Humor in Medicine—Part I: Humor and Laughter as a Therapeutic Tool

by Robert Kennedy

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"Laughter is the most inexpensive and most effective wonder drug. Laughter is a universal medicine."
—Bertrand Russell, philosopher and Nobel Prize winner(1)

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Definitions

Laughter is an unconscious response to social and linguistic cues. Each person's laugh is unique and is usually an expression of happiness involving typical facial movements and contractions of the respiratory muscles, followed by short vowel-like syllables often transcribed as "ha-ha" or "hee-hee." These syllables are part of the universal human vocabulary, produced and recognized by people of all cultures.(3,4)

Given the universality of the sound, our seeming ignorance about the purpose and meaning of laughter is remarkable. We somehow laugh at just the right times, without consciously understanding why we do it. Laughter is primarily a social vocalization that binds people together. "It is a hidden language that we all speak. It is not a learned group reaction but an instinctive behavior programmed by our genes. Laughter bonds us through humor and play."(4)

Humor has been defined as "something that is, or is designed to be, comical or amusing," and this area of research has been termed "gelotology" from the Greek "gelos," or "laughter,"(5,6) Humorous communication certainly causes increased feelings of happiness and laughter in those responding to it, whether because of witty comments or amusing behavior. Humor can be present in any social situation; yet, what is perceived as amusing varies widely among individuals, societies, and cultures. Everyone enjoys laughing, but a misjudged humorous comment can cause offense. So, while laughter is almost always positive, humor itself can provoke mixed emotional responses.(3)

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Physiology of Laughter

Laughter disorder research suggests a neuroanatomical circuitry for the production of laughter. This may include the anterior cingulate gyrus, which provides emotional consciousness to an individual's experiences; it is partially under frontal cortical control. The caudal hypothalamus is also involved, acting as the center of coordination for emotional changes including laughter. The temporal-amygdala structures may provide emotional coloring to perceptions and aid in comprehending humor. Finally, the ventral pontomedullary center for laughter coordinates facial expression, expirations, and emotional vocalization.(3)

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Laughter's Effects on Stress

Psychoneuroimmunological (PNI) researchers have repeatedly documented that increased stress levels can lead to changes in psychological and physiological functioning. In addition to changes in the usual stress hormones—ACTH, cortisol, epinephrine, and norepinephrine—many other chemical messengers are influenced by exposure to stressors. Production and release of prolactin, growth hormone, insulin, glucagon, thyroid hormone, and gonadotropins can be affected by physical and emotional stress.(7) Levels of neurotransmitters, neurohormones, cytokines, and various cells in the immune system can also be affected by stress.(8)

The psychodynamic viewpoint, according to Sigmund Freud, described humor as one of the strongest of the defense mechanisms that allow an individual to face problems and avoid negative emotions.(9) It is believed to be effective in distancing oneself, framing problems with perspective, and proactively managing distress.(3)

Although physiological research on the effects of humor on the body is only just developing, there may be quantifiable health care benefits to humor, and specifically, laughter.(10) Research into measuring humor and sense of humor using self-report instruments, peer ratings, and comedy monologues suggests that humor moderates stressful life events' effects on salivary immunoglobulin, positive affect, and mood disturbances such as depression.(11) Similar moderating effects of humor have also been identified for insomnia, loneliness, and self-esteem, but not for anxiety.(12)

Individuals with chronic or terminal illnesses or disabilities often use humor in an attempt to make themselves more socially acceptable, to identify with others, and to distance themselves from their troubles. Humor can also be used by some in social settings to challenge assumptions others hold about disease, and in health settings it is often used to manage feelings, hide embarrassment, reduce tension, share a sense of solidarity with others, or encourage others to examine themselves. Jokes and humor can dispel tension, introduce "awkward" topics, and convey messages about difficult subjects (such as death) that might be deemed unacceptable if conveyed seriously.(13) Some individuals with disabilities see humor as their only means of making contact with others.

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Therapeutic Use of Humor

Recent Evidence
A recent literature review sought to identify, critically evaluate, and summarize the laughter literature across a number of fields related to medicine and health care, seeking to assess the extent to which laughter's health-related benefits are supported by empirical evidence. The authors point out that because of the varying focus of many studies, it was necessary to distinguish between humor and laughter to assess health-related outcomes elicited by laughter only. The data were thematically analyzed to summarize laughter's health-related outcomes, relationships, and general robustness.(14)

The authors of the literature review concluded that laughter has shown physiological, psychological, social, spiritual, and quality-of-life benefits. The analysis revealed that the therapeutic efficacy of laughter is mainly derived from spontaneous laughter, which is triggered by external stimuli or positive emotions, and from self-induced laughter, which occurs both with and without humor and is triggered by oneself at will. The authors noted that the brain is not able to distinguish between these types; therefore, it is assumed that similar benefits may be achieved with one or the other. Although there are not enough data to demonstrate that laughter is an all-around healing agent, this review concluded that there exists sufficient evidence to suggest that laughter has some positive, quantifiable effects on certain aspects of health. Study researchers also noted that adverse effects and contraindications are very limited.(14) In rare, specific cases, the appearance of laughter-induced syncope has been reported.(15) Contraindications are nearly nonexistent; however, precaution is advised with patients who were recently released from surgery or who have glaucoma or certain cardiovascular or respiratory diseases.(14)

Humor Therapy and Pain
A recent study in the Journal of Aging Research evaluated the effectiveness of a humor therapy program in relieving chronic pain, enhancing happiness and life satisfaction, and reducing loneliness among older persons with chronic pain. Older persons in a nursing home participated in an 8-week humor therapy program (experimental group n = 36), while those in another nursing home were treated as a control group (n = 34) and were not offered the program. Upon completion of the humor therapy program, the experimental group experienced significant decreases in pain and perception of loneliness, as well as significant increases in happiness and life satisfaction; the control group did not.(16)

Very little research with children or adolescents has studied the specific utility of humor for children undergoing stressful or painful procedures. A pilot study of pain in children collected preliminary data on a sample of 18 children aged 7 – 16 years. Participants watched humorous videotapes before, during, and after a standardized pain task. Pain appraisal (ratings of pain severity) and pain tolerance were recorded and examined in relation to humor indicators (number of laughs/smiles during each video and child ratings of how funny the video was). The children demonstrated significantly greater pain tolerance while viewing funny videos than when viewing the videos only immediately before or immediately after the task. The results suggest that humorous distraction is useful to help children and adolescents tolerate painful procedures. The authors pointed out that further study is indicated to explore the specific mechanism of this benefit.(17)

Therapeutic Humor as Complementary and Alternative Medicine
In this era of evidence-based medicine, it would be appropriate to use laughter or humor therapy as complementary-alternative medicine (CAM) in preventing and treating illness, although further, well-designed research is warranted.(14) The Association for Applied and Therapeutic Humor (AATH) is an international community of various business and health professionals who incorporate humor into their daily lives. AATH provides evidence-based information about current research and practical applications of humor. According to the AATH, the official definition of "therapeutic humor" is "any intervention that promotes health and wellness by stimulating a playful discovery, expression, or appreciation of the absurdity or incongruity of life's situations. This intervention may enhance health or be used as a complementary treatment of illness to facilitate healing or coping, whether physical, emotional, cognitive, social, or spiritual."(18)

Numerous chronic, incurable diseases (cancer, dementia, hypertension, diabetes, chronic pain, etc.) have no effective treatment, leaving patients with these conditions to deal with the symptoms.(19) To facilitate better management of these chronic diseases, recent attention has focused on the use of CAM with Oriental and traditional medicines.(20) CAM is defined by the American Cancer Society as "supportive methods used to complement evidence-based treatment. Complementary therapies do not replace mainstream treatment and are not promoted to cure disease. Rather, they control symptoms and improve well-being and quality of life."(21) In contrast, alternative therapies or medicine use non-mainstream treatments that patients sometimes used instead of orthodox treatments. Examples of alternative medicine include music therapy, drama therapy, aromatherapy, exercise, herbal remedies, acupuncture, and yoga, among others.(22) However, use of these therapies has not been well-defined. Some are based on legend or belief, whereas others are traditionally applied but without any scientific basis.(19)

Laughter has a unique position in CAM. The benefits of laughter have been recognized historically. Laughter has been regarded as beneficial for human health for a long time; some of the benefits attributed to laughter include improved immunologic(23) and endocrinologic(24) responses and increased pain tolerance.(17) Laughter therapy, humor therapy, laughter meditation, and laughter clubs all have unique implications for group programs and self-management techniques. For practitioners to implement credible programs and effectively teach self-management techniques, further empirical research on the physical, psychosocial, and placebo effects of laughter and humor need to be conducted.

One physician, Madan Kataria, MD, who practiced and taught laughter yoga, started the Laughter Club in Mumbai, India, in 1995. The first session had five participants. Today, an estimated 300,000 people worldwide regularly practice "Laughter for Health." His next project is the Laughter University, which will have campuses on five continents (the first is currently under construction in India). These will be major educational and research institutions.(18)

Here is our question for reflection: If humor and laughter have such an integral place in humanity, then why not in medicine and health care?

Over the years, I have encountered a surprising number of instances in which, to all appearances, patients have laughed themselves back to health, or at least have used their sense of humor as a very positive and adaptive response to their illness.—Raymond A. Moody, MD(1)

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Clinical Connections

• Humor in health settings it is often used to manage feelings, hide embarrassment, reduce tension, and share a sense of solidarity with others.
• Although there are not enough data to demonstrate that laughter is an all-around healing agent, a number of studies have concluded that there exists sufficient evidence to suggest that laughter has some positive, quantifiable effects on certain aspects of health.
• One of the promising targets for humor as a therapeutic intervention lies in the area of pain management.

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Post-Compass Questions™

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References

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