing states that our expectations arise as a combination of top-down processes (e.g., our belief patterns) and bottom-up processes (e.g., interpretation of bodily sensations and other ongoing aspects of everyday experience). In this model, the brain is an active participant rather than a passive observer; we are continually making predictions about the environment and ourselves that are compared to our subsequent, actual experiences. Across time, our predictions change as the brain identifies discrepancies between our predictions and actual outcomes, subsequently adjusting our framework of expectations to be more accurate in the future. However, our existing belief structures may alter the interpretation of these incoming signals. For example, we may interpret our prior experiences with high levels of pain after exercise as indicative that the same outcome will occur when we exercise in the future, and we may become vigilant for evidence of this pattern in the future, making it harder to change this expectation. Often, it is only through consistent, repeated changes in our behavior (such as changing our approach to exercise or physical activity) as well as the introduction of new information (such as reassurance from medical providers that exercise will not hurt the body) that we may change the expectation about exercise and pain flares in the future.

In the context of injustice perception, the predictive processing model applies in 2 ways. First, many of us may have deeply-held beliefs related to justice in the world; experiencing chronic pain while others around us do not may violate our expectations to be treated fairly and justly, particularly when we can identify others who may be to blame for our suffering. Further, the model suggests that our prior experiences of injustice may infiltrate our expectations about the likelihood of unjust experiences in the future and, speculatively, may bias us towards finding more sources of injustice in the future. Given that both persistent physical symptoms and interactions with some aspects of the medical or legal system may create unjust experiences, this pattern of beliefs may become very resistant to change.

It should be noted that at this stage our model is largely theoretical and based primarily on separate readings of the clinical pain literature and the computational neuroscience literature. Ultimately, however, we speculate that our model may be valuable because it emphasizes 2 related avenues for addressing unhelpful beliefs about pain. First, proper education regarding pain and its meaning may help prime the brain to seek corrective experiences for the existing and often counterproductive belief structures (e.g., that pain is unchangeable, catastrophic, and outside of one’s control). Second, changes to context (e.g., changing our behavioral efforts or social environment) is also key, as these changes may lead to changes in the stream of feedback to the brain that may across time contribute to changes in our expectations. It is our belief that these processes must be addressed in tandem. Without effective education, the short-term benefits to behavior change may not result in lasting changes to beliefs about pain, while providing education without accompanying contextual or behavioral changes may miss the opportunity to reinforce the importance of self-management in creating long-lasting changes to pain.

About John (Drew) Sturgeon

Drew SturgeonDrew is a clinical psychologist in the Department of Anesthesiology and Pain Medicine at the University of Washington School of Medicine. He completed his PhD in clinical psychology at Arizona State University and postdoctoral pain psychology training in the Department of Anesthesiology, Perioperative, and Pain Medicine at the Stanford University School of Medicine. His research interests include contributors to resilience in chronic pain, comprehensive statistical modeling of adaptation to chronic pain, fatigue, and social factors in the experience of pain. He is a native Michigander with an affinity for good food, sports, and literature and is an aspiring (and largely unsuccessful) runner and hiker.


[1] Sullivan MJ, Adams H, Horan S, Maher D, Boland D, Gross R. The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. Journal of occupational rehabilitation. 2008 Sep 1;18(3):249-61.

[2] Sullivan, M. J., Scott, W., & Trost, Z. (2012). Perceived injustice: a risk factor for problematic pain outcomes. The Clinical journal of pain, 28(6), 484-488.

[3] Giummarra MJ, Ioannou L, Ponsford J, Cameron PA, Jennings PA, Gibson SJ, Georgiou-Karistianis N. Chronic pain following motor vehicle collision: a systematic review of outcomes associated with seeking or receiving compensation. The Clinical journal of pain. 2016 Sep 1;32(9):817-27.

[4] Ioannou LJ, Cameron PA, Gibson SJ, Gabbe BJ, Ponsford J, Jennings PA, Arnold CA, Gwini SM, Georgiou-Karistianis N, Giummarra MJ. Traumatic injury and perceived injustice: Fault attributions matter in a “no-fault” compensation state. PloS one. 2017 Jun 5;12(6):e0178894.

[5] Bissell D, Ziadni M, Sturgeon J, Martin K, Guck A, Trost Z. (359) The impact of perceived discrimination, injustice beliefs, and sleep disturbance on anger experience in chronic low back pain. The Journal of Pain. 2017 Apr 1;18(4):S64.

[6] Bissell DA, Ziadni MS, Sturgeon JA. Perceived injustice in chronic pain: an examination through the lens of predictive processing. Pain management. 2018 Mar;8(2):129-38.