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Perceived Injustice: A Risk Factor for Problematic Pain Outcomes

Sullivan, Michael J. L. PhD; Scott, Whitney BA; Trost, Zina PhD

doi: 10.1097/AJP.0b013e3182527d13
Special Topic Series

Background: Emerging research suggests that perceptions of injustice 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 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 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 perceptions 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, maladaptive coping, heightened displays of pain behavior, anger, and revenge motives.

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.

Department of Psychology, McGill University, Montreal, QC, Canada

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:

Received September 29, 2011

Accepted February 25, 2012

© 2012 Lippincott Williams & Wilkins, Inc.