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Risibility. The Superior Therapeutic Intervention?

Dad always thought laughter was the best medicine, which I guess is why several of us died of tuberculosis.

~Jack Handey, “Deep Thoughts

We have a saying in medicine that you can’t kill a jerk.  Not that we try to kill anyone, but that particularly unpleasant individuals, rife with psychopathology, survive whatever illness comes their way.  The corollary is that particularly nice people are prone to having horrible diseases with unpleasant outcomes.  We all know intellectually that it is not true, but there is an ongoing feeling in health care providers that somehow patient personality determines the consequences of their diseases.  As an aside, I am often  left with the explanation for patients that the reason for their odd infection comes down to bad luck.  Everyone responds something to the effect that “Typical. I get all the bad luck.”  I have never had a patient say, “That’s odd, I am usually so lucky.”

On the question of nurture versus nature, raising two children has convinced me of the relative lack of importance of nurture in the personalities of my children.  While abusive/pathologic environments will certainly lead to pathologic personalities,  for the average child raised in middle class America I can’t help but think that, to quote Popeye, “I yam what I yam and that’s all what I yam.”  I expect to be schooled in the comments on that subject.  Yes, I read the Blank Slate and have some understanding of the literature.  And yet.  My kids, my friends kids.  I watch them grow in what is (and isn’t) a similar environment and end up with diverse personalities that often appear present before they can speak.  I am well aware of the multiple logical fallacies that lead to that conclusion.  Parenthood and medical practice (where people seem to do the same damn stupid things over and over) have lead me to the conclusion that free will is mostly a myth and we are mostly programmed to behave the way we do. Discuss.  It is not the main point of the post, but my bias.

“Nothing shows a man’s character more than what he laughs at.” ~Johann Wolfgang von Goethe

One personality trait is a sense of humor.  No one admits to being a bad driver and I have never met someone who admits that they lack a sense of humor.   Humor is, of course, personal.  I find Seinfeld irritating, not funny.  The rest of my family does not share that assessment.  During Pulp Fiction, my wife and I realized that we were the only ones in the theater laughing during the scene when they are doing a cardiac injection to revive Uma Thurman after her drug overdose.  I once read that in choosing a mate, the best indication of long term compatibility was whether or not you both share a understanding of the essential hilarity of Bob and Ray.  I would agree and wonder if eHarmony uses that in their compatibility tests.  What would those examples say about whether or not I have a sense of humor and if so what kind?

What effects, if any, does a sense of humor have on health?  Emotional states alter physiology, some for the better, some for the worse. The popular opinion is that laughter is of benefit; there is a reason Reader’s Digest didn’t call their column ‘Schadenfreude, the Best Medicine.’   Are funny people or people who laugh easily more prone to better health because they have a sense of humor or laugh?  Or it is an association without causation, that whatever personality that laughs easily also leads to improved health outcomes?

“Whoever said ‘laughter is the best medicine’ never had gonorrhea.”  ~Kat Likkel and John Hoberg

Perhaps the topic of laughing your way to health gained the most traction with the publication in 1979 of Norman Cousins book, Anatomy of an illness as perceived by the patient: reflections on healing.  The book, which I read thirty years ago, details how, after being diagnosed with ankylosing spondylitis, Cousins left the hospital for a nice hotel, where he treated himself with good food, high dose vitamin C, and laughter from watching Marx brothers movies.

Did he have  ankylosing spondylitis?  The interwebs suggest he did not, and I can’t find the diagnostic criteria that were used to make the diagnosis and ankylosing spondylitis is a disease that can spontaneously resolve.  So causality is particularly problematic in Cousins’ case, since the diagnosis is uncertain. Even though I am an avowed Marxist, I would be suspicious of the power of Duck Soup to alter the course of disease for the better, as is the popular misconception of Mr. Cousin’s book.  I would not doubt that a good laugh will help decrease the perception of the severity of pain, as Mr Cousin’s suggested.

Is laughter medically beneficial?  Is a sense of humor medically beneficial?  Not the same question.

“Perhaps I know best why it is man alone who laughs; he alone suffers so deeply that he had to invent laughter.”  ~Friedrich Nietzsche

Laughter, of note, is not limited to humans :

Vocalizations referred to as “laughter” also occur in great apes engaged in tickling and social play. Vettin and Todt have shown key similarities in the respective acoustics of play- and tickling-induced vocalizations in juvenile chimpanzees (Pan troglodytes) and tickling-induced laughter in adult humans.

They estimated that laughter has been present in the human lineage for 10 to 16 million years.  I would estimate that is also how long humans have been farting.  Still nothing funnier to my children.

And some suggest that rats have a laughter equivalent with play and tickling.  Tickling rats.  I laugh at the mental image.  Is that laughter, if not the best medicine, a useful therapeutic intervention?

Laughter decreases blood glucose two hours after eating in type 2 diabetics.  I prefer eating in restaurants.   Laughter leads to vascular relaxation and decrease in serum cortisol,  decreases renin in type 2 diabetics, and increases natural killer cell function.

Some studies seemed needlessly perverse:

Twenty-four male patients with atopic eczema viewed a humorous film (Modern Times, featuring Charlie Chaplin). Just before and immediately after viewing, semen was collected, and seminal B cells and sperms were purified. Seminal B cells were cultured with sperms and IgE production was measured, while expression of galectin-3 on sperms was assessed.

RESULTS: After viewing the humorous film, IgE production by B cells cultured with sperms was significantly decreased. Moreover, expression of galectin-3 on sperms was reduced.

I can’t access the complete reference to discover the rationale behind the study, except, perhaps, to induce giggling.

“I am thankful for laughter, except when milk comes out of my nose.”  ~Woody Allen

Are there clinical correlates to these  physiologic effects? Sort of.

Laughter may help the depressed (why wouldn’t it?) and cheer up the schizophrenic (what a surprise).  Pello the clown, with his noted a humor intervention, decreased air trapping in COPD patients and laughing decreases the bronchial responsiveness in asthmatics.

That is about it for the medical application of laughter.  A smattering of small studies, rarely repeated, with small numbers of patients published in the more obscure journals.  I would not doubt the laughter is of benefit, but the benefit is small.

What is more interesting are the pathologic laughter syndromes: some (Angelmans) are genetic and some due to central nervous system strokes or tumors.  I suppose the silver lining for these unfortunates is the beneficial physiologic effects  of the continued laugher. Somehow the potential health benefits do not seem worth it.

These studies involved making people laugh, usually with movies.  Humor is not without its dangers in the medical field, given the idiosyncratic nature of what people find funny.

When used sensitively, respecting the gravity of the situation, humor can build the connection among the caregiver, patient, and family. However, insensitive joking is offensive and distressing, and experience suggests a variable acceptance of humor by patients with life-threatening illnesses, making humor a high-risk strategy.

So if laughter is the best medicine, it is best used sparingly and with the knowledge that as an intervention to cause lasting physiologic change, laughter has had little support.

“A sense of humor always withers in the presence of the messianic delusion, like justice and truth in front of patriotic passion” ~ Henry Louis Mencken.

Maybe it is not laughing that is important, but the more vague idea of having a sense of humor, that is important to health.

Four studies have tested the association between sense of humour and longevity. One reported that comedians and serious entertainers on average die earlier than authors. Two publications from the Terman Life-Cycle Study reported a negative association. Cheerfulness (sense of humour and optimism) was the index variable in the first study. In the second study, optimism was taken out, but the negative association prevailed. The fourth study reported a 31% reduction of mortality risk among patients with end-stage renal failure provided that they scored above the median on a test of sense of humour.

Dr Sven Svebak evaluated a sense on humor based on three questions and looked at survival in a large cohort of Norwegians who were being followed for long term health, much like the Framingham study.  The questions he used were

“Do you easily recognize a mark of humorous intent?” (Cognitive; N = 53,546; standardized item alpha = .91, item correlating .87 with sub-scale sum);

“Persons who are out to be funny are really irresponsible types not to be relied upon” (Social; N = 52,198; standardized item alpha = .91, item correlating .88 with sub-scale sum); and

“Do you consider yourself to be a mirthful person?” (Affective; N = 53,132; standardized item alpha = .74, item correlating .78 with sub-scale sum).

The participants responded to four-step scales (labeled for the three items respectively: very sluggishly – very easily; yes indeed – not at all; not at all – yes indeed).

Not an impressive criteria for determining a sense of humor and this is noted in the discussion of the article.  “It may be regarded a hazardous task to assess psychological characteristics by use of three items.”  However, they felt that similar studies in depression validated the approach.

These questions  measure  friendly humor. The test is not sensitive to humor that creates conflicts, is insulting or that is a variation of bullying.  So much for laughing at my posts as evidence of a sense of humor.

What they found was those with a friendly sense of humor as judged by these three questions were more likely to survive compared to those that scored low on a sense of humor.

The authors are quite thoughtful on the applicability of this study:

There is a semantic point in the affective item where “mirthful” was used in the present study instead of “cheerful.” In Norwegian as well as English language “cheerful” and “mirthful” (Norwegian equivalent “munter”) can refer to a subjective state of mirthfulness as well as to the overt expression of mirth through smiling and laughing. The present assessment was by subjective report that may have addressed both the subjective and the expressive tendencies of an individual for being mirthful. A subjective state of mirthfulness appears to be closely related to cognitive processes, whereas expressive display is often triggered by social context. Support to this view came from the relatively high coefficient of correlation between scores on the cognitive and the affective items (r = .40: Table 4). In prospective studies of positive wellbeing, subjective state appears to have been at focus and has proven to reduce mortality. This association has been a fairly consistent pattern of outcome in prospective studies of healthy populations as well as of diseased populations.

In light of these findings for positive wellbeing, as well as of the complex conceptual content of sense of humor, it is possible that sense of humor is best conceived of as one aspect of a broader psychological characteristic that facilitates a general state of wellbeing, rather than a specific emotional state of mirthfulness.

Emphasis mine. I think this is interesting and have little argument with the study except in on interview, Dr. Svebak stated “He adds that a sense of humor can be learned and improved through practice.”

There I have my doubts.  I cannot find evidence that people can learn to appreciate humor or learn to become humorous.  In my experience (do I dare use those words?) the capacity for understanding and producing humor appears fixed.

That has therapeutic implications.  If a sense of humor can be developed, the humorless grouch can be taught to laugh and experience the benefits of humor.  More likely, your sense of humor, like your ability to run the mile or learn French, is mostly static in the adult.

Being thoughtful, the authors conclude

There is a risk of taking the present humor findings too far as a booster of longevity. The role of confounding variables is hard to precisely assess in multi- variate approaches, partly because of the often opportunistic availability of such variables in population research projects as well as all the potentially relevant variables that may have been included, but were left out for many reasons, such as lack of funding and time consuming data sampling procedures. The present study included quite a range of variables that are well established in the scientific community as influencing health hazard. A cautious approach is to directly compare hazard ratios across the range of variables, including traditional risk variables as well as an index of sense of humor.

An interesting study with a nuanced discussion. However, a molehill of interesting information does not prevent some doctors for making a mountain of advice.  The You Docs are hard at work again.

“Analyzing humor is like dissecting a frog. Few people are interested and the frog dies of it.” ~EB White

In this new Norwegian study, researchers who tracked the health of 70,000 people found that those who scored highest on sense-of-humor tests were twice as likely as dour sorts to still be alive — and laughing — seven years later. You didn’t have to be the type that laughs at the drop of a hat, either. All sorts of humor styles boosted survival. “A twinkle in your eye can be more than enough,” notes lead researcher Sven Svebak of the Norwegian University of Science and Technology.

Oh, for that twinkle in the eye, the key to health.  The study, based on three questions, makes no conclusions based on humor styles.

What’s behind humor’s life-prolonging powers? For one thing, laughter is a mini-workout. Ten to 15 minutes of mirth burns up to 40 calories and exercises your abdominal muscles.

About the same as is burned during 15 minutes of sex.  For a real work out combine the two as has been what my partners do… I may be oversharing here.  Everything can be considered a “mini workout” and is a lame reason to suggest laughter as medicine. Given how much I laugh, where is my 6-pack?

The You Docs evidently reviewed the same marginal literature and discovered that

A good belly laugh also boosts your immunity, motivating natural killer cells in your bloodstream to work harder.

In one study, watching a funny movie relaxed the endothelium — the fragile inner lining of your arteries — enough to boost blood flow by 15 percent. Laughter eases stress and reduces levels of the high-anxiety hormone, cortisol. In people with diabetes, it can even help keep blood sugar lower and steadier.

Then there’s resilience. Laughter helps you build and maintain friendships, eases fears and gives you a hand at coping with whatever life throws your way. It may also thwart the flu and protect against cancer.

The last two I cannot find the reference for, but protecting against cancer? My goodness.  They make it sound so all encompassing, rather than the limited results I found.  And they never mentioned the sperms.

“What soap is to the body, laughter is to the soul.”  ~Yiddish Proverb

The You Docs end with suggesting by suggesting you get a daily dose of humor for its health benefits, and they give multiple ways to find a good laugh.  It is interesting how the authors of the study suggest that humor is part of an over-arching personality, whilst the You Docs go for simplistic and overwrought advice:

Get your daily quota of yucks. Check in with yourself at lunch time: Have you chuckled today, or maybe even gotten that tingly “this is hysterically funny” feeling? If not, do something about it. E-mail or call your funniest friend. Plan to watch your favorite sitcom or wise-cracking commentator tonight. The Web is loaded with joke sites, bookstores are brimming with humor books, video stores offer thousands of comedies and stand-up comic shows. Make it a point to learn at least one new joke a week, then tell it to your friends.

See the humor in your life. You took the stray cat you rescued to be spayed and discovered that she’s a he? Trade funny stories: Make it a habit to ask friends and family about the most ridiculous thing that’s happened to them today, this week, this month.

Discover what really tickles your funny bone. Your sense of humor is as unique as your fingerprints, so stop laughing at what you think you ought to find amusing (Who does that? Besides Ed McMahon?  If he had heeded that advice, he would have lived longer than 86 years) and do a little research into what really hits your sweet spot. Try watching, reading or listening to types of humor that are new for you. You may discover you prefer political humor or cowboy jokes, martini-dry wit or a really bad knock-knock (Or the You Docs).

It is always curious how a few studies of limited scope get inflated.  Sad advice really. Research what makes you laugh.  That is one of many annoyances of the alt med life style recommendation: the medicalization of the joys of life.  Drink red wine because it is good for you, not because it is joy in a bottle. Eat chocolate because it is a natural medicine, not because it is delicious.  Laugh because it improves your health, but not because it soothes your soul.  I prefer to laugh and eat and drink and work for the significant pleasures these things provide, not for their minimal health benefits. Live a good life and you will reap the rewards.  I see a lot of people at the end of their lives. When people look back, the regrets they express  are not for the time they wished they had spent laughing to manage their sugars, but the time they did not spend laughing with their loved ones.

Fortunately I read the You Docs: they provide me yucks, in both senses of the word.  As a result I expect I am never going to get ill, never get cancer and will live forever.

So tell me.  Are you healthier after reading this blog?

Posted in: Clinical Trials, Faith Healing & Spirituality, Humor, Science and Medicine

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