The impact of perceived injustice on pain and psychological outcomes after traumatic injury: a longitudinal analysis

ABSTRACT

Individuals' appraisals regarding the injustice of their pain or physical injury have emerged as a significant risk factor for worse physical and psychological outcomes. Injustice appraisals are defined by perceptions of external blame for pain or injury and viewing pain or injury as a source of irreparable loss. To date, research on the impact of injustice appraisal has been primarily cross sectional, and existing longitudinal studies have examined injustice appraisals at only 2 time points in the context of rehabilitation treatment. This study examined the trajectory of injustice appraisals in 171 patients admitted for traumatic injury at admission, as well as 3, 6, and 12 months after discharge and examined injustice appraisals as a potential moderator of recovery after injury. Findings can be summarized as follows: First, injustice perception was largely stable in the 12 months after hospital discharge. Second, elevated injustice perception was associated with decreased recovery in pain intensity and depressive symptomatology over the study period but did not moderate changes in pain catastrophizing or posttraumatic stress symptomatology over time. This study is the first naturalistic prospective analysis of injustice appraisal following trauma admission within the American healthcare system. Findings indicate that injustice appraisals do not naturally decrease in the aftermath of traumatic injury and may be a risk factor for poorer physical and psychological recovery. Future research should examine additional sociodemographic and psychosocial factors that may contribute to elevated injustice appraisal, as well as ways of addressing the potential deleterious impact of injustice appraisals in treatment settings.

Altered social decision making in patients with chronic pain

BACKGROUND

Chronic pain affects up to 20% of the population, impairs quality of life and reduces social participation. Previous research reported that pain-related perceived injustice covaries with these negative consequences. The current study probed whether chronic pain patients responded more strongly to disadvantageous social inequity than healthy individuals.

METHODS

We administered the Ultimatum Game, a neuroeconomic social exchange game, where a sum of money is split between two players to a large sample of patients with chronic pain disorder with somatic and psychological factors (n = 102) and healthy controls (n = 101). Anonymised, and in truth experimentally controlled, co-players proposed a split, and our participants either accepted or rejected these offers.

RESULTS

Chronic pain patients were hypersensitive to disadvantageous inequity and punished their co-players for proposed unequal splits more often than healthy controls. Furthermore, this systematic shift in social decision making was independent of patients' performance on tests of executive functions and risk-sensitive (non-social) decision making .

CONCLUSIONS

Our findings indicate that chronic pain is associated with anomalies in social decision making (compared to healthy controls) and hypersensitivity to social inequity that is likely to negatively impact social partaking and thereby the quality of life.

Cross-cultural adaptation and validation of the Hebrew version of the Injustice Experience Questionnaire - long and short versions

PURPOSE

To translate, validate, and culturally adapt the Injustice Experience Questionnaire (IEQ) and IEQ Short Form (IEQ-SF) into Hebrew, as measuring tools for examining feelings of injustice in cases of accidents and chronic pain.

METHODS

The translation was performed in several steps following the cross-cultural adaptation process. A sample of 150 patients suffering from traumatic injury fill out a battery of questionnaires: IEQ, IEQ-SF, Hospital Anxiety and Depression Scale (HADS), Numeric Pain Rating Scale (NPRS), and Pain Catastrophizing Scale (PCS), which were used for calculating construct validity. A test-retest was performed on 41 patients.

RESULTS

The IEQ and IEQ-SF found Cronbach's alpha of 0.92 and 0.84, respectively. Test-retest reliability for IEQ (ICC: 0.94) was found to be excellent. Spearman's correlation coefficient between IEQ and PCS was 0.68, NPRS (severe pain: 0.45, average pain: 0.51), HADS (anxiety: 0.62, depression: 0.60). The correlation between IEQ-SF and PCS was 0.67, with HADS (anxiety: 0.52, depression: 0.48). A weak correlation was found for NPRS (severe pain: 0.30, average pain: 0.34).

CONCLUSIONS

The Israeli translation and cross-cultural adaptation of the IEQ and IEQ-SF questionnaires were found to be valid and reliable.Implications for rehabilitationThe perception of injustice is a significant mental and psychological factor for recovery after accidents and injuries.This study translated, validated and culturally adapted the Injustice Experience Questionnaire (IEQ) and the short form into Hebrew.The questionnaires were found to be valid and reliable in Hebrew.

Injustice Through Cultural Lens: A Pilot Qualitative Exploration of Pain-Related Injustice Appraisals Among Arab-Americans with Chronic Low Back Pain

The current qualitative study sought to obtain an in-depth understanding of how Arab-Americans conceptualize perceived injustice concerning their chronic low back pain (CLBP) by reflecting on the Injustice Experience Questionnaire (IEQ). Twelve Arab-American adults with CLBP were recruited from a metropolitan area in Alabama using a purposive sampling technique. Participants took part in individual, face-to-face, semi-structured interviews reflecting on each statement from the IEQ. Descriptive data analysis was generated for demographic and pain variables. Directed content analysis was conducted to identify themes and sub-themes. 'Blame and unfairness' and 'severity and irreparability of loss,' the 2 established theoretical factors comprising pain-related injustice appraisal were used as predominant themes. Acceptance emerged as an inductive theme with the following sub-themes: positive appraisal and resilience, attempts to reduce pain, religious values and fate, and belief that everything happening for a reason. The influence of religion was noted across all themes. The current pilot findings suggest that Arabic culture, heavily infused with Islamic beliefs, influences how Arab-Americans conceptualize pain-related injustice appraisals. Additional exploration of the cultural appropriateness of the IEQ among individuals of Arab background is needed to further elaborate on the subject of faith and religious belief suggested by the current study. Perspective: Although the study findings largely reflected established injustice literature constructs, several emergent themes regarding pain-related injustice appraisal were influenced by the participants' culture and religious beliefs. These findings may indicate that specific psychotherapeutic approaches that have been proven effective among some groups may not function similarly in other populations.

Perceived Injustice Is Associated With Pain-related Function and Mood in Youth With Acute Musculoskeletal Pain

OBJECTIVES

Perceived injustice (PI), which is one's appraisal of justice or fairness regarding the pain experience, is an emerging area of interest in pediatric pain research. No previous studies have investigated PI in youth with acute pain. To fill this gap, this study examined (1) associations among PI, pain-related function, and psychological function in treatment-seeking youth with acute musculoskeletal (MSK) pain, and (2) the impact of parent-child PI discordance on children's pain and psychosocial function.

MATERIALS AND METHODS

Participants were youth (aged 11 to 17, 55% male) with acute pain (onset <1 mo) recruited from emergency departments or outpatient clinics and participating parents (102 parent-child dyads). Dyads completed study questionnaires within 1 month of the child's pain onset.

RESULTS

Youth-reported PI was significantly correlated with poorer physical and psychosocial quality of life, higher pain catastrophizing, higher fear of pain, increased pain-related disability, and greater depression and anxiety. Furthermore, PI was significantly associated with the physical quality of life, psychosocial quality of life, and pain-related disability. Moreover, discordance in youth and parent ratings of PI was associated with children's psychological and pain-related function. Specifically, compared with Concordant dyads, youth in the Discordant dyads (youth high PI/parent low PI) reported significantly poorer physical quality of life, psychosocial quality of life, higher pain-related disability, depression, anxiety, and pain catastrophizing.

DISCUSSION

These findings reveal that PI in youth with acute MSK pain is associated with quality of life and pain-related disability. Furthermore, results highlight the importance of discordance between youth and parent reports of PI on pain-related functioning.

Development and validation of a daily Injustice Experience Questionnaire

BACKGROUND

Patterns of cognitive appraisal related to chronic pain may manifest differentially across time due to a variety of factors, but variability of injustice appraisals across time has not been examined. The current study details the validation of a brief, daily version of the Injustice Experience Questionnaire (IEQ), which measures injustice appraisals related to the experience of pain and disability.

METHODS

Injustice Experience Questionnaire items were adapted for daily use and evaluated using cognitive interviews, and the resulting measure was administered for 10 days to two Internet-based samples of US adults with chronic lower back pain.

RESULTS

Study 1 (N = 126) refined the 12-item IEQ measure into a six-item short form; exploratory factor analyses suggested optimal model fit for the two-factor model established in the original IEQ. Using confirmatory factor analyses, Study 2 (N = 131) replicated the two-factor structure and demonstrated significant correlations of the Daily IEQ with other relevant constructs to chronic pain, such as pain catastrophizing, pain intensity, pain-related activity and social interference, depressed mood and anxiety. Daily IEQ items showed a significant degree of clustering (intraclass correlations ranging from .577 to .735) but demonstrated sufficient variability at the daily level to allow for daily-level analysis.

CONCLUSIONS

Injustice appraisals show a sufficient degree of daily variability to warrant their measurement as a time-varying construct. Further examination of antecedents and correlates of daily injustice appraisals, as well as their potential role as mechanisms of effect, may better explain the dynamics of affective and behavioral responses to chronic pain.

SIGNIFICANCE

The current study presents a validation of a daily version of the Injustice Experience Questionnaire in chronic low back pain. Results indicate that injustice appraisals vary significantly from day to day, and daily variability in injustice perception shows robust associations with pain intensity, pain-related interference in physical and social activity, and mood in chronic low back pain. These results emphasize the importance of assessing injustice perception as a time-varying, rather than stable construct in future empirical and clinical studies.

The relation between perceived injustice and symptom severity in individuals with major depression: A cross-lagged panel study

BACKGROUND

Perceived injustice has been associated with problematic recovery outcomes in individuals with debilitating health conditions. However, the relation between perceived injustice and recovery outcomes has not been previously examined in individuals with debilitating mental health conditions. The present study examined the relation between perceived injustice and symptom severity in individuals undergoing treatment for Major Depressive Disorder (MDD).

METHODS

The study sample consisted of 253 work-disabled individuals with MDD who were referred to an occupational rehabilitation service. Participants completed measures of depressive symptom severity, perceived injustice, catastrophic thinking, pain and occupational disability at three time-points (pre-, mid- and post-treatment) during a 10-week behavioural activation intervention.

RESULTS

Regression analysis on baseline data revealed that perceived injustice contributed significant variance to the prediction of depressive symptom severity, beyond the variance accounted for by time since diagnosis, pain severity and catastrophic thinking. Prospective analyses revealed that early treatment reductions in perceived injustice predicted late treatment reductions in depressive symptom severity.

LIMITATIONS

The study sample consisted of work-disabled individuals with MDD who had been referred to an occupational rehabilitation service. This selection bias has implications for the generalizability of findings.

CONCLUSION

The findings suggest that perceived injustice is a determinant of symptom severity in individuals with MDD. The inclusion of techniques designed to reduce perceived injustice might augment positive treatment outcomes for individuals receiving treatment for MDD.

Belief in a just world, health-related quality of life, and mental health among Chinese patients with chronic obstructive pulmonary disease

PURPOSE

Personal belief in a just world (PBJW) has been demonstrated to protect mental health. However, whether general belief in a just world (GBJW) serves adaptive functions for mental health across different groups and cultures remains unclear. This study explored the effects of PBJW and GBJW on mental health and moderating effects of PBJW and GBJW on the relation between health-related quality of life and mental health among patients with chronic obstructive pulmonary disease (COPD) in China.

METHODS

A total of 147 patients with COPD (90.5% male; mean age = 64.44 years) completed measures of health-related quality of life, depression, anxiety, PBJW, and GBJW and provided pulmonary function data.

RESULTS

Younger age and female sex were related to higher depression; female sex, living with others, and high financial burden were associated with higher anxiety. Worse health-related quality of life and lower PBJW were associated with higher depression and anxiety. An interaction between health-related quality of life and BJW was revealed. For patients with low PBJW, lower health-related quality of life was correlated with higher depression. For patients with stronger endorsement of GBJW, worse health-related quality of life was associated with higher depression and anxiety, but the variance of anxiety caused by interaction was insignificant.

CONCLUSIONS

The findings suggest that for patients with COPD experiencing health deterioration, holding strong PBJW but weak GBJW may be beneficial for mental health. Our study advances our understanding of the different functions of PBJW and GBJW in mental health across different groups and cultures.

Injustice is Served: Injustice Mediates the Effects of Interpersonal Physical Trauma on Posttraumatic Stress Symptoms and Depression Following Traumatic Injury

Previous research has consistently found that traumas of an interpersonal nature are associated with elevated levels of posttraumatic stress symptoms (PTSS). In the current study, we examined whether feelings of injustice related to sustained physical trauma mediate the association between the interpersonal nature of a traumatic injury and two outcomes: PTSS and depressive symptoms. The sample consisted of 176 patients admitted to a Level 1 trauma center for traumatic injuries. Participants completed measures of PTSS, depressive symptoms, and injury-related injustice perception at baseline and again at 3- and 6-month postinjury follow-ups. The results revealed that, compared to noninterpersonal injuries, interpersonal injuries were related to significantly higher levels of perceived injustice, PTSS, and depressive symptoms at all three assessment points, except for PTSS at baseline, ds = 0.47-1.23. These associations remained significant after accounting for injury severity. It is important to note that higher levels of perceived injustice 3-month postinjury follow-up mediated the association between the interpersonal nature of the trauma and higher levels of PTSS and depressive symptoms at 6 months postinjury. Our results suggest injustice may be an important factor that helps explain why interpersonal traumas are associated with poorer mental health outcomes than noninterpersonal traumas. Additionally, the current study provides some of the first prospective analyses of injustice perception and trauma outcomes.

Perceived Injustice Mediates the Relationship Between Perceived Childhood Neglect and Current Function in Patients with Chronic Pain: A Preliminary Pilot Study

Cumulative evidence supports the association between perceived childhood neglect and adulthood psychological and physical health. To date, pathways mediating this association remain largely unknown, though other evidence suggests that negative patterns of appraisal, including injustice perception related to pain, may be shaped by prior adverse social experiences. Consequently, the current study examined perceived injustice about chronic pain as a possible factor connecting childhood neglect and pain-related outcomes, given its relevance for both adaptation to chronic pain and to prior adverse life experiences. Patients (n = 742) visiting a tertiary pain clinic completed a survey administered via the Collaborative Health Outcomes Information Registry. Path modeling analyses were used to examine perceived injustice as a mediator of the relationships between childhood neglect and affective distress and physical function, after controlling for pain intensity and pain catastrophizing. Patients endorsing childhood neglect reported higher levels of perceived injustice and worse affective distress and physical function. Further, inclusion of perceived injustice as a mediator fully accounted for the relationship between neglect and current levels of physical function, and accounted for a significant proportion of the relationship between neglect and current levels of affective distress. These preliminary findings suggest that perceived injustice appears to be a more proximal factor by which prior experiences of neglect may adversely affect adaptation to chronic pain. Given the single-item assessment of childhood neglect and cross-sectional nature of the current findings, further research may focus on replicating these findings in longitudinal studies with validated measures and examining other adverse social experiences (e.g., abuse, social disparities) that may contribute to injustice perception and poor pain-related outcomes.

A Systematic Review of the Association Between Perceived Injustice and Pain-Related Outcomes in Individuals with Musculoskeletal Pain

Objective

A growing body of literature shows that justice-related appraisals are significant determinants of pain-related outcomes and prolonged trajectories of recovery. We conducted a systematic review of the literature assessing the relationship between perceived injustice and pain-related outcomes in individuals with musculoskeletal pain.

Design and Participants

A search of published studies in English in PubMed, PsychInfo, Embase, and Cochrane Database of Systematic Reviews from database inception through May 2019 was performed. Search terms included “perceived injustice,” “injustice appraisals,” “perceptions of injustice,” and “pain” or “injury.”

Results

Thirty-one studies met inclusion criteria. Data for a total of 5,969 patients with musculoskeletal pain were extracted. Twenty-three studies (71.9%) reported on individuals with persistent pain lasting over three months, and 17 studies (53.1%) reported on individuals with injury-related musculoskeletal pain. Significant associations were found between perceived injustice and pain intensity, disability and physical function, symptoms of depression and anxiety, post-traumatic stress disorder, quality of life and well-being, and quality of life and social functioning.

Conclusions

This systematic review summarizes the current evidence for the association between perceived injustice and pain-related outcomes. There is strong evidence that perceived injustice is associated with pain intensity, disability-related variables, and mental health outcomes. Implications and directions for future research are discussed.

Injustice Appraisal, but not Pain Catastrophizing, Mediates the Relationship Between Perceived Ethnic Discrimination and Depression and Disability in Low Back Pain

Despite growing evidence of significant racial disparities in the experience and treatment of chronic pain, the mechanisms by which these disparities manifest have remained relatively understudied. The current study examined the relationship between past experiences of racial discrimination and pain-related outcomes (self-rated disability and depressive symptomatology) and tested the potential mediating roles of pain catastrophizing and perceived injustice related to pain. Analyses consisted of cross-sectional path modeling in a multiracial sample of 137 individuals with chronic low back pain (Hispanics: n = 43; blacks: n = 43; whites: n = 51). Results indicated a positive relationship between prior discriminatory experiences and severity of disability and depressive symptoms. In mediation analyses, pain-related appraisals of injustice, but not pain catastrophizing, were found to mediate these relationships. Notably, the association between discrimination history and perceived injustice was significantly stronger in black and Hispanic participants and was not statistically significant in white participants. The findings suggest that race-based discriminatory experiences may contribute to racial disparities in pain outcomes and highlight the specificity of pain-related, injustice-related appraisals as a mechanism by which these experiences may impair physical and psychosocial function. Future research is needed to investigate temporal and causal mechanisms suggested by the model through longitudinal and clinical intervention studies. PERSPECTIVE: More frequent prior experiences of racial discrimination are associated with greater depressive symptomatology and pain-related disability in individuals with chronic low back pain. These associations are explained by the degree of injustice perception related to pain, but not pain catastrophizing, and were stronger among black and Hispanic participants.

Hide Your Pain: Social Threat Increases Pain Reports and Aggression, but Reduces Facial Pain Expression and Empathy

Earlier research studying the effects of social threat on the experience and expression of pain led to mixed results. In this study, female participants (N = 32) came to the lab with 2 confederates. Both confederates administered a total of 10 painful electrocutaneous stimuli to the participant. The framing of the administration was manipulated in a within-subjects design: In the low social threat condition the participant was told that the confederate could choose between 10 and 20 pain stimuli, thus they believed that this confederate chose to administer the minimum allowed number of pain stimuli. In the high social threat condition the confederate had a choice between 1 and 10 stimuli, thus they believed that this confederate chose to administer the maximum allowed number of stimuli. Participants reported on the intensity, unpleasantness, and threat value of the painful stimuli, and their facial expression was recorded. Moreover, aggression and empathy toward the confederates were assessed. As hypothesized, participants reported increased pain intensity, unpleasantness, and threat in the high social threat condition compared to the low social threat condition, but showed less facial pain expression. Finally, participants exhibited increased aggression and reduced empathy toward the confederate in the high social threat condition. PERSPECTIVE: Social threat reduces painful facial expression, but simultaneously increases pain reports, leading to a double burden of the person in pain. Additionally, social threat affected social relationships by increasing aggression and reducing empathy for the other.

Justice for all? Beliefs about justice for self and others and telomere length in African Americans

OBJECTIVE

Believing in justice can protect health. Among marginalized racial minorities however, both endorsing and rejecting beliefs about justice might be critical. The current research examined links between African Americans' beliefs about justice for self and for others and telomere length (TL)-an indicator of biological aging that is increasingly implicated in racial health disparities, with shorter telomeres indicating poorer health.

METHOD

Healthy African Americans (N = 118; 30% male; M age = 31.63 years) completed individual differences measures of justice beliefs for self and others and then provided dried blood spot samples that were assayed for TL.

RESULTS

We expected that a belief in justice for self would be positively associated with TL, whereas a belief in justice for others would be negatively associated. A significant 3-way interaction with chronological age confirmed this hypothesis-among older African Americans, TL was positively associated with believing in justice for self, but only when this belief was accompanied by a weak endorsement of the belief in justice for others.

CONCLUSION

Findings underscore that for racial minorities, health might be best protected when justice beliefs are both endorsed and rebuffed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Examining Injustice Appraisals in a Racially Diverse Sample of Individuals With Chronic Low Back Pain

Injustice perception has emerged as a risk factor for problematic musculoskeletal pain outcomes. Despite the prevalence and impact of chronic low back pain (CLBP), no study has addressed injustice appraisals specifically among individuals with CLBP. In addition, despite racial/ethnic disparities in pain, existing injustice research has relied almost exclusively on white/Caucasian participant samples. The current study examined the associations between perceived injustice and pain, disability, and depression in a diverse community sample of individuals with CLBP (N = 137) -51 (37.2%) white, 43 (31.4%) Hispanic, 43 (31.4%) black or African American). Anger variables were tested as potential mediators of these relationships. Controlling for demographic and pain-related covariates, perceived injustice accounted for unique variance in self-reported depression and disability outcomes, but not pain intensity. State and trait anger, and anger inhibition mediated the association between perceived injustice and depression; no additional mediation by anger was observed. Significant racial differences were also noted. Compared with white and Hispanic participants, black participants reported higher levels of perceived injustice related to CLBP, as well as higher depression and pain-related disability. Black participants also reported higher pain intensity than white participants. Current findings provide initial evidence regarding the role of injustice perception specifically in the context of CLBP and within a racially diverse participant sample. Results highlight the need for greater diversity within injustice and CLBP research as well as research regarding socially informed antecedents of injustice appraisals. Perspective: Perceived injustice predicted worse outcomes in CLBP, with effects partially mediated by anger. Black participants reported worse pain outcomes and higher injustice perception than their white or Hispanic counterparts. Given racial inequities within broader health and pain-specific outcomes, this topic is critical for CLBP and perceived injustice research.

Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption

BACKGROUND AND PURPOSE

Previous research has highlighted the importance of cognitive appraisal processes in determining the nature and effectiveness of coping with chronic pain. Two of the key variables implicated in appraisal of pain are catastrophizing and perceived injustice, which exacerbate the severity of pain-related distress and increase the risk of long-term disability through maladaptive behavioural responses. However, to date, the influences of these phenomena have not been examined concurrently, nor have they been related specifically to quality of life measures, such as life satisfaction.

METHODS

Using data from an online survey of 330 individuals with chronic pain, structural path modelling techniques were used to examine the independent effects of pain catastrophizing, perceived injustice, and average pain intensity on life satisfaction. Two potential mediators of these relationships were examined: depressive symptoms and pain-related interference.

RESULTS

Results indicated that depressive symptoms fully mediated the relationship between pain catastrophizing and life satisfaction, and pain interference fully mediated the relationship between pain intensity and life satisfaction. Both depressive symptoms and pain interference were found to significantly mediate the relationship between perceived injustice and life satisfaction, but perceived injustice continued to demonstrate a significant and negative relationship with life satisfaction, above and beyond the other study variables.

CONCLUSIONS

The current findings highlight the distinct affective and behavioural mediators of pain and maladaptive cognitive appraisal processes in chronic pain, and highlight their importance in both perceptions of pain-related interference and longer-term quality of life.

Growing pains: understanding the needs of emerging adults with chronic pain

BACKGROUND

Emerging adulthood (18-30 years), in the Western world, is often a time of identity development and exploration, focusing on areas of work, relationships and education. Individuals with chronic illnesses, such as chronic pain, may be more vulnerable to facing challenges during this time. This study aims to investigate the needs of young adults (YAs) attending a tertiary level National Health Service (NHS) Pain Management Programme (PMP) Service in the United Kingdom; exploring how these needs may translate on to clinical assessment and the delivery of rehabilitation interventions.

METHOD

This is a descriptive qualitative study influenced by phenomenological approaches. YA with a diagnosis of chronic pain were recruited and assigned to one of four focus groups facilitated by a clinical psychologist and occupational therapist. A semi-structured interview guide was used to help facilitate the group discussion.

RESULTS

Qualitative analysis identified four key themes in understanding the needs of YAs with chronic pain: (1) thwarted opportunities, (2) peer separation, (3) perceived illness validity in the context of age and (4) dependency/parental enmeshment.

CONCLUSIONS

The emerging adulthood literature provides a valuable framework for examining a normal developmental trajectory and highlights the relevance of age-related processes in YAs with chronic pain. The idealisation of opportunity and the role of perception in this developmental phase both appear relevant. It is significant that emotional stability is not yet established in emerging adulthood and links to unhelpful management strategies that may be differentiated from older populations are identified.

Social Disruption Mediates the Relationship Between Perceived Injustice and Anger in Chronic Pain: a Collaborative Health Outcomes Information Registry Study

BACKGROUND

Perceptions of pain as unfair are a significant risk factor for poorer physical and psychological outcomes in acute injury and chronic pain. Chief among the negative emotions associated with perceived injustice is anger, arising through frustration of personal goals and unmet expectations regarding others' behavior. However, despite a theoretical connection with anger, the social mediators of perceived injustice have not been demonstrated in chronic pain.

PURPOSE

The current study examined two socially based variables and a broader measure of pain interference as mediators of the relationships between perceived injustice and both anger and pain intensity in a sample of 302 patients in a tertiary care pain clinic setting.

METHODS

Data from the Collaborative Health Outcomes Information Registry (CHOIR) were analyzed using cross-sectional path modeling analyses to examine social isolation, satisfaction with social roles and activities, and pain-related interference as potential mediators of the relationships between perceived injustice and both anger and pain intensity.

RESULTS

When modeled simultaneously, ratings of social isolation mediated the relationship between perceived injustice and anger, while pain-related interference and social satisfaction did not. Neither social variable was found to mediate the relationship between perceived injustice and pain intensity, however.

CONCLUSIONS

The current findings highlight the strongly interpersonal nature of perceived injustice and anger in chronic pain, though these effects do not appear to extend to the intensity of pain itself. Nevertheless, the results highlight the need for interventions that ameliorate both maladaptive cognitive appraisal of pain and pain-related disruptions in social relationships.

Perceived Injustice Is Associated With Pain and Functional Outcomes in Children and Adolescents With Chronic Pain: A Preliminary Examination

Chronic pain is prevalent in children/adolescents and contributes to high rates of healthcare utilization. Research suggests injustice perceptions about pain are important in adult patients and a possible treatment focus. We conducted a preliminary evaluation of the psychometric properties of the Injustice Experiences Questionnaire (IEQ) and the relationship between injustice perceptions, pain, and functioning in chronic pain patients (N = 139, mean age = 15 years, 72% female) presenting to a pediatric pain clinic. Patients completed measures assessing pain intensity, injustice perceptions about pain, catastrophizing, overall functional disability, emotional functioning, social functioning, and school functioning. The IEQ showed good reliability and validity. Higher levels of perceived injustice were associated with higher levels of pain intensity, catastrophizing, and functional disability, and with poorer emotional, social, and school functioning. Additionally, perceived injustice remained significantly associated with pain intensity, functional disability, emotional functioning, social functioning, and school functioning after accounting for relevant demographic and clinical factors. This is the first study to suggest that injustice perceptions are important in the experience of pediatric chronic pain patients. Future studies should more thoroughly examine the psychometric properties of the IEQ in children/adolescents and elucidate the causal nature of these relationships, which will inform treatment efforts to improve pediatric pain care.

PERSPECTIVE

This initial investigation suggests that injustice perceptions about pain can be reliably and validly measured and are tied to important clinical outcomes in children/adolescents. Future studies that replicate and extend these preliminary results are necessary to determine the extent to which injustice perceptions are an important target for intervention.

Social redistribution of pain and money

People show empathic responses to others’ pain, yet how they choose to apportion pain between themselves and others is not well understood. To address this question, we observed choices to reapportion social allocations of painful stimuli and, for comparison, also elicited equivalent choices with money. On average people sought to equalize allocations of both pain and money, in a manner which indicated that inequality carried an increasing marginal cost. Preferences for pain were more altruistic than for money, with several participants assigning more than half the pain to themselves. Our data indicate that, given concern for others, the fundamental principle of diminishing marginal utility motivates spreading costs across individuals. A model incorporating this assumption outperformed existing models of social utility in explaining the data. By implementing selected allocations for real, we also found that while inequality per se did not influence pain perception, altruistic behavior had an intrinsic analgesic effect for the recipient.