A Laughing Matter

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 While not a substitute for traditional curative measures, laughter does offer many positive health benefits including stress reduction and elevates hope. Maybe it’s time to stop being so serious?

The origin of the phrase “laughter is the best medicine” is unknown. Some date it as far back as the time of Solomon (approx 950 BCE), citing his proverb “a merry heart is like medicine.” I have often wondered if there is a kernel of truth to the idea that laughter improves one’s health, and, if so, how big that kernel is. In our current age when costly medicines are peddled to consumers amidst dubious politics and ethics, despite soaring numbers needed to treat, and rampant side effects, could laughter actually be as effective as a medicine? Or is looking to humor for healing as outdated as looking to the humors for disease?

It turns out that there is a field of laughter medicine research. People have used the scientific method to try to answer the question of whether and how laughter affects human health and the human experience of disease. The studies tend to be small and heterogeneous in design and implementation. In addition, studies variously focus on humor-induced laughter, humor itself, or laughter in the absence of humor. However, the available results may give you cause to smile.

Mechanism of Action

A 2010 multi-disciplinary literature review identified many physiologic benefits of laughter.(1)  It “exercises and relaxes muscles, improves respiration, stimulates circulation, decreases stress hormones, increases immune system defenses, elevates pain threshold and tolerance, enhances mental functioning.”

The psychological benefits of laughter have been better established than the physiologic. Laughter1 “reduces stress, anxiety, and tension and counteracts symptoms of depression; elevates mood, self-esteem, hope, energy, and vigor; enhances memory, creative thinking, and problem solving; improves interpersonal interaction, relationship, attraction, and closeness; increases friendliness and helpfulness and builds group identity, solidarity, and cohesiveness; promotes psychological well-being; improves quality of life and patient care; and intensifies mirth and is contagious.”

The mechanisms are, as would be expected, multi-factorial and not well understood, but are hypothesized to involve respiratory, cardiovascular, neuroendocrine, immunomodulatory, and interpersonal effects.

Administration and Benefits:

There is no established way to prescribe or administer laughter. Some laughter researchers recommend at least 15-20 minutes a day.(2)  Interestingly, both stimulated laughter, which is defined as involuntary laughter in response to a stimulus, as well as simulated laughter, which is self-induced and is not a response to something humorous, may have similar benefits. This finding provides some support for the growth of laughter clubs, laughter yoga, and laughter gymnastics, all of which provide and promote organized group laughter opportunities.(1) They may involve some stretching and movement along with laughter.

Interventional and randomized controlled trials of simulated, self-induced laughter have shown that brief, regular episodes of simulated laughter improved depression symptoms, perceived stress levels, insomnia, anxiety levels, pain levels, and mobility. One study focused on patients with chronic pain, primarily those with fibromyalgia, and found significant improvements in the above symptoms within that group as well.

A quasi-experimental study of nursing home residents in Turkey found that residents who were engaged in twice-weekly laughter therapy scored significantly higher in quality of life metrics. (3)

Very preliminary studies of laughter therapy and humor in dialysis patients have been found to help reduce pain. Bennet et al suggest that the discomfort associated with dialysis and chronic kidney disease can be reduced by such things as “raucous simulated laughter,” laughter clowns, humorous videos, and laughter yoga.(4)

In addition to its benefits for patients, laughter therapy could be beneficial for medical professionals as well. While it certainly cannot solve all the underlying problems that lead to physician and nurse burnout, it could potentially relieve the experience and symptoms of burnout. A study of nursing students concluded that after participating in laughter yoga, students had less anxiety and depression, experienced generally improved health, and had less difficulty sleeping.(5)

Simulated laughter can be practiced in a group setting, along with other movements, interactions, or exercise.(6) The benefits of group laughter may in part be due to the social interaction that it fosters in addition to the laughter itself. If you watch some of the laughter therapy videos,(7) it is hard not to laugh along with them. Simulated laughter can also be practiced individually, though it may be best to practice when you are alone, not in the middle of a crowded elevator.

Laughter and Pain

Several studies have shown that laughter reduces the experience of pain. There is a fascinating first-hand account in the NEJM from 1976 of a man who intentionally used laughter, as well as high dose vitamin C and several other things, to cure what he had been told was a virtually incurable disease. While he admitted that he may have been “the beneficiary of a mammoth venture in self-administered placebos,” he wrote that “10 minutes of genuine belly laughter had an anesthetic effect and would give me at least two hours of pain-free sleep.”(8)

Perhaps future studies in the ED could determine the best mechanism to induce or facilitate laughter in patients in order to reduce their pain. This could be a useful adjunct given the rising concern surrounding opioid abuse and tolerance. I would, however, caution against the establishment of laughter metrics. There are plenty of cases in which levity would be inappropriate. Furthermore, given the heterogeneity of ED populations, their varying degrees of injury or illness, and the differences in baseline humorousness of emergency physicians, it cannot be expected that every physician can provide comparable hilarity. It is also doubtful that door-to-laughter metrics would do much to elevate the mood and humor of any ED physician.

Side Effects and Adverse Reactions

The risks of laughter are minimal. There are case reports of laughter-induced syncope, but it is uncommon. Patients who have had recent surgery or who have elevated intra-ocular pressure may want to limit themselves to a moderate chuckle, and not indulge in such vigorous laughter that it induces a valsalva pressure. Similarly, patients with stress incontinence may wish to empty their bladders before a hearty chortle. There are no contra-indications or dose variations based on age, gender, or pregnancy status. There may be situational contra-indications. For example, in the middle of a lecture, a spontaneous laugh may be perceived as betraying an underlying psychiatric pathology or psychosis. In addition, caution should be used in public places, as researchers note that laughter is, in fact, contagious.

Humor and laughter have a complex interplay. While laughter without humor can still have potential physiological benefits, there may be potential risk to humor without laughter. William Strean, in his article Laughter Prescription wrote “humor without laughter might not produce those benefits [of laughter]and potentially could have adverse effects on the therapeutic relationship.”(2)  One important implication: we should actually laugh out loud when something is humorous, rather than typing LOL while keeping a straight, unamused face.

It should also be noted that laughter is not suggested as a replacement for traditional, allopathic medical therapies, but as a potential adjunct to provide support, and as a complementary and alternative medicine therapy.

Cost

While both stimulated and simulated individual laughter are free, organized laughter clubs typically charge fees similar to group fitness classes, which may typically range from $5-15 per class.

Summary

“Laughter can relieve suffering but it cannot cure disease.” (4,9) Suffering is the negative personal experience that results from a disease process. It has complex physical, emotional, psychological, and social dimensions. While laughter can no more cure cancer than essential oils, perhaps it can improve individuals’ coping abilities and reduce their experience of suffering.

So I leave you with this low-risk, potentially beneficial script:

Rx: Raucous laughter, 15-20 minutes daily. Can use additional doses as needed for pain, depression, anxiety, burnout and insomnia. Refills: unlimited.

References

  1. Mora-Ripoll R. The therapeutic value of laughter in medicine. Altern Ther Health Med. 16(6):56-64. http://www.ncbi.nlm.nih.gov/pubmed/21280463. Accessed February 12, 2018.
  2. Strean WB. Laughter prescription. Can Fam Physician. 2009;55(10):965-967. http://www.ncbi.nlm.nih.gov/pubmed/19826144. Accessed February 12, 2018.
  3. Kuru N, Kublay G. The effect of laughter therapy on the quality of life of nursing home residents. J Clin Nurs. 2017;26(21-22):3354-3362. doi:10.1111/jocn.13687
  4. Bennett PN, Parsons T, Ben-Moshe R, et al. Laughter and humor therapy in dialysis. Semin Dial. 2014;27(5):488-493. doi:10.1111/sdi.12194
  5. Yazdani M, Esmaeilzadeh M, Pahlavanzadeh S, Khaledi F. The effect of laughter Yoga on general health among nursing students. Iran J Nurs Midwifery Res. 2014;19(1):36-40. http://www.ncbi.nlm.nih.gov/pubmed/24554958. Accessed March 10, 2018.
  6. Mora-Ripoll R. Potential health benefits of simulated laughter: A narrative review of the literature and recommendations for future research. Complement Ther Med. 2011;19(3):170-177. doi:10.1016/j.ctim.2011.05.003
  7. Laughter Yoga University – For Health, Happiness, and World Peace. https://laughteryoga.org/. Accessed March 10, 2018.
  8. Cousins N. Anatomy of an Illness (as Perceived by the Patient). N Engl J Med. 1976;295(26):1458-1463. doi:10.1056/NEJM197612232952605
  9. Moffat R. Is laughter a form of therapy? Med Leg J. 2013;81(Pt 1):49. doi:10.1177/0025817213476396

ABOUT THE AUTHORS

Dr. Shenvi is an assistant professor in the department of emergency medicine at the University of North Carolina. She authors RX Pad each month in EPM.

Karen Serrano, MD is an assistant professor in the department of emergency medicine at the University of North Carolina.

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