Part I (continued)

How Humor Contributes to Physical Health

While we wait for researchers to settle this issue, I fully agree with the advice given by long-term AIDS survivor Michael Callen (who died in 1993): "It simply makes sense to try to mobilize whatever immune-system enhancing effects might flow from marshaling the mind. After all, even if your T-cells don't increase, how can having a cheerful, frisky, life-affirming attitude possibly hurt? . . . I highly recommend daily doses of laughter."²²

Gamma Interferon

Humor has also been shown to increase levels of gamma interferon, a complex substance that plays an important role in the maturation of B cells, the growth of cytotoxic T cells, and the activation of NK cells.²³ It also tells different components of the immune system when to become more active, and regulates the level of cooperation between cells of the immune system. Given the specific types of immunoenhancement resulting from humor discussed above, this effect on gamma interferon is to be expected.

Taken as a whole, it's clear that there is something about humor and laughter that causes the immune system to "turn on" metabolically and do more effectively what it is designed to do--promote health and wellness in the face of internal or external threats.  But your sense of humor is not a magic bullet, which will cure cancer or other illnesses. Rather, it creates internal conditions, which support the body's basic healing and health-maintaining mechanisms.

My guess is that future research will show that a major component of the power of humor to promote health and healing lies in its capacity to pull us out of the chronic negative mood we're left in by the constant stress in our lives, and to replace that mood with a more positive, optimistic outlook that lowers stress hormones and leaves the immune system operating on a higher level.

Duration of Humor-Induced Immunoenhancement

Only a few studies have examined the duration of the immunoenhancement effects of humor.  This may be an artificial question, since emotional changes are known to cause fluctuations in the immune system, and your emotional state generally depends on whether or not you're dealing with anything stressful at the moment. If something happens to make you angry or anxious soon after watching a comedy video, this counteracts the immune benefits resulting from the video.  This is where the strength of your own sense of humor comes in.  If you are able to find a light side of the situation, you sustain the immunoenhancing benefits resulting from the humor you've been exposed to.

The limited research along these lines suggests that a strengthened immune system is sustained for 30 minutes for IgA, IgG, number of B cells, activation and number of T cells, activation and number of natural killer cells, and gamma-interferon.  The immunoenhancement effect was still present 12 hours later for IgA, IgG, number of B cells, complement 3 and gamma-interferon.²⁴ No attempt has been made to study durations beyond 12 hours.

Sense of Humor and Immunity

Given all the evidence that watching a humorous video strengthens different components of the immune system, it makes sense that individuals who have a better developed sense of humor--meaning that they find more humor in their everyday life, seek out humor more often, laugh more, etc.--should have a stronger immune system, because they get more of the kinds of benefits offered by watching a comedy video by exercising their sense of humor more often. Consistent with this expectation, three studies have shown that individuals with higher scores on a sense of humor test have higher "baseline levels" of IgA.²⁵

If people with a better sense of humor have a stronger immune system than their humor-impaired friends, you might expect that those with a less developed sense of humor would show more immunoenhancement from watching a comedy video. The available research, however, suggests that the opposite is true.  Individuals with higher sense of humor scores show the greatest increase in IgA after watching a funny video.²⁶ This suggests that those with a better sense of humor may have appreciated the videos more, or laughed more.

"The simple truth is that happy people generally don't get sick."

           (Bernie Siegel, M.D.)         

Humor's ability to protect you against immunosuppression during stress was evident in a study, which compared people with a well-developed sense of humor (they found a lot of humor in their everyday life or frequently used humor to cope with stress) to people with a poor sense of humor. Among those who rarely found humor in their own lives, especially when under stress, greater numbers of everyday hassles and negative life events were associated with greater suppression of their immune system (IgA).  Among those with a well-developed sense of humor, on the other hand, everyday hassles and problems did not weaken the immune system.²⁷ Their sense of humor helped keep them from becoming more vulnerable to illness when under stress.

The Role of Mood

Your immune system is very sensitive to your mood, being stronger on your "up" days, and weaker on "down" days.  This has been shown for both IgA and natural killer cell activity.²⁸ It appears to be the negative emotion or mood that accompanies stress that is responsible for the reduced level of antibody response when the immune system is asked to fight a virus or other antigen.  This has been shown with reduced levels of natural killer cell activity,²⁹ lymphocyte proliferation,³⁰ serum antibody response to Hepatitis B vaccine,³¹ and salivary IgA response to a novel antigen,³² to name a few. 

Part of the health-promoting power of your sense of humor lies in the fact that it helps keep the negative events that occur in your life from disturbing your mood.³³ It helps you keep an upbeat, optimistic outlook, even in the face of stress.  Bernie Siegel has long emphasized the importance of a positive, optimistic mood in fighting cancer and sustaining wellness,³⁴ and your sense of humor is one of the best ways you have to maintain this mood on high-stress days.

Which is More Important, Laughter or the Experience of Humor?

A key question with the immune system research concerns the relative importance of laughter versus the mental/emotional experience of humor.  Only two studies have addressed this issue.  In one, half the participants were encouraged to laugh at the comedy video, while the other half were asked to suppress laughter while watching.  Comparable levels of increased salivary IgA were found for the two groups.³⁵ Since laughter did not boost the amount of IgA increase, this suggests that the experience of humor may be more important than how much you laugh. However, another study showed that how funny you find the video is not related to the amount of IgA increase shown.³⁶ The precise way in which one's own sense of humor provides immunoenhancement benefits is clearly complicated, and is not yet well understood.

Pain Reduction

I lived in Paris for three years in the 1980s. I spent a lot of time in a little neighborhood cafe, and almost every time I stopped by for an espresso, there was an old man at his corner table laughing with friends.  He rarely went more than 10 minutes without laughing.  I was amazed at this and asked him how he managed to stay in such a wonderful mood all the time.  To my surprise, he said his laughter didn't always mean he was in a good mood. He laughed for two reasons. One was in order to get into a good mood.  He lived alone and didn't like it.  He knew that laughter would lift his spirits, so he forced himself to laugh until he really was feeling good.

The other reason was that he had arthritis and had a lot of aches and pains. One day he and his friends were doubling up with laughter about pranks they had played when they were kids.  He noticed that his arthritis pain had disappeared during the laughter and didn't show up again until an hour later.  From that day on, he was a laugher.  It was his way of managing pain.  He took control of his pain in a way that also improved the quality of his life.  Recent research has supported his approach to pain management. When elderly residents of a long-term care facility watched funny movies, the level of pain they experienced was reduced.³⁷

A man went to his doctor complaining of painful headaches. After concluding his tests, the doctor said, "There's only one solution, but it's extreme: castration."  The patient said he could never resort to that, and he walked out.

 As the weeks went on, his headaches got so painful that he couldn't take it any longer.  Finally, he went back to the doctor and agreed to the castration.  The operation was a big success, and the patient couldn't believe that his headaches were finally gone. He felt like a new man. He was so excited about his new life that he went to a tailor and bought a whole new set of clothes--suits, shirts, socks, even underwear.

In jotting down all the appropriate information, the tailor finally asked, "What size underwear do you wear?"

 "Forty," replied the man.

 "Oh no," said the tailor. "You're a 44.  If you wear underwear that tight, you'll get terrible headaches!"

Norman Cousins drew the attention of the medical community to this phenomenon in his book Anatomy of an Illness, as noted above.  His spinal disease left him in almost constant pain.  But he quickly discovered while watching comedy films that belly laughter eased his pain.  In his last book, Head First: The Biology of Hope, he noted that 10 minutes of belly laughter (just counting the laughing time) would give him two hours of pain-free sleep.

Dr. James Walsh, an American physician, noted in his 1928 book Laughter and Health, that laughter often reduced the level of pain experienced following surgery and appeared to promote wound healing, but medical researchers seem to have been unaware of Walsh's observation.  It was only after the publication of Cousins' book that researchers began to study laughter's ability to reduce pain.

Several studies have showed that watching or listening to humorous tapes increases the length of time individuals can endure having their hand in ice water before experiencing discomfort.³⁸ Amazingly, people who found the comedy material funnier were able to leave their hand in longer than those who found it less funny. Individuals who created humor more often themselves also showed reduced sensitivity to pain from the ice water, in comparison to those who created little humor.³⁹ The level of pain experienced during hydrotherapy (a very painful experience) by two young girls with burns was also found to be reduced by watching cartoons during hydrotherapy.⁴⁰

Having a good sense of humor may yield the same pain-reducing benefits provided by watching a comedy video. Using a procedure called transcutaneous end nerve stimulation to induce pain, individuals who watched a humorous video reported less pain than those who watched a nonhumorous video.⁴¹ But, those who watched the non-humorous video who scored high on a measure of sense of humor showed just as much resistance to discomfort and pain as did people who watched the funny video.  So a good sense of humor does seem to help in managing pain.

"Humor is the instinct for taking pain playfully."

(Max Eastman)                       

A Japanese study showed that listening to an hour of traditional comic stories (Rakugo) reduced the level of pain experienced by rheumatoid arthritis patients.⁴² This is an especially important finding, since the symptoms experienced by these patients (as well as patients with multiple sclerosis and numerous other medical conditions) generally worsen in the presence of negative emotional states. Finding something to laugh at when you're in pain can help reduce the pain at the same time that it substitutes a more positive for a negative mood and lifts your spirits.  This may explain why rheumatoid arthritis patients who report more chronic pain also say they look for humor more often in everyday life.⁴³ They've learned that humor helps manage their pain.

Finally, a Swedish physician reported that six women suffering from painful muscle disorders got significant relief from pain through a 13-week course in humor therapy.⁴⁴ Throughout this period, they read funny books, listened to or watched funny tapes, and worked at "giving higher priority to humor in their everyday lives." They also attended lectures on humor research. Those patients who laughed the most in group sessions showed the greatest symptom reduction.

There is also widespread anecdotal evidence that laughter can help manage pain.  Norman Cousins once described in a speech how he, Dr. Carl Simonton, and Jose Jimenez (a comedian from the old Steve Allen Show) went to talk to a group of patients at a VA Hospital.  Jimenez had them falling off their chairs laughing. The doctors later told Cousins that 85% of the patients had been experiencing pain when they entered the room.  But the laughter reduced or eliminated the pain for most of them.

In a study of 35 patients in a rehabilitation hospital, 74% agreed with the statement, "Sometimes laughing works as well as a pain pill."⁴⁵ The patients had such conditions as traumatic brain injury, spinal cord injury, arthritis, limb amputations, and a range of other neurological or musculoskeletal disorders. Given the power of humor and laughter to reduce pain, it is not surprising that humor has been applied as a "treatment" in managing pain associated with burns and dental work,⁴⁶ and as a component of general nursing care.⁴⁷

Nurses often tell me they know a patient who tried Cousins' approach and found that it also reduced their pain. But not all who try it experience pain reduction. The reason for this inconsistency remains unclear.

"A clown is like an aspirin, only he works twice as fast."

         (Groucho Marx)

For those who do experience pain reduction following laughter, why does it occur? One possibility is distraction.  Humor draws attention away from the source of discomfort--at least momentarily.  The most commonly given explanation, however, is that laughter causes the production of endorphins, one of the body's natural painkillers. This explanation makes good sense, but as of 1998, no one has been able to demonstrate it with data.  Investigators who have tried to show the endorphin-humor connection have failed to do so.⁴⁸

Regardless of whether laughter does or does not cause the release of endorphins into the blood stream, its ability to reduce pain is undoubtedly partly due to its reduction of muscle tension. Even brief relaxation procedures have been shown to reduce pain--both in laboratory and clinical settings.⁴⁹ Many pain centers around the country now use meditation and other relaxation techniques to reduce the level of pain medication needed by patients.  Laughter is just one additional technique for achieving the same effect.

This muscle relaxation effect has its practical side in hospitals. Some nurses tell patients jokes before giving them shots, because they know it keeps them from tightening up their muscles in anticipation of the shot.

To give you an idea of Cousins' sense of humor, one morning a nurse brought in a specimen bottle (to obtain a urine sample), and left it on his breakfast tray.  There was also a bottle of apple juice on the tray, so Cousins poured some of it into the specimen bottle and finished his breakfast.  When the nurse returned, she held the bottle up to the light and said, "Hmmm, it looks a little cloudy today."  Cousins picked it up and said, "Well then, let's run it through again."  And he drank it!  Since this story is widely shared, other patients have been known to try the same trick.  If you try it, be sure to keep track of which bottle is yours!

On another occasion, Cousins was about to take a bath in a tub filled with an oily substance designed to ease some of his joint problems.  He described it as "a cross between stale oatmeal and used crankcase oil." When the nurse left for a moment, leaving the bottle containing the oily stuff near the tub, Cousins poured most of it down the drain.  When the nurse returned, he held up the bottle and said, "I'm terribly sorry, but I can't get the rest of this down."

Cardiac Exercise

Have you managed to avoid getting caught up in the jogging, aerobics, and jazzercise crazes of recent years? If you hate to work out, laughter may be the exercise program you've been looking for.  It's fun, requires no special training, shoes, or clothes. You don't even have to leave your couch or office to do it.  And it takes no extra time from whatever you're already doing.

The next time you're having a good belly laugh, put your hand over your heart when you stop laughing.  You'll see that your heart is racing, even after 15-20 seconds of laughter. It will remain elevated for 3-5 minutes. This has caused some to refer to laughter as "internal jogging." You can give your heart a good workout several times a day, just by laughing. One physician noted that his patients who say they laugh regularly have lower resting heart rates.  While this is no substitute for real exercise, many seniors and bed-ridden patients don't have the option of other forms of physical exercise. For them, laughter is FUNdamental to good cardiac conditioning.

Other Benefits

Blood Pressure

Other physical health benefits may result from humor and laughter, but scientists have been very slow in looking for them.  Laughter may turn out, for example, to help lower blood pressure. As your heart beats more rapidly during laughter, it pumps more blood through your system, producing the familiar flushed cheeks. Not surprisingly, blood pressure increases during laughter, with larger increases corresponding to more intense and longer-lasting laughs. If this were a lasting increase, it might point to a harmful effect of laughter.  When laughter stops, however, blood pressure appears to drop below the level shown before the laughter started.⁵⁰ This drop below the pre-laughter baseline is short-lived, so it's not clear whether regular laughter helps keep blood pressure within manageable limits.

There is some evidence that the relationship between blood pressure and humor may be different for men and women.⁵¹ Women who score higher on measures of sense of humor have been shown to have lower blood pressure than low sense of humor women, suggesting that a good sense of humor does help protect them against hypertension.  A better sense of humor in this study, however, did not reduce the amount of blood pressure elevation among women during stressful situations. Men with higher humor scores did not show the generally lower blood pressure levels showed by women, but a better sense of humor did reduce the extent of their blood pressure increase under stress.  More research will be required to sort these differences out, but these findings indicate that humor does offer some protection against the harmful effects of elevated blood pressure for both sexes.

In connection with job-related stress, individuals in higher-level occupations may want to make a special effort to improve their humor skills, since recent research has shown that the amount of stress-related elevation in blood pressure appears to be greater among those with higher-level jobs.⁵² Among African Americans, hypertension was greater among higher-level occupations in general--regardless of the stress of the moment.⁵³

Respiration

Laughter triggers a peculiar respiratory pattern, which offers health benefits for certain individuals. In normal relaxed breathing, there is a balance between the amount of air you take in and breathe out. The problem is that when you are not breathing deeply, a considerable amount of residual air remains in the lungs. When you're under stress, breathing becomes even shallower and more rapid, reducing the amount of oxygen taken in and producing a still greater amount of residual air.  This breathing also occurs more from the chest, instead of the diaphragm. (Relaxation techniques emphasize the importance of breathing from the diaphragm.) As this residual air stays in the lungs for longer periods of time, its oxygen content drops and the level of water vapor and carbon dioxide increases.⁵⁴ The health risk here arises for individuals prone to respiratory difficulties, since the increased water vapor creates a more favorable environment for bacterial growth and pulmonary infection.

Frequent belly laughter reduces this risk by emptying your lungs of more of the air that's taken in. When you laugh, you push air out of your lungs until you can't push out any more. Then you take a deep breath and start the same process all over again. Each time you laugh, you get rid of the excess carbon dioxide and water vapor that's building up and replace it with oxygen-rich air.

Hospitalized patients with respiratory problems are often encouraged to breathe deeply and exhale fully, but nurses have difficulty getting them to do so.  Most patients enjoy a good laugh, though, so many nurses have learned to tell them a joke from time to time or give them a comedy tape to view.

Emphysema and other respiratory patients often have a build-up of phlegm or mucous in their respiratory tracts.  Nurses try to get them to cough to loosen up and expel these substances, but they generally don't enjoy coughing, so the phlegm builds up.  When they laugh, however, they inevitably start coughing, producing exactly the effect the nurses want--and the patients have a good time in the process.

Sedimentation Rate

One of the most interesting observations made by Norman Cousins' doctor following Cousins' use of humor and other positive emotions to fight his disease was that laughter reduced his sedimentation rate--an index of the degree of infection or inflammation in the body. Since Cousins' illness involved severe inflammation of the spine, his sedimentation rate was very high.  His physician, Dr. William Hitzig, measured his sedimentation rate before and after rounds of hearty belly laughter while watching comedy films. He found that "just a few moments of robust laughter . . . knocked a significant number of units off the sedimentation rate. What to him was most interesting of all was that the reduction held and was cumulative."⁵⁵ Cousins noted that this reduced sedimentation rate was followed by increased mobility and reduced pain.  Unfortunately, this is a single case, so there is no way of determining whether laughter really did cause the reduced inflammation.  But Dr. Hitzig's observation is of such clear importance to medical research that it's surprising that investigators have not attempted to study it further.

Perceived Health

Another way to determine the relationship between humor and health is to simply ask people about their health.  This generally is referred to as "perceived health."  Both college students and older adults (55+) who report using humor more often as a coping style perceive themselves to be in better physical health.⁵⁶ A study of 36 executive women showed that those with higher scores on a measure of sense of humor reported fewer symptoms associated with physical health problems.⁵⁷ In the study of patients in a rehabilitation hospital described earlier, 94% of the patients indicated that when they laughed, they felt better.⁵⁸