When people think about chronic pain, it is often focused on physical symptoms. However, there is a great shift towards a biopsychosocial (compromising biological, psychological and social factors) thinking of pain1 to understand the complete context. Recent research highlights the role of perceived injustice (PI)—a psychological factor that can significantly impact how individuals experience and cope with pain2.
What is Perceived Injustice?
Feelings of injustice especially tend to arise when someone experiences a perceived gap between reality and expectations, leading to feelings of undeserved hardship or irreparability3,4. A typical example of perceived injustice can be found in the whiplash population: Someone was hit by a car while driving a car herself. She blames the person who hits her for her physical and material damages. After several months, she blames the driver who hit her for her neck pain due to the whiplash injury.
Feelings of injustice especially arise when there is a gap between what someone expects and the harsh reality they face. Since its relationship with adverse outcomes, it must certainly not be underestimated, especially knowing that perceived injustice is a commonly found appraisal cognition seen in 33% up to 76% of people with pain5.
How Does Perceived Injustice Affect Pain?
Perceived injustice can worsen pain through several mechanisms: cognitive, emotional, behavioural, and social processes.
Perceived injustice often goes hand in hand with pain catastrophizing2,6— an exaggerated negative mental set with elements of rumination, magnification, and helplessness 7. This can lead to intense focus on pain and suffering, which worsens physical and emotional distress. Interestingly, while pain catastrophizing predicts pain severity, perceived injustice is more closely linked to disability and occupational outcomes8.
Another potentially relevant factor to consider in the relationship with perceived injustice in people with chronic pain is pain acceptance. Pain acceptance seems to play an important role in the mediation of the relationship between perceived injustice and different pain outcomes, including pain disability and psychological distress9.
People with high levels of perceived injustice are more likely to experience anger6. This emotional distress can inhibit the body’s natural pain relief mechanisms and increase muscle tension, worsening pain10,11. Perceived injustice also contributes to depression in people with chronic pain, as it fosters feelings of helplessness and invalidation12,13.
Those experiencing perceived injustice often show increased protective pain behavior6,14, where pain is exaggerated as a way of expressing suffering14. This can lead to greater reliance on opioids15 and studies show that people with higher perceived injustice are more likely to use opioids long-term16, which can have harmful side effects like opioid-induced hyperalgesia (increased sensitivity to pain)17,18.
Blame plays a big role in perceived injustice19. Individuals may direct their frustration toward healthcare providers20,21 or even loved ones22. This can harm patient-clinician relationships23-25, reducing the effectiveness of treatment26,27, and lead to social isolation3, which further exacerbates pain outcomes.
Why Does It Matter?
Perceived injustice is strongly linked to negative outcomes in chronic pain, such as negative pain outcomes, psychological distress, and a poorer quality of life. Addressing this psychological factor in treatment may help break the cycle of pain and improve recovery outcomes. Therefore, our research group investigated the effectiveness of a perceived injustice-targeted pain science education intervention with the use of motivational interviewing techniques throughout the sessions in breast cancer survivors. Results of this study will be analyzed in the near future. Keep an eye on our social media and blogposts to be updated on the results!
Eva Roose
Eva Roose is a physiotherapist working in the Pain in Motion research group and Rehabilitation Research group (Vrije Universiteit Brussel), and REVAL research group (Universiteit Hasselt) since 2020. Her research focuses on perceived injustice in chronic pain and cancer survivors. She does also clinical work with chronic pain patients for Pain in Motion at the University Hospital of Brussels.
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References:
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5. Roose E, Lahousse A, Robbeets A, et al. The Prevalence of Perceived Injustice and Factors Associated With Perceived Injustice in People With Pain: A Systematic Review With Meta-analysis. Pain Physician 2023; 26(2): E1-e49.
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