PREFACE Psychological well-being is a subjective term that means different things to different people. Psychological health, otherwise called mental health, is a relative state of mind in which a person who is healthy is able to cope with and adjust to the recurrent stresses of everyday living in an acceptable way. This book discusses topics such as: sexuality as a critical factor for health, quality of life and well-being, the well-being of Russian and Ukranian adolescents in the post-Perestroika period, participation in sports and its potential to confer numerous physical and psychological health benefits, work-related stress and its relation to ill-health and decreased productivity, among others. Chapter 1- Referring to the popular saying that laughter is the best medicine, many things are mixed up, for instance, laughter, exhilaration, humor, cheerful mood, and cheerfulness as a trait. In the media, putative facts are wrongly interpreted or made up and unreflectively copied again and again. Several of the misconceptions have even found their way into scientific publications. This chapter attempts to clear up some popular misunderstandings and the confusion of concepts, and explains which of those are related to health or well-being and which cannot be related to health at all. Special emphasis is placed on cheerfulness, which is a well-defined psychological construct. Added to this are some explanations and tips that may help the readers to be more critical towards study reports themselves. Finally, author discuss what may be the use of common laughter- and humor-related courses or workshops, and how the development of a more cheerful disposition could be promoted. Chapter2- The positive psychological functioning has received several approaches along the history. Author must distinguish between the hedonic approach, which speaks of the ―subjective well-being‖ relating it to happiness, and the eudaemonic approach, which relates the ―psychological well-being‖ to human potential development. In this second thinking trend author find authors like Maslow and Rogers. These authors focused on self-actualization and on the view of the fully functioning person respectively, as ways to achieve well-being and personal fulfillment. More recently, Carol Ryff has divided this construct in 6 dimensions: Self-acceptance, Positive relations with others, Autonomy, Environmental Mastery, Purpose in Life and Personal Growth. In order to asses the 6 dimensions mentioned, Ryff created the ―Psychological well-being scales‖, with 20 items each. After that, shorter versions have been proposed, due to the 120 items of the original ones. Psychological well-being positively correlates to factors as satisfaction with life, self- esteem or internal control, and negatively to depression or the powerful others.
ii Ingrid E. Wells Likewise, the health levels positively correlates to the 6 factors of the psychological well- being above. When author speak about psychological well-being by sex, women have higher scores in ―relations with others‖ and in ―personal growth‖, even though men get better scores in self- esteem and self-concept. As for differences by ages, literature speaks about higher scores in the group of aged people on some factors, like ―autonomy‖ and ―environmental mastery‖. In other factors like, ―personal growth‖ and ―purpose in life‖, young people have higher scores. Regarding the differences by education and occupation level, the psychological well- being positively relates to a higher educational and occupational level. Maintaining a good psychological well-being level can be an important protective factor when it comes to suffer several physical or psychological problems, and it is interesting to investigate the extent to which influences the development and evolution of certain health problems. Chapter3- Two hundred and fourteen employees, 136 men and 78 women, responded to Subjective Stress Experience Questionnaire, Stress and Energy Scale, Hospital Anxiety and Depression Scale, Job Stress Survey, Partnership Relations Quality Tests (e.g. Sexual life Satisfaction, and Partnership Relation Quality), and Positive and Negative Affect Scale. Health-promoting advantages of sexual life satisfaction in counteracting illhealth associated with different types of stress were observed. Men participants‘ Sexual life Satisfaction was predicted by intercourse frequency, accordance with desired frequency, intercourse satisfaction, frequency of sexpartners, women‘s participants‘ Sexual life Satisfaction was predicted by intimate communication, caressing and cuddling, and desire. Level of Sexual life Satisfaction and gender influenced coping (e.g. cognitive, emotional, social), depression anxiety, Partnership Relation Quality, thoughts of divorce, negative affect, general stress, and dispositional optimism. Regression analyse showed that work-stress was predictive and sexual life satisfaction was counter-predictive for depression, anxiety, general stress and psychological stress and thereby buffering the negative effects of work stress. Chapter4- From the beginning of the 21st century, most of the republics of the former Soviet Union enjoyed a period of rapid economic growth and relative political stability which, however, in some countries, was accompanied by restrains of civil rights (Baker and Glasser, 2007; Shevtsova, 2005). This is in sharp contrast to the previous period of perestroika, which was characterized by drastic democratic reforms, but also by political turmoil, economic instability, and social unrest (Yakovlev, 1996). The effect of the recent socio-economic changes on the psychological well-being of the citizens of the former Soviet Union has not yet been investigated, and this study aims to partially fill this gap. In the present article, author compare macro-level socio-economic indexes in Russia and Ukraine in 1999 and 2007 and analyze socio-economic changes that occurred in the two countries during these years. Author compare the psychological well-being of adolescents who attended high schools in Russia and Ukraine in 1999 with that of adolescents who attended high schools in these countries in 2007. Finally, author examine the demographic, socioeconomic, and psychological variables that affect the adolescents' psychological well-being. Chapter5- Objectives: The purpose of this study was to examine the utility of ‗additive‘ versus ‗balanced‘ models for understanding the relationship between perceived psychological need satisfaction derived from adapted sport and global well-being.
Preface iii Methods: Participants (N = 177; 51.41% male) drawn from cohorts reporting either a sensory (15.2%) or physical (80.1%) disability completed a self-report instrument capturing perceived competence, autonomy, and relatedness experienced in adapted sport and global self-esteem using a cross-sectional design. Results: Bivariate correlations revealed positive relationship between indices of perceived psychological need satisfaction and between fulfillment of competence, autonomy, and relatedness needs via sport with global self-esteem. Multiple regression analyses indicated that ‗balanced‘ psychological need satisfaction did not account for additional variance in global self-esteem after controlling for the contributions of individual needs in the ‗additive‘ model. Perceived competence was the strongest predictor of global self-esteem followed by perceived autonomy and relatedness. Conclusions: These observations provide support for an ‗additive‘ model extrapolated from Deci and Ryan‘s (2002) assertions more so than a ‗balanced‘ model (Sheldon and Niemiec, 2006) with regards to understanding the relationship between fulfillment of basic psychological needs and well-being in adapted sport athletes. Further research examining the role of ‗additive‘ versus ‗balanced‘ models in reference to understanding issues of strength versus integration of perceived psychological need satisfaction seems warranted with additional emphasis on broadening the scope of well-being criterion assessed in adapted sport contexts. Chapter6- Asperger Syndrome (AS) is marked by severe social impairments. Despite a rising prevalence of AS (Edmonds and Beardon, 2008), there are few studies of these individuals, especially those concerning their social well-being. This paper reviews studies on humor and discusses its role in the social functioning of people with AS. Although studies are few, research generally suggests that individuals with AS are somewhat impaired in their ability to process humorous materials due to fragmented cognitive processes. Because humor plays an essential role in social interactions in everyday life, these findings suggest that the lack of ability to appreciate humor may be partly responsible for the social deficits in people with AS. There is a need for more research into the social competence of individuals with AS, especially in relation to the use of humor in regulating social behaviors. Chapter7- This study examined the relation between the Big Five personality traits and eudaimonic well-being in Iran, which is an understudied country in the well-being literature. Participants were 240 undergraduates at the University of Tehran. In this study, purpose in life, personal growth, and social well-being scales were used to assess eudaimonic well-being, given the central role these constructs play in the existing models of eudaimonic well-being. Findings revealed that, among the Big Five personality traits, conscientiousness and neuroticism were the most vigorous predictors of eudaimonic well-being. Results also revealed that male students scored significantly higher than female students on social well- being. Furthermore, gender moderated the relation between eudaimonic well-being and two traits of extraversion and agreeableness. These relations were significantly stronger for male students than female students. Implications of the results are discussed. Chapter8- Background. Work-related stress is known to be a cause of ill health and decreased productivity and work in the education sector is thought to be particularly stressful. However few studies have considered health outcomes or personal risk factors predictive of work-related stress and health in head teachers.
iv Ingrid E. Wells Aims. To investigate health and job commitment in head teachers in West Sussex, UK and to determine personal risk factors most likely to predict cases of work-related stress and those with poor health in this group. Methods. A cross sectional study, by postal questionnaire, in a population of 290 head teachers and college principals. The measuring instrument was a validated questionnaire, ASSET (a short stress evaluation tool) and additional questions derived from previous studies. ―Caseness‖ was defined as respondents who felt work was ―very or extremely stressful‖. Results were compared with those for a general population of workers (GPN) and a group of managers and professionals (MPN). Results. Prevalence rate of work-related stress in head teachers was 43%. Head teachers had higher levels of job commitment but poor physical and mental health when compared to a general population group. Psychological well-being, particularly of females and primary head teachers, was also worse than a comparative group of managers and professionals. Teaching less than 5 hours per week was a significant predictor of caseness. Female gender was a significant predictor of poor psychological well-being. Conclusion. Prevalence of stress in head teachers in West Sussex is high and has an effect on psychological well-being in particular. Compared to other similar professionals head teachers have poor psychological health. Gender and school type influences outcome, female head teachers have worse health outcomes. Chapter9- Even though the wellbeing literature in psychology is fairly massive, earlier attempts at defining the term have failed to emphasize the pertinence of cultural factors in obtaining a more socially appropriate definition of the term. Hitherto, diagnostic manuals and authors in the area of mental health have been largely driven by medically related models as backgrounds in giving explanations in the area of psychological wellbeing. However, many societies (with their pre-historic values and precepts) had long existing frameworks for establishing psychological health or illness before the advent of current nosological approaches. While it is inappropriate to question the scientific basis of current theories, advancing knowledge within the vicissitudes of our historical past in the context of newer information require the adoption of current gains in scientific transformation of the area of psychological health; considering peculiar traditional perception of mental health and illness across cultures. This paper attempts to illustrate the relevance of culture and sub-cultural practices in defining the concept of psychological well being, yet appreciating the need to situate these within the global definition of psychological health. When this is adopted by psychologists and other mental health practitioners, establishing individual and group norms on the mental health-illness continuum will be more society and context specific. The divergence will also yield broader explanations to the existing dogmas in diagnostic criteria in mental health literature. With this in view, the discipline of psychology will be adding value to evidence based assessment and diagnosis, strengthening the insistence on reliability and validity in psychology. Chapter10- The Estonian translation of the Oxford Happiness Measure (a derivative from the Oxford Happiness Inventory) was completed by a sample of 154 students. Two main conclusions can be drawn from the data generated by the study. The first conclusion concerns the coherence of this Estonian translation of one of the instruments within the Oxford family of happiness indices. Given the high level of internal consistency reliability of the careful translation of the parent instrument, it is reasonable to assume that this translation is accessing
Preface v the same psychological domain as the parent instrument. On the basis of the present findings it is clearly worth investing in further validation studies using the Estonian instrument. The second conclusion concerns the broader value of the Oxford Happiness Measure. While the present study appears to have been the first formal attempt to publish on the psychometric properties of this derivation from the Oxford Happiness Inventory, the data suggest that this more straightforward and more economical version of the original instrument functions with a similar high level of internal consistency reliability. On the basis of the present findings it is clearly worth investing in further reliability studies using the original English language form of the instrument. Chapter11- Self Determination Theory (Deci & Ryan, 2000) hypothesizes that psychological needs for autonomy, competence, and relatedness are essential for psychological health. The 16 fundamental motives posited by Reiss (Reiss & Havercamp, 1998) have also been proposed as primary motivational variables. Reiss criticizes basic need theory because it assumes that intrinsic motivation is based on pleasure. The present chapter addresses similarities and differences between psychological needs and fundamental motives and their relations to well-being. Data is presented regarding the relations of needs and motives to both eudaimonic and hedonic aspects of well-being as measured by (a) meaning in life, and (b) positive and negative affect, respectively. Also addressed are the relations of needs and motives to intrinsic and extrinsic motivation. Results showed all three needs and several fundamental motives were related to measures of well-being. None of the needs, but several of the motives, were related to intrinsic motivation. Results suggest there are basic differences between psychological needs and fundamental motives but both are important to psychological adjustment.
PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS PSYCHOLOGICAL WELL-BEING No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.
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PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS PSYCHOLOGICAL WELL-BEING INGRID E. WELLS EDITOR Nova Science Publishers, Inc. New York
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CONTENTS Preface Don't Take an X for a U: Why Laughter Is Not the Best Medicine, i Chapter 1 but Being More Cheerful Has Many Benefits 1 Chapter 2 Ilona Papousek and Günter Schulter 77 Chapter 3 Psychological Well-Being, Assessment Tools and Related Factors 115 Chapter 4 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez, Fernando Andrés Pretel, José Miguel Latorre 135 Chapter 5 Postigo and Francisco Escobar Rabadán 157 Chapter 6 Sexual Satisfaction as a Function of Partnership Attributes and 171 Chapter 7 Health Characteristics: Effect of Gender 185 Chapter 8 Ann-Christine Andersson Arntén and Trevor Archer 199 The Psychological Well-Being of Russian and Ukrainian Adolescents in the Post-Perestroika Period: The Effects of the Macro- and Micro-Level Systems Eugene Tartakovsky Strength Versus Balance: The Contributions of Two Different Models of Psychological Need Satisfaction to Well-Being in Adapted Sport Athletes Virginia L. Lightheart, Philip M. Wilson and Kristen Oster Asperger Syndrome, Humor, and Social Well-being Ka-Wai Leung, Sheung-Tak Cheng and Siu-Siu Ng Big Five Personality Traits as Predictors of Eudaimonic Well-being in Iranian University Students Mohsen Joshanloo and Samaneh Afshari Health, Job Commitment and Risk Factors Associated with Self- Reported Work- Related Stress in Headteachers: Cross Sectional Study Samantha Phillips
vi Contents 213 Chapter 9 Chapter 10 The Need for Cultural Contextualisation in Establishing 223 Psychological Wellness or Illness 231 Chapter 11 Adebayo O. Adejumo 245 Index Internal Consistency Reliability of the Estonian Translation of the Oxford Happiness Measure: Contributing to Positive Psychology in Estonia Ahto Elken, Leslie J Francis and Mandy Robbins Relations of Fundamental Motives and Psychological Needs to Well-Being and Intrinsic Motivation Kenneth R. Olson and Brad Chapin
In: Psychological Well-Being ISBN 978-1-61668-180-7 Editor: Ingrid E. Wells, pp. 1-75 © 2010 Nova Science Publishers, Inc. Chapter 1 DON'T TAKE AN X FOR A U: WHY LAUGHTER IS NOT THE BEST MEDICINE, BUT BEING MORE CHEERFUL HAS MANY BENEFITS Ilona Papousek and Günter Schulter Karl-Franzens-University, Department of Psychology, Graz, Austria ABSTRACT Referring to the popular saying that laughter is the best medicine, many things are mixed up, for instance, laughter, exhilaration, humor, cheerful mood, and cheerfulness as a trait. In the media, putative facts are wrongly interpreted or made up and unreflectively copied again and again. Several of the misconceptions have even found their way into scientific publications. This chapter attempts to clear up some popular misunderstandings and the confusion of concepts, and explains which of those are related to health or well- being and which cannot be related to health at all. Special emphasis is placed on cheerfulness, which is a well-defined psychological construct. Added to this are some explanations and tips that may help the readers to be more critical towards study reports themselves. Finally, we discuss what may be the use of common laughter- and humor- related courses or workshops, and how the development of a more cheerful disposition could be promoted. INTRODUCTION \"Be careful about reading health books. You may die of a misprint\", said Mark Twain. Misprints may occur. But the claims that laughter makes you healthy and happy, improves the world, and prevents wars must be intended as a joke. The fact that astoundingly many people do not laugh about these jokes might indicate that not all people who are concerned with laughter also have a well-developed sense of humor. Generally, in the context of health-
2 Ilona Papousek and Günter Schulter related issues many things are mixed up, not only laughter and humor, but also exhilaration, cheerful mood and cheerfulness as a trait. The confusion begins with the popular saying \"Laughter is the best medicine\". Very likely, there was a time when this proverb read a bit differently, that is, \"A cheerful heart is good medicine\" (Bible, 17,22; or \"A merry heart doeth good like a medicine). This older variety of the saying is nearer to the truth than the mistakable 'Laughter is the best medicine', which has probably developed from the initial proverb at some time (which, by the way, continues with \"... but a broken spirit dries up the bones\"). Other clever proverbs are not nearly as readily circulated; for instance, \"Even while laughing a heart can ache\" (14,13). But an aching heart is not cheerful, and only a cheerful heart is good medicine … Referring to the saying \"Laughter is the best medicine\", putative facts are often wrongly interpreted or made up in the media and, because they sound so pleasant, unreflectively copied again and again without further research, and with a little amplification added from time to time. If some information repeatedly turns up in the media, in time most people believe it. Not even scientists are immune to being deluded. Consequently, some of the misconceptions spread by the media at times even turn up in scientific publications. This chapter attempts to clear up some popular \"misprints\" in the media and to straighten out which concepts are mixed up and which of those are related to health and which cannot be related to health or well-being at all. It explains from a natural scientist‘s point of view why cheerfulness, which is a well-defined psychological construct, can have many benefits for health and well-being, and which of these are in line with current scientific evidence—and which are not. Finally, some simple interspersed tips should help those who are interested to become more critical towards reports in the media themselves. Surely new ones are added every week. The authors are biological psychologists who, in the framework of their research on emotion and psychosomatics, have also been concerned with laughter-, humor-, and cheerfulness-related issues for several years. For some time, the first author was also engaged as a teacher in training programs for people who offered humor or laughter courses or planned to offer such courses. There, and in numerous encounters with journalists, she came across the same mistakes and fallacies again and again. She has been confronted with great difficulties to correctly estimate the worth of reports in the media, and with the attempts to substantiate the usefulness of laughter- or humor-related courses with putative facts that were wrongly interpreted, or were false altogether, or made-up, or had nothing to do with the offered course at all. She also got to know the stubborn resistance against information that was not in line with what people believe or what they would like to believe. Certainly, it is the personal choice of an individual to learn what scientific evidence can prove and disprove in the aggregate, or to rather keep believing in what he or she believes or the Guru believes or pretends to believe. However, as experience teaches, most people who actually do not want to know anything, do want to know what it is that they don't want to know. Therefore, this chapter should be interesting for those who would like to know why and how cheerfulness can improve well-being, and which benefits can be expected and which not.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 3 But it should also be interesting for those who do not actually want to know, and in particular for those who do not want to take an X for a U1. WHAT IS MEANT BY CHEERFULNESS? In the following, we use the term \"cheerfulness\" or \"trait cheerfulness\" to designate a temporally stable affective trait, that is, a habitual disposition that people have for months or years. Trait cheerfulness manifests itself in various ways. Cheerful people have a positive and light-hearted attitude to life, they approach difficult situations and adversity with humorous serenity and are less affected by them. They get in a cheerful mood more easily and more often and adopt a cheerful and humorous attitude in social situations (Ruch and Zweyer, 2001). It may also be helpful to add what is not meant by cheerfulness, that is, to demarcate the term from other terms that may come into one's mind. To discuss seriously whether laughter or cheerfulness may be good for your health or well-being, it is important to keep several concepts apart and to ask which of those may actually be beneficial. First, it is important to differentiate which aspect is to the fore: the emotional, the cognitive, or the behavioral aspect. The emotional aspect relates to how one is feeling. Cheerful mood and exhilaration are relevant feelings in this context. Humor, in the sense of perceiving something as funny, is a cognitive phenomenon. It primarily relates to thinking, to grasp, to understand something. It is a matter of recognizing the punch line of a joke or of recognizing the absurdness of a situation or an event. Actually, humor is a broad concept that has been defined either as the perception of something as funny, the ability to perceive something as funny (\"humorous people\", \"sense of humor\"), or also as something that is perceived as exhilarating (e.g., a certain kind of joke; \"that's my kind of humor\"; Forabosco, 1992). Smiles and laughter are behavioral aspects. They relate to what one is doing, the movements of the facial muscles and the voice box (Figure 1). These aspects are not simply interchangeable without further ado; they are not synonyms. Laughter, humor, and cheerful mood may also occur independently of each other. Different brain regions contribute to each of the three aspects, their physiological concomitants differ, and they have different effects on one's own behavior and on the behavior of the people around (Goel and Dolan, 2001; Iwase et al., 2002; Wild et al., 2006). It is of course true that there are situations in which two or all three aspects are active together. For instance, laughter (behavior) and cheerful mood (emotion) are often a consequence of humor (the perception of something as funny). But smiles or laughter may also occur in situations that have nothing to do with cheerful mood or humor, for instance, in a state of shock, during aggressive disputes, to express superiority, or to subvert power structures or challenge the status of others. 1 Roman numbers were written as letters: X was used for 10 and V (later written as U) for 5. Thus, someone who \"made an X for a U\" tallied up double the amount. \"To make an X for a U\" figuratively means to cheat someone.
4 Ilona Papousek and Günter Schulter Figure 1. Figure 2. Various kinds of humor have nothing to do with cheerful mood, either, for instance, cynical or hostile humor (Arendt, 1986; Darwin, 1872; Van Hooff, 1972; Ruch, 1993a). Second, it is very important to differentiate within the emotional part between cheerful mood, exhilaration, and cheerfulness as a trait (Figure 2). Cheerful mood refers to the currently dominating feeling, that is, one feels cheerful, lighthearted, in a good mood for a couple of minutes or a bit longer. Exhilaration refers to the process of becoming cheerful. One is exhilarated by something and then in a cheerful mood for a while (Ruch, 1993b). Trait cheerfulness refers to a habitual disposition that people have for months or years, a general disposition to feel cheerful. Even people with a pronounced cheerful disposition are not continuously in a cheerful mood but are also sad or angry from time to time. The other way around, someone who is exhilarated or feeling cheerful right now, at the moment, is not necessarily someone who has a habitual disposition to cheerfulness. A further concept that should be distinguished from cheerfulness is happiness. In psychology, happiness either refers to a positive mood state triggered by a certain condition such as sex, beautiful music, or winning a competition, or is used as a synonym for life satisfaction. In different schools of philosophy and religion, happiness is defined in various
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 5 ways, which also finds expression in substantial cultural differences. None of these variants is included in the definition of trait cheerfulness. Consequently, for the mentioned and other reasons, what is said in this chapter about cheerfulness does not equally hold true for exhilaration, cheerful mood, humor, laughter, or happiness. IS LAUGHTER “HEALTHY”? A saying like \"Laughter is the best medicine\" exists in many cultures. But what is actually meant by it (or should be meant by it)? The saying seems to mislead many people to believe that the action of laughing by itself may be healthy. But what can really be beneficial: The behavior (laughter), the cognitive aspect (perceiving something as funny), the feeling of being exhilarated, or cheerfulness as a disposition? The misconception that the action of laughing may be healthy by itself is supported by many media reports that are obviously governed by a strong popular belief (Mahony, Burroughs, and Lippman, 2002). But there is no convincing scientific evidence that laughter as such may be beneficial in some way or other. Studies that are readily cited by the media and in the Internet often suffer from appalling methodological flaws; sometimes they do not even exist, or they are actually studies on exhilaration or cheerful mood. Evidence that does not correspond to the belief is swept under the table; putatively supportive reports, in return, are copied over and over again. Thus, taken together, a picture is drawn in the media and in the internet that is not in accordance with the actual state of research at all. Sometimes it is argued that laughter may be healthy because it is associated with deeper breathing and, thus, should have the same effects as breathing therapy or breathing meditation. But the physiological effects of laughter do not correspond to the effects of deep breathing in the context of relaxation. Some are even diametrically opposed. For instance, relaxed deep breathing lowers blood pressure, whereas laughter temporarily increases blood pressure (McMahon, Mahmud, and Feely, 2005; Mori et al., 2005). The only possible immediate beneficial effect of laughter by itself may have something to do with breathing, though: Hearty laughter is associated with increased expiration and a marked narrowing of the diameter of the airways. For sheer physical reasons, this results in higher speed of airflow. That can provoke irritation of the throat and a cough that could perhaps facilitate the ejection of particles or mucus from the airways and might represent a certain short-term benefit for smokers, for example. But two or three breaths later, everything is as it was before, and the process does not have any health effects in the longer term. In asthma patients, for instance, these temporary changes of the respiratory system can even be unfavorable and may provoke or promote an attack (Filippelli et al., 2001; Liangas, Yates, Wu, Henry, and Thomas, 2004). Another constantly recurring claim is that laughter may relax the muscles. But measures of muscle tension during and after laughter showed that that is not true, either. While laughing, the muscles are even more tense than before. The fallacy of muscle relaxation has probably developed from the observation that during very hearty laughter, the knees may soften and bend and people prostrate. But this is attributed to the inhibition of a reflex through which small alterations in muscle tone are immediately corrected and which normally helps to keep standing in spite of gravity. Therefore, this effect is not due to muscle relaxation but to a temporary muscle weakness. The excitability of muscle fibers is reduced, similar to the
6 Ilona Papousek and Günter Schulter feeling not to be able to lift the arm or the leg any more after intense physical effort. Beyond that, this effect is not due to laughter as such, but to the emotional arousal during intense exhilaration. Intense negative emotional arousal has exactly the same effect (Chapman, 1976; Overeem, Lammers, and Van Dijk, 1999; Overeem, Taal, Ocal, Lammers, and van Dijk, 2004). It has no relevance to health or well-being whatsoever. Laughing very heartily can also be quite exhausting, thus, people may also mix up the feeling of exhaustion with that of relaxation. One of the most widely cited and therefore well-known stories in this context is that of the publicist Norman Cousins who allegedly recovered from ankylosing spondylitis, a rheumatoid disease through laughter (and wrote a book about it). This story does not qualify as a proof of beneficial effects of laughter at all, because it is completely obscure what may have actually promoted Cousins' recovery. It could as well have been his enormous Vitamin C consumption, a particular personality trait such as optimism or a will to live, some other factor, chance, or the disease might have been misdiagnosed in the first place (Martin, 2001). To be able to attribute disease and recovery to a particular reason and exclude other reasons, legends and journalistic self-reports are no suitable means. For this, controlled scientific studies in large samples are needed. But there is no evidence from serious scientific studies at all that one might be able to \"laugh away\" rheumatoid or other diseases. (See also \"Don't take an X for a U, Tip 1\" and \"Tip 2\"). These are only a small selection of popular fallacies. In general, there is no scientific evidence that laughter as such, the behavior, the motor action of laughing may have any benefits that could be relevant to the preservation or recovery of health or well-being. Similar can be said about humor in general (Martin, 2001). However, humor should be considered in a more differentiated way. A certain form of humor can be regarded an element of trait cheerfulness (see \"Stress and strain\" and \"Ways to enhance cheerfulness\"). IS EXHILARATION “HEALTHY”? If it cannot be said that laughter as such, the behavior, is good for something; what about exhilaration and cheerful mood, then, that often accompany laughter? Unfortunately, relevant benefits are unlikely, if only because considerations of plausibility speak against it. That is because exhilaration and cheerful mood are present only briefly - and are gone again in a short time. Of course, you cannot expect that something that is there briefly and gone again in a short time may have effects that are of any relevance to health or well-being. Only such effects can be \"healthy\" that are present for some time. Most diseases and complaints do not develop because of a single short event, either, except perhaps bone fractures and intoxication. But then it has never been claimed that exhilaration may prevent from bone fractures and intoxication. What happens during exhilaration and temporary cheerful mood in the body: If it is intense enough, exhilaration causes a short-lived increase of heart rate and blood pressure, a transient rise of stress hormones, temporarily impaired lung function, and other effects that are related to emotional arousal such as minor changes in certain immune parameters. Exhilaration of lower intensity does not have any noteworthy physiological concomitants at all (Frazier, Strauss, and Steinhauer, 2004; Hubert, Moller, and deJong-Meyer, 1993; Levi,
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 7 1965; Martin, 2001; McMahon et al., 2005; Neuman and Waldstein, 2001; Pressman and Cohen, 2005; Ritz, George, and Dahme, 2000). The short-lived physiological changes that can be observed during and immediately after intense exhilaration are the same that are present during exposure to a stressor, when one is angry, worried, or frightened. That is, they follow all kinds of acute emotional arousal, no matter if it is positively or negatively valenced (Martin, 2001; Pressman and Cohen, 2005; Ring et al., 2000; Ritz and Steptoe, 2000; Watkins, Grossman, Krishnan, and Sherwood, 1998). Thus, the physiological concomitants of exhilaration are completely unspectacular. They correspond to a normal and usually harmless stress response of the body (see \"Don't take an X for a U, Tip 4\"). Such responses are completely normal and occur in everybody every day. They are important to meet changing demands that arise from emotional activation and other kinds of strain. It does not make a substantial difference, whether the stress is experienced negatively (such as the state during dental treatment) or positively (such as the state during a passionate kiss). At most, these short-term changes may be relevant to people who are already seriously ill, who, for instance, have chronic diseases such as cardiovascular disease or asthma, because they might trigger an attack (Pressman and Cohen, 2005). That, however, can hardly be referred to as \"healthy\" (see also \"Cardiovascular health\"). In healthy or largely healthy people, the transient physiological concomitants of exhilaration are not relevant to health or well-being at all. The same holds for the perception of something as funny (cognitive aspect, humor) and laughter (behavior). For the same reasons that apply to exhilaration, their concomitants, which ever they may be, cannot be \"healthy\". Most people accept that something that is there briefly and gone again in a short time cannot be relevant to health or general well-being. However, many people cling to the belief or the hope that the short-term effects of exhilaration may automatically become persistent, if they are often exhilarated. But that is not necessarily true. Short-term effects do not become automatically persistent, if one is just doing the things that elicit these effects more frequently. Although that may happen in some cases, in some cases the opposite may be true. In most cases, nothing at all happens in the long-term. For that reason, the findings of most studies that evaluate the effects of exhilaration (by cartoons, films, etc.) on physiological parameters are not conclusive. The short-lived changes of physiological functions that are observed in such studies do not allow conclusions about the occurrence and direction of persistent changes after frequent exhilaration. However, by far the most statements about putative health effects of exhilaration or laughter that are spread by the media have been derived from such studies that had only evaluated what had happened directly during exhilaration or a few seconds afterwards. But only physiological effects that persist can play a role for the development of complaints and diseases, changes that are still there when one is not exhilarated at the moment or is not currently laughing at something; changes that persist for such a long time that factors that are relevant to health or well-being may be durably altered. In addition, these changes must have a certain magnitude to make an impact on health or well-being (see also \"Don't take an X for a U, Tip 5\"). It is not possible to simply reason long-term, durable changes from the transient effects of short-term exhilaration or cheerful mood (Steptoe and Wardle, 2005). The same holds for humor (perceiving something as funny) and laughter. In this context, the wish often seems to be father to the belief. Moreover, many people do not seem to mind that their wishes are contradictory. People wish, for instance, that frequent exhilaration should cause a persistent increase in immune parameters (long-term effect same as short-term effect), but that blood
8 Ilona Papousek and Günter Schulter pressure and stress hormones should decrease (long-term effect opposite to short-term effect). Beyond that, people wish that the long-term changes produced by frequent exhilaration should be opposite to the consequences of stress or worry, although the short-term effects are the same. Taken together, in scientific studies that specifically aimed at evaluating differences between individuals who laugh frequently or infrequently, who like humor very much or not so much, or are joking frequently or infrequently none of these wishes could be convincingly confirmed. Professional humorists are not healthier and do not feel better than others, either (Martin, 2001; Svebak, Martin, and Holmen, 2004). Only then are there positive correlations with beneficial factors when frequent laughter and frequent joking is coupled with trait cheerfulness, a cheerful disposition, a positive attitude to life. But that is not necessarily the case. By far not everyone who laughs or jokes frequently has a cheerful disposition (Keltner and Bonanno, 1997; Korotkov and Hannah, 1994; Kuiper and Martin, 1998; Martin, 2001). Certain forms of humor and laughter have nothing to do with cheerfulness at all, such as cynical, hostile, disparaging or aggressive humor, sneering, cold, deprecating or wry smiles, nervous giggle, spiteful, sardonic, bitter, and faked laughter. In other words: For fundamental considerations alone, laughter, the perception of something as funny, exhilaration and transient cheerful mood cannot be \"healthy\". Only trait cheerfulness has the potential to slow down adverse developments of well-being and health and perhaps to improve existing problems. It will be outlined below to what extent there is in fact evidence for that. DON'T TAKE AN X FOR A U Tip 1: Different People Are Different The media and the internet are full of stories about what is \"healthy\", drinking wine, laughing, a certain waist circumference, religious belief, sex, and much more. For several reasons, most of these claims should not be taken seriously. Certainly, scientific expertise and methodological knowledge and experience are required in order to be able to appropriately evaluate the worth of scientific and non-scientific information. Scientific experts in the field, who have learned and practiced that for many years, look up the original literature, evaluate the research report and the quality of the journal in which the report has been published, and never rely on one study only, but obtain an overall picture of the current state of knowledge. Of course, one cannot demand that from anyone else. (That is why scientists help out by writing books). But if one is interested, it is actually quite easy to tell apart wishful thinking and advertising messages from serious reports, it is just needed to pay attention to a few details. With our tips, we would like to make some suggestions for that. Sitting on the floor is good for your health! Do you sometimes suffer from headaches? In his talk in the community hall on Friday evening, the Floor-Sitting-Therapist X. Wye read out a letter of the 42 years old housewife E.K. in which she wrote: I sit on the floor for half an hour every day and I never had headaches in the past year. Wye said: Children sit much more often on the floor than adults. Let's learn sitting on the floor again and thereby prevent headaches and other diseases of civilization. A Floor-Sitting seminar with X. Wye will take place on ...
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 9 A report about a single person who has a special characteristic or who experienced something peculiar is sufficient for many people to believe in certain relationships, for instance, that headaches and other complaints can be prevented by sitting on the floor. But why cannot anything be deduced from the observation that a woman who sits on the floor every day never has headaches? One reason for that is that different people are different. Individuals differ from each other in all physical and psychological characteristics. There is no characteristic that is equal in all humans. For instance, the frequency of headaches is different in different people. The frequency of headaches is also different in different people who are sitting on the floor every now and again (see Figure 3a). Some did not have any headaches during the past year, some did, some had very many indeed. The same holds true for people who always sit on chairs (see Figure 3b). Among the people sitting on chairs, too, some did not have any headaches during the past year, many did. It is just that different people are different. E.K. is one of those sitting on the floor every now and again, incidentally one who never had headaches during the past year. Instead of E.K., F.L. could have raised his hand, who also sits on the floor and suffered from headaches on 55 days during the past year (see Figure 3a). If F.L. had raised his hand, should we have concluded and believed that sitting on the floor causes headaches and should therefore be avoided at all costs? What if G.M. had raised his hand who never sits on the floor but strictly insists on chairs and did not have any headaches during the past year, either? Should we have concluded and believed, then, that sitting on chairs prevents from headaches? Figure 3a.
10 Ilona Papousek and Günter Schulter Figure 3b. If we pick any person whoever out of the many people who are all different from each other, we may believe whatever we like, but we do not know anything at all. For we do not know how often all other people who were not picked suffer from headaches. In actual fact, the distribution of the people sitting on the floor and the distribution of the people sitting on chairs are exactly identical (see Figure 3). That is, taken together, there are as many people suffering never, rarely and often from headaches among the people sitting on the floor as among the people sitting on chairs. Thus, if we would compare all people who are sitting on the floor every now and again with all people sitting exclusively on chairs, we would realize that there is no difference at all. Taken together, they suffer from headaches equally often. Of course, they differ from each other, some have many headaches, some only a few. But considered as a whole, it does not make any difference whether one sits on the floor or on chairs. If one looks at one individual only, be it E.K. or F.L. or G.M. or any other person, nothing can be deduced at all. For different people are always different. If a story is told of a single person, considered as a whole it could be as reported, it could not make any difference at all, or exactly the opposite could be the case. Consequently, it proves nothing, if someone tells a story about a woman who laughed every day and got cured of her cancer (or if one happens to know someone like that), neither if it is two or three of them. For many who laugh every day will not be cured, and some will die of their disease. Likewise, many of those who are not laughing every day will be cured of their cancer and some not, and some of them will die. It is only that the stories of those are not told. If we really want to know whether people who are sitting on the floor every day have fewer headaches than people sitting on chairs (or whether people who are laughing every day
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 11 will have a better chance to be cured of cancer than others), all people sitting on the floor had to be compared to all people sitting on chairs (or all people having cancer and laughing every day had to be compared to all people having cancer and not laughing so much). As those would be too many people to examine, in most cases it is not possible to compare all of them. Therefore, scientists draw samples according to certain rules and compare those samples. Since different people are different, samples always differ from each other, too. That is why scientific methods are applied, in order to decide whether the observed differences are large enough to assume that they are not merely coincidental, that is, that they are not only there, because different people are different. To be able to apply these methods and to be able to evaluate if they have been correctly applied by others, and if all other required rules for the conduction of serious comparisons were followed, very much knowledge and experience is needed. But what everybody is able to recognize are those reports about some single person or a few people who have some characteristic or other or to whom something or other happened. In such cases, scepticism is appropriate. For someone may want to make an X for a U. TRAINING OF CHEERFULNESS As noted before, cheerfulness is a trait, a habitual disposition to cheerfulness and serenity that people have for a long time. But that does not mean that a person either has or does not have cheerfulness, that there are people who are just lucky to have a cheerful disposition and others who are not. Neuroscientific evidence indicates that affective traits can be trained, that is, that they can be purposefully changed by appropriate programs (Davidson, Jackson, and Kalin, 2000). Figure 4.
12 Ilona Papousek and Günter Schulter Training always aims at achieving long-lasting, durable effects. Therefore, training cheerfulness does not stand for putting people into high spirits for a short time, but for inducing a long-term, permanent upward shift of well-being in everyday life. In Figure 4, a schematic representation of such a shift (4c) is contrasted with the naturally occurring fluctuations of mood (4a) and fluctuations due to repeated exhilaration (4b): a) An individual's current emotional state is subjected to naturally occurring fluctuations that are due to annoyances and positive events in everyday life. Every now and again one is exhilarated by something (for instance, a funny film), and mood becomes more positive for a short while. But afterwards everything is as it was before. In the longer term, nothing changes. b) Exhilaration that is more frequent also puts a person into high spirits for a short while only. The general level of affect does not change in the longer term. At least it does not change automatically. If applied artfully and with professional psychological know-how, humor and exhilaration can be used as tools for the training of cheerfulness and, hence, for achieving more lasting shifts. But it is by far not enough to watch a funny film every now and again, or to join a \"laughter club\", or to occasionally crack jokes or laugh at jokes. For the enhancement of cheerfulness, a training program is required in which humor or exhilaration is purposefully applied in order to set certain processes in motion (an example of such a training program is given at the end of this chapter). People who just laugh more often do not feel better in the longer term, that is, their average level of affect is not more positive than that of people laughing less often (Kuiper and Martin, 1998). c) Training of cheerfulness: The level of well-being is durably changed in the positive direction. There are still ups and downs in the current mood state, but in the aggregate, the level of well-being is raised. Only these persistent improvements in everyday life are related to various psychological, physical, and social benefits. What the figure does not show is that, in time, upward swings (i.e., in the positive direction) will become more frequent and more pronounced, whereas downward swings (in the negative direction) will become less frequent, less pronounced, and will last less long. Training cheerfulness does not only make sense in particularly humorless or depressed people. The body of scientific evidence indicates that the enhancement of cheerfulness may have benefits in any case, no matter if someone has only little cheerfulness or already a more pronounced cheerful disposition in the first place. Every improvement helps, from a low to a slightly higher level as well as from a medium to an even higher level. That is, even quite cheerful individuals may benefit from becoming still a bit more cheerful. OVERDOSE OF CHEERFULNESS? Is it possible to have too much cheerfulness? In other words, can it also be unfavorable to be cheerful and serene? The answer is simple: Everything at the proper time. Just as it is important that the body responds with appropriate physiological changes (see \"Don't take an
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 13 X for a U, Tip 4\"), in times of stress or adversity it is also important to emotionally respond in a flexible and adaptive manner. Flexible means to rapidly adapt to changing situations and to quickly return to prestress levels upon offset of the challenge. Adaptive means that the magnitude of the response is appropriate for the degree of stress, that is, both excessive responses to minor stress and inadequate (weak) responses to more considerable stress would be maladaptive (Dienstbier, 1989; Friedman and Thayer, 1998; Papousek, Schulter, and Premsberger, 2002). Thus, if, for instance, the doctor tells you that you suffer from a dangerous disease, it is not only normal but also appropriate and important to be worried. However, when the danger is over and recovery is certain or very likely, your emotional state should quickly return to normal. Or if, for instance, you are treated unjustly by your boss, it is appropriate and important to be angry. But the anger should not exceed an appropriate degree, that is, it should pass by without consequences for your own health, that of your boss, and of the office furniture, and the anger should quickly subside after the incident. To advocate for more cheerfulness does not mean recommending to grin broadly and whistle a happy song all day long, no matter what happens. It does not mean to be unworried if there is a justified reason to be worried, neither to deny real problems nor suppress negative feelings. Also, people with a cheerful disposition are certainly sad, angry, and worried from time to time, when there is reason for it. That is right and important. But people that are more cheerful take things easier, they recover faster and get back into a positive mood more easily than people with a less cheerful disposition. If it does not correspond to the current situation, an excessively cheerful mood state may in fact be unfavorable. That applies, for instance, to very risky situations in which people with an extremely cheerful and optimistic mood state might underestimate dangers and might not be cautious enough. When having a serious disease, an inappropriate, extremely cheerful and optimistic mood may result in not taking the disease seriously and not complying with the doctor's instructions and may that way have an adverse influence on the course of the disease. However, this only holds for extremely cheerful and relaxed mood in situations in which it is inappropriate. In contrast to that, for the same reasons cheerfulness as a trait (i.e., a cheerful disposition) may be beneficial. People with a more cheerful disposition more likely gather advice and make more effort to recover than people with a depressive disposition (Martin et al., 2002; Moskowitz, 2003). Thus, in particular situations it may be unfavorable to be in a very cheerful mood state. But it is never wrong to have a cheerful disposition. (Here it is again, the difference between a cheerful mood state and cheerfulness as a trait, i.e., as a general disposition of an individual). WHAT'S THE USE? Cheerfulness as a trait involves being in a cheerful mood more easily, more often, and for longer times and dealing with mischance and adverse circumstances with humorous serenity. That feels good. Positive emotions just feel good. Having that more often is perhaps already the most important reason why it is worth to aim at more cheerfulness. Of all traits that people can have, depression (i.e., the disposition to feel depressed, to have little energy, to notice predominantly the negative aspects of a situation, etc.) and the disposition for cheerfulness are the strongest and most consistent predictors of life satisfaction (within the limits that are
14 Ilona Papousek and Günter Schulter given by the personal circumstances, of course). People who are prone to experience more cheerfulness and less depression are more likely to find life beautiful (Diener and Larson, 1993; Schimmack, Oishi, Furr, and Funder, 2004). But that is not nearly everything. Cheerfulness is related to several advantages and to a collection of personal resources that can sustainably promote emotional well-being in the long run. It is associated with robust emotional well-being that can also withstand future challenges. In other words, cheerfulness does not only feel good in the present, but also increases the likelihood that one will feel good in the future (Fredrickson and Joiner, 2002; Steptoe, O'Donnell, Marmot, and Wardle, 2008). STRESS AND STRAIN Circumstances involving stress or strain are a part of everybody's life. However, how stressful and threatening a situation is perceived depends on a person's appraisal of the situation and his or her ability to cope (Lazarus and Folkman, 1984). Consequently, different people perceive the same situation as differently stressful. What is an overwhelming burden for one person, may be a manageable challenge for another one. There is scientific evidence that people that are more cheerful generally use more successful, more helpful coping strategies, that is, strategies that help them to deal and cope with adversity. Fort instance, when thrown out of balance, they more likely react with positive self-instructions (\"I will manage that\") than less cheerful people do. They reflect about how they can deal with the difficult situation or minimize the significance of the problem. Less cheerful people are more likely to react to problems in a manner that may even increase the feeling of being stressed. For instance, they ruminate about the problem even when the situation is long over, pity themselves, swear at themselves, or give up. Consequently, individuals that are more cheerful experience the same adverse situations as less awful and less stressful than individuals with a less cheerful disposition, and more likely stand up to stress and adversity (Folkman and Moskowitz, 2000; Fredrickson and Joiner, 2002; Gendolla and Krüsken, 2001a, 2001b; Lazarus and Folkman, 1984; Papousek et al., 2010; Ruch and Zweyer, 2001; Strand et al., 2006). People with negative affective traits, in particular depression, are characterized by a narrowed attentional focus that is very much directed at themselves and burdening issues. Consequently, they may not see or realize potentially helpful things. The same thoughts circulate their minds constantly, and they find it very difficult to interrupt the loop of thoughts, which makes the depressed mood even worse. A positive affect disposition, instead, is related to a broader focus of attention and more flexible thinking, which may additionally facilitate successful coping. The wider scope of attention enables them to perceive and consider more aspects in their environment and of their knowledge, memory etc., and, thus, to escape their thoughts and worries more easily. Cheerful individuals also shift their attention and their strategies more easily. Therefore, they more easily see and find a solution, a way out of difficult circumstances (Ashby, Isen, and Turken, 1999; Compton, Wirtz, Pajoumand, Claus, and Heller, 2004; Derryberry and Tucker, 1994; McLaughlin, Borkovec, and Sibrava, 2007; Rowe, Hirsh, and Anderson, 2007; Wadlinger and Isaacowitz, 2006). These features of
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 15 cheerfulness may not only reduce the feeling of stress but may also potentially contribute to finding better and faster solutions to problems. Related to that, a cheerful, serene attitude towards oneself and the things one is scared or annoyed of or that are a burden facilitates a change of perspective and a more positive reappraisal of the situation. Looking at problems from a different angle may make them seem less important. For example, if you can laugh at your own shortcomings and mishaps, or at the exam situation of which you are actually afraid of, or at an unpleasant medical examination, because you also see a funny side of the situation, the perspective changes and you gain emotional distance from yourself and your problems. Consequently, difficult circumstances may be experienced less stressful, annoying, or threatening (Kuiper, Martin, and Olinger, 1993; Lefcourt et al., 1995; Martin, 2001; Newman and Stone, 1996; Ventis, Higbee, and Murdock, 2001). It has also been demonstrated that the emotional well-being of people with a cheerful disposition is more robust. That is, there must be more going on to throw cheerful individuals out of balance, to make them depressed or furious or nervous, than is the case with less cheerful persons. Moreover, a disposition to positive affect and a more positive appraisal of difficult situations and circumstances does not only contribute to less experience of stress and to not letting oneself get worked up so easily, but also to faster and more efficient recovery from stressful situations and events (Fredrickson and Levenson, 1998; Kallus, 2002; Newman and Stone, 1996; Ong, Bergeman, Bisconti, and Wallace, 2006; Papousek et al., 2010; Ruch and Köhler, 1999; Tugade and Fredrickson, 2004; Tugade, Fredrickson, and Barrett, 2004; Zautra, Smith, Affleck, and Tennen, 2001). In summary, trait cheerfulness does not only help to keep balance and to experience difficult circumstances less awful and burdening. It also helps to cope with adversities more efficiently and quickly and to regain balance, should it be necessary. The consequence of all this is: Individuals that are more cheerful feel less stressed and strained overall. Scientific studies also demonstrated that persons felt less stressed and tense after their cheerfulness had been enhanced by a professional intervention. In one study, a group of people participated in a professional cheerfulness training (1-2-H Cheerfulness Training®; two-day introductory session plus 15 training sessions lasting 45 min each). The degree to which cheerfulness was enhanced correlated with the reduction of perceived stress in everyday life. The relief of stress was also reflected in a reduction of blood pressure that can be regarded a physiological and objective indicator of stress and tension. In a control group not participating in the training, perceived stress and blood pressure did not change within the same period (Papousek and Schulter, 2008). Another study showed that a professional and systematic cheerfulness training may not only reduce the degree of subjectively experienced stress in daily life, but may also improve several aspects of the ability to recover quickly and efficiently (1-2-H Cheerfulness Training®; two-day introductory session plus several weekly training sessions). As a result, spare time and pauses were experienced as more restorative. The effects exceeded those of autogenous training (an established relaxation technique), which was conducted in a control group (Lederer, 2007). In a further study, a group of high school teachers participated in a cheerfulness-training course (1-2-H Cheerfulness Training®; two-day introductory course plus several weekly training sessions). Several days before the introductory course and again several days after the end of the training period, various aspects of well-being were assessed. The same measures
16 Ilona Papousek and Günter Schulter were taken in a control group not participating in the training. The study showed that the effects of improved cheerfulness were also present in the occupational environment. After the training period, the teachers experienced less stress in their jobs than before. On average, the degree of perceived stress was reduced by 14 percent. They felt less overworked, less worn out, less burnt out after the training. Job satisfaction improved, too, that is, satisfaction with work, with the school, with the working conditions, on average by 11 percent. Moreover, the reduced perception of stress and the general improvement of mood had also an effect on the social life. After the training period, they rated the quality of their contacts with colleagues more positively (on average by about 14 percent). They felt more relaxed, more confident, and more open in their social encounters. In the control group not participating in the training, the same aspects did not change within the same period (Papousek, 2008). Efficient coping strategies, adequate recovery after stress and the related feeling to not be under permanent stress, satisfaction with the job and the working conditions, and intact social contacts are considered protective factors that may prevent or slow down the development of burnout symptoms (Graham, Potts, and Ramirez, 2002; Hoyos and Kallus, 2005; Visser, Smets, Oort, and De Haes, 2003). Certainly, the enhancement of cheerfulness can only contribute to making the development of burnout symptoms less likely, it cannot totally prevent them. The risk of burning out does not only depend on the affective traits of an individual, but to a considerable extent on the structural conditions of work. Examples of factors that can contribute to the development of burnout are shortage of staff, unclear requirements, lack of support by superiors, lack of personal control over the environment and others. Certainly, such unfavorable job conditions cannot be changed by the affective dispositions of single employees. However, as a matter of fact, under the same job conditions, only some people develop burnout symptoms, whereas others do not, not so easily, or not so quickly. Thus, there is some scope left that is independent from the structural conditions that can be used to do something for oneself and to counteract the development of burnout and other stress-related conditions. DON'T TAKE AN X FOR A U Tip 2: Changes Can Materialize on Their Own Suppose that you hear or read that it was observed that a group of people having fever drank a glass of water from the holy well of St. Barbara and on average had much less fever two days later. Does this make you believe that the water from the holy well of St. Barbara has an antipyretic effect (i.e., helps to reduce temperature)? Suppose you hear or read that a patient with a rheumatoid disease watched funny films every day and was cured several months later. Does this make you believe that laughing at funny films brings you back to health? Suppose you hear or read that every year at a given day during winter a village community in an arctic region holds a ceremony during which the village elders sing certain songs and throw frozen fish into the air, in order that it will get warm again. And indeed, every year, several weeks after the ceremony was held, it gets warmer. It never happened that it stayed cold after the village community held their ceremony. The village residents firmly
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 17 believe that the ceremony causes the cold winter to end and summer to return. Do you believe it, either? Does the fact that it gets warmer again every year after the village community held their ceremony prove that the ceremony is the cause of the return of summer? Does it prove that summer returns every year, because the village community takes care of it? No, you probably do not believe that. You probably think that it may well be that summer follows winter anyway, no matter whether that village community in the Arctic holds a ceremony or not and how many frozen fish are thrown into the air. Of course, the fact that summer returns every year does not prove that the annual ceremony of the arctic village community is the cause for it. All the same, the fall of body temperature in the group who drank holy spring water does not prove that the water was the cause of it. Neither does the recovery of a patient who watched funny films for several months prove that laughing at the films was the cause for his recovery. In all three examples, it is always the same problem: It may be true that summer would have come anyway, also without the ceremony of the arctic village community. It certainly may be true, either, that the fever would have ceased anyway, also without the holy spring water. And it certainly may be true that a patient recovers without watching funny films. What is the point? The arctic village community holds its ceremony every year. For generations there was no year in which the ceremony did not take place. And of course, summer returned every year anew. To find out if the ceremony is the cause of the return of summer, the whole village community had to be locked up during the entire winter season, in order to prevent the ceremony from being held. If it is true that the ceremony is the cause of the return of summer, in this year winter must never end and it must not get warmer. Only then, it could be excluded that summer returns on its own. To be able to attribute an effect to a certain cause, it is essential to also test a control condition. In the example of the arctic village community, the control condition would be that the community cancels the ceremony. One could, for instance, cancel the ceremony every second year for some years and observe in which years summer returns and in which not. Only if summer returns in all years with the ceremony and does not return in the years without the ceremony, it could be concluded that summer does not return by itself, but that the ceremony is the cause for it. (Since the ceremony is totally fabricated, it can be asserted that summer will return in any case, for sure). In the example with the holy well another group of patients had to be observed, who also suffer from fever of approximately the same height and for the same time and who have the same illnesses as the group drinking the holy water. This second group only gets normal tap water (that would be the control condition in this case). It would only be an indication of an antipyretic effect of the water of the holy well of St. Barbara, if the body temperature dropped to a greater extent after drinking holy water than after drinking normal tap water. Without such a control condition, it cannot be decided if the decrease of body temperature is attributable to the holy water or if it is just that time went by, that is, that the fever dropped on its own. (If it would be done carefully, the participants would not be told whether the water they are drinking stems from the well of St. Barbara or from the tap, in order to exclude a placebo effect). The same holds true for the funny films. Without an appropriate control condition, it cannot be excluded that the patient would have recovered anyway. In this case, two groups of patients would be required, with the same diagnoses, the same age, the same states of health, and the same medical treatments. Only one group watches funny films, the other group
18 Ilona Papousek and Günter Schulter watches to the same extent films that are not particularly funny. Only then can it be determined whether it is not as likely to recover without as with watching funny films. As different people are different, it has to be taken into account again that there will always be differences between groups of people. (For instance, different people also differ in how fast their body temperature returns to normal). That is why certain rules must be followed in such studies and additional scientific methods must be applied to be able to decide if the observed differences are large enough to assume that they are not merely coincidental, that is, that they are not only there, because different people are different. For this and for the evaluation of studies that were conducted by others, much professional knowledge and experience is needed. But everybody can recognize reports that are by no means serious, that is, reports of studies in which changes were investigated without an appropriate control condition; studies in which it was not evaluated whether the changes also would have materialized on their own (or for another plausible reason). In these cases, someone makes an X for a U. EMOTIONAL WELL-BEING Having a high degree of cheerfulness does not simply mean that one is prone to be in a positively valenced mood. Cheerfulness is associated with a collection of personal resources that individuals can draw on during adverse circumstances. Resources are tools that can help to cope with certain demands. With the aid of personal resources, one better stands up to stressful events and circumstances and recovers faster and more efficiently. That is so important because stress plays a part in the life of everyone. Even minor annoyances such as that one drops the milk carton on the kitchen floor, has put on another kilo, that the son left his footprints on the freshly polished floor, or all toilets are occupied, may considerably contribute to the feeling of being stressed. Or else may not. It is assumed that the ability to draw on helpful personal resources is even more important to general well-being than the degree of unfavorable affective traits such as anxiety or pessimism (Cohn, Fredrickson, Brown, Mikels, and Conway, 2009; Steptoe et al.. 2008; Tugade et al., 2004; Zautra, Johnson, and Davis, 2005). Resources that are related to trait cheerfulness are, for instance, the already mentioned coping strategies, flexibility, a humorous, serene attitude towards oneself and the given personal circumstances (see \"Stress and strain\"), but also a cheerful and humorous attitude in social situations with associated beneficial effects on social life and social support (see \"Social life\"). Thus, for instance, when cheerful individuals are sitting in the waiting room of a doctor for a while, they tend to approach other waiting people with a smile and perhaps make a cheerful, encouraging comment on the long waiting time and their possible causes, instead of quickly falling into despair or staring hostilely at the others and wishing that those who came first may be even more unnerved, give up and go home. In turn, they benefit from the positive reactions of the others and the related positive effects on their own mood. When they notice that they have left the office key at home for the second time within one month, cheerful individuals smile to themselves and ask their colleague or the secretary eyes a- twinkle to please help them out, instead of getting furious, kicking the office door, chucking the briefcase into the corner of the secretary's office and ruminating for hours how they can
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 19 be so stupid. When cheerful persons make a mistake during a speech or a job interview, they do not panic, or hope with their face red as a beetroot that nobody has noticed the mistake, but they calmly take note of their error and correct it with a smirk, perhaps even with an appropriate humorous remark. In the long run, the collection of resources accompanying cheerfulness puts a brake on the development of negative affective traits such as depression, worry, or the permanent feeling of stress. But there is even more to it than that. Cheerfulness directly fosters other positive emotional traits such as vitality, alertness, and relaxation and in the long run contributes to a lasting and robust enhancement of emotional well-being. The resources that are available when having a high degree of cheerfulness are used with success on many occasions. Thereby over time new resources develop. For instance, individuals acquire the attitude of being the architect of their own fortune and face difficulties with composure, because they trust in the ability to cope stress and adversity and that there will always be a way out. In further consequence, they can even better manage upcoming problems. This, in turn, further fosters the development of positive affective traits and resources, and so forth. Thereby a process is set in motion, which sustainably advances the enhancement of emotional well-being like an upward spiral (Fredrickson and Joiner, 2002; Hobfoll, 1989; Kallus, 2002; Salovey, Rothman, Detweiler, and Steward, 2000). With the treatment of negative affect alone all this cannot be achieved. That is why there is more to the training of cheerfulness than, for instance, the removal of depressive symptoms or the reduction of fears and worries, more than the attenuation of a certain negative affect. Cheerfulness sustainably promotes the enhancement of emotional well-being, also and in particular in the future. In various other contexts, too, the promotion of positive characteristics and resources seem to be more effective than only attenuating negative affect. For instance, a high degree of trait positive affect and resources helps to keep balance in stressful situations and also, for instance, in the face of disease or pain, and is related to overall life satisfaction. A relatively lower degree of negative affect alone does not have this effect (Cohn et al., 2009; Zautra, Fasman, et al., 2005). For several aspects of physical well- being and health, for which the degree of negative traits like depression, worry or the persistent experience of stress plays an important part, too, there is some evidence that a lack of trait positive affect is even more unfavorable than a high degree of negative affective traits (Benyamini, Idler, Leventhal, and Leventhal, 2000; Cohen, Doyle, Turner, Alper, and Skoner, 2003; Cohen, Alper, Doyle, Treanor, and Turner, 2006; Ostir, Markides, Black, and Goodwin, 2000; Ostir, Markides, Peek, and Goodwin, 2001; Pettit, Kline, Gencoz, Gencoz, and Joiner, 2001; Pressman and Cohen, 2005). Scientific studies demonstrated that after participating in an intervention program with which cheerfulness can be successfully trained, not only the feeling of stress and tension decreased, but that this was also accompanied by a more general improvement of emotional well-being. In a study in which a systematic training was conducted (1-2-H Cheerfulness Training®), some time after the end of the training not only the degree of cheerfulness was higher than before, but the participants were in a generally better mood, they felt considerably more calm, alert, active and less anxious than before. On average, the values in the applied diagnostic instruments were more positive by about 16 percent. In the control group not participating in the training, none of these indicators changed within the same period (Papousek and Schulter, 2008).
20 Ilona Papousek and Günter Schulter A program that aims at enhancing cheerfulness as a trait is suited to stimulate the upward spiral towards emotional well-being in healthy individuals. It is suited to attenuate negative affect and to sustainably foster positive emotional traits and the development of successful personal resources. A noticeable benefit can always be achieved, whether positive and negative affective traits balance each other before the training, or the balance is positive, or negative traits predominate (see also \"Training of cheerfulness\"). However, there are limits to the adequacy and the success that can be expected from such an intervention. A limit is definitely exceeded, when the current emotional state is distinctly disturbed. The training of cheerfulness primarily has potential for improvements in the future. It is appropriate when one aims at achieving sustainable changes in the long run. It is not suitable as a quick help in a crisis. In a crisis, cheerfulness does only help, if one is already able to draw on helpful personal resources, that is, if one already has a sufficiently high degree of trait cheerfulness. Directly in a serious emotional crisis or immediately afterwards and immediately after traumas or blows of fate, a cheerfulness intervention is not appropriate. At the proper time, grief, anxiety, and angriness are right and necessary reactions, for which one should take enough time. When needed, professional psychological counseling or psychotherapy can help to be able to manage. Yet this period should not last too long, and after an appropriate amount of time, one should recover as completely as possible. Some time after periods of severe stress, for instance, after loss of a closely related person, loss of employment, severe illness, and other serious adversities, when one has the feeling that it is time to step back into life, an intervention enhancing cheerfulness may be useful. Cheerfulness also helps to broaden a person's thinking and behavioral repertoires (whereas the repertoire is restricted during grief, anxiety, and anger).That is, more cheerfulness helps to be able to turn to new thoughts and activities again, to let go of entrenched patterns of thinking, to strike new paths, instead of constantly ruminating on the same thoughts and worries and withdrawing from the world (Fredrickson, 2004; Tugade et al., 2004). In the case of major affective disorders and personality disorders (e.g., major depression, anxiety disorders, schizophrenia, addiction, borderline, obsessive-compulsive disorders) a cheerfulness intervention does not help. In these cases, psychiatric and/or psychological or psychotherapeutic treatment is required. Severe mental diseases and disorders are also accompanied by biological changes in the brain that in many cases can be best treated with drugs. An intervention program to enhance cheerfulness can by no means replace necessary drugs and therapies. During acute mental illness, a cheerfulness intervention is also misplaced as a supplementary treatment. Only when patients are completely or largely symptom-free after treatment, one can think of applying an intervention to enhance cheerfulness, in order to help building positive resources. A scientific study showed that in psychiatric rehabilitation, an intervention program for the enhancement of cheerfulness may facilitate advances, but only to a limited extent. In this study a group of in-patients of a psychiatric rehabilitation clinic took part in a cheerfulness training, in addition to their other therapies (1-2-H Cheerfulness Training®; introductory course plus periodic training sessions for five weeks, twice a week; the standard method was slightly modified to adapt it to the special requirements of the sample). The participants had no acute symptoms during their stay at the clinic; diagnoses were predominantly depressive disorders. As compared to a carefully selected control group, the participants of the training showed a more pronounced reduction of subjective impairment by psychological and physical symptoms and a greater feeling of confidence in social situations at the end of their six weeks
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 21 stay in the clinic. For other indicators that can show marked improvements in healthy individuals within this period, the positive intervention did not show any additional benefits as compared to the effects of the usual therapy program (depression, anxiety, alertness, vitality; Nograsek, 2006). Thus, although there may be some benefits in patients in rehabilitation after mental disease, they are considerably smaller than in healthy individuals. It might also be that further measurable changes would only appear after longer training periods. A prerequisite for the applicability of such an intervention is in any cases a sufficient degree of functionality in the patients. DON'T TAKE AN X FOR A U Tip 3: Co-Occurrence or Cause and Effect Every week the media publish new stories about things that are said to be \"healthy\". In the majority of cases, these claims are based on the observation of a simple correlation: In individuals who have a certain characteristic, it is more likely that another characteristic is observed either. Suppose that individuals who are joking more often are compared to individuals who never or rarely joke. Suppose that it is observed that those who joke more often on average have better health than those who never or rarely joke, that they, for instance, have fewer cardiovascular diseases. Can it be concluded from the observation of co- occurrence of frequent joking and a healthier heart that joking is \"healthy\" and prevents from disease? No, because only a correlation was found; two things frequently co-occur. In order to learn whether something is really \"healthy\", one also needs to determine what is the cause and what the effect. There are always at least three possibilities for that. In the given example, these are (see Figure 5): First, it might be that frequent joking is the cause and a healthy heart is the effect. That would imply that the frequency with which one jokes causally influences the likelihood to get cardiac disease, for instance, because frequent joking is accompanied by some favorable long- term changes of physiology. Second, the reverse might be true, that is, cardiac health might be the cause and joking the effect. It is just as well possible that some people do not joke so often or not joke at all, because they have cardiac disease and know that or do not feel well and, hence, do not feel like joking. Perhaps this may even be more obvious than the first possibility. Third, it might neither be true that joking causally influences cardiac health, nor that cardiac disease is the cause for less frequent joking. Nevertheless it is possible that it is observed that frequent joking and healthy hearts often co-occur, that is, if there is a third variable that influences both the frequency of joking and cardiac health. In the given case, membership in a well-functioning social group could be such a third variable, which is accompanied by convivial gatherings increasing the likelihood of joking, and also by social support that can play a part in staying healthy and feeling healthier. Thus, in that case it would have been observed that joking and good cardiac health often co-occur, only because the social situation of an individual influences both the frequency of joking and his or her cardiac health. But joking and health are not directly related at all, neither in one nor in the
22 Ilona Papousek and Günter Schulter other direction. There may also be several \"third variables\" (in most cases, there are indeed several). Figure 5. The claim that joking is 'healthy' would only be correct if the first of these possibilities was true, that is, if frequent joking would in fact causally influence cardiac health. If one of the other possibilities is true, the claim that joking is healthy, is wrong. How can it be determined what is cause and what effect? An important consideration in that context is that only that can causally influence something else that was there first (the other way round it would not be possible). Suppose, for instance, the traffic lights break down at a busy junction; ten minutes later two vehicles are involved in an accident. Since the traffic lights went out before the accident happened, the accident could have been caused by the break down of the traffic lights. The traffic lights could also have broken down in consequence of the accidence, for instance, because the involved cars crashed the traffic lights. But then the accident would have had to happen first, before the break down of the traffic lights. Therefore, in the given example, we can rule out the possibility that the accident caused the break down of the traffic lights. However, there might be a \"third variable\", for instance, a thunderstorm could have caused the break down of the traffic lights and at the same time the accident (e.g., because of aquaplaning). In this case, the break down of the traffic lights and the accident would be in no direct relationship to each other. That is, in order to determine what is cause and what effect, studies are essential that do not only examine how often two things co-occur at a fixed point in time, but that also take into account what was there first. That is possible with prospective or with experimental studies. In prospective studies, persons are examined who are healthy at the first time of measurement. To stick to the example above, in a prospective study it would first be evaluated in many healthy individuals, how often they joke during a regular week. Subsequently, it would be observed during the following ten or twenty years which individuals get a cardiac disease and which not. In this case, it would be clear that the frequency of joking was there before the cardiac disease. If individuals who joke more frequently develop cardiac disease less often over the course of the following years, this would be an indication that joking might in fact causally influence health. It cannot be the other way round (cardiac health being the cause of joking more frequently twenty years earlier). However, it cannot be excluded automatically that there are 'third variables'. For this, possible third variables have to be controlled, that is, respective data have to be collected, too. With the help of certain scientific methods, it can be determined, then, whether one or several of these variables are responsible for the observed correlation. In an experimental study, the putative cause is purposefully manipulated. In the given example, a large group of people could be obligated to tell a certain number of jokes every
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 23 week over an extended time. Another group would be obligated to not tell any jokes at all (over the same period). The time period must be long enough so that cardiac diseases may develop. Afterwards it would be observed which people get ill and which not. In this case, it is also clear which of the two variables was there first, because it is purposefully arranged that way. Should it really be true that joking prevents from cardiac disease, the likelihood to develop cardiac disease must be lower in the joking than in the non-joking group. It is quite difficult and, therefore, a matter for experts, to determine whether studies have been adequately controlled and all scientific rules that are required for reliable conclusions have been followed. But in most cases, it can be recognized very easily whether studies were conducted prospectively or experimentally, often also directly in media reports. If it was only observed that two things co-occur, it is not possible to determine what is the cause and what the effect, and whether the two variables are directly causally related at all. If only such a simple observation of co-occurrence is available and it is nevertheless claimed that something is \"healthy\", someone makes an X for a U. PSYCHOSOMATICS Generally speaking, the field of psychosomatics is about how psychological processes and characteristics can influence the functions of body organs. Among the psychological processes and characteristics are thoughts, feelings, moods, personality characteristics, affective traits and so forth. Functions of body organs may be, for instance, functions of the heart, the gastrointestinal system, or the immune system. Psychosomatic processes constantly occur in our daily lives. They are totally normal and harmless and even very important, because through these processes, the body adapts to current demands. In everyday life, the demands on various body functions are changing continuously. They change when a person stands up or goes up a few stairs, and also change when a person is nervous, for instance. Therefore, the heart is not only beating faster when your are climbing stairs, but also when your are nervous and anxious, because your have to take an exam in a few moments or because you hear steps behind yourself, and also when your are excited and on cloud nine, because you kiss your new boyfriend (or girlfriend) for the first time. Psychological processes such as thoughts, feelings, moods, or perceptions are generated in the brain, and brain regions that are involved in it can intervene in the regulation of body functions via complex nervous connections. Therefore, also thoughts or emotions or the sight of the beloved in the distance can change functions of body organs. For this purpose, neurons of the \"highest\" brain regions (the cerebral cortex) send signals, via several relay stations, down to the organs. In addition, the release of hormones plays a part in it (Cechetto and Saper, 1990; Lovallo, 1997; Mayer, 2000). However, psychological processes do not only cause short-term changes of body functions, such as during temporary emotional stress or excitement. Processes that are related to affective traits such as depression, that last for some time, can also cause longer-lasting changes of processes regulating body functions. When that happens, something in the interplay between psychological and bodily processes will not work as perfectly anymore as it should. The altered processes may be less efficient and less adaptive and, in the long run, unfavorable to the respective organ system (Depue and Monroe, 1986; Sheffield et al., 1998).
24 Ilona Papousek and Günter Schulter Therefore, psychosomatic processes may also play an important role in connection with health and disease. The concepts and knowledge about interrelations of the mind and the body, how psychological processes can cause or influence bodily symptoms or can affect well-being, and the approaches to consider psychosomatic processes in medical practice, have changed very much during the past decades. However, in the popular literature the older concepts are often still present. Therefore, we will very briefly contrast them with the contemporary view. If, for instance, a patient suffers from persistent constipation and abdominal pain, it is sensible to check whether there is a tumor, inflammation, damage of the nerves or any other somatic problem. But quite often, nothing abnormal is detected in traditional medical examinations, although the patients suffer from their complaints. This is particularly often the case with gastrointestinal complaints. In up to 50 percent of the patients having gastrointestinal complaints, there is no apparent medical condition that may account for the symptoms experienced. Beyond that, even if there may be a pathological finding in the gut, it often cannot explain the type and strength of the symptoms (Kroenke and Harris, 2001). In historical terms, the possibility that psychological factors play a part in well-being and health, was taken into consideration in different ways. According to the dualistic or \"traditional medical\" approach that traces back to Decartes (1596-1650), \"real\" somatic problems on the one hand and psychological factors on the other hand are completely dissociated from each other. First, it is examined whether there is any abnormality of the body. If no somatic problem is found, then it is concluded that there has to be damage to the mind. Consequently, a mental disorder such as hysteria, hypochondria, or somatization disorder is diagnosed. That is, according to the dualistic concept, either the body is affected (\"somatic\", \"physical\" or \"organic\" disorders) or the mind is affected (\"psychological\" or \"mental disorders\"). Either the symptoms are attributed to the body, or they are attributed to the mind. If the symptoms are attributed to a somatic problem, they are accepted as \"real\". If the symptoms are attributed to the mind, they are not accepted as \"real\". According to this concept, a patient with constipation and intestinal pain in whom no physical abnormality is found in the gut is not \"really\" ill, does not have \"real\" complaints; the symptoms, the complaints only exist \"in the mind\". At least implicitly, this assumption is still widespread both in medicine and in the general population, although it is clear by now that it has to be regarded outdated and unscientific (Lovallo, 1997; Mayer, Munakata, and Chang, 1997; White and Moorey, 1997; Wilhelmsen, 2000). The psychoanalytic approach, which has its origin in the for its time innovative considerations of Sigmund Freud (1846-1939), has been a progress in so far as it includes the possibility that even \"real\" somatic disorders can develop through psychological processes. Consequently, even when a somatic cause is present, a contribution of psychological factors is not automatically excluded, although the idea of \"imagined\" illnesses is still present, and the patients are in part blamed for their complaints. In the psychoanalytic approach, attempts to explain psychosomatic processes are characterized by prescientific analogical thinking. Therefore, constipation, for instance, is attributed to characteristics such as parsimony or the attitude \"I can't expect anything from others, therefore I don't need to give anything to others\" (analogy: that is why I do not give away my excrements, either), or tidiness (analogy: I do not want to cause dirtiness), or \"fear of too much overspending\" (analogy obvious; Klußmann, 1992). Also still included is the assumption that psychosomatic processes play a part only or predominantly for certain diseases or symptoms, which are denoted \"psychosomatic
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 25 diseases\". The psychoanalytic analogical ideas of the development of diseases and complaints have not been empirically confirmed (i.e., through scientific studies), and are untenable from a contemporary scientific perspective. It is clear by now that it is not possible to attribute a certain disease or a certain symptom to a certain personality trait. In modern, contemporary approaches of psychosomatic medicine that are often referred to as \"biobehavioral\" or \"biopsychosocial\" concepts, \"organic\", \"mental\", and \"psychosomatic\" diseases are not rigorously distinguished any more. Instead, it is assumed that both aspects (i.e., somatic and psychological) play a role in all diseases and complaints (with sometimes one aspect and sometimes the other on the fore). It is known by now that even in diseases with a clear somatic cause, psychological factors can influence the severity of the disease or the likelihood of a flare-up and can substantially co-determine the severity of pain. Thus, patients with a certain disease may vary in their illness expression from asymptomatic to severely disabled, despite comparable objective medical findings. Moreover, it is assumed that diseases and complaints do never exist exclusively in the mind (or \"in one's imagination\"), but that complaints that cannot be explained by a distinct somatic cause, too, are related to \"real\" physiological disorders (disorders of function). In the case of constipation, for instance, they may be related to slightly disturbed motor function or altered sensitivity of the sensory receptors in the gut, which can be due to small alterations of the information transfer in the bidirectional pathways between brain and gut (Mayer, 1999; Naliboff, Chang, Munakata, and Mayer, 2000; Wood, Alpers, and Andrews, 1999). Instead of wrapping the mechanisms how psychological factors can affect well-being and health in a veil of mystery such as \"somatization\", these mechanisms and processes now are extensively investigated scientifically. As already mentioned, the attempt to link certain diseases or symptoms to certain personality traits failed. But by now, it is very well established by very much scientific work that predominantly three affective traits are related to the development, the course, and the severity of all kinds of somatic complaints and diseases: persistent experience of stress, depression, and anxiety or worry (Hubbard and Workman, 1998). Note that this concerns affective traits, that is, durable characteristics of individuals. Certainly, a person does not become ill when he or she is stressed or sad or worried once or from time to time. Neither do persons become ill when they are often stressed, sad, or worried, if they quickly and completely recover in between. But persistent experience of stress over a long time or persistent depressive mood or anxiety can adversely affect physical well-being and health. In part, the significance of these negative emotional traits for the development, the course, and the severity of complaints and diseases is impressive. That is particularly true for complaints and diseases in which the processes underlying the symptoms take a longer time to develop (Booth-Kewley and Friedman, 1987; Hubbard and Workman, 1998; Pressman and Cohen, 2005). How is it possible that affective traits will affect physical well-being and health? As noted above, the brain adapts all body functions to the current demands. Changing demands may be signaled by the body (e.g., high traffic volume in the gut, but also small changes of all kinds of physiological variables), or by the brain itself (e.g., perception of the voice of the beloved on the phone). Various structures of the brain, the respective body organ or organ system, the nerve connections between the brain and the body organs, and hormonal changes all are participating in these regulation processes, which are essential for the organism to
26 Ilona Papousek and Günter Schulter function properly. Normally, the body functions are optimally adapted to the current demands by these constantly occurring regulation processes. Affective traits such as the persistent experience of stress, depression, and worry are also related to certain processes and activation patterns in the brain, which can cause small alterations of adaptation processes (Bremner et al., 1997; Fuchs and Fluegge, 1995; Papousek and Schulter, 2001, 2002). Since the way in which the brain regulates the body functions is slightly changed, the adaptation processes may not work entirely as they should, and the results of the adaptation processes may not optimally correspond to the current demands any more. For instance, neurons may be prompted to send signals to a certain organ that cause a response that is a bit too weak or a bit too strong according to the current demands. A bit too much or too few of a hormone may be released. Receptors in the gut may respond a bit too sensitively or not sensitively enough. The cardiac rhythm may be slightly disturbed, and coagulation of blood platelets may be slightly reduced or enhanced. The immune system may respond a bit too strongly and inflammation processes may exceed the actual demand, and so forth (Friedman and Thayer, 1998; Hughes and Stoney, 2000; Joynt, Whellan, and O'Connor, 2003; Mayer, 1999; Miller, Chen, and Zhou, 2007; Plotsky, Owens, and Nemeroff, 1998; Thayer, Friedman, and Borkovec, 1996). If that remains so for a short time only, it will have no particular effects. But if the disturbances remain for a longer time, such minor dysfunctions of adaptation processes may affect the function of body organs, that is, the organ will not entirely work as it ideally should. Consequently, complaints may occur or diseases may be advanced (Clauw and Chrousos, 1997; Depue and Monroe, 1986; Papousek et al., 2002; Ringel and Drossman, 1999; Sheffield et al., 1998). Beyond that, affective traits cannot only affect physical well-being and health by the direct biological route, but also by pathways that are more indirect. For example, negative affective traits are often accompanied by adverse behavioral patterns such as tobacco smoking, alcohol, drugs, lack of exercise, malnutrition, and lack of compliance with the doctor's recommendations (Brummett et al., 2003; Cohen and Rodriguez, 1995; DiMatteo, Lepper, and Croghan, 2000; Joynt et al., 2003; Kritz-Silverstein, Barrett-Connor, and Corbeau, 2001; Patton et al., 1996). Negative affective traits may also be linked to unfavorable cognitive characteristics. Examples are the degree of attention allocated to the symptoms and the appraisal of symptoms. When a person is anxious and worried, his or her attention is much more directed at the pain, and the pain is perceived as more threatening. Consequently, the pain is experienced as more severe and less tolerable (Miron, Duncan, and Bushnell, 1989; Villemure and Bushnell, 2002). Finally, social factors may play a role. Depression, for instance, is often accompanied by withdrawal from friends and family. At the same time, friends and family often gradually retreat from a depressed person, because communication may be burdensome (Coyne, 1976; Troisi and Moles, 1999). Consequently, depressed people receive less social support that in many cases would be helpful to appropriately interpret symptoms and complaints, to make use of medical facilities, to maintain independent living, and so forth.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 27 DON'T TAKE AN X FOR A U Tip 4: Stress Responses Are Not \"Unhealthy\" When you have to do an exam or a speech, when you are engaged in a passionate kiss, when it is already late and you have to catch the train, when your national team scores a goal at the World Cup, when you are sitting in the dentist's chair waiting for the dentist, when you crack a joke, when your favorite football club has lost the game, when you unwrap a present from a kind friend of yours, when your daughter does not return home as agreed, when you are laughing heartily at a memory with your friends ..., then for a short time all kinds of physiological functions change. Thus, various psychological processes also elicit changes in the body. Since all those examples are accompanied with the activation of strong feelings, many changes are equal or similar in all examples; some changes meet specific requirements of the specific situation. The assumption that physiological responses to psychological processes (so-called stress responses) are unhealthy, is one of the most widespread fallacies that are still persistently spread explicitly or implicitly via popular books, wellness folders, advertising brochures, etc. In every day life, the term \"stress\" is often used to express that one feels uncomfortably burdened (\"I have so much stress!\"). From a biological point of view, stress relates to every kind of short-term strain. The strain consists in that changed conditions (physical or mental performance, excitement, etc.) lead to altered demands on somatic (and psychological) functions. It can be elicited, for instance, by running up the stairs, doing a speech, or kissing passionately. Therefore, the strain may also be experienced as positive, desirable, and pleasant. The organism reacts by adapting the functions to the altered demands (e.g., the heart beats a bit faster). This adaptation represents the \"stress response\". If the body would not permanently adapt its functions to the current demands, an unfavorable situation would arise. As an intuitive example, one may think of a plant that grows best if it gets neither too much nor too little water according to its demands. How much water it needs depends on the current conditions such as sunlight, air temperature, humidity, wind strength, etc. The plant certainly needs more than water to grow optimally. In humans, being a bit more complicated than a plant, it depends on the fine-tuning of hundreds of parameters how optimal the body works under certain conditions. Therefore, all functions must be permanently regulated and adapted to the current conditions and demands. In former times, it was thought that it might be the healthier the less the body responded to emotional strain (and many people still mistakenly believe it even nowadays). It was thought that every stress response of the body would be detrimental. But stress responses are not only totally normal and occur in everyone every day, but they are important and necessary adaptation responses. Today it is assumed that responding flexibly and adaptively to changing demands is important for staying healthy. Flexible means that it is important that the body functions quickly adjust to the changed conditions. Adaptive means that too strong but also too weak stress responses are in the long run unfavorable to health and physical well-being. A quick, distinct response that also quickly returns to baseline when the stress is over is considered a \"healthy\" stress response (see Figure 6). In rest conditions, too, the body functions should adapt accordingly (Brosschot, Gerin, and Thayer, 2006; Dienstbier, 1989;
28 Ilona Papousek and Günter SchulterS treng th of r espon seStren th of r espon seStr ength of response Streng th of re spon se Friedman and Thayer, 1998; Heponiemi et al., 2007; Hoehn-Saric and McLeod, 1988, 2000; McEwen, 1998; Papousek et al., 2002). The outdated negative view of stress responses is associated with a concept that draws back to Cannon, who lived at the beginning of the twentieth century. His concept, although outdated, can still be found in many books and various kinds of brochures. Cannon believed that the stress response always proceeded in the same way. To put it simply, he thought that the organism always reacted with a general, unspecific activation of the sympathetic nervous system. (The sympathetic nervous system is part of the autonomic nervous system through which the brain sends signals to the body organs). General and unspecific means that not only certain organs or organ systems are addressed but that always the whole organism is activated. According to Cannon's view, the purpose of the stress response is to activate the whole body, in order to prepare it to \"fight or flight\". Cannon deduced this assumption from observations of animals that were exposed to extreme, acutely life-threatening conditions. What Cannon observed were emergency responses of the body that reflected the attempt to survive in an extreme situation that is a matter of life and death. In normal every day conditions, such a general, unspecific activation of the whole body does not occur. For stress responses in normal conditions (i.e., in conditions that are not acutely life threatening) the concept of Cannon is definitely wrong (Jänig and Häbler, 2000). Today it is known that in conditions of stress, the brain sends differentiated signals to the body organs through specific nerve pathways. By specific nerve pathways, one understands a chain of neurons that are responsible for the regulation of a certain function of a certain organ or organ system. Differentiated signals are signals that are not uniformly sent out to the whole body, but that differ depending on the specific nerve pathway and organ. Both the sympathetic and the parasympathetic branch of the autonomic nervous system are involved in the adaptation processes, as well as a cocktail of hormones the composition of which can also be very specific. With all this, the body functions are precisely adapted to changing demands. Ti me Time Ti me Ti me S t re ss Stres s Str ess S tr ess 'h ealthy ': dist inct 'unhealthy': r espo nse 'unhealth y': re spons e 'unhealthy ': pr ol onged is too w eak is too str ong and resp onse respons e wit h fast on set is delayed o nset a nd qu ick return to base line af ter ce ssation of the str ess Ex ampl es for 'healthy' an d 'unh ealthy' stress response s Figure 6.
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 29 The more flexible and the better the body functions are adapted to the demands of the current situation, the \"healthier\" the stress response is. Therefore, failing to respond or responding too weakly according to the current demands or responses with a delayed onset is as unfavorable as too strong or prolonged responses. Thus, if someone claims that the body's responses to emotional strain are generally adverse, an X is made for a U. Only then are stress responses \"unhealthy\", if the results of the regulation processes are not fully in accordance with the current demands. There are numerous reasons why deviations in adaptation processes may occur. Persistent negative emotional traits such as depression, anxiety, and chronic experience of stress are among the factors that can contribute to the development of minor alterations of adaptation processes (Cohen et al., 2000; Fuchs and Fluegge, 1995; Hughes and Stoney, 2000; Oswald et al., 2006; Peeters, Nicholson, and Berkhof, 2003; Plotsky et al., 1998; Thayer et al., 1996). THE POSITIVE SIDE OF THE PSYCHOSOMATIC COIN There is much more research on the impact of negative than of positive affective traits on well-being and health. Taken together, there are over 20 times more studies on the concomitants of negative affect than there are on health-related aspects of positive affect, although there is even evidence that positive affective traits may be associated with longevity (Danner, Snowdon, and Friesen, 2001; Pressman and Cohen, 2005). The current knowledge about psychosomatic processes has nearly exclusively developed based on investigating the negative side of the psychosomatic coin. Surely, that can be attributed to the general principle that everything that causes disturbances attracts more attention and on the first glance seems to be more interesting than something is that may attenuate adverse processes and, consequently, may prevent disorders. This phenomenon is also reflected in the news culture. (Particularly the bad news and reports of disasters are the most interesting news). Therefore, much more is known about the negative side of the psychosomatic coin. Nevertheless, turning the coin over it seems justified to deduce certain expectations about the psychosomatic sequelae of cheerfulness. The key factor is the lasting beneficial effects of cheerfulness on psychological health. More trait cheerfulness results in feeling less stressed, depressed, worried, and anxious; not only because cheerfulness and negative mood are incompatible, but above all because cheerfulness is associated with the ability to better deal and cope with adversity and, thus, difficult circumstances are experienced less awful and burdening (see \"Stress and strain\"). Consequently, it can be expected that by enhancing cheerfulness in every day life, the well-known sequelae of stress, depression, and anxiety can be warded off or at least considerably attenuated. Beyond that, a cheerful disposition also contributes to faster and more efficient recovery from adverse circumstances and the associated negative feelings. That way imbalances produced by stress, anger, sadness, worry, etc. are quickly readjusted, and the development of lasting changes that may affect health in the long run is prevented (Tugade and Fredrickson, 2004). That also implies that in order to stay healthy, it is in no way necessary to have never negative feelings, be never sad, angry, or stressed. On the contrary, given the respective circumstances, it is right and important to also react emotionally (to an appropriate extent). What is important is that the negative mood does not last too long and that one sufficiently recovers both emotionally and physically. That is, it
30 Ilona Papousek and Günter Schulter is important, for instance, that one does not ruminate and worry about a situation long after it is settled or over, and that the stress-induced physiological changes quickly return to baseline (Brosschot et al., 2006; Heponiemi et al., 2007; Kallus, 2002). Trait cheerfulness facilitates that. That is, if an individual can cope more successfully with stress and adversity in every day life, adequately recovers from stress, anger, sadness, worry, etc. and, hence, does not permanently feel stressed, or worried, or depressed, then adverse consequences of negative affective traits on physical health can be warded off. That is of great value, because the impact of negative affective traits on well-being and health can be substantial. In addition, these relationships are not only interesting for individual persons and their families and friends. Studies indicated that it strongly depends on psychological factors if and to what extent health care facilities are used. Experts estimated that only 12 to 25 percent of utilization of health care services can be explained by objective morbidity or disability alone. In all other cases, the emotional condition of a patient plays at least an important part. Moreover, it was estimated that approximately 50 percent of all visits to doctors can be attributed to so-called functional disorders and diseases, in which psychological factors play a particularly important role for the development, severity, and course of the disorder and in most cases there is no medical diagnosable condition. It was also calculated that systematic programs to improve the emotional condition of patients and their coping with stress could considerably reduce the costs of the health care system (Berkanovic, Telesky, and Reeder, 1981; Cummings and van den Bos, 1981; Sobel, 2000). That is, cheerfulness can play a part in contributing to not letting chronic stress, anger, sadness, depression, worry, or anxiety set processes in motion that in the long run may affect health or may hinder or slow down recovery. This positive side of the psychosomatic coin is of great value. However, there will not be any effects beyond that. It is not to be expected that more cheerfulness will turn you into superman or supergirl, that you will become healthier than healthy, extra-robust, mega potent. That will not be the case for sure. Details of what can be expected from the enhancement of cheerfulness in every day life will be summarized below. CARDIOVASCULAR HEALTH Particularly convincing evidence for the health-related impact of negative and positive affective traits has been provided for cardiovascular diseases. In well-controlled prospective studies it was repeatedly demonstrated that negative emotional traits have to be regarded as important risk-factors, independently of other known risk-factors such as smoking, lack of exercise, eating habits, etc. (Frasure-Smith and Lesperance, 2005; Gallo, Ghaed, and Bracken, 2004; Kamphuis et al., 2006; Middleton and Byrd, 1996). Thus, negative affective traits are independent risk-factors, that means, that the correlation between chronic stress, depression, worry, anxiety and cardiovascular disease can not be entirely attributed to the fact that people with negative affective traits have a less healthy life-style (e.g., smoke more, exercise less, have a less healthy diet). The affective disposition plays an additional role, in addition to these well-known risk factors (obviously through biological mechanisms). Being a risk-factor means that not everyone with a disposition to negative affect in time develops cardiovascular
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 31 disease, but just that it is more likely. The same holds for all other risk factors. Not all smokers will die of a heart attack, but the risk to develop heart problems is greater if you smoke. Of course, the significance of all this becomes the greater, the more independent risk factors accumulate in an individual. Besides the psychological factors that are generally important for psychosomatic relationships (chronic stress, depression, worry/anxiety), the disposition to get heavily annoyed at minor events in every day life seems to play an important role for the development of cardiovascular disease. It has been demonstrated in prospective studies that in people with a chronic disposition to be annoyed or angry, the risk to develop cardiovascular disease is twice as high as in people who tend to handle adverse situations and circumstances with serenity. The tendency to brood on the angry thoughts for longer times seems to be a particularly unfavorable disposition (Brosschot et al., 2006; Kawachi, Sparrow, Spiro, Vokonas, and Weiss, 1996; Williams et al., 2000). As opposed to that, there is first evidence that a positive affect disposition can be regarded as a protective factor, that is, as something that makes the development of diseases less likely (Rozanski and Kubzansky, 2005; Steptoe and Wardle, 2005). Positive and negative affective traits also influence the probability of developing cerebral strokes (Jonas and Mussolino, 2000; Ostir et al., 2001). These relationships have also been shown for predisposing factors, that is, for somatic changes that, for their part, promote the development of cardiovascular disease and stroke. Prospective studies demonstrated, for instance, that negative affective traits (chronic experience of stress, depression, anxiety) increase the probability of developing chronic hypertension, also independently of other known risk-factors such as smoking, lack of exercise, etc. That holds true for people at middle age and even for adolescents and young adults who are completely healthy at the time of the first examination (Brady and Matthews, 2006; Davidson et al., 2000; Jonas, Franks, and Ingram, 1997; Jonas and Lando, 2000). Similar holds true for atherosclerosis, which progresses faster in people with a higher disposition for depression, anxiety, or chronic anger (Matthews, Owens, Edmundowicz, Lee, and Kuller, 2006, Matthews, Raikkonen, Sutton-Tyrell, and Kuller, 2004; Paterniti et al., 2001; Raikkonen, Matthews, Sutton-Tyrrell, and Kuller, 2004). It has also been reported that chronic experience of stress, depression, and anxiety is related to certain inflammatory processes in the blood vessels that also play a part in the development of cardiovascular disease (Jain, Mills, von Känel, Hong, and Dimsdale, 2007; Joynt et al., 2003; Kop et al., 2002; Libby, 2003; Miller and Blackwell, 2006; Pitsavos et al., 2006; Ross, 1999). These findings, too, have been shown both for older and for otherwise healthy people at middle age. In addition to that, it has been demonstrated that even individuals with relatively low levels of negative emotional traits are at elevated risk, that is, with levels that are far from abnormity or clinically relevant psychological disorders. Findings also suggest that affective traits may be linked with later disease in a graded manner, that is, cardiovascular diseases, strokes, and respective predisposing factors such as hypertension seem to be more likely the higher is the disposition to negative affect (Gallo et al., 2004; Jonas and Lando, 2000; Kawachi et al., 1996; Kubzansky et al., 1997, Kubzansky, Kawachi, Weiss, and Sparrow, 1998; Kubzansky, Davidson, and Rozanski, 2005; Kubzansky and Kawachi, 2000; Rugulies, 2002; Williams et al., 2000). Taken together, it can be concluded from the body of scientific evidence that the enhancement of cheerfulness as a trait can be a useful preventive measure. Improved coping and the development of successful personal resources enhance emotional well-being
32 Ilona Papousek and Günter Schulter enhanced on a lasting basis. One faces adversity with serenity rather than being ferociously angry or devastated. Situations and circumstances are experienced less burdening and can be managed more effectively. One feels confident being able to successfully manage stressful or difficult situations and that there will always be a way out. Consequently, adverse processes induced or augmented by the chronic experience of stress, depression, worry, or anger are warded off in the long run. Transitory states of stress, sadness, worry, or anger, elicited by certain events, are no harm, because a high level of cheerfulness is also associated with faster and more efficient recovery from stress and negative mood, and, thus, these emotional turbulences will not affect health (see \"The positive side of the psychosomatic coin\"). The scientific findings also indicate that the promotion of cheerfulness may already be useful in completely healthy and young individuals, because the affective disposition that one has when young co-determines the probability of cardiovascular problems at an older age. The processes that are induced or augmented by negative affective traits have their effects only after a longer time, and significant health effects will only occur after many years. With a higher level of cheerfulness, these processes can be warded off or at least attenuated or delayed. Scientific evidence also indicates that the promotion of cheerfulness is useful in individuals who are not seriously depressed or anxious and do not feel heavily stressed. Since affective traits are linked with the likelihood of later cardiovascular disease in a graded manner, improvement is always possible. That is, every improvement of one's dispositional affect may contribute to reducing the risk of developing cardiovascular disease. Improving it from good to even a bit better will reduce the risk just the same as improving it from bad to slightly less bad, but just at a different level. However, it is essential that the enhancement of cheerfulness and serenity is lasting. Transient episodes of cheerful mood, exhilaration, or laughter do not have any effects that may be relevant to cardiovascular health (see \"Is exhilaration healthy?\"). Certain forms of humor and laughter (that have nothing to do with cheerfulness) such as cynical or aggressive humor or sardonic laughter even belong to a complex of personality characteristics that are linked to a heightened probability of developing cardiovascular disease (Martin, 2001). Another important conclusion follows from the observation that chronic stress, depression, worry, anxiety, and the disposition to being angry are risk-factors that are (at least partly) independent from other risk-factors such as smoking, lack of exercise, etc.: The enhancement of cheerfulness can absolutely not replace other important preventive measures such as giving up smoking, more exercise, healthy eating, etc. But it may be a useful additional measure, and it could perhaps help abandon other \"unhealthy\" behavior. Thus, a higher level of cheerfulness can help to ward off unfavorable alterations of the cardiovascular system and, hence, to prevent disease. But what about if something has already happened, if a heart attack has occurred or surgery was necessary? Numerous controlled prospective studies indicated that patients with a less depressed and anxious disposition have a better prognosis. More anxious patients, particularly if they lack efficient coping strategies and, thus, feel at the mercy of the situation, are more likely to develop dangerous complications such as ventricular fibrillation (dysrhythmia) or ischemia (impaired myocardial blood flow) during their stay at the hospital directly after an acute heart attack. During the weeks and years after a heart attack or a bypass surgery, patients with a less depressive and anxious or worried disposition are markedly less likely to develop another heart problem or die of one. This is independent from the severity of the first incident and the general health
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 33 status of the patients. Even a slightly higher negative affect disposition, by far within the normal range, affects the risk for complications, relapses, and mortality (Barefoot et al., 1996; Blumenthal et al., 2003; Bush et al., 2001; Frasure-Smith, Lesperance, and Talajic, 1995; Kubzansky et al., 1997; Lesperance, Frasure-Smith, Talajic, Bourassa, 2002; Middleton and Byrd, 1996; Moser et al., 2007). Therefore, obviously an improvement of affect has the potential to slow down or attenuate adverse processes even when a person has already fallen ill. Selective measures for the enhancement of cheerfulness as a disposition, therefore, could also be useful within the context of rehabilitation after cardiovascular disease and surgery. Of course, it is important to note, again, that the enhancement of cheerfulness can be a useful additional measure, in addition to other proved measures such as systematic exercise programs, but cannot replace them. For severely ill cardiac patients who generally should avoid excitements, for instance, patients with severe angina pectoris, no programs should be selected that include strong emotional arousal through intense exhilaration or hearty laughter. Emotional arousal, no matter if it is experienced negatively or positively, is accompanied by changes of various cardiac parameters, increase of blood pressure, etc. Under certain circumstances, intense exhilaration and hearty laughter could, therefore, (like intense anger, anxiety, etc.) provoke attacks. If excitements do not constitute an acute risk, short episodes of cheerful mood, exhilaration, and laughter do not have any effects that may be relevant to cardiovascular health (Gabbay et al., 1996; Moller et al., 1999; Pressman and Cohen, 2005). In any case, positive effects can only be expected, if a program can provide a lasting enhancement of cheerfulness and serenity in everyday life. Beyond that, it is important to note that the potential of emotional factors to influence bodily processes is of course limited. If the disease is already far advanced, or if the kidney or the heart already fails, not even permanent emotional factors can effect something (Pressman and Cohen, 2005). FUNCTIONAL COMPLAINTS In European countries, about 75 percent of adults report having at least some subjective health complaints (Eriksen, Svendsrod, Ursin, and Ursin, 1998). About one third of all somatic symptoms reported in primary care fall into the category of so-called functional complaints or functional disorders (Kroenke and Harris, 2001). These terms are used to define symptoms that are the result of organs or organ systems not functioning normally, but not being associated with structural or biochemical abnormalities. Consequently, x-rays, blood tests, CT scans, or endoscopic exams have essentially normal, that is, non-disease results (Drossman, Corazziari, Talley, Thompson, and Whitehead, 2000). Among the most common functional complaints are gastrointestinal symptoms such as abdominal pain, constipation, diarrhea, and bloating, which are subsumed in the term \"Irritable Bowel Syndrome\". When diagnosed by standardized diagnostic criteria, about 8 to 17 percent of all adults in western countries suffer from this complex of complaints. Single functional gastrointestinal symptoms are much more widespread (Drossman et al., 1993; Leibbrand, Cuntz, and Hiller, 2002). It has been estimated that functional disorders are responsible for 25 to 50 percent of all visits to gastroenterologists, although only a small proportion of patients with these symptoms present to the doctor (Olden, 1998). Thus,
34 Ilona Papousek and Günter Schulter functional gastrointestinal complaints have also a major economic impact. Other symptom groups subsuming functional complaints are, for instance, fibromyalgia (widespread muscle pain, enhanced sensitivity to pain, tiredness) or the \"chronic fatigue syndrome\". But these are only labels, in order to give the patients (and the health insurance companies) a diagnosis. The expression of the illness can vary considerably, and on the other hand, the various syndromes (i.e., symptom-groups) have many symptoms in common. The range of functional complaints is much more multifaceted than a reduction to a small number of syndromes suggests. Many very different complaints can result from functional disorders. Functional disorders are not dangerous, but the symptoms can have a considerable impact on quality of life. Attention is very much focused on one's own feelings and inner sensations, often leaving not much energy for other things of life, and some patients are even restricted in their everyday activities (Tveito, Passchier, Duivenvoorden, and Eriksen, 2004). It is important to note that even when the doctor cannot find anything wrong, functional complaints are not pretended or \"all in the head\". In contemporary medicine, they are regarded as an expression of disorders of function that are \"real\" and that can be treated. They develop from slight dysfunction of regulation processes that, in time, can cause symptoms (Clauw and Chrousos, 1997; Depue and Monroe, 1986; Papousek et al., 2002; Ringel and Drossman, 1999; Sheffield et al., 1998; Staud, 2006; see \"Psychosomatics\"). Psychological factors play a major role for the development and the course of such dysfunctions, and for the extent of complaints and how symptoms are interpreted (Cohen and Williamson, 1991; Papousek and Schulter, 2002; Pennebaker, 1982; Petrie, Moss-Morris, Grey, and Shaw, 2004). Individuals with a higher degree of negative affective traits such as chronic stress, depression, worry, or anxiety are more likely to develop functional complaints and report more complaints than individuals with a more positive affect disposition. Even if a medically diagnosed disease is present, they experience more or more severe complaints than the underlying disease would suggest (Cohen et al., 1995; Hubbard and Workman, 1998; Watson and Pennebaker, 1989). It is also true, of course, that it will negatively influence one's mood if one is affected by somatic symptoms. But controlled prospective studies demonstrated that negative affective traits may indeed increase the likelihood of somatic complaints and may worsen existing complaints (see \"Don't take an X for a U, Tip 3\"). In contrast, people with a more positive affect disposition generally feel more healthy and have less somatic complaints, even when they are objectively as healthy or ill as others, and they are less likely to develop functional disorders in the future. All this holds for young adults as well as for people at medium or older age (Brosschot et al., 2006; Cohen et al., 1995, 2003; Hirdes and Forbes, 1993; Okun, Stock, Haring, and Winter, 1984; Pettit et al., 2001; Pressman and Cohen, 2005; Thomsen et al., 2004). More cheerfulness in everyday life can attenuate negative emotional characteristics and foster positive ones (see \"Emotional well-being\"), by which the adverse effects of depression and anxiety on the number and extent of somatic complaints can be warded off. But in connection with somatic complaints it is also particularly important that cheerfulness is accompanied by effective coping strategies (see \"Stress and strain\"). Therefore, individuals with a more cheerful disposition can better deal with somatic complaints and also tend to behave in a more sensible way: They take their symptoms easier in the first place, they are more likely to consider what they can do about them themselves, to talk to someone who is close to them, and visit a doctor when it is appropriate. Consequently, they more successfully
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 35 cope with their complaints; they experience them as less awful and frightening, can gain distance and are not worrying so much about their symptoms. Particularly ruminating about the symptoms, envisioning all kinds of terrifying scenarios, and related worries can considerably worsen somatic complaints, also because they prevent an individual from recovering in between times from the emotional strain (Brosschot et al., 2006; Gendolla, Abele, Andrei, Spurk, and Richter, 2005; Thomsen et al., 2004). Effective interventions can help, e.g., interventions that succeed in stopping ruminating on the same thoughts and worries all day. An experimental study in which a large group of people participated in such an intervention demonstrated that the number of somatic complaints was markedly reduced after the intervention, as compared to a control group who did not participate. The improvement involved a wide range of symptoms such as gastrointestinal pain, cough, dizziness, low back and neck pain, heartburn, hot flushs, etc. (Brosschot and van der Doef, 2006). Interruption of rumination and worry is also a concomitant of the enhancement of cheerfulness (see \"Stress and strain\"). It also has been directly demonstrated that the degree of somatic complaints can be reduced by purposefully training cheerfulness. After a respective training program lasting several weeks, participants in whom cheerfulness was already considerably increased also felt physically better. In a control group not participating in the program, nothing changed in the same period (Papousek and Schulter, 2008). Certainly, all that does not mean that it may be recommended to thin, with unrealistic optimism to be invulnerable and to simply ignore symptoms. Symptoms are not only annoying, but are also important information that something is not as it should be. Thus, it is not a good strategy to simply ignore symptoms that are present. A doctor should clear symptoms that persist or constantly recur. Having more cheerfulness has nothing to do with forcefully suppressing negative thoughts and somatic complaints. Individuals that are more cheerful automatically have more emotional and physical well-being. To just describe one's situation more positively as it is experienced (to \"whitewash\"), does not help either, it does not improve somatic complaints (Pettit et al., 2001). To worry about one's symptoms and still not visit a doctor is not useful, either. On the contrary, it prolongs the unfavourable loop of thoughts. To keep worrying and ruminating, even after visiting the doctor, and even when the doctor has not found anything (and, thus, it is probably not a dangerous disease but a functional disorder), will probably also increase the problems. But more cheerfulness as a trait can be effective against that. Therefore, more cheerfulness in every day life can contribute to feeling physically better and to developing less somatic symptoms. But miracles are of course not to be expected. Particularly if someone has already serious and persistent problems, the enhancement of cheerfulness might provide some relieve; but to get rid of them, additional measures will definitely be required. CHRONIC PAIN Chronic pain is usually defined as persistent or recurring pain that lasts for six months or longer. It is wide spread. In European countries, for instance, about 20 to 25 percent of the adult population have chronic low back, shoulder, or neck pain (Bergman et al., 2001; Picavet
36 Ilona Papousek and Günter Schulter and Schouten, 2003). That psychological factors strongly influence chronic pain is beyond doubt (Campbell, Clauw, and Keefe, 2003; Janssen, 2002). In fact, it has been found that the severity of pain and how much a patient needs help depends more on the affective disposition of an individual than on the extent of the anatomical damage determined by radiography (Salaffi, Cavalieri, Nolli, and Ferraccioli, 1991). Chronic pain can have a clear medical cause (e.g., injury or degeneration) or not (functional disorder). In both cases, the same psychosomatic processes co-determine the duration and the severity of the pain and the associated emotional strain. To understand the influence of feelings, thoughts and affective traits on pain, it is important to know that certain groups of neurons in the brain produce the experience of pain. If we, for instance, cut our finger with the kitchen knife, neurons send a message from the finger to the brain that damage has happened. Only when these signals have arrived and are processed at certain locations in the brain, we feel pain. Due to the arriving signals, the brain also \"knows\" where they come from. Therefore, it feels like the finger would hurt. But in fact, the brain feels the pain (and not the finger). The finger alone is not able to convey the experience of pain. The severity of the pain we experience certainly depends on the size of the injury we caused with the kitchen knife. But it is at least as important what happens in the brain at that moment. For various parts of the brain intervene in the perception of pain. They send out signals on their part that can attenuate, inhibit, or also reinforce the transfer of the report on damages from the finger into the brain. Other parts of the brain determine whether a message from the body is experienced as pain at all and determine the appraisal of the pain, for instance, as threatening, intolerable, burdening, unimportant, etc., sometimes even as erotic. The activity of these intervening parts of the brain, in turn, is related to the affective dispositions and mood states of an individual and to the other activities, the brain is occupied with at the moment (Fields, 2000; Jasmin, Rabkin, Granado, Boudak, and Ohara, 2003). As psychological processes such as feelings, thoughts, etc. can strongly influence the perception of pain, because various parts of the brain intervene in the pain experience, intriguing things are possible, such as that after an accident and severe injury one experiences pain only after having fled the danger-zone or help has arrived; or that some people voluntarily dangle themselves from a meat hook or can pierce their cheeks with a spear. (Talented people can practice to reinforce the required pain-inhibiting processes in the brain). The intervening processes of the brain are also the reason why \"medication\" that is expected (or believed) to alleviate pain, has a certain pain-alleviating effect, even when it does not contain any active ingredients, but, for instance, only consists of dextrose ('Placebo-effect'; Levine and Gordon, 1984; Petrovic, Kalso, Pettersson, and Ingvar, 2002; Sauro and Greenberg, 2005). The other way round, pain is perceived as more severe during depressed, anxious, or tense mood states, and the pain is less bearable and more burdening the more threatening it is perceived and the more a person is worried and frightened of it (Campbell et al., 2003; Janssen, 2002; Ochsner et al., 2006; Sharp, 2001). Chronic pain is associated with durable but reversible alterations in the brain and in the function of nerve cells in the spinal cord that cause hypersensitivity of the pain perception system. Consequently, even weak stimuli and stimuli that the brain normally would not interpret as pain (e.g., slight pressure) may produce a strong experience of pain. Emotional factors can reinforce these alterations and can contribute to the prolongation of respective processes (Staud, 2006). In prospective studies, a depressed disposition was even identified as the most important predictor of the development and maintenance of chronic pain. Permanent
Don't Take an X for a U: Why Laughter is Not the Best Medicine … 37 worry and ruminating about the pain or possible disease also plays an important part, because it makes people extremely focus on themselves and their pain, which may also reinforce the perception of pain (Brosschot, 2002; Campbell et al., 2003; Forseth, Forre, and Gran, 1999; Severeijns, Vlaeyen, Van den Hour, and Weber, 2001; Sharp, 2001). Taken together, it can be deduced from the existing evidence that a high degree of cheerfulness can help to prevent the development of chronic pain. In case of existing chronic pain, it may bring some relief. Various factors play a part in that. The above-mentioned adverse effects of negative affective traits such as depression, anxiety, and chronic experience of stress are prohibited, because trait cheerfulness implicates that they are only present to a smaller degree (see \"Emotional well-being\" and \"Stress and strain\"). The processes that are responsible for the development and maintenance of chronic pain are not brought forward, and the perception of pain is not additionally reinforced. Consequently, patients with chronic diseases such as rheumatism or fibromyalgia who have a generally more positive affect disposition suffer less pain, also in the future (Zautra, Johnson, et al., 2005). In addition to that, individuals that are more cheerful tend to use more effective coping strategies (see \"Stress and strain\"). Thus, they can also better cope with chronic pain. They experience the pain as less burdening and threatening, they worry less, and do not catastrophize and fall into despair so quickly, should the pain return or become more intense. They also recover faster and more efficiently after periods of intense pain (Strand et al., 2006; Zautra et al., 2001; Zautra, Johnson, et al., 2005). Moreover, cheerfulness promotes a change of perspective and, consequently, helps to gain distance from oneself and one's pain (see \"Stress and strain\"). This also helps to appraise the pain as less threatening. And the less threatening the pain is perceived and the less worries and fears are related to it, the less severe the pain is experienced and the better a person can bear up against it (Ochsner et al., 2006; Sharp, 2001). An additional effect is that individuals that are more cheerful do not think at the pain all the time and do not permanently concentrate on it. Pain is experienced less severe and intolerable if the attention is not only focused on the aching body part, but if one occupies oneself (i.e., the brain) with other things. Neuroscientific studies have shown that that is due to altered activity of those parts of the brain that are participating in the processing and in the reinforcement and attenuation of pain perceptions (Miron et al., 1989; Nouwen, Cloutier, Kappas, Warbrick, and Sheffield, 2006; Petrovic, Petterson, Ghatan, Sone-Elander, and Ingvar, 2000; Tracey et al., 2002; Villemure and Bushnell, 2002). By way of exception, in connection with pain even the short-lived concomitants of exhilaration have some worth (see \"What is meant by cheerfulness\" for the difference between cheerfulness and exhilaration). Scientific studies showed that during exhilaration (e.g., watching a funny film, comedy, etc.) pain sensitivity may decrease for a short while (Cogan, Cogan, Waltz, and McCue, 1987; Weisenberg, Raz, and Tener, 1998; Zweyer, Velker, and Ruch, 2004). This effect can probably be attributed to distraction, that is, to the fact that less attention is directed to the pain or the aching body part; possibly also to some unspecific effect of emotional arousal, i.e., of strong feelings. Films that are comparably interesting and elicit a comparably strong emotional response but are not exhilarating have essentially the same effect as exhilaration (e.g., horrified feelings during a disaster film). It is known that a transitory inhibition of pain perception also occurs during the state of shock after an accident. If the elicited feeling is not really intense, pain perception is only slightly
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