The role of perceived injustice in chronic pain

It is increasingly recognized that the meaning individuals give to their chronic pain experience has an important influence on their pain-related adjustment. Recent research suggests that many patients with chronic pain experience their situation with a sense of injustice [1]. Patients with chronic pain often experience numerous losses, including loss of function, identity, and quality of life, and they may blame others for these losses. Research in patients with pain has defined perceived injustice as an evaluation of the severity of pain-related loss, blame, and a sense of unfairness [3]. Perceived injustice appears to influence recovery following painful injury. Studies have linked perceived injustice to greater pain intensity, disability, and mental health problems in patients with chronic pain [4]. Analogous findings have been shown in healthy individuals experiencing acute pain [5].

Despite these findings, it was not previously known how perceived injustice might influence pain outcomes. Therefore, we wanted to identify factors that might help explain this relationship [2]. Evidence from social psychology suggests that anger is the most likely emotional response to perceiving injustice. Additionally, research in patients with pain suggests that both the intensity of anger and the manner in which individuals regulate anger (e.g., by expressing or suppressing it) are associated with more negative pain outcomes. Taken together, we predicted that anger intensity and anger regulation style would help explain the relationship between perceived injustice and pain outcomes.

We asked patients with chronic musculoskeletal pain (primarily low back pain and fibromyalgia) to complete questionnaires measuring perceived injustice, anger, pain intensity, disability, and depressive symptoms. We found that anger intensity completely explained the relationship between perceived injustice and pain intensity. Anger intensity and anger suppression (i.e., the tendency keep anger “bottled up”) partially explained the link between perceived injustice and depressive symptoms. Anger did not explain the association between perceived injustice and pain-related disability.

The results suggest that anger management interventions might reduce the impact of perceived injustice on pain intensity and depressive symptoms. However, additional intervention strategies may be needed to reduce the impact of perceived injustice on pain-related disability.  Although speculative, interventions that validate patients’ pain and suffering (and, by association, the injustice experienced) may help reduce disability in patients who perceive injustice [3]. Future research is needed to test the usefulness of these interventions to mitigate the impact of perceived injustice in patients with pain. For further information on this research, please visit http://sullivan-painresearch.mcgill.ca/.

About Whitney Scott

Whitney ScottWhitney is completing her doctoral degree in clinical psychology at McGill University. Under the supervision of Dr. Michael Sullivan, her thesis research examines the role of perceived injustice in chronic pain. She is also interested in clinical decision-making and clinically meaningful change in the chronic pain context. Whitney has also gained clinical experience working with patients with chronic pain through her predoctoral internship in psychology at the Alan Edwards Pain Management Unit.

References

1. McParland J, Hezseltine L, Serpell M, Eccleston C, & Stenner P (2011). An investigation of constructions of justice and injustice in chronic pain: a Q-methodology approach. J Health Psychol, 16 (6), 873-83 PMID: 21430131

2. Scott W, Trost Z, Bernier E, & Sullivan MJ (2013). Anger differentially mediates the relationship between perceived injustice and chronic pain outcomes. Pain, 154 (9), 1691-8 PMID: 23707294

3. Sullivan MJ, Adams H, Horan S, Maher D, Boland D, & Gross R (2008). The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. J Occup Rehabil, 18 (3), 249-61 PMID: 18536983

4. Sullivan MJ, Scott W, & Trost Z (2012). Perceived injustice: a risk factor for problematic pain outcomes. The Clinical journal of pain, 28 (6), 484-8 PMID: 22673480

5. Trost Z, Scott W, Lange J, Manganelli L, Bernier E, Sullivan M. An experimental investigation of the effect of a justice violation on pain experience and expression among individuals with high and low just world beliefs. Eur J Pain 2013.