Research Paper- MLA Format (24 hours)

 

1) Minimum 3 full pages 

               

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All paragraphs must be narrative and cited in the text- each paragraphs

            Bulleted responses are not accepted

            No write in the first person.

            

3) It will be verified by Turnitin and SafeAssign

4) 8 References (See attach)

_________________________________________________________________

1) Make a research paper following the outline (Outline-File 1) information not included in the outline is not accepted

2) Only use the attached articles as a source of information. There are a total of 8 articles.

Humor and Laughter may Influence Health. I. History and Background

Advance Access Publication 16 January 2006 eCAM 2006;3(1)61–63

doi:10.1093/ecam/nek015

Review

Humor and Laughter may Influence Health. I. History and
Background

Mary Payne Bennett1 and Cecile A. Lengacher2

1Indiana State University College of Nursing, IN, USA and 2University of South Florida College of Nursing, FL, USA

Articles in both the lay and professional literature have extolled the virtues of humor, many giving the

impression that the health benefits of humor are well documented by the scientific and medical commun-

ity. The concept that humor or laughter can be therapeutic goes back to biblical times and this belief has

received varying levels of support from the scientific community at different points in its history.

Current research indicates that using humor is well accepted by the public and is frequently used as a

coping mechanism. However, the scientific evidence of the benefits of using humor on various health

related outcomes still leaves many questions unanswered.

Keywords: Humor – Health

Can Humor and Laughter Influence
Health Outcomes?

History

Using humor to decrease stress, diminish pain, improve quality

of life and even attempt to improve immune functioning has

recently become a popular topic in the lay and professional

literature (1–4). Laughter in response to a humorous stimulus

is a natural occurrence and does not require large amounts of

time or money in order to implement. While therapies such

as relaxation and exercise require significant time and commit-

ment, and therapies such as herbs or massage can be expen-

sive, use of humor can be easily implemented and cost

effective. However, clinical benefits must still be documented

before this therapy can be widely supported by the health care

community.

Diverse literature suggests that effects of humor on various

outcomes such as stress, health and immune function have

been well-documented by empirical research and are therefore

commonly accepted. The work of Cousins (5), Fry (6–11),

Berk (12–17) or the field of Psychoneuroimmunology (PNI)

is frequently cited as supporting the role of humor in healing.

However, despite media claims, relatively few professional

articles examine the scientific basis for these claims. There

are a few studies that have examined the effects of humor or

laughter on psychological outcomes, such as stress. However,

there are a very limited number of studies that document

the effects of laughter on physiological outcomes, and no

controlled studies have been identified that document the

effects of laughter on clinical health outcomes.

So what do we really know about the role of sense of humor,

use of humor by patients with various illnesses, or the effects

of laughter on various health related outcomes? Is use of

humor an approach that we should implement in our practices

and/or recommend to our patients? This is the first of the four

articles that reviews, clarifies and synthesizes the professional

literature concerning humor and health outcomes. This first

paper presents basic background on the theoretical under-

pinnings concerning how the mind can affect the body, such

as the effects of stress on immune functioning. Research in

this area provides fundamental support for the supposition

that interventions that lower stress may also help improve

physiological outcomes. The second paper reports studies

that document patient interest in and use of humor as a com-

plementary therapy, and provides evidence to support that

humor may be one of the more frequently used complement-

ary therapies. The third paper describes studies that report

For reprints and all correspondence: Mary Payne Bennett, Indiana State
University College of Nursing, IN, USA. Tel: 1-812-237-2320;
Fax: 1-812-237-8895; E-mail: mbennett2@isugw.indstate.edu

� The Author (2006). Published by Oxford University Press. All rights reserved.

The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access
version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press
are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety
but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

the relationship between sense of humor and various health

outcomes. The final paper examines either the effect of a

humorous stimulus and/or effects of laughter on health out-

comes. These latter two parameters are difficult to separate,

since patients who are exposed to a humorous stimulus usually

respond with laughter, however, not all studies separately

document laughter and exposure to a humorous stimulus.

This review is based on a search of Pub-Med and

PsychINFO, using the search terms humor and laughter,

plus bibliographic review for older articles that may not be

documented in the databases. A search using those terms pro-

duced 324 hits, from which 55 relevant articles were obtained.

Only original empirical research reporting the psychological or

physiological effects of humor or laughter are reported here,

with the main focus on research documenting health related

outcomes. Owing to small sample sizes in most studies and

the limited number of available reviews, sample size was not

used as a determinant to exclude certain analyses from our

review. A meta-analysis was not possible owing to the use

of multiple measures of sense of humor and various outcomes

utilized in the studies reviewed.

Definitions

A full discourse on humor theory is beyond the scope of this

review, but certain basic definitions are essential. From a psy-

chological perspective, humor involves cognitive, emotional,

behavioral, psycho-physiological and social aspects (18). The

term humor can refer to a stimulus, which is intended to pro-

duce a humorous response (such as a humorous video), a men-

tal process (perception of amusing incongruities) or a response

(laughter, exhilaration). Laughter is the most common expres-

sion of humorous experience. Humor and laughter are also

typically associated with a pleasant emotional state (18). For

the purpose of these reviews, humor is defined as a stimulus

that helps people laugh and feel happy. Laughter is a psycho-

physiological response to humor that involves both character-

istic physiological reactions and positive psychological shifts.

Sense of humor is a psychological trait that varies considerably

and allows persons to respond to different types of humorous

stimuli. It is necessary to differentiate between these variables,

as some analyses of humor use a humor stimulus (such as a

video) to determine the effect of ‘humor’ on an outcome, while

others look specifically at the effects of laughter on these out-

comes. Still others analyze various ways to measure sense of

humor, in an attempt to determine whether scoring higher on

a sense of humor instrument is related to various health related

outcomes.

Stress, Psychoneuroimmunological
Reactions and Health

Theoretical Framework and Early Experiments

What is the underlying theoretical framework that helps

explain why use of a complementary therapy, such as humor,

may affect health? It may be that these therapies work by

reducing the effects of stress. Interest in the influence of

psychological factors on susceptibility to certain disease states

goes back to the times of Galen (19), when it was noted that

persons who developed cancer often had a ‘melancholic’

personality. Since then, numerous clinicians have shared

anecdotal data concerning the development of cancer or other

diseases in persons with certain psychological styles, or after

a stressful life event, such as bereavement (20).

Selye’s work was one of the first to document the general

effects of stress on the sympathetic nervous system, endocrine

system and lymphatic organs (21). Further studies established

that activation of the stress response could also be triggered

by acute emotions, physical exertion, cold and pain (22). Later,

Lazarus and Folkman (23) broadened the definition of stress

from Selye’s concept of ‘environmental demands’ to include

psychological components such as appraisal and coping.

While Lazarus and Folkman’s theory helped to explain the

moderation of stressors using coping mechanisms, it did not

attempt to explain the possible consequences of these coping

mechanisms in terms of physiological effects on immune func-

tioning. The field of PNI brings all of these factors together in

a testable theoretical framework. PNI started from a multi-

factorial model of illness, which included stress, coping and

disease formation (24). This theory was further developed

by Solomon (1987) to include the impact of stress on the

immune system in disease formation (25). Later, the term

‘psychoneuroimmunology’ was coined by Ader and Cohen

(26) to describe the basic phenomena of this theory: interac-

tions between the nervous system and the immune system,

and the subsequent effects of these interactions upon disease

development/progression.

PNI and Stress

PNI researchers have repeatedly documented that increased

stress levels can lead to changes in psychological and physio-

logical functioning. In addition to changes in the usual stress

hormones such as ACTH, cortisol, epinephrine and norepi-

nephrine, many other messengers are influenced by exposure

to stressors. Production and release of prolactin, growth hor-

mone, insulin, glucagon, thyroid hormone and gonadotrophin

can be affected by physical and emotional stress (27). Levels

of neurotransmitters, neurohormones, cytokines and various

cells in the immune system can also be affected by stress (28).

A Neurological Approach to Laughter

Ideally, we would be able to draw a flow chart that outlines all

of the neurological processes involved in the effects of laugh-

ter on stress and immune functioning. But unfortunately, the

state of the science is not to that level at this time. We really

know very little about how the brain functions in response to

a humorous stimulus. According to Curtis (27), speech and

laughter are both uniquely human. But while there is consider-

able information on the neuronal representation of speech,

little is known about brain mechanisms of laughter. We do

have some evidence that the supplementary motor area of the

62 Humor and laughter may influence health

brain is involved in this response. Curtis reports that ‘electrical

stimulation in the anterior part of the human supplementary

motor area (SMA) can elicit laughter’ (29). Moreover, it has

been proposed by Tanji (30) and Picard and Stick (31) that

the anterior part of the SMA is part of a further development

in humans to accommodate the specialized functions of

speech, manual dexterity and laughter. This area might corre-

spond to the pre-supplementary motor area, a region situated

anterior to the SMA proper, recently described in non-human

primates, and thought to be involved in high-level motor pro-

gramming (30,31). Finally, Fried and Wilson (32) have exam-

ined putative regions in the brain using electric current that

stimulates laughter. The data suggest that this is at least one

anatomical location for the neurological response to humorous

stimuli. However, more research is needed to determine how

these neurological changes subsequently affect the physiolo-

gical response to stressors, and possibly improve immune

functioning.

References
1. Balick M, Lee R, The role of laughter in traditional medicine and its

relevance to the clinical setting: Healing with ha! Altern Ther Health
Med 2003;9:88–91.

2. Bennett H, Humor in medicine. South Med J 2003;96:1257–61.
3. MacDonald C, A chuckle a day keeps the doctor away: therapeutic humor

and laughter. J Psychosoc Nurs Ment Health Serv 2004;42:18–25.
4. Weiss R, Initiative proves laughter is the best medicine. Health Prog

2002;83:54.
5. Cousins N, Anatomy of an Illness as Perceived By the Patient. Toronto:

Bantam, 1979.
6. Fry W, Mirth and oxygen saturation levels of peripheral blood. Psychother

and Psychosom 1971;19:76–84.
7. Fry W, The respiratory components of mirthful laughter. J Biol Psychol

1977;19:39–50.
8. Fry W, Humor, physiology, and the aging process. In Nahemov L,

McCluskey-Fawcett K, McGhee P, (eds), Humor and Aging, Orlando,
Florida: Academic Press, 1986, pp. 81–98.

9. Fry W, Savin W, Mirthful laughter and blood pressure. Humor: Int J
Humor Res 1988;1:49–62.

10. Fry W, The physiological effects of humor, mirth, and laughter. J Am
Med Assoc 1992;267:1857–8.

11. Fry W, The biology of humor. Humor: Int J Humor Res 1994;7:111–26.
12. Berk L, Tan S, Nehlsen-Cannarella S, Napier B, Lewis J, Lee J, et al,

Humor associated laughter decreases cortisol and increases spontaneous
lymphocyte blastogenesis. Clin Res 1988;36:435A.

13. Berk L, Tan S, Napier B, Evy W, Eustress of mirthful laughter modifies
natural killer cell activity. Clin Res 1989;37:115A.

14. Berk L, Tan S, Fry W, Napier B, Lee J, Hubbard R, et al, Neuroendocrine
and stress hormone changes during mirthful laughter. Am J Med Sci
1989;298:391–6.

15. Berk L, Tan S, Fry W, Eustress of Humor associated laughter modulates
specific immune system components. Annals of Behavioral Medicine
Supplement, Proceedings of the Society of Behavioral Medicine’s 16th
Annual Scientific Sessions 1993;15:S111.

16. Berk L, Tan S, Eustress of mirthful laughter modulates the immune system
lmyphokine interferon-gama. Annals of Behavioral Medicine Supple-
ment, Proceedings of the Society of Behavioral Medicine’s 16th Annual
Scientific Sessions 1995;17:C064.

17. Berk L, Felten D, Tan S, Bittman, Westengard J, Modulation of neuro-
immune parameters during the eustress of humor-associated mirthful
laughter. Altern Ther Health Med 2001;7:62–72, 74–6.

18. Martin R, Humor, laughter, and physical health: methodological issues
and research findings. Psychol Bull 2001;127:504–19.

19. Chiappelli F, Prolo P, Cajulis OS, Evidence-based research in com-
plementary and alternative medicine I: History. Evid Based Complement
Alternat Med 2005;2:453–8.

20. Locke S, Kraus L, Modulation of natural killer cell activity by life stress
and coping ability. In Levy S (ed), Biological Mediators of Behavior
and Disease: Neoplasia. New York: Elsevier, 1982, pp. 3–28.

21. Seyle H., The general adaptation syndrome and the diseases of adaptation.
J Clin Endocrinol Metab 1946;6:117–230.

22. Cannon W, Bodily Changes in Pain, Hunger, Fear and Rage. Boston:
Charles T. Branford, 1946.

23. Lazarus R, Folkman S, Stress, Appraisal, and Coping. New York:
Springer, 1984.

24. Engel G, Psychological Development in Health and Disease. Philadelphia:
Saunders, 1962.

25. Soloman G, Psychoneuroimmunoloic approaches to research on AIDS.
Ann N Y Acad Sci 1987;494:928–36.

26. Ader R, Cohen N, Conditioned immunopharmacologic responses. In
Ader R (ed), Psychoneuroimmunology. New York: Academic Press,
pp. 6–38.

27. Curtis G, Psychoendocrine stress response: Steroid and peptide hormones.
In Stoll BA (ed), Mind and Cancer Prognosis. Chichester: John Wiley &
Sons, 1979, pp. 61–72.

28. Anderson G, Kiecolt-Glaser J, Glaser R, A biobehavioral model of cancer
stress and disease course. Am Psychol 1994;49:389–404.

29. Fox PT, Ingham RJ, Ingham JC, Hirsch TB, Downs H, Martin C, et al,
A PET study of the neural systems of stuttering 158. Nature 1996;382:
158–61.

30. Tanji J, New concepts of the supplementary motor area. Curr Opin
Neurobiol 1996;6:782–7.

31. Picard N, Strick PL, Motor areas of the medial wall: a review of their
location and functional activation. Cereb Cortex 1996;6:342–53.

32. Fried I, Wilson CL, Electric current stimulates laughter. Nature 1998;
391:650.

Received March 30, 2005; accepted December 29, 2005

eCAM 2006;3(1) 63

Laughter prescription

Vol 55: october • octobre 2009 Canadian Family Physician • Le Médecin de famille canadien 965

Commentary
Laughter prescription
William B. Strean PhD

Laughter is the tonic, the relief, the surcease for pain.
Charlie Chaplin

I
t has been more than 30 years since Norman Cousins
published an article in the New England Journal of
Medicine1 extolling the potential medicinal benefi ts

of laughter and humour. Yet the study of laughter still
occupies a rather modest place in scientific inquiry.2

It was not until 1995 that laughter as an exercise, or
laughter yoga, emerged systematically through laugh-
ter clubs. The popularity of such laughter programs has
grown markedly during the past decade. With increasing
recognition, one might expect that there would be grow-
ing application of laughter and humour for their comple-
mentary and alternative medical benefi ts. (It should be
noted that laughter is an adjunct to and not a replace-
ment for accepted therapies.) They are easy to prescribe
and there are no substantial concerns with respect to
dose, side effects, or allergies. It seems, however, that
the medical community has been reluctant to embrace
and support laughter for health.

History and importance of the
role of humour in medicine
Humour researchers3-8 have reported shortcomings of
studies on the physiologic effects of laughter. For example,
“Taken together, the empirical studies reviewed … provide
little evidence for unique positive effects of humor and
laughter on health-related variables.”4 Other commenta-
tors have cautioned practitioners about advocating the
benefi ts of laughter, fashioning themselves as self-styled
laughter police. “For practitioners to implement credible
programs and effectively teach self-management tech-
niques, further empirical research on the physical, psycho-
social, debonafi de [sic], and placebo effects of humor and
laughter needs to be conducted.”9 Furthermore, Bennett10

argued that although humour and laughter have been the
focus of attention in the popular media and medical lit-
erature, and despite statements about the health benefi ts
of humour, current research was insuffi cient to validate
such claims. He identifi ed support for the role of humour
and laughter in other areas, including patient-physician
communication, psychological aspects of patient care,
medical education, and reducing stress among med-
ical professionals. It is also important to note that while
humour and laughter are often connected, there are
some important distinctions. For example, laughter yoga

produces laughter and the concomitant physiologic bene-
fi ts without the use of humour; humour without laughter
might not produce those benefi ts and potentially could
have adverse effects on the therapeutic relationship.

When considering new pharmacologic interventions
or invasive procedures, it is quite appropriate to place the
onus of proof of effi cacy on the creator of the protocol.
This mind-set is driven by appropriate concerns for false-
positive errors. Given the side effects and inherent risks
associated with pharmaceuticals, one exercises caution
to be clear that the intended effect is achieved beyond
reasonably considered chance factors. Thus recommen-
dations suggest P values be set conservatively and tech-
niques employed to avoid a “false discovery rate.”11

Similar thinking seems to have been applied to the
consideration of laughter’s potential medicinal effects.
Although proponents of laughter and humour can be
traced back to the Bible (“A merry heart doeth good
like a medicine, but a broken spirit drieth the bones”
[Proverbs 17:22]), and a variety of medical benefi ts of
laughter have been supported through research, the
scales seem to remain tipped markedly in the direction
of caution.

The most positive claim that researchers seem will-
ing to make is that “current research indicates that using
humor is well accepted by the public and is frequently
used as a coping mechanism. However, the scien-
tific evidence of the benefits of using humor on vari-
ous health related outcomes still leaves many questions
unanswered.”12

Biology of laughter and humour
There are, however, several good reasons to conclude
that laughter is effective as an intervention. Although
the evidence (detailed below) demonstrating laughter’s
benefi ts could be stronger, virtually all studies of laugh-
ter and health indicate positive results. Similarly, there
are almost no negative side effects or undesirable rami-
fications associated with laughter as an intervention.
This is a case in which the appropriate logic might be
more akin to the legal perspective of “innocent until
proven guilty.”

Yet, given the prevailing orientation toward laughter
as an intervention, an exhaustive review of the medical
literature to assess demonstrated benefi ts of laughter

GOCFPlus

The English translation of this article, is
available at www.cfp.ca. Click on CFPlus
to the right of the article or abstract.

La traduction en français de cet article se trouve
à www.cfp.ca. Allez au texte intégral (full text)
de cet article en ligne, puis cliquez sur CFPlus
dans le menu en haut, à droite de la page.This article has been peer reviewed.

Can Fam Physician 2009;55:965-7 (Eng), CFPlus (Fr)

966 Canadian Family Physician • Le Médecin de famille canadien Vol 55: october • octobre 2009

Commentary

was completed. Several databases were searched for
all occurrences of laughter, and reviews of laughter
and humour2,4,13,14 were examined. The intent was to
find studies related to benefits of laughter and laugh-
ter effects. Although the literature contains “an abun-
dance of non–evidence-based opinion”14 exploring how
laughter and humour should or should not be applied in
medical settings, there is also a substantial body of well-
researched information demonstrating many benefits
and potential benefits of laughter and humour. Future
studies might enhance the literature by considering
that laughter is highly social and examining laughter in
social settings. Furthermore, careful descriptive work
linking physiologic systems with types, kinds, and con-
texts of laughter will be valuable.2

Morse’s conclusion about laughter and humour in
the dental setting summarized the literature to date:
“Laughter and humor are not beneficial for everyone, but
since there are no negative side effects, they should be
used … to help reduce stress and pain and to improve
healing.15 Findings range from suggesting that, in addi-
tion to a stress-relief effect, laughter can bring about
feelings of being uplifted or fulfilled16 to showing that the
act of laughter can lead to immediate increases in heart
rate, respiratory rate, respiratory depth, and oxygen con-
sumption.17 These increases are then followed by a per-
iod of muscle relaxation, with a corresponding decrease
in heart rate, respiratory rate, and blood pressure.

Overall, the arguments against using laughter as
an intervention appear to be both unduly cautious and
based on the desire for more evidence. The arguments
in favour of laughter as an intervention are grounded in
the virtually universal positive results associated with
existing studies of laughter. Although scholars and prac-
titioners recognize the value of further study, more rep-
lication, and identification of specifics, the call for more
application of laughter as an intervention seems war-
ranted. Perhaps it is time to usher in a new era in which
we reverse our concerns about errors.

It might be time to start giving more credence to posi-
tive views about laughter, such as that laughter might
reduce stress and improve natural killer cell activity.
As low natural killer cell activity is linked to decreased
disease resistance and increased morbidity in those
with cancer or HIV disease, laughter might be a useful
cognitive-behavioural intervention.18

The many voices of cancer survivors and of those who
have employed laughter in their recoveries supply fur-
ther promising support. One such person, Scott Burton,
said, “The other reactions; anger, depression, suppres-
sion, denial, took a little piece of me with them. Each
made me feel just a little less human. Yet laughter made
me more open to ideas, more inviting to others, and
even a little stronger inside. It proved to me that, even
as my body was devastated and my spirit challenged, I
was still a vital human.”19 Perhaps medical prescription of

laughter and humour can illuminate what cancer patients
already know; studies have shown that 50% of cancer
patients used humour20 and 21% of a group of breast can-
cer patients used humour or laughter therapy.21

Clinical evidence
As Rosner22 reported, randomized controlled clinical
trials have not been conducted validating the thera-
peutic efficacy of laughter. Benefits, however, have
been reported in geriatrics,23 oncology,24-26 critical care,27
psychiatry,28,29 rehabilitation,30 rheumatology,1 home
care,31 palliative care,32 hospice care,33 terminal care,34
and general patient care.35 These and other reports
constitute sufficient substantiation to support what is
experientially evident—laughter and humour are thera-
peutic allies in healing.

One area where questions remain is the effect of
laughter on the so-called stress hormones: epinephrine,
norepinephrine, and cortisol. This is important because
it is theorized that if laughter does, in fact, decrease
stress hormones, this would be one mechanism that
might explain the proposed connection between laugh-
ter and immune function, and from there to improved
health outcomes.17

“The relationship between humor and health is a com-
plex one. Groucho Marx once noted that ‘A clown is like
an aspirin, only he works twice as fast.’ Patch Adams,
the founder of the Gesundheit community, where laugh-
ter therapy is a daily medical routine, would no doubt
agree. Both men, to do their work, require a commun-
ity—the former as an audience and the latter to mag-
nify the power of the healing response. After all, half of
the fun in laughter, as well as healing, is sharing it.”36
Yet, research might not be ready and able to measure
and understand the complexities of how laughter works,
particularly when laughter occurs in a group environ-
ment, such as laughter clubs. “The prevailing medical
paradigm has no capacity to incorporate the concept
that a relationship is a physiologic process, as real and
as potent as any pill or surgical procedure.”37

Clinical bottom line
As Robert Provine, the noted laughter researcher, com-
mented in the documentary Laugh Out Loud, “Until the
scientists work out all the details, get in all the laugh-
ter that you can!”38 Medical practitioners could begin to
help patients get more laughter in their lives. Following
the announcement of a study of the benefits of laughter
on endothelial function,39 Dr Michael Miller, one of the
study’s authors, said he envisioned a time when phys-
icians might recommend that everyone get 15 to 20
minutes of laughter in a day in the same way they rec-
ommend at least 30 minutes of exercise. Although phys-
icians’ advice about health-promoting behaviour might
have a limited effect in some cases,40 it can certainly be
a catalyst for change.41 Specifically, medical practitioners

Vol 55: october • octobre 2009 Canadian Family Physician • Le Médecin de famille canadien 967

Commentary

might acquaint themselves with opportunities such as
laughter clubs, which are available for their patients and
provide information and endorsements. Let us begin to
consider that, along with eating your vegetables and
getting enough sleep, laughter is a sound prescription as
a wonderful way to enhance health.
Dr Strean is an Associate Professor in the Faculty of Physical Education and
Recreation at the University of Alberta in Edmonton.

competing interests
None declared

correspondence
Dr William B. Strean, University of Alberta, Physical Education and Recreation,
P-408 VVC, Edmonton, AB T6R 1L5; telephone 780 492-3890; fax 780 492-2364;
e-mail billy.strean@ualberta.ca

the opinions expressed in commentaries are those of the authors. Publication
does not imply endorsement by the College of Family Physicians of Canada.

references
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research findings. Psychol Bull 2001;127(4):504-19.

5. Martin RA. Is laughter the best medicine? Humor, laughter, and physical
health. Curr Dir Psychol Sci 2002;11(6):216-20.

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and laughter. J Psychosoc Nurs Ment Health Serv 2004;42(3):18-25.
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Physiol Regul Integr Comp Physiol 2000;279(1):R1-8.
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risks for older adults. Educ Gerontol 2001;27(3-4):323-39.
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health care and nursing: a narrative review. J Adv Nurs 2008;61(6):584-95.
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the dental setting. J N J Dent Assoc 2007;78(4):32-6.
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17. Bennett MP, Lengacher C. Humor and laughter may influence health.
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18. Bennett MP, Zeller JM, Rosenberg L, McCann J. The effect of mirthful
laughter on stress and natural killer cell activity. Altern Ther Health Med
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19. Burton S. Why not laugh? Minneapolis, MN: Inconvenience Productions; 2003.
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Nurses’ experiences of humour in clinical settings

Original Article
http://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)

Iran University of Medical Sciences

____________________________________________________________________________________________________________________
1. MSc, RN, PhD, Assistant Professor in Nursing, Babol University of Medical Sciences, Mazandaran, Iran. ghafarifateme@yahoo.com
2. (Corresponding author) PhD, Professor, Nursing and Midwifery Care Research Centre, School of Nursing and Midwifery, Tehran Univer-
sity of Medical Sciences, Tehran, Iran. nahid.nayeri@gmail.com
3. BS, MSCN, Senior Lecturer, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran.
Mehraneshali@yahoo.com

Nurses’ experiences of humour in clinical settings

Fatemeh Ghaffari1, Nahid Dehghan-Nayeri2, Mahboubeh Shali3

Received: 22 April 2014 Accepted: 12 August 2014 Published: 17 February 2015

Abstract
Background: Providing holistic nursing care when there is a shortage of personnel and equipment

exposes nurses to stress and a higher risk of occupational burnout. Humour can promote nurses’
health and influence nursing care. The aim of this study was to describe nurses’ experiences of hu-
mour in clinical settings and factors affecting it.

Methods: This qualitative study investigated nurses’ experiences of humour. Five hospitals affiliat-
ed to Tehran University of Medical Sciences provided the setting for this study. The participants
comprised of 17 nurses with master’s and Baccalaureate degrees (BSN) in nursing. These nurses
worked at educational hospitals affiliated to Tehran University of Medical Sciences and had mini-
mum work experience of 12 months in various clinical wards. Nurses from all wards were invited to
participate in this study. The data were collected through semi structure interviews using guides
comprising probing questions. Telephonic interviews were used to further supplement the data. The
data were analysed using conventional content analysis.

Results: The data were classified into five themes including the dynamics of humour, condition
enforcement, Risk making probability, Instrumental use and Change: opportunities and threats.

Conclusion: Understanding nurses’ perceptions and experiences of humour helps identify its con-
tributing factors and provides valuable guidelines for enhancing nurses and patients’ mental, emo-
tional and physical health. Spreading a culture of humour through teaching methods can improve
workplace cheerfulness and highlights the importance of humour in patient care in nurses and nurs-
ing students.

Keywords: Humour, Nursing Care, Interaction, Communication, Qualitative Study.

Cite this article as: Ghaffari F, Dehghan-Nayeri N, Shali M. Nurses’ experiences of humour in clinical settings. Med J Islam Repub Iran
2015 (17 February). Vol. 29:182.

Introduction
Nurses are faced with various stressors,

such as personnel shortages and limited re-
sources, long working hours (1), not taking
part in clinical decisions and working under
pressure or working with people with inad-
equate clinical skills (2,3). These could lead
to occupational burnout. Manifesting as
emotional exhaustion, depersonalization
and personal inefficiency, occupational
burnout among nurses has attracted consid-

erable scholarly attention in recent decades.
Humour has been identified as an important
attribute that could help prevent and de-
crease burnout among nurses (2).

Humour is a cognitive, emotional, behav-
ioural, psychological and social phenome-
non (5, 6). It is an inseparable part of daily
life, and at times it is regarded as a means
of dealing with one’s problems, and a gen-
erally positive and universal experience for
people from different cultural and social
backgrounds around the world (6) and is

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defined as a person’s ability to appreciate
the funny side of a situation(7). The im-
portance of humour in nursing care was
introduced four decades ago (8). Coser was
the first to posit that humour is related to
disease and the stress of hospitalization for
patients. The results from his study re-
vealed that humour is a means for manag-
ing threatening situations like hospitaliza-
tion (9). Thereafter, the potency of humour
in reducing patients’ stress was gradually
recognized; hence, it is currently an estab-
lished nursing research field (10). Re-
searchers currently consider humour as an
acceptable practice in nursing care (4).
Henderson argued that humour and laugh-
ter among patients and health workers can
be as good as, or surpass treatment(11)
while, for Yura and Walsh, humour and wit
help broaden patients and nurses’ outlook
on life(12). According to Robinson (1997),
in nursing care, the goals of humour enable
the development of relationships, anxiety
relief, anger using socially acceptable
means, learning and avoidance or denial of
hurt(13).

Working in jobs in which the worker is
faced with pains and problems of other in-
dividuals, increases the possibility of ex-
haustion. Therefore, humour strategy is
needed more although there have been so
many texts about humour function. Be-
sides, the researchers came across few stud-
ies related to the use of humour in nursing
(14, 15) and they found that there has been
less use of humour despite the need of ap-
propriate mental serenity in clinical places.
Besides, people think that nurses should be
serious when are at clinical places, and the
nurses think that they are not allowed to
humour patients during the process care.
Humour can enhance health promotion
among nurses and the quality (4) of patient
care (4); it is also considered a patient care
strategy (5).

Fry believes that humour is essential for
one’s development in relation to social life
and experiences. However, there are vary-
ing views regarding the role of humour in
nursing care (16). Humour manifests within

social contexts and, therefore, varies across
cultures. Given the importance of the social
context in relation to humour, Iran’s unique
cultural and religious landscape provides an
ideal setting for the use of a qualitative
study to identify previously unexplored as-
pects of humour and its practical signifi-
cance in this context. Nurses might have a
better understanding of the complexities of
humour in clinical settings, which serve as
a focus of the current study (5). A study on
nurses’ experiences of humour in nursing
care can facilitate better understanding of
the needs, challenges and any other issues
surrounding this phenomenon. Moreover, it
could facilitate a happy and safe nursing
environment for both the patients and nurs-
es. Thus, this study explores the nurses’
experiences of humour in clinical settings
and factors affecting it.

Methods
Design
A qualitative design with conventional

content analysis was used in this study.
Content analysis is a qualitative analytical
method through which data are summa-
rized, described and interpreted. It is used
to identify main themes from the data and
is appropriate for examining experiences
and attitudes toward a particular subject
(17).

Data collection
A purposive sample includes individuals

with direct experience of the phenomenon
of interest, who can provide insight into the
research question. The sample comprised of
17 nurses with Master’s and Baccalaureate
degrees (BSN) in nursing, who were invit-
ed to participate in the study from various
wards. The data were collected through
semi structured interviews using guides
comprising probing questions. Telephonic
interviews were used to further supplement
the data. Interviews began with general
questions, and depending on the partici-
pants’ responses, moved toward more de-
tailed questions. Interviews continued until
data saturation. Initial questions were

F. Ghaffari, et al.

3MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir

‘What are your experiences of humour?’,
‘As a nurse, what do you do to make your
working shift more pleasant?’, and ‘What
factors make you use or not use humor?’
Depending on the participants’ preferences,
interviews were conducted in the research-
er’s room in the nursing department. Each
interview was audio-taped and completed
in one session. In total, six face-to-face in-
terviews and eleven by phone interviews
were conducted, each lasting 20–40
minutes and 15–20 minutes, respectively.
The data were collected between 2012 and
2013.

Data Analysis
Conventional content analysis informed

by Graneheim and Lundman’s method was
used to analyse the data (18). Immediately
after each interview, the contents of the in-
terview were documented by the research
team. Then, the texts were read several
times to obtain a general understanding of
participants’ statements, in line with the
study objectives. We reviewed the final
codes, including their defining properties
and their relationship to each other in order
to reach consensus regarding the central,
unifying theme emerging from the data.
The research team extracted meaning units
or initial codes, which were merged and
categorized according to similarities and
differences.

Rigor
To verify the data, Guba and Lincoln’s

four criteria were used (17). The researcher
was on the field for 11 months. Combined
triangulation methods were used for data
collection. The results were verified and
confirmed through peer and member
checks. In this respect, the initial codes and
categories were provided to some partici-
pants of the study, and they were given
enough time to tell the researcher their
complementary or corrective comments by
phone. Some of the codes were changed
according to the participants’ comments.
The corrective comments of two university
professors who were expert in qualitative

studies were used as peer check in the data
analysis. In-depth, analytical and clear de-
scriptions of obstacles and limitations dur-
ing data collection by the researchers ena-
bled the data’s transferability. Maximum
variation sampling was used (participants’
age, sex, shifts, work experiences, wards
and education levels varied) to enable the
proportionality or transferability of the re-
sults to other contexts. The researcher rec-
orded and reported the study’s various pro-
cesses to enable replication.

Ethical Considerations
Permission to conduct this study was ob-

tained from the Ethics Committee of Teh-
ran University of Medical Sciences. The
participants were informed of the study ob-
jective, were assured of the anonymity and
confidentiality of their data, and provided
written consent to participate in the study.
The interview venue and time were agreed
upon with the participants, and the results
were made available to them if they
wished.

Results
These nurses worked at five teaching

hospitals affiliated to Tehran University of
Medical Sciences, with minimum clinical
experience of 12 months. Participants’
mean (±SD) age was 24.15 ± 6.12 years,
with mean (±SD) work experience of 5.18
± 3.9 years; the majority 28(59%) worked
night shifts.

The participants’ experiences were classi-
fied into five themes; namely, the dynamics
of humour, condition enforcement, risk
making probability, instrumental use and
change: opportunities and threats (Table 1).

Dynamics of Humour
Religious beliefs, understanding humour

and situation assessment (timing) are sub-
categories representing the underlying fac-
tors or important dynamics of humor.

Religious Beliefs: As it is detested in Is-
lam to make humour with a guy of a differ-
ent gender, our participants did consider
their religious beliefs.

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A nurse said, “Humor calls for being able
to relate well to the patients; however, be-
cause I am a Muslim, I cannot behave too
friendly with the male patients.”

Understanding Humour: Participants be-
lieved that it was important to consider pa-
tients and their companions, as their under-
standing of nurse’s humor would help re-
solve any misunderstandings; and the pa-
tient would be less cautious around the
nurse and this would minimise patients’
harsh reactions toward nurses.

Nurses’ appraisal of humor in the work-
place ranged from positive to negative. The
majority believed that humour affected pa-
tient outcomes positively and that it pre-
served and promoted nurses’ physical and
mental health. Based on their experiences,
nurses considered humor a workplace re-
quirement and essential for patient care in
stressful situations.

‘Being humorous or not is a personality
trait–all medical team members, even pa-
tients, must appreciate humour; otherwise,
humorous people could come across chal-
lenges or opportunism due to misunder-
standings.’

Another group of nurses perceived humor
negatively, arguing that humor can surpass
the private boundaries between people.
Through humor, people attempt to enter
others’ life worlds and the understanding
resulting from such relations could be dam-
aging.

Another nurse commented, “Humor sets
the ground for insults between people. I
have to take care of my patient and that
does not require humor.”

Situation Assessment: A nurse’s appraisal
and understanding of his or her standing
with a colleague or patient could help de-
termine the appropriateness of humor in the
clinical context. For instance, acquaintance
history, previous friendship, work history,
time spent working with someone, occupa-
tional rank or duration of a patient’s hospi-
tal stay could determine the type of out-
comes emerging from a presumably hu-
morous situation. Timing, personal charac-
teristics and the cultural context constitute
the subcategories of situational assessment.

Timing
Timing is important and a nurse should

pick the best time to use humour. This fa-
cilitates mutual trust between the nurse and
the patient or the nurse and her/his col-
leagues and demonstrates the nurse’s ethi-
cal inclinations. Not considering the appro-
priate timing for humour, leads to anger,
aggression and relationship breakdown
with the patient. Recognising a suitable
time depends on factors such as a patient’s
physical, mental and psychological state, as
well as diagnosis and disease progression.

One nurse said, “I joked with a patient
who had just been informed of her diagno-
sis of breast cancer by the doctor. This re-

Table 1. Themes Extracted from the Participants’ Experiences
Major ThemesSubthemes

Dynamics of humourReligious Beliefs
Understanding Humour
Situation Assessment
Timing
Consideration of Unique Personal Characteristics
The Cultural Context

Condition enforcementTime Pressure
Unsuitable Environment
Social Considerations
Organisational Considerations

Risk Making ProbabilityFear of Abuse
Fear of Stigma

Instrumental UseRidicule Labelled as Humour
Criticism Labelled as Humor
Personality Assessment

Change: Opportunities and ThreatsRenewal and Exhaustion
Formation of Constructive and Destructive Relationships
Security to Sense of Threat

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5MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir

sulted in her detesting me and not talking to
me for a long time.”

Consideration of Unique Personal Char-
acteristics: Most nurses believed that un-
derstanding and analysing a patient or col-
league’s personality and their demographic
characteristics such as age, gender, socio-
economic level, personality and mood is
necessary when using humour. Still, most
believed that personal characteristics are
not taken into account by most nurses when
using humour. Misunderstandings, fol-
lowed by anger, grudges, broken interper-
sonal relationships, and patients’ reluctance
to receive care and requesting to be dis-
charged before completing the treatment
process, delayed care by nurses and re-
questing to change wards can result from
neglecting patients and nurses’ personal
characteristics when using humour.

A nurse commented, “When you are
providing care to an elderly patient, you
can get closer to the patient. However,
when it is a young or female patient or a
patient’s companion, then you won’t feel
that comfortable to humour the patient or
get close to her/him.”

Cultural Context: The use of humour re-
quires an understanding of differences in
culture, upbringing, language and meanings
attached to words, education level and so-
cial class. Nurses associate shame, which
arises from cultural barriers and contributes
towards limited use of humour in clinical
settings, with lack of confidence, an inferi-
ority complex, feeling insecure, lack of
trust and failure to adjust to the workplace,
which in turn hampers social interaction.
This was more prevalent among married,
female nurses, who considered intimate re-
lationships with the opposite sex an in-
fringement of family privacy.

One nurse commented, “My family has
taught me not to joke with the opposite sex.
Humour facilitates intimacy and close rela-
tionships between people and this is in con-
flict with what I have learnt from my fami-
ly.”

Condition Enforcement
Participants considered condition en-

forcement as the most important barrier to
the use of humour in clinical settings. Time
pressure, an unsuitable environment, and
potential risks comprised the subcategories
of this theme.

Time Pressure: Given their high workload
and care provision for many patients, nurs-
es typically experience time pressure. The
nurses believed that humour can occur
when nurses and patients share pleasant
experiences. This requires intimate and
long-term relationships that are hampered
by nurses’ time constraints. These also af-
fect nurses’ relationships with colleagues,
with whom they casually interact mainly
during teatime.

Another nurse said, “Sometimes I do not
even have the time to greet patients, let
alone connect and share jokes with them.”

Unsuitable Environment: Nurses’ use of
humour in clinical settings is constrained
by social and organisational protocol as
discussed below.

Social Considerations: According to the
nurses, the appropriateness of humour is
also determined by one’s patients and col-
leagues, as they must be able to appreciate
humour. Thus, nurses should be protected
from the negative consequences of humour,
including harassment and defamation of
character and professional identity. How-
ever, many believed that sharing jokes with
someone of the opposite sex is hardly ac-
ceptable and often results in misunder-
standings due to restrictions surrounding
male-female relationships in the Iranian
society.

A nurse said, “Most men, especially
young ones cannot take a joke. Once, there
was a young male patient whom I joked
with, and this led to him harassing me. He
was always at the nursing station. He would
get close and ask private questions.”

Organisational Considerations: An imper-
sonal, unfriendly organisational atmosphere
with minimum interpersonal relationships
cannot render humour a constructive strate-
gy for dealing with stressful situations.

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One nurse commented, “In my organisa-
tion, humour and laughter are considered
unethical behaviour for nurses. If I joke
with a female colleague, I immediately no-
tice nursing managers’ harsh reactions.”

Risk Making Probability
Nurses considered themselves at risk of

mental, social and family harm because of
their humour. Fear of abuse and stigma
comprise the subcategories of this theme.

Fear of Abuse: Fear of abuse involves
nurse-nurse, nurse-patient, or nurse-
organisation interactions. Despite their pos-
itive appraisal of humour use in patient
care, some nurses believed that getting too
close to the patient facilitates entry into
each other’s private lives. They were con-
cerned about the closeness and intimacy
resulting from the use of humour, equating
it with sharing private information. Thus,
they preferred not to present opportunities
for such problems to occur by limiting their
relationships with patients. Concerns about
unfavourable reactions from patients or
their companions, blurring of boundaries,
loss of mutual respect and fear of being
abused following unreserved interaction
with a patient were among the nurses’ con-
cerns. Most participants cited the possibil-
ity of an emotional relationship between
nurses and patients following the use of
humour during casual interactions, believ-
ing that this could cause irreparable harm to
the nurse and the patient. Furthermore,
concerns about possible harassment by the
patient as a result of the relationship, fol-
lowed by the disintegration of one’s family
relationships and the shame suffered before
one’s colleagues or family were among the
nurses’ main concerns regarding humour
use in patient care. These concerns were
also apparent in relation to the use of hu-
mour with colleagues.

A nurse said, “I had a young male patient
once; whenever he wanted to call me, he
would tap my shoulder. He considered it
humorous, but it bothered me. When it was
my shift, it worried me that he might in-
trude and not respect my privacy. I tried to

keep a distance from him.”
Fear of Stigma: Participants had concerns

about nursing managers, colleagues and
patients’ potential stigmatisation of the be-
haviour, labelling it as promiscuous or irre-
sponsible. This influenced their use of hu-
mour in clinical settings.

‘Once, I joked with a patient and my su-
pervisor witnessed it and told me to behave
myself carefully, since in his view, joking
was not a proper thing to do by a nurse’.

Instrumental Use
This theme included nurses’ experiences

of humour in clinical settings, with ridicule,
criticism and personality assessment la-
belled as humour.

Ridicule Labelled as Humour: According
to the participants, some nurses and pa-
tients regard the use of contemptuous
words, behaviour, or text as humour. Par-
ticipants believed that ridiculing patients’
lack of medical knowledge or terminology,
their accents and exposing their physical
problems when providing care were com-
mon among their colleagues and often la-
belled as humour.

A nurse said, “Once, one of my col-
leagues began making fun of me; she
walked like me and mimicked my manner-
isms and when she realised that I was up-
set, she said she was joking.”

Criticism Labelled as Humour: The par-
ticipants believed that, sometimes, their
colleagues disguised harsh criticism against
them as humour. In the participants’ view,
tolerating criticism aimed at destroying
their character and job situation was worse
than the joke itself. They believed that
nurses and patients should clearly define
what constitutes a joke.

One nurse said, “When my colleague
wants to put me down, she criticises me or
questions my work, disguising it as a joke.
She says anything she wants and when she
realizes that I am annoyed, she says she
was joking.”

Personality Assessment: Participants stat-
ed that the use of humour by their col-
leagues, patients, or patients’ companions

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was a means to assess the situation, open-
ing them up to psychological, emotional,
and physical abuse.

‘There is a patient who always tries to get
close to me and uses one-liners to test me.
He wants to see if he can invade my priva-
cy or not. When he notices that I am angry,
he uses humour as a strategy.’

Change: Opportunity and Threats
In the nurses’ view, humour can range

from a sense of renewal to weariness, the
formation of constructive to destructive re-
lationships and from a sense of security to a
sense of threat.

Renewal and Exhaustion: Participants as-
serted that a nurse must be serious in clini-
cal settings. However, they believed that
the use of humour can make the workplace
pleasant and counteract the hardships of a
heavy workload. Humour can help nurses
deal with stressful situations, such as ex-
haustion resulting from a high workload
and enables them to rest physically, mental-
ly, and emotionally. In anxiety-provoking
situations, such as caring for an ill patient,
exposure to organisational stressors and
severe shortage of equipment and person-
nel, humour enables nurses to consider the
positive aspects of a situation and manage
it effectively to theirs and patients’ ad-
vantage. Humour can result in a change in
disposition, a sense of peace and increased
ability to care for patients. Nurses also be-
lieve that humour can help them deal with
patients’ provocative behaviour, anger and
aggression, in turn relieving patients’ fear,
anger, and worries. Moreover, nurses be-
lieve that humour can reduce the severity of
patients’ pain, which patients mostly com-
plain about.

‘Sometimes, humour, even a moment’s
laughter together, lightens a difficult shift
and motivates us to continue – a joke sus-
tains our energy until the shift ends.’

However, humour can also wear nurses
and patients down physically and emotion-
ally, leading to tiredness, negativity to-
wards the workplace, anger, aggression,
fear and hopelessness.

‘When I joked with my colleague, I dis-
tempered her and I felt that she got so an-
gry that she left her duty.’

Formation of Constructive and Destruc-
tive Relationships: According to the partic-
ipants, being pleasant can lead to ac-
ceptance of the nurse by patients and col-
leagues and foster new relationships, feel-
ings of closeness and solidarity and open
communication lines. Furthermore, humour
elicits patients’ willingness to learn, coop-
eration and offers a distraction from the
disease. A nurse’s use of humour during
social interaction can discard stress, dissat-
isfaction, disagreements and resolve un-
pleasant encounters with others. Nurses use
different strategies to establish relationships
with shy (embarrassed), unsociable and im-
patient patients in order to obtain infor-
mation about their ailments or relieve them
of loneliness. They consider humour an ef-
fective strategy in such cases.

‘When an asthmatic patient would not al-
low me to use a spray on him, I began to
joke with him; he laughed a lot and then
tried to cooperate with me; his attitude
completely changed.’

Although the majority of the nurses be-
lieved that humour with colleagues and pa-
tients facilitated cooperation during patient
care, some believed that, if humour is used
for pretence, abusing others and venting, it
could destroy interpersonal relationships
and lead to anger and disheartenment. They
believed that when humour hurts others and
invades personal boundaries, then it cannot
be considered constructive. The partici-
pants argued that a relationship must be
defined for both parties and should not be
so open as to lead to the use of unusual and
insulting words or behaviour unbecoming
of nurses.

‘A male colleague used to exceed his lim-
it with the excuse of joking and I used to
get very angry – then gradually, our rela-
tionship cooled off and got darker and
darker until we changed wards – I felt that I
could not work with him anymore.’

Security to Sense of Threat: Humour ena-
bles friendly conversations and a sense of

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empathy. Shared feelings are associated
with a sense of security for patients and
nurses engaging in humour while interact-
ing. Humour can keep a long-term relation-
ship among colleagues pleasant, exciting,
lively and renewed. In clinical settings,
humour can help nurses resolve conflicts
and disagreements.

‘When my colleague joked with me, I
saw the relationship as open and could tell
him about my worries and work problems –
this lessened my worries, increased my
confidence and made me feel secure.’

Nurses believed that inappropriate jokes
make working shifts unpleasant and threat-
en one’s family and work status, also creat-
ing a sense of mental, emotional and physi-
cal harassment. Such jokes can also lead to
harassment by colleagues or patients in oc-
cupational and non-occupational settings,
which reduces motivation to provide pa-
tient care and an interest in nursing. Feel-
ings of insecurity were even more prevalent
among married nurses, as they tended to
argue with their spouses, who tried to pre-
vent them from continuing to work in the
nursing field. In some cases, marital con-
flict has occurred due to suspicion arising
from humour being used at work and
spouses objecting to their wives’ relation-
ships with their colleagues and patients.

‘Once my husband came to pick me up,
he understood that one of my male col-
leagues had joked with me and so whenev-
er he came to pick me up, we had a lot of
problems at the way home.’

In the nurses’ view, sharing jokes with
others at work should not lead to overly
caring for one another. However, the ma-
jority felt that they were being scrutinised
by their managers due to shared humour
with colleagues or patients. This resulted in
feeling a perceived threat to one’s security,
which is a prerequisite for enjoying one’s
work.

‘When I joked with a female patient, I re-
alised that she looked at me differently in
the next shift – after a while she asked me
for a date. This was very unpleasant for
me.’

Verbal or written warnings and threats of
demotion or even suspension were a con-
tentious issue for the nurses, eliciting inse-
curities regarding the use of humour in
clinical settings.

‘I was penalised by a nursing manager af-
ter a colleague complained about me joking
with him. I only wanted to make him laugh,
but he was annoyed.’

Discussion
In this study, the first theme related to

dynamics of humour, with ‘Understanding
humour’ emerging as the first subcategory.
For the participants, the use of humour is
determined by dynamics in clinical settings.
Some participants believed that humour is
necessary to make the working environ-
ment pleasant and drives the nurses to cre-
ate opportunities for the use of humour dur-
ing their minimal, casual interaction with
patients and colleagues (19). Studies show
that nurses’ perception of sense of humour
was a major factor in using sense of hu-
mour at patients’ bedside. The nurses avoid
using their sense of humour unless they be-
lieve that joking can help the mental health
of the patients and nurses, and recognize it
as a caring strategy. Conversely, negative
perceptions of humour limit its use in pa-
tient care (20). Apt posits that, prior to the
use of humour, it is essential to consider
people’s perception of humour, particularly
those informed by culture (21) .

Religious beliefs were considered another
dynamic of humour. In the participants’
view, humour is in conflict with religious
principles. Sometimes, due to staff shortag-
es and patients care needs, nurses had to
work with colleagues of the opposite sex on
the same shift or care for patients of the
opposite sex. This meant that some could
not use humour in the clinical context.
Most nurses cannot joke with the opposite
sex in the clinic due to their religious be-
liefs. The participants believed that hu-
mour fosters friendly relationships between
people, which go against their religious be-
liefs, particularly when involving members
of the opposite sex. However, in the reli-

F. Ghaffari, et al.

9MJIRI, Vol. 29.182. 17 February 2015 http://mjiri.iums.ac.ir

gious Iranian culture, humour is considered
a pleasant attribute, recommended to a cer-
tain extent by religious leaders. In the Is-
lamic view, humour is approved, so long as
it is not associated with sinful behaviour,
including: belittling, ridiculing, slander,
back-stabbing or such (22). In the Islamic
view, making a friendly and close commu-
nication with the other sex, which is the
background for using a sense of humour is
considered a sin. Considering others’ reli-
gious beliefs is necessary when using hu-
mour (23).

Assessing the situation was identified as
another dynamic of humour. Most partici-
pants emphasised the need to time the use
of humour according to others’ physical,
mental, and emotional disposition. Consid-
ering whether a patient or colleague is in a
position to appreciate humour could pre-
vent misunderstandings. Moreover, nurses
must consider the cultural context when
using humour. Scholars believe that rela-
tionships form the basis for patient care,
and therefore, the use of humour in nursing
care. However, it is important to consider
the cultural backgrounds of individuals
with whom one has relationships (19) and
maintain some distance, verbally or physi-
cally. According to the Islamic culture of
Iran, physical distance enables the protec-
tion of individuals’ religious beliefs, pro-
fessional identity and reputation, as well as
a chance to contemplate, heal and recognise
others. Providing culturally safe care is a
requirement in skilled nursing care (24-27).
Disregarding norms can be considered an-
noying or insulting, least of all funny. Thus,
nurses must use humour carefully, not chal-
lenging the society’s norms, as these differ
across societies (23). Humour should be
like looking through a shattered glass win-
dow; the subject can be seen, but what is
seen is different in reality.

The second theme, the constraint of con-
dition, was considered one of the main ob-
stacles in the use of humour in clinical set-
tings. In the participants’ view, maintaining
boundaries in one’s behaviour and speech
can lessen nurses’ concerns about the con-

sequences of humour in interpersonal rela-
tionships and, therefore, enable its use.
Limits and boundaries are associated with
self-restraint, which enables compassion
among nurses, informed development of
relationships and, consequently, use of hu-
mour, while maintaining commitment to
one’s religious beliefs.

The instrumental use of humour through
ridicule or criticism hampers its acceptance
in clinical settings. Participants believed
that the use of humour to ridicule others
can seriously damage others’ personality
and disrupt or completely destroy relation-
ships. This is referred to as aggressive hu-
mour, wherein an individual attempts to
taunt and make fun of others and freely
cracking insulting jokes, disregarding the
impact of these jokes on others (28). The
nurses must guard against criticising col-
leagues or patients’ beliefs, appearance or
issues that are important to them (2). This
belief gradually limits nurses’ use of a
sense of humour in the clinical settings
through changing the people’s attitude to-
ward the effectiveness of the sense of hu-
mour on patients and nurses’ health. Ac-
cording to Martin et al., the undesirable as-
pects of humour, such as misunderstand-
ings, hurt, being laughed at and banter are
often overlooked (6,29).

This study shows an increasing use of
humour in daily life, particularly nursing
care(4,30). In this study, the nurses be-
lieved that humour provides an opportunity
for change. In relation to this, the results
showed that the consequences of humour
can range from revival to exhaustion. In
addition to enabling mental rest, humour
helps change patients’ perspectives regard-
ing their health condition (4), helps reframe
difficult situations(23) and enables them to
cope with various challenges(31). It also
helps nurses to deal with difficult situations
and patients (5), calms anxious patients (4)
and is associated with job satisfaction and
motivation. Humour can enhance creativity,
values, promoting ethical and responsible
behaviour, induce trust and reliance, as well
as enable people overcome sadness, despair

Nurses’ experiences of humour in clinical settings

10 MJIRI, Vol. 29.182. 17 February 2015http://mjiri.iums.ac.ir

and sorrow(32). For our participants, hu-
mour can result in the strengthening or dis-
integration of interpersonal relationships.
Researchers believe that humour in patient
care results in a change in patients’ experi-
ences, less social distance, anxiety and
stress among patients(33), improved learn-
ing outcomes (2), open nurse-patient com-
munication (34) and identification of pa-
tients’ needs, a bond between nurses and
patients (5) and among nurses, patients
showing their emotions and the preserva-
tion of their dignity (4), feelings of intima-
cy and common understanding and estab-
lishment of trust between patients and nurs-
es. In such circumstances, patients can
freely communicate their feelings to nurses,
and this lessens the stress resulting from
their respective states (23). Moreover, the
results showed that joking can change the
effective interpersonal relationships into
grudge, seeking revenge and annoyance.
Joking may destroy the intimacy and vio-
late human rights. Paradoxically, humour
may have negative effects, which are not
always taken seriously (30). Lyttle believes
that humour is like a double-edged blade
capable of harming personal relationships
(35); when timing is wrong, people may
feel insulted or angry (2). Yura et al.
(1988), believe that although laughing with
others positively impacts relationships,
laughing at others has an entirely negative
effect on relationships (2). Still, given their
roles, nurses can resolve misunderstand-
ings. In patient care, nurses can use humour
for informing the patient of his or her
health condition and they can also use hu-
mour positively in order to establish rela-
tionships with patients (30). Du Pre and
Beck suggested that it is necessary for
nurses to use planned humour while check-
ing a patient’s health status, since this in-
creases the nurse’s influence on the patient
and encourages cooperation from the latter
during treatment (36).

The results obtained from this study are
context-specific; thus, further quantitative
studies are required for the generalizability
of the findings.

Conclusion
Recognising nurses’ perceptions and ex-

periences of humour helps identify its ef-
fects; thus, we should provide valuable in-
sights to ensure the mental, emotional and
physical health of the nurses and patients.
Effective methods include promoting a cul-
ture of humour in care settings through
training strategies aimed at enhancing
cheerfulness in the workplace and high-
lighting the importance of humour in pa-
tient care for nurses and nursing students.
Establishing norms and improving organi-
zational culture to reduce social and organ-
izational constraints of humour are other
important actions which need to be consid-
ered.

References
1. Farsi Z, Dehghan‐Nayeri N, Negarandeh R,

Broomand S. Nursing profession in Iran: an
overview of opportunities and challenges. Japan
Journal of Nursing Science. 2010;7(1):9-18.

2. Buxman K. Humour in the OR: A Stitch in
Time? AORN journal. 2008;88(1):67-77.

3. Rafii F, Oskouie SH, Nikravesh M. Conditions
Affecting Quality of Nursing Care in Burn Centers
of Tehran. Iran Journal of Nursing. 2007;20(51):7-
24.

4. Åstedt‐Kurki P, Isola A. Humour between nurse
and patient, and among staff: analysis of nurses’
diaries. Journal of advanced nursing. 2001;
35(3):452-458.

5. Beck CT. Humour in nursing practice: a
phenomenological study. International journal of
nursing studies. 1997;34(5):346-352.

6. Martin RA. The psychology of humour: An
integrative approach: Access Online via Elsevier;
2010.

7. Isola A, Åstedt‐Kurki P. Humour as
experienced by patients and nurses in aged nursing
in Finland. International journal of nursing practice.
1997;3(1):29-33.

8. Cousins N. Anatomy of an illness (as perceived
by the patient). Nutrition Today. 1977;12(3):22-28.

9. Coser RL. Some social functions of laughter.
Human relations. 1959. Available at: http://www.
professormarkvanvugt.com/files/LaughterasSocialL
ubricant .

10. Adams P, Mylander M. Good health is a
laughing matter. Caring-Washington Dc. 1992;
11:16-16.

11. Henderson A, Twentyman M, Heel A, Lloyd
B. Students’ perception of the psycho-social clinical
learning environment: an evaluation of placement

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models. Nurse education today. 2006;26(7):564-
571.

12. Yura H, Walsh MB, Garzón N. The nursing
process: assessing, planning, implementing,
evaluating. 1988.

13. Robinson VM. Humour and the health
professions: CB Slack Thorofare NJ; 1977.

14. Henderson V, Nite G. Principles and practice
of nursing. AJN The American Journal of Nursing.
1978;78(9):1574.

15. Åstedt‐Kurki P, Liukkonen A. Humour in
nursing care. Journal of advanced nursing. 1994;
20(1):183-188.

16. Fry W. Humour, physiology, and the aging
process. Humour and aging. 1986:81-98.

17. Polit DF. Essentials of nursing research:
Appraising evidence for nursing practice: Lippincott
Williams & Wilkins; 2013.

18. Graneheim UH, Lundman B. Qualitative
content analysis in nursing research: concepts,
procedures and measures to achieve trustworthiness.
Nurse education today. 2004;24(2):105-112.

19. Adamle K, Turkoski B. Responding to patient-
initiated humour: guidelines for practice. Home
healthcare nurse. 2006;24(10):638-644.

20. Naderi F, & Shokouhi M. The relationshipes
of the optimism, humour, social maturity and death
anexiety among Ahvaz Golestan hospital nursses.
New Finding in Psychology.2009; 4(10):85-94.

21. Apte ML. Humour and laughter: An
anthropological approach: Cornell university press
Ithaca, NY; 1985.

22. Khoshouei M, OREYZI SSHR, AGHAEI A.
Construction and validation of sense of humour
questionnaire. Psychological Research. 2009; 12(1-2
(23);0-0.

23. Dean RAK, Major JE. From critical care to
comfort care: the sustaining value of humour.
Journal of Clinical Nursing. 2008;17(8):1088-1095.

24. Pasco ACY, Morse JM, Olson JK. Cross‐
Cultural Relationships Between Nurses and Filipino
Canadian Patients. Journal of Nursing Scholarship.
2004;36(3):239-246.

25. Kirsh GA, Kuiper NA. Positive and negative

aspects of sense of humour: Associations with the
constructs of individualism and relatedness.
Humour. 2003;16(1):33-62.

26. Donnelly PL. Ethics and cross-cultural
nursing. Journal of Transcultural Nursing. 2000;
11(2):119-126.

27. Bakerman H. Humour as a nursing
intervention. Axone (Dartmouth, NS). 1997; 18(3):
56.

28. Liu KWY. Humour styles, self-esteem and
subjective happiness. Humour. 2012;1:21-41.

29. Martin RA, Puhlik-Doris P, Larsen G, Gray J,
Weir K. Individual differences in uses of humour
and their relation to psychological well-being:
Development of the Humour Styles Questionnaire.
Journal of research in personality. 2003;37(1):48-75.

30. McCreaddie M, Wiggins S. The purpose and
function of humour in health, health care and
nursing: a narrative review. Journal of advanced
nursing. 2008;61(6):584-595.

31. Rice HJ. The relationship between humour and
death anxiety: Retirado dia; 2004. Available at:
http://clearinghouse.missouriwestern.edu/manuscrip
ts/153.asp.

32. Vilaythong AP, Arnau RC, Rosen DH,
Mascaro N. Humour and hope: Can humour
increase hope? Humour. 2003;16(1):79-90.

33. Chiarello MA. Humour as a teaching tool. Use
in psychiatric undergraduate nursing. Journal of
psychosocial nursing and mental health services.
2010;48(8):34.

34. Bennett WL, Ennen CS, Carrese JA, et al.
Barriers to and facilitators of postpartum follow-up
care in women with recent gestational diabetes
mellitus: a qualitative study. Journal of Women’s
Health. 2011;20(2):239-245.

35. Lyttle J. The judicious use and management of
humour in the workplace. Business Horizons.
2007;50(3):239-245.

36. du Pré A, Beck CS. “How can I Put this?”
Exaggerated Self-Disparagement as Alignment
Strategy during Problematic Disclosures by Patients
to Doctors. Qualitative health research. 1997;
7(4):487-503.

outline- File 1 x

Benefits of Laughter

Benefits of Laughter.
Introduction- Laughter has been shown to have calming, pain-relieving and stress-reducing effects because it releases endorphins; effect similar to that produced by morphine and serotonin, whose effect produces well-being, improves health and mood
I. The influence of humor on health.
A. Traditional medicine and humor
B. Mood, anxiety, stress and Health
C. Neurological approach to laughter
II. Power of laughter
A. Sharing laughter
B. Benefits of laughter from a scientific and physiologic perspective
C. The laughter virus
III. Laughter as a complement to medical treatments.
A. Humour in clinical settings
B. Therapeutic Efficacy
Conclusion- Laughter in the healthcare environment aims to improve the mental health of patients by addressing psychological and emotional needs, providing a holistic view of medical practice ensuring the well-being of patients.

Proving the Power of Laughter

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

The Laughter Prescription

262

Jul • Aug 2016American Journal of Lifestyle Medicine

AnAlytic
Dexter Louie, BA, Karolina Brook, MD, and Elizabeth Frates, MD

Abstract: Laughter is a normal and
natural physiologic response to certain
stimuli with widely acknowledged
psychological benefits. However,
current research is beginning to show
that laughter may also have serious
positive physiological effects for those
who engage in it on a regular basis.
Providers who prescribe laughter to
their patients in a structured way may
be able to use these natural, free, and
easily distributable positive benefits.
This article reviews the current
medical understanding of laughter’s
physiologic effects and makes a
recommendation for how physicians
might best harness this natural
modality for their patients.

Keywords: laughter; prescription;
lifestyle medicine; treatment

L
aughter is a complex emotional
response to one’s environment,
situation, and stimuli. Studied for

many years, it was not generally
perceived to have any particular healing
effect until 1979, when Norman Cousins
published As Anatomy of an Illness. In
this book, Cousins described laughter as
creating an analgesic effect for pain
caused by his ankylosing spondylitis.1
Since that time, interest in laughter as a
potential therapeutic option has grown,
both in popular culture as well as in
scientific research, where the field of
psychoneuroimmunology attempts to

explore the impact of laughter on our
physiology and psychology.

Current research indicates that laughter
has quantifiable positive physiologic
benefits. So far, these benefits have been
small and not yet widely corroborated, but
in this era of preventative medicine, they
indicate that research on laughter is not
only timely and useful but also potentially
fiscally sound. This is because laughter is
(usually) free, and often without side
effects. A 2010 review cataloged the
available scientific evidence on the
physical benefits of both spontaneous and
simulated laughter.2 This article will

update and expand on the 2010 review in
order to enhance practitioners’ general
knowledge and understanding of how
laughter pertains to medicine. Additionally,
we will make recommendations as to how
laughter might be incorporated into a
lifestyle medicine approach.

What Is Laughter?

“Laughter” and “humor,” though often
used interchangeably, have different
definitions. Humor refers to the stimulus,

such as a joke, which evokes a response.
In contrast, laughter refers to a physical
reaction characterized by a distinct
repetitive vocal sound, certain facial
expressions, and contraction of various
muscle groups. One study identified 5
separate types of laughter: genuine
(“spontaneous”), self-induced
(“simulated”), stimulated (eg, tickling),
induced (ie, via drugs), and pathological.2
Pathological laughter and crying is
typically defined as a disorder of
emotional expression due to damage of
pathways in the cortex and brainstem,3
and this is distinctly different from the

laughter and humor discussed in this
article. Laughter can be experienced both
individually, for example, while recalling
a particular event, watching television, or
reading a book, or socially in groups, for
example, participating in a yoga laughter
group or sharing stories with friends.

Theories of Laughter:
Why Do We Do It?

Theories of laughter attempt to explain
the psychological motivations behind

550279AJLXXX10.1177/1559827614550279American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine
research-articleXXXX

The Laughter Prescription:
A Tool for Lifestyle Medicine

Current research indicates that
laughter has quantifiable positive

physiologic benefits.

DOI: 10.1177/1559827614550279. Manuscript received December 9, 2013; revised May 9, 2014; accepted May 30, 2014. From the University of California, San Francisco,
California (DL); and Harvard Medical School, Boston, Massachusetts (KB, EF). Address correspondence to Elizabeth Frates, MD, Institute of Lifestyle Medicine, Joslin Diabetes
Center, One Joslin Place, Boston, MA 02215; e-mail: efrates1@partners.org.

For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.

Copyright © 2014 The Author(s)

mailto:efrates1@partners.org

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263

vol. 10 • no. 4 American Journal of Lifestyle Medicine

genuine, or “spontaneous,” laughter.
Although one review4 catalogued over
100 individual theories of laughter, the
field is dominated by 3 in particular:
release theory, superiority theory, and
incongruity theory.5 Release theory
argues that laughter is the physical
manifestation of repressed desires and
motivations. Superiority theory posits
that laughter is a means of increasing
one’s self-esteem at the expense of
others.6 By contrast, incongruity theory
states that humor is created by a sense of
incongruity between 2 or more objects
within a joke.7 Currently, there is no
concrete consensus on which theory is
the most valid or most complete.

What Do We Understand
About the Health
Benefits of Laughter
From a Scientific and
Physiologic Perspective?

It is commonly accepted that laughter
produces psychological benefits, such as
improving affect, depression, anxiety,
and stress.8-10 Nevertheless, there is
growing evidence that laughter as a
physical activity can additionally produce
small but quantifiable positive
physiological benefits. The literature on
laughter can be separated based on the
type of laughter studied: spontaneous or
self-induced.

Spontaneous laughter differs
significantly from self-induced laughter.
The former refers to “genuine” or
unforced laughter, often in response to a
stimulus, whereas the latter describes
laughter that is simulated de novo.
Spontaneous laughter is often associated
with positive mood, whereas simulated
laughter is primarily physical and is not
necessarily associated with positive
emotions or feelings. Neuroimaging
suggests that different neural pathways
are used in these 2 forms of laughter.11

Do spontaneous and simulated laughter
have the same effect on the body? One
theory, the motion creates emotion
theory (MCET),2 posits that the body
does not actually know the difference
between intentionally laughing and
laughing instinctively. Therefore, if one

induces oneself to laugh (by simulating
or self-inducing laughter), the body can
be coaxed into an identical physiologic
response. According to the MCET,
simulated laughter can capture the
positive benefits of spontaneous
laughter—but without using any humor
at all. This is distinctly unlike the other
theories of laughter, which argue that the
benefits arise from nonphysical sources,
for example, positive mood.

Positive mood is closely tied to
spontaneous laughter, and it is thought to
have independent cognitive effects of its
own.12 However, parsing out the
interaction between positive mood and
spontaneous laughter has been difficult. A
study involving 87 subjects reported that
manipulating mood with music and
video—specifically a peppy Mozart piece
paired with a video of a laughing baby,
versus music from Schindler’s List and a
news report about an earthquake—
significantly affected performance on a
creative thinking task of learning
involving the classification of picture sets
with visually complex patterns.13
However, another study of 60 subjects
randomly assigned to watch a neutral,
positive affect, or comedy video found
that compared to a comedy video
(presumably elicits both laughter and
positive affect), a video that produced
only positive affect and no laughter was
not enough to cause endorphin release.14
Another study of 33 people found that
natural killer cell activity increased only
when the subject exhibited mirthful
laughter while watching a humorous
video (mean increase of 15.77 LU, P =
.037).15 Otherwise, if the subject watched
the video but did not laugh, natural killer
cell activity actually decreased. Because of
the difficulty of the task and the paucity
of research on the topic, this article will
consider positive mood and spontaneous
laughter together as a unit, and make no
effort to distinguish between the two.

Spontaneous Laughter

Spontaneous laughter—also known as
“genuine” laughter—has been far more
widely studied. One early study examined
the stress hormones levels of 10 subjects

watching an hour-long humor video.16
Among experimental subjects, cortisol
decreased from 240 ± 60 at baseline to 90
± 10 a half-hour after finishing the video,
compared to control subjects who
decreased from 390 ± 90 to 270 ± 60 after
the same amount of time. The
experimental group had a significantly
larger reduction (P = .011), although both
groups had a consistent drop from
baseline. A larger, more recent study
involving 52 patients shown a 1-hour
humor video found increases in natural
killer cell activity, IgG, IgM, and other
leukocytes.17 Other studies (n = 33 and 21)
have corroborated some of these findings,
determining that natural killer cell activity
was higher in the group watching the
comedic video compared to the
control.15,18 Interestingly, another study of
20 subjects found that an amusing film
actually produced similar increases in
epinephrine and norepinephrine levels as
an aggression-provoking one.19 The
authors postulated that this was due to the
emotional arousal, which can elevate
sympathetico-adrenomedullary activity
regardless of whether or not the arousal is
positive or negative.

Other studies have linked laughter and
humor with increased levels of pain
tolerance. In one, 200 subjects were
subjected to a painful cold-pressor
stimulus after being shown a film. Those
who viewed a humorous film had a
significant advantage in pain tolerance
time after a 30-minute wait period.20
Another experiment of 40 subjects found
that a laughter-inducing narrative, as
opposed to other forms of distraction
such as an interesting narrative audio
tape, increased discomfort thresholds.21
Similarly, a study of threat-induced
anxiety involving 53 subjects found that
those exposed to a humorous tape
recording consistently rated themselves
as less anxious and reported smaller
increases in stress as the time to receive
an electric shock approached.22

The cardiovascular effects of laughter
appear to be quantifiable, although
potentially short-lived. A study of 10
healthy subjects showed that cardiac
parasympathetic activity decreased
immediately on watching a comedy

264

Jul • Aug 2016American Journal of Lifestyle Medicine

video, and just as quickly returned to
baseline when finished.23 This was in
comparison to tragedy videos, in which
the parasympathetic activity also
dropped, but did not return to baseline
afterward. Some of the temporary effects
of laughter on the cardiovascular system
are predictable, given that laughter
involves an increase in physical activity
from baseline. A study of 8 subjects
found that laughter appears to
significantly increase stroke volume and
cardiac output, while significantly
decreasing oxygen consumption,
arteriovenous oxygen difference, and
total peripheral resistance.24 A study of
blood pressure involving 16
normotensive subjects found that
laughing during a blood pressure
measurement increased systolic blood
pressure by an average of 12 points.25
This research suggests that the body
responds physiologically to a bout of
laughter as it does to a bout of exercise.

In 2011, additional studies further
suggested the positive effects of
spontaneous laughter. For example, a
study presented at the European Society
of Cardiology 2011 Congress found
vasodilative effects lasting up to an hour
after watching a comedic movie scene,
whereas an action scene prompted
vasoconstriction.26 Another study used
humor therapy as “medication” to treat
agitation in patients with dementia. The
SMILE study found a 20% reduction in
agitation using humor therapy, which is
an improvement comparable to the
common use of antipsychotic drugs but
without the side effects. Agitation levels
remained lower at the 26-week follow up.
In this study, humor therapy used trained
staff as “Laughter Bosses” to act much like
the “Clown Doctors” used in hospitals on
children’s wards to help improve mood
and increase lightheartedness. (SMILE
study results were presented at the
National Dementia Research Forum 2011
on September 22 and 23.)

Self-Induced, or
Simulated Laughter

In contrast to spontaneous laughter, the
proposed benefits of simulated laughter

are largely based on the MCET: that the
physical act of laughing is enough to
create a positive physiologic response.
Research on simulated/self-induced
laughter, as opposed to spontaneous
laughter, is very recent, and therefore
only preliminary results are available.

A randomized control longitudinal
study in India recruited 115 IT
professionals to participate in 7 sessions
of laughter yoga as a way to reduce
stress.27 The type of laughter yoga used
consisted of bursts of simulated laughter
followed by yogic deep breathing
relaxation techniques. This study found
no significant change in heart rate,
respiratory rate, heart rate variability,
breath rate, or secretory IgA in either
group. However, the laughter yoga group
had a significantly greater drop in blood
pressure (Laughter Yoga group = 7.46
mm Hg; Control group = 3.03 mm Hg),
as well as a lower postintervention
systolic blood pressure (Laughter Yoga
group = 120.78 mm Hg; Control group =
125.96 mm Hg, P < .04). Additionally, the Laughter Yoga group showed a significant drop in cortisol levels (pre-intervention: 0.25 ± 0.14; post- intervention: 0.18 ± 0.11) whereas the Control group did not. Another study of laughter yoga examined 60 depressed geriatric patients in Tehran, Iran.28 Study subjects were randomized to receive laughter yoga therapy, exercise therapy, or nothing. Both laughter yoga and exercise therapy groups had a significant decrease in depression scores compared to the control group (P < .001 and P < .01, respectively), and the laughter yoga group had an additional increase in life satisfaction compared to the control group (P < .001). Interestingly, no significant differences were found between the laughter yoga and exercise groups. Summary of Literature Current literature on laughter is promising, suggesting that laughter has many positive physiologic effects on the body. It remains important, however, to retain a certain amount of healthy skepticism until results have been repeated and reaffirmed. In this vein, there remains much to do in terms of determining the duration and long-term impact of these effects. In terms of methodology, randomized control trials are in short supply compared to intervention trials,2 as are standardized instruments to help better compare results among studies. Increased methodological rigor will be important for the future. Furthermore, the distinction between spontaneous versus self-induced/simulated laughter remains an important area for exploring the MCET. Finally, having higher-powered studies that can parse out the difference between positive mood and the physical act of spontaneous laughter, for instance, can help further our understanding on the topic. There is great potential for future research in laughter. Randomized controlled large-scale trials are needed to further elucidate the physiologic effects of laughter. Laughter and Professionalism: Should Physicians Use Humor as a Tool to Induce Therapeutic Laughter? An important remaining question is whether or not laughter can be made into a convenient, useful therapy for patients. Laughter has no side effects, is readily accessible—already permeating many of our daily social interactions. Thus, whether the intent is to help a patient achieve positive physiologic benefits or simply enhance provider– patient communication, it deserves a closer examination to determine its applicability in the medical setting. Of course, health is a serious and often grave matter, and humor delivered at inappropriate times can be devastating, insensitive, and crass. In this vein, certain types of humor must be considered off-limits—in particular cynical and derogatory humor directed at the patient. Unfortunately, some studies indicate that avoiding these types of humor, including “dark” and/or negative humor as a coping mechanism for providers, can be 265 vol. 10 • no. 4 American Journal of Lifestyle Medicine more difficult than imagined.29-31 Indeed, negative humor can be passed down as a sort of “hidden curriculum” and perpetuated through many generations of providers.32 Within the bounds of appropriateness, however, both humor and laughter can be beneficial. For one, laughter shared between the provider and patient conveys a measure of trust and light- heartedness. Furthermore, humor can improve communication, as a joke can signal a transition in the conversation from the serious to more benign topics. In general, medical providers do best when acting cautiously and following the patient’s lead. Knowing a patient well and acknowledging any humor expressed by him or her is recommended. One additional unexplored field is the possibility of using laughter “therapy” as a means of sparking a more creative approach to lifestyle change. Depressed mood has been shown to be associated with decreased physical activity and weight gain in several societies. A recent survey of roughly 1500 Israelis33 used logistic regression and showed that less exercise and more weight was correlated with depressive symptoms after adjusting for confounders, although whether the direction of the correlation is such that mood causes the decrease in activity or vice versa is unclear. Given that laughter and humor is a key element to happiness and is often used as a therapeutic tool for depression,7,34 both traditionally and more recently in the form of “Laughter Yoga” exercises mentioned above,27,28 it could potentially be used to counteract the effects of depression and aid new approaches to lifestyle change. More recently, laughter and humor are being used in geriatric care of patients with dementia,35 resulting in a positive climate that could also potentially be fertile ground for instituting lifestyle changes. The Laughter Prescription: A Speculative Template One method for putting laughter into practice is to discuss laughter with the patient during a visit. Providers can ask, “What has made you laugh recently?” or “How often do you laugh?” Inquiring about laughter opens the door to light heartedness and also could lead to counseling on laughter and sharing the latest research with the patient. More important, it allows the provider to determine what the patient finds funny, thereby allowing the provider to tailor recommendations to better fit the patient’s needs and preferences. This also contains the potential to deepen the therapeutic relationship between patient and provider. Put together with a more structured approach, the health care provider could consider prescribing laughter to patients. The MCET theory states that it may be enough for patients to simply self-induce the physical act of laughing in order to gain positive benefits. Therefore, prescribed laughter may be very helpful in that all patients—even those potentially unwilling to seek out comedy or humor—can still engage in laughter and derive benefits from it. There are laughter yoga classes and videos available online and even courses offered at local recreations centers. If a patient fails to benefit from the therapy, then very little—if anything—is lost in the attempt, as there are no side effects. As such, adding in a brief 1-minute conversation on laughter may represent an additional fast, inexpensive, and no-risk tool in the physician’s toolbox. We propose that laughter prescriptions might contain detailed information as to the frequency, intensity, time, and type of laughter (forming the useful mnemonic “FITT”), much like pharmacological prescriptions and exercise prescriptions. This format aims to give patients clear and easy-to-remember guidelines. It is also a way to present laughter in a serious manner. When prescribing laughter, it would be of utmost importance to individualize the recommendations, taking into consideration the patient’s own sense of humor and willingness to engage in new activities, such as laughter yoga. An example of a laughter prescription: (F) Frequency: once a week (I) Intensity: belly laughing (T) Time: 30 minutes (T) Type: your favorite sit-com Laughter prescriptions remain largely speculative, but existing research indicates that efficacious laughter “treatments” typically occur once a week or less, for 30 to 60 minutes.36 Nevertheless, shorter frequencies and times, such as individual sessions as short as 20 minutes, can still have a positive impact.18 Intensity remains an open-ended question. It remains unclear how much, or with what amount of enthusiasm, one’s laugh leads to emotional and physical benefits. Type is the most variable factor of all. Again, tailoring recommendations to what the patient finds funny is an important part of creating an effective prescription. Furthermore, whether or not humor is even needed to generate laughter (eg, laughter yoga instead of watching comedies) is up to the individual patient. Another consideration is the idea of group laughter, or laughter shared among other people. Although most studies look at the impact on one’s body through the use of a humorous cartoon, in reality this is only a small aspect of all the stimuli that humans find amusing. Social laughter often occurs in a situation with a stand-up comedian. One functional magnetic resonance imaging study looking at the effect of stand-up comedians found that clips considered humorous activated reward centers in the brain.37 Another study from Israel looked at the effect of humorous videos on schizophrenic inpatients and found an improvement in patient’s psychopathology, mood, and mental status.38 A randomized controlled trial done in Japan, which allocated 27 individuals older than 60 to weekly 120-minute group laughter-with-exercise sessions over 3 months, found an increase in self-rated health as well as in objective bone mineral density, and a decrease in HbA1c levels,39 suggesting that group laughter sessions may be a way to encourage the elderly to exercise. However, it is currently unknown the extent to which group laughter provides 266 Jul • Aug 2016American Journal of Lifestyle Medicine different benefits compared to laughing on one’s own. There are barriers to implementing laughter therapy into one’s practice. Finding the time to discuss laughter, even just a 1-minute conversation, is understandably challenging. Giving a laughter prescription to patients suffering from depression and dementia could also be difficult. Significant life stressors, such as a recent death in the family, moving to a new home, being fired from a job, and so on, understandably make people feel unwilling or unable to laugh; however, laughter might still prove to be effective medicine in these situations. In such cases, it might take social support from friends and family in order to help the patient to engage in laughter. Thus, like many lifestyle behaviors, it is likely best if the environment and the people closest to the patient are on board with the laughter prescription in order for it to be successful long term. Conclusion While it is well known that both laughter and humor can have deep and long-lasting psychological effects, it is only recently that our knowledge of the physiologic effects of laughter has grown. This modern change has been in no small part driven by the practices of laughter yoga and similar self-induced, or simulated, forms of laughter. Whereas laughter and humor were once thought of as nearly interchangeable, laughter is now a distinct physical action that can be effective on its own. Currently, research is indicating that the physical act of laughing, even without humor, is linked to chemical changes in the body that potentially reduce stress and increase pain tolerance. Understanding the distinction between spontaneous and simulated laughter is likely to become a stronger point of emphasis moving forward. The United States is presently straining under the weight of rapidly increasing medical costs. Although there are limitations to the current medical literature on laughter, enough evidence indicates that laughter may be employed as part of our basic armamentarium to help prevent diseases, reduce costs, and ensure a healthier population. While more research must be done, it is also important to acknowledge there is not much to lose in laughing. With no downsides, side-effects, or risks, perhaps it is time to consider laughter seriously. Acknowledgments The authors would like to thank David Roberts, MD, for his invaluable expertise and assistance in preparing this article for publication. AJLM References 1. Cousins N. An Anatomy of an Illness. New York, NY: WW Norton; 1979. 2. Mora-Ripoll R. The therapeutic value of laughter in medicine. Altern Ther Health Med. 2010;16(6):56-64. 3. Parvizi J, Anderson SW, Martin CO, Damasio H, Damasio AR. Pathological laughter and crying: a link to the cerebellum. Brain. 2001;124(pt 9): 1708-1719. 4. Foot H, McCreaddie M. Humour and laughter. In: Hargie O, ed. The Handbook of Communication Skills. 3rd ed. London, England: Routledge; 2006:293-322. 5. Smuts A. Humor. Internet Encyclopedia of Philosophy. http://www.iep.utm.edu/ humor/. Accessed November 10, 2011. 6. Mulder MP, Nijholt A. Humour research: state of the art. http://wwwhome. cs.utwente.nl/~anijholt/artikelen/ ctit24_2002 . Accessed August 29, 2014. 7. Seaward BL. Humor’s healing potential. Health Prog. 1992;73(3):66-70. 8. Foley E, Matheis R, Schaefer C. Effect of forced laughter on mood. Psychol Rep. 2002;90(1):184. 9. Kuiper NA, Martin RA. Laughter and stress in daily life: relation to positive and negative affect. Motiv Emot. 1998;22:133-153. 10. Szabo A, Ainsworth SE, Danks PK. Experimental comparison of the psychological benefits of aerobic exercise, humor, and music. Humor. 2005;18: 235-246. 11. Iwase M, Ouchi Y, Okada H, et al. Neural substrates of human facial expression of pleasant emotion induced by comic films: a PET study. NeuroImage. 2002;17:758-768. 12. Pae CU, Jhoo JH, Yoon IY, et al. Availability of brain serotonin transporters (5-HTT) is associated with low positive mood in healthy elderly subjects. Int J Clin Pharmacol Ther. 2012;50:533-539. 13. Nadler RT, Rabi B, Minda JP. Better mood and better performance. Learning rule- described categories is enhanced by positive mood. Psychol Sci. 2010;21:1770-1776. 14. Dunbar RIM, Baron R, Frangou A, et al. Social laughter is correlated with an elevated pain threshold. Proc Biol Sci. 2012;279:1161-1167. 15. Bennett MP, Zeller JM, Rosenberg L, McCann J. The effect of mirthful laughter on stress and natural killer cell activity. Altern Ther Health Med. 2003;9(2):38-45. 16. Berk LS, Tan SA, Fry WF, et al. Neuroendocrine and stress hormone changes during mirthful laughter. Am J Med Sci. 1989;298:390-396. 17. Berk LS, Felten DL, Tan SA, Bittman BB, Westengard J. Modulation of neuroimmune parameters during the eustress of humor associated mirthful laughter. Altern Ther Health Med. 2001;7:62-72. 18. Takahashi K, Iwase M, Yamashita K, et al. The elevation of natural killer cell activity induced by laughter in a crossover-designed study. Int J Mol Med. 2001;8:645-650. 19. Levi L. The urinary output of adrenalin and noradrenalin during pleasant and unpleasant emotional states: a preliminary report. Psychosom Med. 1965;27:80-85. 20. Weisenberg M, Raz T, Hener T. The influence of film-induced mood on pain perception. Pain. 1998;76:365-375. 21. Cogan R, Cogan D, Waltz W, McCue M. Effects of laughter and relaxation on discomfort thresholds. J Behav Med. 1987;10:139-144. 22. Yovetich NA, Dale JA, Hudak MA. Benefits of humor in reduction of threat-induced anxiety. Psychol Rep. 1990;66:51-58. 23. Sakuragi S, Sugiyama Y, Takeuchi K. Effects of laughing and weeping on mood and heart rate variability. J Physiol Antropol Appl Human Sci. 2002;21:159-165. 24. Boone T, Hansen S, Erlandson A. Cardiovascular responses to laughter: a pilot project. Appl Nurs Res. 2000;13:204-208. 25. McMahon C, Mahmud A, Feely J. Taking blood pressure—no laughing matter! Blood Press Monit. 2005;10:109-110. 26. O’Riordan M. Laughter and therapy could go a long way for the heart. Medscape Today News. http://www.medscape.com/ viewarticle/748773. Published August 29, 2011. Accessed August 31, 2011. 27. Nagendra HR, Chaya MS, Nagarathna R, Kataria M, Manjunath MK, Rao R. The Efficacy of Laughter Yoga on IT Professionals to Overcome Stress. Mumbai, http://www.iep.utm.edu/humor/ http://www.iep.utm.edu/humor/ http://wwwhome.cs.utwente.nl/~anijholt/artikelen/ctit24_2002 http://wwwhome.cs.utwente.nl/~anijholt/artikelen/ctit24_2002 http://wwwhome.cs.utwente.nl/~anijholt/artikelen/ctit24_2002 http://www.medscape.com/viewarticle/748773 http://www.medscape.com/viewarticle/748773 267 vol. 10 • no. 4 American Journal of Lifestyle Medicine India: Laughter Yoga International. http://www.yogalaff.com/docs/8-INDIA- LAUGHTER-STUDY . Published 2007. Accessed August 29, 2014. 28. Shahidi M, Mojtahed A, Modabbernia A, et al. Laughter yoga versus group exercise program in elderly depressed women: a randomized controlled trial. Int J Geriatr Psychiatry. 2011;26:322-327. 29. Dharamsi S, Whiteman M, Woodllard R. The use of cynical humor by medical staff: implications for professionalism and the development of humanistic qualities in medicine. Educ Health (Abingdon). 2010;23:533. 30. Wear D, Aultman JM, Varley JD, Zarconi J. Making fun of patients: medical students’ perceptions. Acad Med. 2006;81:454-462. 31. Wear D, Aultman JM, Zarconi J, Varley JD. Derogatory and cynical humour directed towards patients: views of residents and attending doctors. Med Educ. 2009;43(1):34-41. 32. Berk R. Derogatory and cynical humour in clinical teaching and the workplace: the need for professionalism. Med Educ. 2009;43(1):7-9. 33. Khalaila R, Litwin H. Changes in health behaviors and their associations with depressive symptoms among Israelis aged 50+. J Aging Health. 2014;26: 401-421. 34. Davidhizar R, Vance A. In pursuit of happiness. Todays OR Nurse. 1994;16(4): 41-44. 35. Hafford-Letchfield T. Funny things happen at the Grange: introducing comedy activities in day services to older people with dementia—innovative practice. Dementia (London). 2013;12:840-852. 36. Mora-Ripoll R. Potential health benefits of simulated laughter: a narrative review of the literature and recommendations for future research. Complement Ther Health.
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37. Franklin R Jr, Adams R. The reward of a
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Bleich A. The effect of humorous movies
on inpatients with chronic schizophrenia. J
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39. Hirosaki M, Ohira T, Kajiura M, et al.
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The role of laughter in traditional medicine and its relevance to the clinical setting

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The science of laughter

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therapeutic_value_of_laughter_in_medicine

NAflRATIVE REVIEW

THE THERAPEUTIC VALUE OF
LAUGHTER IN MEDICINE

Ramon Mora-Ripoll, MD, PhD

Objective • The aim of this review is to identiiy, critically evalu-
ate, and summarize the laughter literature across a number of
fields related to medicine and health care to assess to what extent
laughter health-related benefits are currently supported by
empirical evidence.

Data Sources and Study Selection • A comprehensive laughter
literature search was performed. A thorough search of the gray
literature was also undertaken. A list of inclusion and exclusion
criteria was identified.
Data Extraction • It was necessary to distinguish between
humor and laughter to assess health-related outcomes elicited
hy laughter only.
Data Synthesis • Thematic analysis was applied to summa-
rize laugliter health-related outcomes, relationships, and
general robustness.
Conclusions: Laughter has shown physiological, psychological.

social, spiritual, and quality-of-life benefits. Adverse effects are
very limited, and laughter is practically lacking in contraindica-
tions. Therapeutic efficacy of laughter is mainly derived fi-om
spontaneous laughter (triggered by external stimuli or positive
emotions) and self-induced laughter (triggered by oneself at will),
both occurring with or without humor. The brain is not able to
distinguish between these types; therefore, it is assumed that
similar benefits may be achieved with one or the other. Although
there is not enough data to demonstrate that laughter is an ail-
around healing agent, this review concludes that there exists suf-
ficient evidence to suggest that laughter has some positive, quan-
tifiable effects on certain aspects of health. In this era of evidence-
based medicine, it would be appropriate for laughter to be used as
a complementary/alternative medicine in the prevention and
treatment of iQnesses, although further well-designed research is
warranted. (Altem Ther Health Med. 2010;16(6):56-64.)

Ramon Mora-Ripoll, MD, PhD, is medical scientific director
at Organización Mundial de la Risa, Barcelona, Spain.

Corresponding author: Ramon Mora-Ripoll, MD, PhD
E-mail address: ramon.morari@gmail.com

T
hat laughter has health benefits has heen claimed for
centuries; however, during the past decades, several
laughter- and humor-based interventions have
gained widespread acceptance, and scientific studies
of this phenomenon have generated considerable

medical and public interest. In 1976, Norman Cousins published
the article “Anatomy of an Illness” in The New England Journal of
Medicine, in which he explained that 10 minutes of genuine belly
laughter as a result of viewing comic films had a considerable
analgesic effect and gave him at least 2 hours of sleep ftee from
the pain of ankylosing spondylitis.’ It was never clear whether his
pain relief was due to the laughter or to the massive dose of vita-
min C administered simultaneously, but the case became famous
and encouraged scientists to investigate and define how laughter
may heal, founding the basics of current “laughter medicine.”

Though it takes skill and time to develop the science and art
of what makes a person laugh and to ascertain the related bene-
fits, laughter therapy does not require large amounts of time or
money to be applied. Unlike other therapies that are more time-

consuming or expensive, the use of laughter can be implemented
easily and cost-effectively in patient care.” Nevertheless, there
are now so-called “laughter trainers” and accounts all over the
popular media proclaiming the supposed physical, psychologi-
cal, emotional, social, occupational, spiritual, and quality-of-life
benefits of laughter. Scientific data for these claims must be well
documented before evidence-based “laughter medicine” can be
widely supported by the health care community.”‘

The aim of this review is to identify, critically evaluate, and
summarize the laughter literature across a number of fields relat-
ed to health, health care, patient care, and medicine with the
purpose of assessing to what extent laughter health-related bene-
fits are currently supported by empirical evidence.

METHODS
Definitions

This review focuses on the health-related effects of laughter
only. One of the most significant methodological prohlems in
laughter research is the failure to distinguish humor fi-om laugh-
ter. A ftiU discussion on laughter and humor theories is beyond
the scope of this review, but a few basic definitions are essential.”
For the purpose of this review, humor is defined as one of the
stimuli that can help people laugh and feel happy. Sense of humor
is a psychological trait that varies considerably and allows people
to respond to different types of humorous stimuli. And laughter

56 ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL. 16, NO. 6 Therapeutic Value of Laughter in Medicine

is defined as a psychophysiological response'”” to either humor
or any other stimuli with the following characteristics”: (1) pow-
erful contractions of the diaphragm together with repetitive
vocal sounds produced by the action of the resonating chambers
of the pharynx, mouth, and nasal cavities; (2) typical facial
expression (motion of about 50 facial muscles, mainly around
the mouth), which may include the release of tears; (3) motion of
several groups of muscles of the body (more than 300 may be
distinct); and (4) a sequence of associated neurophysiological
processes (cardiovascular and respiratory changes, activation of
neuroendocrine and immune circuits). Internally, laughter comes
with positive psychological shifts and a subjective identifiable
emotion (hilarity) that has been compared to the one coming
from sexual activity or other joyful bodily responses.

It is apparent that humor and laughter are distinct events
(although often associated). Whereas humor is a stimulus and
can occur without laughter, laughter is a response and can occur
without humor.’^ It is necessary to distinguish between these
variables, as many analyses of humor have used a humor stimu-
lus (such as a comic movie) to determine the effect of “humor”
on a health-related outcome, and others look specifically at the
effects of laughter on these outcomes. Still others explore differ-
ent ways to assess sense of humor in an attempt to analyze
whether scoring higher on a sense-of-humor scale is associated
with certain health outcomes.

Design
A systematic review was conducted. This type of review is

particularly useful where the aggregation of data is difficult
because diverse definitions, many studies or fields, and different
outcomes are being analyzed.” A comprehensive laughter and
humor literature search was performed using a variety of data-
bases and keywords. A manual search of relevant sources, a jour-
nal-specific search, and a manual search of references included in
relevant retrieved articles also were included (Table 1). A thor-
ough search of the gray literature also was undertaken (eg,
Google). A list of inclusion and exclusion criteria was identified
(Table 2). All relevant published articles up to 2008 were
reviewed. No papers were excluded on the basis of quality
because of the dearth of literature meeting the established inclu-
sion or exclusion criteria. Thematic analysis was applied to sum-
marize laughter and humor theories, health-related outcomes,
patient outcomes, relationships, and general robustness.”^ This
review was not funded.

RESULTS
The Effects of Laughter on Health Outcomes

The field of medicine is surprisingly less present in laughter
research than would be expected. Its research is mainly dominat-
ed by the field of (medical) psychology across psychobiological,
social, and health domains.

Mechanism of Action
In pursuing the therapeutic efficacy of laughter, four poten-

TABLE 1

Databases

Cochrane Library

Medline

PubMed
SAGE Journals

Science Direct
Internet (Google)

Databases, Journals, and Keywords Searched

Journals specific

Ahem Ther Health Med

BMC Complement

Altem Med

Complement Ther

ClinPraa

Complement Ther Med

Evid Based Complement

AltematMed

] Altem Complement Med

JPsychosom Res

M) Humor Res

Keywords

Laughter (or laugh or
laughing)

Humor (not aqueous.

not vitreous)
Mirth (or mirthful)

Therapy
(or intervention)
Complementary

medicine
Alternative medicine

Holistic medicine
Integrative medicine

Mind-body
Medicine
Health (and health care)

Patient (and patient care)

TABLE 2 Laughter Literature Search: Inclusion and Exclusion Criteria

Inclusion

Laughter or humor intervention main focus of paper

Direct or indirect relationship to health outcomes and medicine/therapy

Paper either research or seminal in some form

Literature review of >15 references (medicine texts only)

Exclusion

Humor stimulus or intervention not eliciting or measuring laughter

Brief items, anecdotes, cartoons, pictures, obituaries, commentaries,

or interviews

Brief literature reviews based on ¿15 references (medicine texts only)

Semantics, linguistics, history (nontherapeutic research), eg, joke con-

structions, entertainment

Textbooks, media-related items, including health promotion

Non-health care occupation-related items

Non-English, non-Spanish language publications

tial mechanisms of action have been established that would dem-
onstrate its direct or indirect health benefits (humor-health
connection).”” First, laughter can lead to direct physiological
changes to the muscular, cardiovascular, immune, and neuroen-
docrine systems, which would have immediate or long-term ben-
eficial effects to the body.'”‘Accordingly, laughter is crucial in
this model and may be expected to have beneficial health out-
comes even without humor, as advocated by the laughter club
movement that originated in India in 1995.” The more you
laugh, the more benefits you obtain. Secondly, laughter can lead
to more positive emotional states, which also may have direct
benefits to health or contribute to a personal perception of better
health or quahty of life.” Laughter is not that essential in this sec-
ond model, as positive emotions may also be elicited by humor
(without laughter), amusement, happiness, joy, love, and others.
Here, the more playful approach to life, the more benefits. Third,

Therapeutic Value of Laughter in Medicine ALTERNATIVE THERAPIES. NOV/DEC 2010. VOL. 16, NO. 6 57

laughter can optimize one’s own strategies for coping with stress
and strengthen personal pain tolerance,™ which may reduce the
negative impact on health benefits that both can have. According
to this stress-moderator model, which provides indirect effects,
laughter during nonstressful times would be less relevant to
health. Finally, laughter may indirectly increase one’s social com-
petencies, which as a result may increase interpersonal skills. In
turn, the greater levels of social support gained may confer stress-
buffering and health-enhancing benefits.^’^^ Laughter’s role is
here a lot less patent, as the main focus is on social skills. No
other potential mechanisms of action for laughter have been
reported as yet.

Therapeutic Efficacy
Although humor and laughter have been used therapeuti-

cally in a variety of medical and other conditions, well-designed
randomized controlled trials (RCTs) have not been conducted to
date validating the therapeutic efficacy of laughter, and only very
few trials have been performed otherwise. However, health out-
comes have been reported in multiple areas of medicine and
patient care. This review has identified health-related laughter
research, excluding pathological laughter, in the following areas:
oncology^’^’; allergy and dermatology”^’; immunology^””; pul-
monology'”‘; cardiology, endocrinology, and metabolism”‘”‘”;
internal medicine and rheumatology”; rehabilitation””; psychia-
try and medical psychology””^”‘; anatomy, neurology, and imag-
ing”””; biophysics and acoustics'”^*; geriatrics and aging’*’*;
pediatrics^”^’; obstetrics”^; surgery”‘”^; dentistry'”*; nursing*'”;
critical, palliative, and terminal care’̂ * ;̂ hospice care*’^’; home
care”‘; general patient care and primary care”‘”; epidemiology
and public health”‘^; complementary and alternative medicine
(CAM)”‘”; and medical and health sciences training.’^”

Physiological Benefits of Laughter
Humor, mirth, and laughter have numerous effects involv-

ing the muscular, cardiovascular, respiratory, endocrine,
immune, and central nervous systems. The effects of laughter on
certain physiological outcomes are briefly summarized in Table
3. The research reviewed in this area relates to the impact of
laughter on the entire body and can be lumped into the following
main physiological effects: laughter (1) exercises and relaxes
muscles, (2) improves respiration, (3) stimulates circulation, (4)
decreases stress hormones, (5) increases the immune system’s
defenses, (6) elevates pain threshold and tolerance, and (7)
enhances mental functioning.

Psychological Benefits of Laughter
The psychological effects of humor and laughter relate pri-

marily to both as a coping mechanism and, to a lesser extent,
their enhancement of interpersonal relationships. Table 4 pro-
vides a brief overview of the effects of laughter on particular psy-
chological outcomes. The research reviewed in this area, somehow
larger and much stronger than the evidence for the physiological
health benefits, can be summarized as follows: laughter (1) reduc-

es stress, anxiety, and tension and counteracts symptoms of
depression; (2) elevates mood, self-esteem, hope, energy, and
vigor; (3) enhances memory, creative thinking, and problem solv-
ing; (4) improves interpersonal interaction, relationship, attrac-
tion, and closeness; (5) increases friendliness and helpfulness and
builds group identity, solidarity, and cohesiveness; (6) promotes
psychological well-being; (7) improves quality of life and patient
care; and (8) intensifies mirth and is contagious.

Safety

The side effects of laugher are very limited. In specific cases,
the appearance of a laughter-induced syncope has been
reported.””‘™ Contraindications are nearly nonexistent; however,
precaution is advised with patients who were recently released
from surgery or who have certain cardiovascular or respiratory
diseases or glaucoma.

Laughter Types and Health Benefits
Several kinds of laughter have been identified depending on

various parameters and different fields of the scientific research.'”
‘” From a medical and therapeutic point of view, five large groups
can be summarized’^: (1) genuine or spontaneous laughter, (2)
self-induced simulated laughter, (3) stimulated laughter, (4)
induced laughter, and (5) pathological laughter. Spontaneous
laughter, unrelated to one’s own free will, is triggered by different
(external) stimuli and positive emotions (ie, happiness, mirth, joy,
fiin, triumph, humor, surprise, emotional release, or by conta-
gion). It has been reported that spontaneous laughter causes typi-
cal contractions of the muscles around the eye socket (Duchenne
laughter/smile””). Self-induced simulated laughter is triggered by
oneself at will, with no specific reason (purposeful, unconditional)
and therefore not elicited by humor, fun, other stimuli, or positive
emotions. Stimulated laughter happens as a result of the physical
(refiex) action of certain external factors (ie, to be ticklish, particu-
lar facial or bodily motions, by pressing laughter bones'”). More
superficial and empty-headed, induced laughter is the conse-
quence of the effects of specific drugs or substances (ie, alcohol,
caffeine, amphetamines, cannabis, lysergic acid diethylamide
[LSD], nitrous oxide or “laughing gas,” and others). Finally, path-
ological laughter is secondary to injuries to the central nervous
system caused by various temporary or permanent neurological
diseases and also may occur with certain psychiatric disorders.
Pathological laughter is developed with no specific stimulus; is
not connected with emotional changes; has no voluntary control
of its duration, intensity or facial expression; and sometimes
comes with “pathological crying.”‘™

The therapeutic benefits of the different types of laughter
concern in particular the first two, spontaneous laughter and self-
induced simulated laughter, and stimulated laughter to a lesser
extent. Table 5 shows the main characteristics of the first two
types of laughter. Spontaneous laughter and self-induced simulat-
ed laughter are not that different than one might believe initially.
The only clear difference is in the initial stage of providing a stim-
ulus and the triggering of laugher. In the first case, an external

58 ALTERNATIVE THERAPIES, NOV/DEC 2010, VOL 16, NO. 6 Therapeutic Value of Laughter in Medicine

Physiological Outcome

TABLE 3 Effects of Laughter on Health-related Physiological Outcomes*

Intervention and Results

Muscle relaxation

Heart rate, respiratory rate, blood pressure,

EE, oxygen levels

Effect on cardiovascular performance

Periods of intense laughter are followed by relaxed muscle tone” or H-reflex depression.”

Laughter led to immediate increases in heart rate, respiratory rate, and oxygen consumption’°°’°’and
may improve oxygen saturation levels’°’̂ ; laughter did not significantly affect heart rate'”” or oxygen con-
sumption'”; following laughter, there is a corresponding decrease in heart rate and respiratory rate”;
laughing had an acute effect on systolic blood pressure’°° ‘°’; no significant effecf” ‘°’; laughter with physi-
cal exercise may be effective to lower the blood pressure as a long-term effect’°’; genuine voiced laughter
caused a 10% to 20% increase in EE and heart rate above resting values, which means that 10-15 min of
laughter per day could increase total EE by 10-40 kcal.”°

Laughter increased stroke volume and cardiac output, and decreased arterial-venous Oj difference and
systemic vascular resistance”; laughter elicited by cinematic viewing improved endothelial-dependent
vasodilation”‘; laughter decreased levels of serum cortisol and plasma von Willebrand factor”^; laughter
induced by a comic movie led to a significant decrease in aortic stiffness and wave reflections.”‘

Cardiovascular protection (long-term effects) Inverse association between propensity to laugh and coronary heart disease””; fewer arrhythmias and
recurrences of myocardial infarctions during cardiac rehabilitation (after myocardial infarction) when
self-selected viewed humor was used as an adjunct to standard therapy”^ mirthful laughter led to lower
the incidence of myocardial infarction in high-risk diabetic patients.””

Endocrine stress markers (cortisol, CgA) and After watching a comic film, laughter reduced serum cortisol levels,”™’ increased salivary CgA levels,’̂ °
increased urinary excretion of epinephrine and norepinephrine'”; appeared to reduce serum levels of
dopac (dopamine catabolite), epinephrine, and HGH”‘; no significant changes were found in serum pro-
lactin, beta-endorphins, ACTH, and norepinephrine”‘”‘; laughter increased beta-endorphins and
HGH’̂ ;̂ laughter elevated breast-milk melatonin in both healthy and atopic eczema mothers^’; behavior
of perceptual anticipation of mirthñil laughter decreased serum cortisol, epinephrine, and dopac.’^’

Exposure to a humorous stimulus increased NK activity ‘̂ “”^; did not significantly increase NK activi-

ty'”; increased SIgA’°’*’^; increased serum IgA, IgG, IgM'”‘; relative increase in total leukocytes and spe-

cific leukocyte subsets.'”

Laughter (film-induced) increased pain tolerance and discomfort thresholds.”°'”*

Viewing a humorous film decreased bronchial responsiveness in asthmatic patients'”; laughter and smil-

ing induced by a humor intervention (clowning) were able to reduce hyperinflation in severe and very

severe COPD patients.'”

Effects in patients with rheumatoid arthritis Mirthfiil laughter decreased serum proinflammatory cytokine levels,”* growth hormone, and IGF-P’;

various hormonal measures

Neuroimmune parameters: salivary IgA
(SIgA), serum immunoglobuline levels, NK
cell activity, leukocyte population

Pain threshold and tolerance

Effects in asthma and COPD patients

(neuroimmune parameters) increased antiinfiammatory cytokine levels”‘; or reduced serum interieukin-6 levels.”‘”‘

Effects in type 2 diabetes patients (blood glu- Inhibitory effect of laughter (elicited by a comedy show) on the increase of postprandial blood glucose
cose levels, neuroimmune parameters, others) level'”‘; laughter infiuenced the gene expression profile in the peripheral blood leukocytes'”^; laughter

may prevent the exacerbation of diabetic nephropathy'” and diabetic microvascular complications”‘;
laughter may contribute to amelioration of postprandial blood glucose elevation through a modulation
of NK cell activity caused by upregulation of relating genes'””; mirthfiil laughter led to lower the serum
epinephrine and norepineprine levels, decreased inflammatory cytokines and C-reactive protein, and
increased HDL cholesterol in high risk diabetic patients with hypertension and hyperlipidemia.”‘

Laughter and humor reduced allergen-induced wheal reactions,” reduced allergen-specific IgE

production,”* improved night-time wakening,'” and reduced serum neurotrophin levels.'”‘

Laughter increased galvanic skin response'”or conductance,'”‘ indicating activation of sympathetic ner-

vous system; laughter episodes (while narrating jokes) led to cessation of binocular rivalry’̂ °; hearty

laughter (while viewing a comic video) elicited waving patterns clearly diflerent from those of coughing

or sneezing.”‘

*EE indicates energy expenditure; CgA, chromogranin A; HGH, human growth hormone; ACTH, adrenocorticotropic hormone; Ig, immunoglobulin; NK, natural
killer; COPD, chronic obstructive pulmonary disease; IGF-1, insulin-like growth factor 1; HDL, high-density lipoprotein.

Effects in atopic dermatitis patients (allergy

parameters)

Other: skin response, binocular rivalry,
diaphragm electromyography

Therapeutic Value of Laughter in Medicine ALTERNATIVE THERAPIES, N O V / D E C 2010, V O L 16, N O . 6 59

TABLE 4 Effects of Laughter on Health-related
Psychological Outcomes

Psychological Outcome Intervention and Results

Effects on mood, stress,

depression and/or anxi-

ety symptoms

Effects on psychotic
symptoms

Performance, personal

efficacy, coping abilities

Psychotherapy, group

therapy, desensitization

Quality of life, patient
care, well-being

Laughter improved mood and positive affect
in healthy adults’̂ ‘” ‘̂; temporarily improved
depressed mood in depression”^; moderated
stress in healthy adults “2,155.156̂ ^ anxiety.™'”

In patients with schizophrenia, a humor
and laughter intervention reduced hostility
and depression/anxiety scores; improved
activation scores and social support”‘^;
lowered the levels of psychopathology; and
improved social competence.’^’

Purposeful laughter significantly increased
different aspects of self-efficacy, including
self-regulation, optimism, positive emo-
tions, and social identification, and main-
tained these gains at follow-up”” ;̂ laughter
and humor improved coping abilities.””””‘

Conversational laughter helped prevent
or resolve risk of confrontation in addic-
tion group therapy'”; humor desensitiza-
tion reduced fear as effectively as tradi-
tional techniques.'”

Laughter and humor improved quality
of life in depressed patients ‘”””; pro-
moted psychological well-heing and
enhanced patient care in different clini-
cal settings .̂ “‘•™™™”‘«

stimulus (coming from other than the laugher) is commonly pro-
vided, and laughter is triggered. In the second case, it occurs by
the laugher him/herself (purposeful laughter). Modern laughter
therapy is based on the following fundamental principle: through
several exercises, techniques, activities, and dynamics, a person or
a group of people is taken to a feeling of lack of inhibitions to
achieve the binomial self-induced laughter-spontaneous laughter
and to experience its physical, psychological, emotional, and spir-
itual benefits. The human brain is not able in the end to distin-
guish spontaneous from self-induced laughter (“motion creates
emotion” theory); therefore, their corresponding health-related
benefits are alleged to be alike, as some authors contend.”
However, further research is warranted to confirm this assump-
tion (no studies were identified in this review). Indeed, self-in-
duced stimulated laughter may lead to a higher “laughter
exposure” both by achieving greater intensity and duration at will
or by triggering contagious and turning into spontaneous laugh-
ter, which might create greater accompanying psychophysiologi-
cal changes.”‘” As a laughter type, self-induced simulated laughter
is becoming increasingly popular worldwide, as it is the founda-
tion of the Laughter Club movement (Laughter Yoga).'””

Laughter Research Pitfalls and Flaws
Though some of the studies on the effects of laughter

TABLE 5 Laughter Medicine: Main Characteristics of Spontaneous
Laughter and Self-induced Simulated Laughter

Genuine expression of

positive emotions

Humor-related

Laughing “at” or “with”
others

Personal engagement/
effort to think

Presence of “Duchenne

laughter/smile”‘

Together with hodily
motion

One’s own fi-ee will

Triggering off stimulus

Contagious

Sett-control on intensity

and duration

Presence of vocal sounds

Most common

vocalizations

Evidence of therapeutic
value in medicine

Best dynamics for exper-
imenting laughter

Spontaneous
Laughter

Yes

Very often, but not

always

Commonly “at”

Often necessary

Very often (when not

fake)

Yes (uncontrolled)

No, unrelated

Identifiable (extemal)

Yes (often)

Minimum or less

Common (50%)'”

Ha/ho

Some studies
conducted

In a group

*Contraction of the muscles around the eye socket.

Self-induced
Laughter

Sometimes

Rarely

Always “with”

Rarely necessary

Often

Yes (controlled)

Yes, purposeñil

None (sett’-induced)

Yes (very often)

Maximum or more

At will

At will:

ha/he/hi/ho/hu

and others

Very few studies

Alone/in a group

marked a new start in research called psychoneuroimmunology,’™
which explores the interactions between the central nervous sys-
tem and the immune and endocrine systems, not all of these
research attempts have been completely successful. The highest-
quality studies were executed on the effects of a humorous stimu-
lus (comic movie) and subsequent laughter on pain tolerance,
which provide strong evidence of increased long-term effects not
merely due to distraction.’However, there is still not enough
empirical evidence that hearty laughter has pain-killing effects or
that laughter stimulates the production of endorphins, other
neurohormones (human growth hormone, oxytocin, melatonin,
prolactin, adrenocorticotropic hormone) and neurotransmitters
(serotonin, dopamine, others).^”‘™The weakest investigations are
those on endocrine stress markers (serum cortisol, salivary, chro-
mogranin A levels, others) and immune system parameters.'”‘
The results were not consistent or conclusive because method-
ological flaws might have prevented the expected physiological
“benefits” from being detected.”

60 ALTERNATIVE THERAPIES. NOV/DEC 2010, VOL. 16. NO. 6 Therapeutic Value of Laughter in Medicine

The criticisms of the weaknesses and quality of the studies
conducted are focused mainly on internal design fiaws and inval-
id/lack of generalizability of results. The main internal flaws
identified, some of them reported elsewhere,^’ included the fol-
lowing: small sample size (210 participants), no randomized
design, inadequate or nonexistent control groups, no standard-
ized baseline measurement, unreliable measures of blood and
saliva assays, no statistical tests or too many, failure to distin-
guish laughter from humor, failure to confirm the presence of
laughter, suboptimal laughter exposure (either insufficient dura-
tion or intensity), failure to differentiate short-term from long-
term effects, and many other confusion factors. Collectively,
current available data reviewed suffer simply ftom too few well-
designed studies to draw valid conclusions about some of the
health-enhancing changes produced from laughter.™

DISCUSSION
In this review, the focus was placed on laughter research

occurring either in the presence or humor or in its absence and
related health benefits. This distinct approach makes this narra-
tive review unique, as most of the previous studies and reviews
have assessed mainly (sense of) humor interventions and their
outcomes, where, unfortunately, laughter, as a common response
to humorous stimuli, was not always present, measured, or moni-
tored.” However, this review may have been limited by the amount
of humor and laughter literature available; the numerous defini-
tions and fields and different methodologies and outcomes ftom
where it emerged; the failure to adjust for the presence, duration,
or intensity of laughter and corresponding effects; and the overall
complexity of the laughter phenomenon itself

Laughter Research Challenges and Future Directions
Laughter research designs can be quite challenging. As pre-

vious studies indicate, some individuals who are exposed to a
humorous stimulus do not always laugh. To help control for this,
it is crucial that fiiture laughter research includes some measure
of subject response to the humorous stimuli whenever it is used
to help elicit laughter. An alternative design to help preclude
laughter absence and to adjust for its intensity and duration is to
conduct self-induced siniulated laughter intervention trials.
Although it has been reported that very few people are able to
convincingly laugh on command,’self-induced laughter is entire-
ly achievable and appears to be the most realistic, sustainable,
and generalizable intervention to be used in future laughter
research. In this review, only two studies experimenting with
purposeful laughter and then assessing its health effects were
identified.’*”‘”‘ Another methodological concern is that of control
groups. The need for at least two additional control groups has
heen suggested’; a negative one to control for the eftect of general
emotional arousal and a positive one to control for positive emo-
tions that are not necessarily laughter-oriented. Larger samples
of healthy subjects and trials in different clinical populations also
are warranted. Therefore, it may he useful for researchers in an
area dominated by psychology to carry out interdisciplinary

studies involving experts from different health care fields.
Laughter researchers also may have difficulty defining pre-

cise and measurable outcomes for a therapy for which the main
effect is often subjective or dependent on the skill of the practi-
tioner and the laugher him/herself. Laughter therapy often has
to be tailored for an individual’s specific needs and may not be
able to be studied at a conventional “active ingredient” or “dose”
level. Moreover, individuals frequently use a variety of CAM
modalities simultaneously or adjunctively with conventional
therapies, which may attenuate or magnify treatment effects.
Some of these challenges have not been properly addressed
through alternative study designs. Collectively, research on
laughter is still in its infancy, and many efforts are required to
enhance the quality and validity of trial designs and health-relat-
ed outcomes, with the imperative need of distinguishing (sense
of) humor and laughter. Clearly, more groundwork is needed to
determine the hest methods of assessing and documenting
health-related outcomes on laughter in different patient popula-
tions. One of the first steps may have been performed by Kimata
et al,™ who recently puhlished some remarkable results on “dia-
phragm EMG (electromyogram),” the first exact system for the
measurement of laughter itself. This measuring system can speci-
fy the starting point and duration of laughter precisely of 1/3000
second; therefore, it will make detailed analysis of the healthy
effects of laughter possible in different clinical settings.
Furthermore, the authors state that this method is suitable as a
precise way to assess any kind of laughter and does not require
any special medical or mechanical techniques, so it also may be
useful for other, nonmedical purposes.

Laughter as Medicine
Western thinking around laughter as a medicine began to

crystallize in 1976 when Cousins published his “Anatomy of an
Illness.” However, inviting and facilitating laughter in therapy is
not the same as developing and using humor to make the patient
laugh. Humor is not necessary to have subsequent laughter.
Adults can laugh without it, as do infants and children. While
laughter medicine takes skill and time to he developed, laughter
therapy itself can be implemented easily and is cost-effective in
patient care.^” Health care professionals do not have to be stand-
up comics, clowns, or magicians to bring laughter into clinical
settings. Just acknowledging how important laughter can be and
having a cheerful and spirited approach is a good place to start.
After all, half of the benefit of laughter, in addition to healing, is
sharing it.”‘ Nevertheless, the health community is still slow in
accepting and considering laughter as a healing tool within
CAM.”* In order to offer patients the benefits of laughter, health
care professionals must be willing to break loose from conven-
tional therapeutic constraints, regain their own laughter, and
learn the techniques to facilitate laughter in their patients.
Laughter deserves a special place in medical practice and daily
life. This is the mission of the Association for Applied and
Therapeutic Humor, an international community of medical,
education, and public speaking professionals who study, practice.

Therapeutic Value of Laughter in Medicine ALTERNATIVE THERAPIES. NOV/DEC 2010. VOL. 16. NO. 6 61

and promote healthy humor and laughter. Based in Spain, the
“Organización Mundial de la Risa” also is investing in laughter
research and training.

Laughter Medicine for Health Care Professionals
Laughter is important in medicine and may enhance conver-

sation between health care professionals and patients.””™ The
abüity to laugh with a patient is a sign of good rapport. Mutual
understanding while sharing some laughs may be more important
than the diagnosis or formal treatment.”‘ Laughter is also a quali-
ty-of-life and well-being enhancement therapy for both health care
professionals and patients.’** Laughter may help dissipate tension,
fear, frustration,”and other stress such as “burnout,” which is
becoming increasingly more common and troublesome among
today’s medical staff.'”‘™ However, laughter is an often neglected
resource in managing personal and professional stress. Proponents
of “positive psychology” have identified humor and laughter as one
of the 24 positive personal “values and attributes.””‘”^ Therefore,
health care professionals can play a significant part in eliciting bet-
ter understanding of laughter benefits in clinical conditions and
real-world life for both patients and themselves. But like any other
skill, the effective use of laughter for therapeutic purposes needs to
be learned, practiced, and developed. Practical guidelines or advice
on laughter therapy have not been developed as yet to help health
care professionals (and others) implement laughter techniques in
their health care portfolio.

CONCLUSIONS
According to this review, the following can be concluded on

the evidence-based therapeutic value of laughter in medicine:

• Current empirical data for the psychological benefits
associated with laughter is stronger than that of its physi-
ological benefits; however, fiarther well-designed research
is warranted in all of these areas.

• Overall, there are not enough research findings to conclude
that laughter is an all-around healing agent, but there is
sufficient evidence to suggest that laughter has some posi-
tive, quantifiable effects on certain aspects of health.

• Laughter as a medicine, as a mind-body therapy for
health care, is almost never used in “traditional” clinical
settings and often overlooked as a form of CAM.

• In this era of evidence-based medicine, it seems appropri-
ate that laughter therapy takes its place as a CAM disci-
pline in the prevention and treatment of illnesses.

• The following seems to be good advice for both patients
and health care professionals: “Add laughter to your
working and daily life, remember to laugh regularly,
share your laughs, and help others to laugh, too.”

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