Psychological Well-Being

PREFACE Psychological well-being is a subjective term that means different things to different people. Psychological he...

Author: Ingrid E. | Ed. Wells

342 downloads 2396 Views 3MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!
Report copyright / DMCA form

DOWNLOAD PDF

PREFACE Psychological well-being is a subjective term that means different things to different people. Psychological health, otherwise called mental health, is a relative state of mind in which a person who is healthy is able to cope with and adjust to the recurrent stresses of everyday living in an acceptable way. This book discusses topics such as: sexuality as a critical factor for health, quality of life and well-being, the well-being of Russian and Ukranian adolescents in the post-Perestroika period, participation in sports and its potential to confer numerous physical and psychological health benefits, work-related stress and its relation to ill-health and decreased productivity, among others. Chapter 1- Referring to the popular saying that laughter is the best medicine, many things are mixed up, for instance, laughter, exhilaration, humor, cheerful mood, and cheerfulness as a trait. In the media, putative facts are wrongly interpreted or made up and unreflectively copied again and again. Several of the misconceptions have even found their way into scientific publications. This chapter attempts to clear up some popular misunderstandings and the confusion of concepts, and explains which of those are related to health or well-being and which cannot be related to health at all. Special emphasis is placed on cheerfulness, which is a well-defined psychological construct. Added to this are some explanations and tips that may help the readers to be more critical towards study reports themselves. Finally, author discuss what may be the use of common laughter- and humor-related courses or workshops, and how the development of a more cheerful disposition could be promoted. Chapter2- The positive psychological functioning has received several approaches along the history. Author must distinguish between the hedonic approach, which speaks of the ―subjective well-being‖ relating it to happiness, and the eudaemonic approach, which relates the ―psychological well-being‖ to human potential development. In this second thinking trend author find authors like Maslow and Rogers. These authors focused on self-actualization and on the view of the fully functioning person respectively, as ways to achieve well-being and personal fulfillment. More recently, Carol Ryff has divided this construct in 6 dimensions: Self-acceptance, Positive relations with others, Autonomy, Environmental Mastery, Purpose in Life and Personal Growth. In order to asses the 6 dimensions mentioned, Ryff created the ―Psychological well-being scales‖, with 20 items each. After that, shorter versions have been proposed, due to the 120 items of the original ones. Psychological well-being positively correlates to factors as satisfaction with life, selfesteem or internal control, and negatively to depression or the powerful others.

ii

Ingrid E. Wells

Likewise, the health levels positively correlates to the 6 factors of the psychological wellbeing above. When author speak about psychological well-being by sex, women have higher scores in ―relations with others‖ and in ―personal growth‖, even though men get better scores in selfesteem and self-concept. As for differences by ages, literature speaks about higher scores in the group of aged people on some factors, like ―autonomy‖ and ―environmental mastery‖. In other factors like, ―personal growth‖ and ―purpose in life‖, young people have higher scores. Regarding the differences by education and occupation level, the psychological wellbeing positively relates to a higher educational and occupational level. Maintaining a good psychological well-being level can be an important protective factor when it comes to suffer several physical or psychological problems, and it is interesting to investigate the extent to which influences the development and evolution of certain health problems. Chapter3- Two hundred and fourteen employees, 136 men and 78 women, responded to Subjective Stress Experience Questionnaire, Stress and Energy Scale, Hospital Anxiety and Depression Scale, Job Stress Survey, Partnership Relations Quality Tests (e.g. Sexual life Satisfaction, and Partnership Relation Quality), and Positive and Negative Affect Scale. Health-promoting advantages of sexual life satisfaction in counteracting illhealth associated with different types of stress were observed. Men participants‘ Sexual life Satisfaction was predicted by intercourse frequency, accordance with desired frequency, intercourse satisfaction, frequency of sexpartners, women‘s participants‘ Sexual life Satisfaction was predicted by intimate communication, caressing and cuddling, and desire. Level of Sexual life Satisfaction and gender influenced coping (e.g. cognitive, emotional, social), depression anxiety, Partnership Relation Quality, thoughts of divorce, negative affect, general stress, and dispositional optimism. Regression analyse showed that work-stress was predictive and sexual life satisfaction was counter-predictive for depression, anxiety, general stress and psychological stress and thereby buffering the negative effects of work stress. Chapter4- From the beginning of the 21st century, most of the republics of the former Soviet Union enjoyed a period of rapid economic growth and relative political stability which, however, in some countries, was accompanied by restrains of civil rights (Baker and Glasser, 2007; Shevtsova, 2005). This is in sharp contrast to the previous period of perestroika, which was characterized by drastic democratic reforms, but also by political turmoil, economic instability, and social unrest (Yakovlev, 1996). The effect of the recent socio-economic changes on the psychological well-being of the citizens of the former Soviet Union has not yet been investigated, and this study aims to partially fill this gap. In the present article, author compare macro-level socio-economic indexes in Russia and Ukraine in 1999 and 2007 and analyze socio-economic changes that occurred in the two countries during these years. Author compare the psychological well-being of adolescents who attended high schools in Russia and Ukraine in 1999 with that of adolescents who attended high schools in these countries in 2007. Finally, author examine the demographic, socioeconomic, and psychological variables that affect the adolescents' psychological well-being. Chapter5- Objectives: The purpose of this study was to examine the utility of ‗additive‘ versus ‗balanced‘ models for understanding the relationship between perceived psychological need satisfaction derived from adapted sport and global well-being.

Preface

iii

Methods: Participants (N = 177; 51.41% male) drawn from cohorts reporting either a sensory (15.2%) or physical (80.1%) disability completed a self-report instrument capturing perceived competence, autonomy, and relatedness experienced in adapted sport and global self-esteem using a cross-sectional design. Results: Bivariate correlations revealed positive relationship between indices of perceived psychological need satisfaction and between fulfillment of competence, autonomy, and relatedness needs via sport with global self-esteem. Multiple regression analyses indicated that ‗balanced‘ psychological need satisfaction did not account for additional variance in global self-esteem after controlling for the contributions of individual needs in the ‗additive‘ model. Perceived competence was the strongest predictor of global self-esteem followed by perceived autonomy and relatedness. Conclusions: These observations provide support for an ‗additive‘ model extrapolated from Deci and Ryan‘s (2002) assertions more so than a ‗balanced‘ model (Sheldon and Niemiec, 2006) with regards to understanding the relationship between fulfillment of basic psychological needs and well-being in adapted sport athletes. Further research examining the role of ‗additive‘ versus ‗balanced‘ models in reference to understanding issues of strength versus integration of perceived psychological need satisfaction seems warranted with additional emphasis on broadening the scope of well-being criterion assessed in adapted sport contexts. Chapter6- Asperger Syndrome (AS) is marked by severe social impairments. Despite a rising prevalence of AS (Edmonds and Beardon, 2008), there are few studies of these individuals, especially those concerning their social well-being. This paper reviews studies on humor and discusses its role in the social functioning of people with AS. Although studies are few, research generally suggests that individuals with AS are somewhat impaired in their ability to process humorous materials due to fragmented cognitive processes. Because humor plays an essential role in social interactions in everyday life, these findings suggest that the lack of ability to appreciate humor may be partly responsible for the social deficits in people with AS. There is a need for more research into the social competence of individuals with AS, especially in relation to the use of humor in regulating social behaviors. Chapter7- This study examined the relation between the Big Five personality traits and eudaimonic well-being in Iran, which is an understudied country in the well-being literature. Participants were 240 undergraduates at the University of Tehran. In this study, purpose in life, personal growth, and social well-being scales were used to assess eudaimonic well-being, given the central role these constructs play in the existing models of eudaimonic well-being. Findings revealed that, among the Big Five personality traits, conscientiousness and neuroticism were the most vigorous predictors of eudaimonic well-being. Results also revealed that male students scored significantly higher than female students on social wellbeing. Furthermore, gender moderated the relation between eudaimonic well-being and two traits of extraversion and agreeableness. These relations were significantly stronger for male students than female students. Implications of the results are discussed. Chapter8- Background. Work-related stress is known to be a cause of ill health and decreased productivity and work in the education sector is thought to be particularly stressful. However few studies have considered health outcomes or personal risk factors predictive of work-related stress and health in head teachers.

iv

Ingrid E. Wells

Aims. To investigate health and job commitment in head teachers in West Sussex, UK and to determine personal risk factors most likely to predict cases of work-related stress and those with poor health in this group. Methods. A cross sectional study, by postal questionnaire, in a population of 290 head teachers and college principals. The measuring instrument was a validated questionnaire, ASSET (a short stress evaluation tool) and additional questions derived from previous studies. ―Caseness‖ was defined as respondents who felt work was ―very or extremely stressful‖. Results were compared with those for a general population of workers (GPN) and a group of managers and professionals (MPN). Results. Prevalence rate of work-related stress in head teachers was 43%. Head teachers had higher levels of job commitment but poor physical and mental health when compared to a general population group. Psychological well-being, particularly of females and primary head teachers, was also worse than a comparative group of managers and professionals. Teaching less than 5 hours per week was a significant predictor of caseness. Female gender was a significant predictor of poor psychological well-being. Conclusion. Prevalence of stress in head teachers in West Sussex is high and has an effect on psychological well-being in particular. Compared to other similar professionals head teachers have poor psychological health. Gender and school type influences outcome, female head teachers have worse health outcomes. Chapter9- Even though the wellbeing literature in psychology is fairly massive, earlier attempts at defining the term have failed to emphasize the pertinence of cultural factors in obtaining a more socially appropriate definition of the term. Hitherto, diagnostic manuals and authors in the area of mental health have been largely driven by medically related models as backgrounds in giving explanations in the area of psychological wellbeing. However, many societies (with their pre-historic values and precepts) had long existing frameworks for establishing psychological health or illness before the advent of current nosological approaches. While it is inappropriate to question the scientific basis of current theories, advancing knowledge within the vicissitudes of our historical past in the context of newer information require the adoption of current gains in scientific transformation of the area of psychological health; considering peculiar traditional perception of mental health and illness across cultures. This paper attempts to illustrate the relevance of culture and sub-cultural practices in defining the concept of psychological well being, yet appreciating the need to situate these within the global definition of psychological health. When this is adopted by psychologists and other mental health practitioners, establishing individual and group norms on the mental health-illness continuum will be more society and context specific. The divergence will also yield broader explanations to the existing dogmas in diagnostic criteria in mental health literature. With this in view, the discipline of psychology will be adding value to evidence based assessment and diagnosis, strengthening the insistence on reliability and validity in psychology. Chapter10- The Estonian translation of the Oxford Happiness Measure (a derivative from the Oxford Happiness Inventory) was completed by a sample of 154 students. Two main conclusions can be drawn from the data generated by the study. The first conclusion concerns the coherence of this Estonian translation of one of the instruments within the Oxford family of happiness indices. Given the high level of internal consistency reliability of the careful translation of the parent instrument, it is reasonable to assume that this translation is accessing

Preface

v

the same psychological domain as the parent instrument. On the basis of the present findings it is clearly worth investing in further validation studies using the Estonian instrument. The second conclusion concerns the broader value of the Oxford Happiness Measure. While the present study appears to have been the first formal attempt to publish on the psychometric properties of this derivation from the Oxford Happiness Inventory, the data suggest that this more straightforward and more economical version of the original instrument functions with a similar high level of internal consistency reliability. On the basis of the present findings it is clearly worth investing in further reliability studies using the original English language form of the instrument. Chapter11- Self Determination Theory (Deci & Ryan, 2000) hypothesizes that psychological needs for autonomy, competence, and relatedness are essential for psychological health. The 16 fundamental motives posited by Reiss (Reiss & Havercamp, 1998) have also been proposed as primary motivational variables. Reiss criticizes basic need theory because it assumes that intrinsic motivation is based on pleasure. The present chapter addresses similarities and differences between psychological needs and fundamental motives and their relations to well-being. Data is presented regarding the relations of needs and motives to both eudaimonic and hedonic aspects of well-being as measured by (a) meaning in life, and (b) positive and negative affect, respectively. Also addressed are the relations of needs and motives to intrinsic and extrinsic motivation. Results showed all three needs and several fundamental motives were related to measures of well-being. None of the needs, but several of the motives, were related to intrinsic motivation. Results suggest there are basic differences between psychological needs and fundamental motives but both are important to psychological adjustment.

PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

PSYCHOLOGICAL WELL-BEING

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS Additional books in this series can be found on Nova‘s website at: https://www.novapublishers.com/catalog/index.php?cPath=23_29&seriesp=Psychology+ of+Emotions,+Motivations+and+Actions

Additional e-books in this series can be found on Nova‘s website at: https://www.novapublishers.com/catalog/index.php?cPath=23_29&seriespe=Psychology+ of+Emotions,+Motivations+and+Actions

PSYCHOLOGY OF EMOTIONS, MOTIVATIONS AND ACTIONS

PSYCHOLOGICAL WELL-BEING

INGRID E. WELLS EDITOR

Nova Science Publishers, Inc. New York

Copyright © 2010 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‘ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Psychological well-being / editor, Ingrid E. Wells. p. cm. Includes index. ISBN 978-1-61209-258-4 (eBook)

Published by Nova Science Publishers, Inc.  New York

CONTENTS Preface Chapter 1

i Don't Take an X for a U: Why Laughter Is Not the Best Medicine, but Being More Cheerful Has Many Benefits Ilona Papousek and Günter Schulter

Chapter 2

Psychological Well-Being, Assessment Tools and Related Factors Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez, Fernando Andrés Pretel, José Miguel Latorre Postigo and Francisco Escobar Rabadán

Chapter 3

Sexual Satisfaction as a Function of Partnership Attributes and Health Characteristics: Effect of Gender Ann-Christine Andersson Arntén and Trevor Archer

Chapter 4

Chapter 5

The Psychological Well-Being of Russian and Ukrainian Adolescents in the Post-Perestroika Period: The Effects of the Macro- and Micro-Level Systems Eugene Tartakovsky Strength Versus Balance: The Contributions of Two Different Models of Psychological Need Satisfaction to Well-Being in Adapted Sport Athletes Virginia L. Lightheart, Philip M. Wilson and Kristen Oster

Chapter 6

Asperger Syndrome, Humor, and Social Well-being Ka-Wai Leung, Sheung-Tak Cheng and Siu-Siu Ng

Chapter 7

Big Five Personality Traits as Predictors of Eudaimonic Well-being in Iranian University Students Mohsen Joshanloo and Samaneh Afshari

Chapter 8

Health, Job Commitment and Risk Factors Associated with SelfReported Work- Related Stress in Headteachers: Cross Sectional Study Samantha Phillips

1 77

115

135

157 171

185

199

vi Chapter 9

Chapter 10

Chapter 11

Index

Contents The Need for Cultural Contextualisation in Establishing Psychological Wellness or Illness Adebayo O. Adejumo Internal Consistency Reliability of the Estonian Translation of the Oxford Happiness Measure: Contributing to Positive Psychology in Estonia Ahto Elken, Leslie J Francis and Mandy Robbins Relations of Fundamental Motives and Psychological Needs to Well-Being and Intrinsic Motivation Kenneth R. Olson and Brad Chapin

213

223

231 245

In: Psychological Well-Being Editor: Ingrid E. Wells, pp. 1-75

ISBN 978-1-61668-180-7 © 2010 Nova Science Publishers, Inc.

Chapter 1

DON'T TAKE AN X FOR A U: WHY LAUGHTER IS NOT THE BEST MEDICINE, BUT BEING MORE CHEERFUL HAS MANY BENEFITS Ilona Papousek and Günter Schulter Karl-Franzens-University, Department of Psychology, Graz, Austria

ABSTRACT Referring to the popular saying that laughter is the best medicine, many things are mixed up, for instance, laughter, exhilaration, humor, cheerful mood, and cheerfulness as a trait. In the media, putative facts are wrongly interpreted or made up and unreflectively copied again and again. Several of the misconceptions have even found their way into scientific publications. This chapter attempts to clear up some popular misunderstandings and the confusion of concepts, and explains which of those are related to health or wellbeing and which cannot be related to health at all. Special emphasis is placed on cheerfulness, which is a well-defined psychological construct. Added to this are some explanations and tips that may help the readers to be more critical towards study reports themselves. Finally, we discuss what may be the use of common laughter- and humorrelated courses or workshops, and how the development of a more cheerful disposition could be promoted.

INTRODUCTION "Be careful about reading health books. You may die of a misprint", said Mark Twain. Misprints may occur. But the claims that laughter makes you healthy and happy, improves the world, and prevents wars must be intended as a joke. The fact that astoundingly many people do not laugh about these jokes might indicate that not all people who are concerned with laughter also have a well-developed sense of humor. Generally, in the context of health-

2

Ilona Papousek and Günter Schulter

related issues many things are mixed up, not only laughter and humor, but also exhilaration, cheerful mood and cheerfulness as a trait. The confusion begins with the popular saying "Laughter is the best medicine". Very likely, there was a time when this proverb read a bit differently, that is, "A cheerful heart is good medicine" (Bible, 17,22; or "A merry heart doeth good like a medicine). This older variety of the saying is nearer to the truth than the mistakable 'Laughter is the best medicine', which has probably developed from the initial proverb at some time (which, by the way, continues with "... but a broken spirit dries up the bones"). Other clever proverbs are not nearly as readily circulated; for instance, "Even while laughing a heart can ache" (14,13). But an aching heart is not cheerful, and only a cheerful heart is good medicine … Referring to the saying "Laughter is the best medicine", putative facts are often wrongly interpreted or made up in the media and, because they sound so pleasant, unreflectively copied again and again without further research, and with a little amplification added from time to time. If some information repeatedly turns up in the media, in time most people believe it. Not even scientists are immune to being deluded. Consequently, some of the misconceptions spread by the media at times even turn up in scientific publications. This chapter attempts to clear up some popular "misprints" in the media and to straighten out which concepts are mixed up and which of those are related to health and which cannot be related to health or well-being at all. It explains from a natural scientist‘s point of view why cheerfulness, which is a well-defined psychological construct, can have many benefits for health and well-being, and which of these are in line with current scientific evidence—and which are not. Finally, some simple interspersed tips should help those who are interested to become more critical towards reports in the media themselves. Surely new ones are added every week. The authors are biological psychologists who, in the framework of their research on emotion and psychosomatics, have also been concerned with laughter-, humor-, and cheerfulness-related issues for several years. For some time, the first author was also engaged as a teacher in training programs for people who offered humor or laughter courses or planned to offer such courses. There, and in numerous encounters with journalists, she came across the same mistakes and fallacies again and again. She has been confronted with great difficulties to correctly estimate the worth of reports in the media, and with the attempts to substantiate the usefulness of laughter- or humor-related courses with putative facts that were wrongly interpreted, or were false altogether, or made-up, or had nothing to do with the offered course at all. She also got to know the stubborn resistance against information that was not in line with what people believe or what they would like to believe. Certainly, it is the personal choice of an individual to learn what scientific evidence can prove and disprove in the aggregate, or to rather keep believing in what he or she believes or the Guru believes or pretends to believe. However, as experience teaches, most people who actually do not want to know anything, do want to know what it is that they don't want to know. Therefore, this chapter should be interesting for those who would like to know why and how cheerfulness can improve well-being, and which benefits can be expected and which not.

Don't Take an X for a U: Why Laughter is Not the Best Medicine …

3

But it should also be interesting for those who do not actually want to know, and in particular for those who do not want to take an X for a U1.

WHAT IS MEANT BY CHEERFULNESS? In the following, we use the term "cheerfulness" or "trait cheerfulness" to designate a temporally stable affective trait, that is, a habitual disposition that people have for months or years. Trait cheerfulness manifests itself in various ways. Cheerful people have a positive and light-hearted attitude to life, they approach difficult situations and adversity with humorous serenity and are less affected by them. They get in a cheerful mood more easily and more often and adopt a cheerful and humorous attitude in social situations (Ruch and Zweyer, 2001). It may also be helpful to add what is not meant by cheerfulness, that is, to demarcate the term from other terms that may come into one's mind. To discuss seriously whether laughter or cheerfulness may be good for your health or well-being, it is important to keep several concepts apart and to ask which of those may actually be beneficial. First, it is important to differentiate which aspect is to the fore: the emotional, the cognitive, or the behavioral aspect. The emotional aspect relates to how one is feeling. Cheerful mood and exhilaration are relevant feelings in this context. Humor, in the sense of perceiving something as funny, is a cognitive phenomenon. It primarily relates to thinking, to grasp, to understand something. It is a matter of recognizing the punch line of a joke or of recognizing the absurdness of a situation or an event. Actually, humor is a broad concept that has been defined either as the perception of something as funny, the ability to perceive something as funny ("humorous people", "sense of humor"), or also as something that is perceived as exhilarating (e.g., a certain kind of joke; "that's my kind of humor"; Forabosco, 1992). Smiles and laughter are behavioral aspects. They relate to what one is doing, the movements of the facial muscles and the voice box (Figure 1). These aspects are not simply interchangeable without further ado; they are not synonyms. Laughter, humor, and cheerful mood may also occur independently of each other. Different brain regions contribute to each of the three aspects, their physiological concomitants differ, and they have different effects on one's own behavior and on the behavior of the people around (Goel and Dolan, 2001; Iwase et al., 2002; Wild et al., 2006). It is of course true that there are situations in which two or all three aspects are active together. For instance, laughter (behavior) and cheerful mood (emotion) are often a consequence of humor (the perception of something as funny). But smiles or laughter may also occur in situations that have nothing to do with cheerful mood or humor, for instance, in a state of shock, during aggressive disputes, to express superiority, or to subvert power structures or challenge the status of others.

1 Roman numbers were written as letters: X was used for 10 and V (later written as U) for 5. Thus, someone who "made an X for a U" tallied up double the amount. "To make an X for a U" figuratively means to cheat someone.

4


Figure 1.

Figure 2.

Various kinds of humor have nothing to do with cheerful mood, either, for instance, cynical or hostile humor (Arendt, 1986; Darwin, 1872; Van Hooff, 1972; Ruch, 1993a). Second, it is very important to differentiate within the emotional part between cheerful mood, exhilaration, and cheerfulness as a trait (Figure 2). Cheerful mood refers to the currently dominating feeling, that is, one feels cheerful, lighthearted, in a good mood for a couple of minutes or a bit longer. Exhilaration refers to the process of becoming cheerful. One is exhilarated by something and then in a cheerful mood for a while (Ruch, 1993b). Trait cheerfulness refers to a habitual disposition that people have for months or years, a general disposition to feel cheerful. Even people with a pronounced cheerful disposition are not continuously in a cheerful mood but are also sad or angry from time to time. The other way around, someone who is exhilarated or feeling cheerful right now, at the moment, is not necessarily someone who has a habitual disposition to cheerfulness. A further concept that should be distinguished from cheerfulness is happiness. In psychology, happiness either refers to a positive mood state triggered by a certain condition such as sex, beautiful music, or winning a competition, or is used as a synonym for life satisfaction. In different schools of philosophy and religion, happiness is defined in various


5

ways, which also finds expression in substantial cultural differences. None of these variants is included in the definition of trait cheerfulness. Consequently, for the mentioned and other reasons, what is said in this chapter about cheerfulness does not equally hold true for exhilaration, cheerful mood, humor, laughter, or happiness.

IS LAUGHTER “HEALTHY”? A saying like "Laughter is the best medicine" exists in many cultures. But what is actually meant by it (or should be meant by it)? The saying seems to mislead many people to believe that the action of laughing by itself may be healthy. But what can really be beneficial: The behavior (laughter), the cognitive aspect (perceiving something as funny), the feeling of being exhilarated, or cheerfulness as a disposition? The misconception that the action of laughing may be healthy by itself is supported by many media reports that are obviously governed by a strong popular belief (Mahony, Burroughs, and Lippman, 2002). But there is no convincing scientific evidence that laughter as such may be beneficial in some way or other. Studies that are readily cited by the media and in the Internet often suffer from appalling methodological flaws; sometimes they do not even exist, or they are actually studies on exhilaration or cheerful mood. Evidence that does not correspond to the belief is swept under the table; putatively supportive reports, in return, are copied over and over again. Thus, taken together, a picture is drawn in the media and in the internet that is not in accordance with the actual state of research at all. Sometimes it is argued that laughter may be healthy because it is associated with deeper breathing and, thus, should have the same effects as breathing therapy or breathing meditation. But the physiological effects of laughter do not correspond to the effects of deep breathing in the context of relaxation. Some are even diametrically opposed. For instance, relaxed deep breathing lowers blood pressure, whereas laughter temporarily increases blood pressure (McMahon, Mahmud, and Feely, 2005; Mori et al., 2005). The only possible immediate beneficial effect of laughter by itself may have something to do with breathing, though: Hearty laughter is associated with increased expiration and a marked narrowing of the diameter of the airways. For sheer physical reasons, this results in higher speed of airflow. That can provoke irritation of the throat and a cough that could perhaps facilitate the ejection of particles or mucus from the airways and might represent a certain short-term benefit for smokers, for example. But two or three breaths later, everything is as it was before, and the process does not have any health effects in the longer term. In asthma patients, for instance, these temporary changes of the respiratory system can even be unfavorable and may provoke or promote an attack (Filippelli et al., 2001; Liangas, Yates, Wu, Henry, and Thomas, 2004). Another constantly recurring claim is that laughter may relax the muscles. But measures of muscle tension during and after laughter showed that that is not true, either. While laughing, the muscles are even more tense than before. The fallacy of muscle relaxation has probably developed from the observation that during very hearty laughter, the knees may soften and bend and people prostrate. But this is attributed to the inhibition of a reflex through which small alterations in muscle tone are immediately corrected and which normally helps to keep standing in spite of gravity. Therefore, this effect is not due to muscle relaxation but to a temporary muscle weakness. The excitability of muscle fibers is reduced, similar to the

6


feeling not to be able to lift the arm or the leg any more after intense physical effort. Beyond that, this effect is not due to laughter as such, but to the emotional arousal during intense exhilaration. Intense negative emotional arousal has exactly the same effect (Chapman, 1976; Overeem, Lammers, and Van Dijk, 1999; Overeem, Taal, Ocal, Lammers, and van Dijk, 2004). It has no relevance to health or well-being whatsoever. Laughing very heartily can also be quite exhausting, thus, people may also mix up the feeling of exhaustion with that of relaxation. One of the most widely cited and therefore well-known stories in this context is that of the publicist Norman Cousins who allegedly recovered from ankylosing spondylitis, a rheumatoid disease through laughter (and wrote a book about it). This story does not qualify as a proof of beneficial effects of laughter at all, because it is completely obscure what may have actually promoted Cousins' recovery. It could as well have been his enormous Vitamin C consumption, a particular personality trait such as optimism or a will to live, some other factor, chance, or the disease might have been misdiagnosed in the first place (Martin, 2001). To be able to attribute disease and recovery to a particular reason and exclude other reasons, legends and journalistic self-reports are no suitable means. For this, controlled scientific studies in large samples are needed. But there is no evidence from serious scientific studies at all that one might be able to "laugh away" rheumatoid or other diseases. (See also "Don't take an X for a U, Tip 1" and "Tip 2"). These are only a small selection of popular fallacies. In general, there is no scientific evidence that laughter as such, the behavior, the motor action of laughing may have any benefits that could be relevant to the preservation or recovery of health or well-being. Similar can be said about humor in general (Martin, 2001). However, humor should be considered in a more differentiated way. A certain form of humor can be regarded an element of trait cheerfulness (see "Stress and strain" and "Ways to enhance cheerfulness").

IS EXHILARATION “HEALTHY”? If it cannot be said that laughter as such, the behavior, is good for something; what about exhilaration and cheerful mood, then, that often accompany laughter? Unfortunately, relevant benefits are unlikely, if only because considerations of plausibility speak against it. That is because exhilaration and cheerful mood are present only briefly - and are gone again in a short time. Of course, you cannot expect that something that is there briefly and gone again in a short time may have effects that are of any relevance to health or well-being. Only such effects can be "healthy" that are present for some time. Most diseases and complaints do not develop because of a single short event, either, except perhaps bone fractures and intoxication. But then it has never been claimed that exhilaration may prevent from bone fractures and intoxication. What happens during exhilaration and temporary cheerful mood in the body: If it is intense enough, exhilaration causes a short-lived increase of heart rate and blood pressure, a transient rise of stress hormones, temporarily impaired lung function, and other effects that are related to emotional arousal such as minor changes in certain immune parameters. Exhilaration of lower intensity does not have any noteworthy physiological concomitants at all (Frazier, Strauss, and Steinhauer, 2004; Hubert, Moller, and deJong-Meyer, 1993; Levi,


7

1965; Martin, 2001; McMahon et al., 2005; Neuman and Waldstein, 2001; Pressman and Cohen, 2005; Ritz, George, and Dahme, 2000). The short-lived physiological changes that can be observed during and immediately after intense exhilaration are the same that are present during exposure to a stressor, when one is angry, worried, or frightened. That is, they follow all kinds of acute emotional arousal, no matter if it is positively or negatively valenced (Martin, 2001; Pressman and Cohen, 2005; Ring et al., 2000; Ritz and Steptoe, 2000; Watkins, Grossman, Krishnan, and Sherwood, 1998). Thus, the physiological concomitants of exhilaration are completely unspectacular. They correspond to a normal and usually harmless stress response of the body (see "Don't take an X for a U, Tip 4"). Such responses are completely normal and occur in everybody every day. They are important to meet changing demands that arise from emotional activation and other kinds of strain. It does not make a substantial difference, whether the stress is experienced negatively (such as the state during dental treatment) or positively (such as the state during a passionate kiss). At most, these short-term changes may be relevant to people who are already seriously ill, who, for instance, have chronic diseases such as cardiovascular disease or asthma, because they might trigger an attack (Pressman and Cohen, 2005). That, however, can hardly be referred to as "healthy" (see also "Cardiovascular health"). In healthy or largely healthy people, the transient physiological concomitants of exhilaration are not relevant to health or well-being at all. The same holds for the perception of something as funny (cognitive aspect, humor) and laughter (behavior). For the same reasons that apply to exhilaration, their concomitants, which ever they may be, cannot be "healthy". Most people accept that something that is there briefly and gone again in a short time cannot be relevant to health or general well-being. However, many people cling to the belief or the hope that the short-term effects of exhilaration may automatically become persistent, if they are often exhilarated. But that is not necessarily true. Short-term effects do not become automatically persistent, if one is just doing the things that elicit these effects more frequently. Although that may happen in some cases, in some cases the opposite may be true. In most cases, nothing at all happens in the long-term. For that reason, the findings of most studies that evaluate the effects of exhilaration (by cartoons, films, etc.) on physiological parameters are not conclusive. The short-lived changes of physiological functions that are observed in such studies do not allow conclusions about the occurrence and direction of persistent changes after frequent exhilaration. However, by far the most statements about putative health effects of exhilaration or laughter that are spread by the media have been derived from such studies that had only evaluated what had happened directly during exhilaration or a few seconds afterwards. But only physiological effects that persist can play a role for the development of complaints and diseases, changes that are still there when one is not exhilarated at the moment or is not currently laughing at something; changes that persist for such a long time that factors that are relevant to health or well-being may be durably altered. In addition, these changes must have a certain magnitude to make an impact on health or well-being (see also "Don't take an X for a U, Tip 5"). It is not possible to simply reason long-term, durable changes from the transient effects of short-term exhilaration or cheerful mood (Steptoe and Wardle, 2005). The same holds for humor (perceiving something as funny) and laughter. In this context, the wish often seems to be father to the belief. Moreover, many people do not seem to mind that their wishes are contradictory. People wish, for instance, that frequent exhilaration should cause a persistent increase in immune parameters (long-term effect same as short-term effect), but that blood

8


pressure and stress hormones should decrease (long-term effect opposite to short-term effect). Beyond that, people wish that the long-term changes produced by frequent exhilaration should be opposite to the consequences of stress or worry, although the short-term effects are the same. Taken together, in scientific studies that specifically aimed at evaluating differences between individuals who laugh frequently or infrequently, who like humor very much or not so much, or are joking frequently or infrequently none of these wishes could be convincingly confirmed. Professional humorists are not healthier and do not feel better than others, either (Martin, 2001; Svebak, Martin, and Holmen, 2004). Only then are there positive correlations with beneficial factors when frequent laughter and frequent joking is coupled with trait cheerfulness, a cheerful disposition, a positive attitude to life. But that is not necessarily the case. By far not everyone who laughs or jokes frequently has a cheerful disposition (Keltner and Bonanno, 1997; Korotkov and Hannah, 1994; Kuiper and Martin, 1998; Martin, 2001). Certain forms of humor and laughter have nothing to do with cheerfulness at all, such as cynical, hostile, disparaging or aggressive humor, sneering, cold, deprecating or wry smiles, nervous giggle, spiteful, sardonic, bitter, and faked laughter. In other words: For fundamental considerations alone, laughter, the perception of something as funny, exhilaration and transient cheerful mood cannot be "healthy". Only trait cheerfulness has the potential to slow down adverse developments of well-being and health and perhaps to improve existing problems. It will be outlined below to what extent there is in fact evidence for that.

DON'T TAKE AN X FOR A U Tip 1: Different People Are Different The media and the internet are full of stories about what is "healthy", drinking wine, laughing, a certain waist circumference, religious belief, sex, and much more. For several reasons, most of these claims should not be taken seriously. Certainly, scientific expertise and methodological knowledge and experience are required in order to be able to appropriately evaluate the worth of scientific and non-scientific information. Scientific experts in the field, who have learned and practiced that for many years, look up the original literature, evaluate the research report and the quality of the journal in which the report has been published, and never rely on one study only, but obtain an overall picture of the current state of knowledge. Of course, one cannot demand that from anyone else. (That is why scientists help out by writing books). But if one is interested, it is actually quite easy to tell apart wishful thinking and advertising messages from serious reports, it is just needed to pay attention to a few details. With our tips, we would like to make some suggestions for that. Sitting on the floor is good for your health! Do you sometimes suffer from headaches? In his talk in the community hall on Friday evening, the Floor-Sitting-Therapist X. Wye read out a letter of the 42 years old housewife E.K. in which she wrote: I sit on the floor for half an hour every day and I never had headaches in the past year. Wye said: Children sit much more often on the floor than adults. Let's learn sitting on the floor again and thereby prevent headaches and other diseases of civilization. A Floor-Sitting seminar with X. Wye will take place on ...


9

A report about a single person who has a special characteristic or who experienced something peculiar is sufficient for many people to believe in certain relationships, for instance, that headaches and other complaints can be prevented by sitting on the floor. But why cannot anything be deduced from the observation that a woman who sits on the floor every day never has headaches? One reason for that is that different people are different. Individuals differ from each other in all physical and psychological characteristics. There is no characteristic that is equal in all humans. For instance, the frequency of headaches is different in different people. The frequency of headaches is also different in different people who are sitting on the floor every now and again (see Figure 3a). Some did not have any headaches during the past year, some did, some had very many indeed. The same holds true for people who always sit on chairs (see Figure 3b). Among the people sitting on chairs, too, some did not have any headaches during the past year, many did. It is just that different people are different. E.K. is one of those sitting on the floor every now and again, incidentally one who never had headaches during the past year. Instead of E.K., F.L. could have raised his hand, who also sits on the floor and suffered from headaches on 55 days during the past year (see Figure 3a). If F.L. had raised his hand, should we have concluded and believed that sitting on the floor causes headaches and should therefore be avoided at all costs? What if G.M. had raised his hand who never sits on the floor but strictly insists on chairs and did not have any headaches during the past year, either? Should we have concluded and believed, then, that sitting on chairs prevents from headaches?

Figure 3a.

10


Figure 3b.

If we pick any person whoever out of the many people who are all different from each other, we may believe whatever we like, but we do not know anything at all. For we do not know how often all other people who were not picked suffer from headaches. In actual fact, the distribution of the people sitting on the floor and the distribution of the people sitting on chairs are exactly identical (see Figure 3). That is, taken together, there are as many people suffering never, rarely and often from headaches among the people sitting on the floor as among the people sitting on chairs. Thus, if we would compare all people who are sitting on the floor every now and again with all people sitting exclusively on chairs, we would realize that there is no difference at all. Taken together, they suffer from headaches equally often. Of course, they differ from each other, some have many headaches, some only a few. But considered as a whole, it does not make any difference whether one sits on the floor or on chairs. If one looks at one individual only, be it E.K. or F.L. or G.M. or any other person, nothing can be deduced at all. For different people are always different. If a story is told of a single person, considered as a whole it could be as reported, it could not make any difference at all, or exactly the opposite could be the case. Consequently, it proves nothing, if someone tells a story about a woman who laughed every day and got cured of her cancer (or if one happens to know someone like that), neither if it is two or three of them. For many who laugh every day will not be cured, and some will die of their disease. Likewise, many of those who are not laughing every day will be cured of their cancer and some not, and some of them will die. It is only that the stories of those are not told. If we really want to know whether people who are sitting on the floor every day have fewer headaches than people sitting on chairs (or whether people who are laughing every day


11

will have a better chance to be cured of cancer than others), all people sitting on the floor had to be compared to all people sitting on chairs (or all people having cancer and laughing every day had to be compared to all people having cancer and not laughing so much). As those would be too many people to examine, in most cases it is not possible to compare all of them. Therefore, scientists draw samples according to certain rules and compare those samples. Since different people are different, samples always differ from each other, too. That is why scientific methods are applied, in order to decide whether the observed differences are large enough to assume that they are not merely coincidental, that is, that they are not only there, because different people are different. To be able to apply these methods and to be able to evaluate if they have been correctly applied by others, and if all other required rules for the conduction of serious comparisons were followed, very much knowledge and experience is needed. But what everybody is able to recognize are those reports about some single person or a few people who have some characteristic or other or to whom something or other happened. In such cases, scepticism is appropriate. For someone may want to make an X for a U.

TRAINING OF CHEERFULNESS As noted before, cheerfulness is a trait, a habitual disposition to cheerfulness and serenity that people have for a long time. But that does not mean that a person either has or does not have cheerfulness, that there are people who are just lucky to have a cheerful disposition and others who are not. Neuroscientific evidence indicates that affective traits can be trained, that is, that they can be purposefully changed by appropriate programs (Davidson, Jackson, and Kalin, 2000).

Figure 4.

12


Training always aims at achieving long-lasting, durable effects. Therefore, training cheerfulness does not stand for putting people into high spirits for a short time, but for inducing a long-term, permanent upward shift of well-being in everyday life. In Figure 4, a schematic representation of such a shift (4c) is contrasted with the naturally occurring fluctuations of mood (4a) and fluctuations due to repeated exhilaration (4b): a) An individual's current emotional state is subjected to naturally occurring fluctuations that are due to annoyances and positive events in everyday life. Every now and again one is exhilarated by something (for instance, a funny film), and mood becomes more positive for a short while. But afterwards everything is as it was before. In the longer term, nothing changes. b) Exhilaration that is more frequent also puts a person into high spirits for a short while only. The general level of affect does not change in the longer term. At least it does not change automatically. If applied artfully and with professional psychological know-how, humor and exhilaration can be used as tools for the training of cheerfulness and, hence, for achieving more lasting shifts. But it is by far not enough to watch a funny film every now and again, or to join a "laughter club", or to occasionally crack jokes or laugh at jokes. For the enhancement of cheerfulness, a training program is required in which humor or exhilaration is purposefully applied in order to set certain processes in motion (an example of such a training program is given at the end of this chapter). People who just laugh more often do not feel better in the longer term, that is, their average level of affect is not more positive than that of people laughing less often (Kuiper and Martin, 1998). c) Training of cheerfulness: The level of well-being is durably changed in the positive direction. There are still ups and downs in the current mood state, but in the aggregate, the level of well-being is raised. Only these persistent improvements in everyday life are related to various psychological, physical, and social benefits. What the figure does not show is that, in time, upward swings (i.e., in the positive direction) will become more frequent and more pronounced, whereas downward swings (in the negative direction) will become less frequent, less pronounced, and will last less long. Training cheerfulness does not only make sense in particularly humorless or depressed people. The body of scientific evidence indicates that the enhancement of cheerfulness may have benefits in any case, no matter if someone has only little cheerfulness or already a more pronounced cheerful disposition in the first place. Every improvement helps, from a low to a slightly higher level as well as from a medium to an even higher level. That is, even quite cheerful individuals may benefit from becoming still a bit more cheerful.

OVERDOSE OF CHEERFULNESS? Is it possible to have too much cheerfulness? In other words, can it also be unfavorable to be cheerful and serene? The answer is simple: Everything at the proper time. Just as it is important that the body responds with appropriate physiological changes (see "Don't take an


13

X for a U, Tip 4"), in times of stress or adversity it is also important to emotionally respond in a flexible and adaptive manner. Flexible means to rapidly adapt to changing situations and to quickly return to prestress levels upon offset of the challenge. Adaptive means that the magnitude of the response is appropriate for the degree of stress, that is, both excessive responses to minor stress and inadequate (weak) responses to more considerable stress would be maladaptive (Dienstbier, 1989; Friedman and Thayer, 1998; Papousek, Schulter, and Premsberger, 2002). Thus, if, for instance, the doctor tells you that you suffer from a dangerous disease, it is not only normal but also appropriate and important to be worried. However, when the danger is over and recovery is certain or very likely, your emotional state should quickly return to normal. Or if, for instance, you are treated unjustly by your boss, it is appropriate and important to be angry. But the anger should not exceed an appropriate degree, that is, it should pass by without consequences for your own health, that of your boss, and of the office furniture, and the anger should quickly subside after the incident. To advocate for more cheerfulness does not mean recommending to grin broadly and whistle a happy song all day long, no matter what happens. It does not mean to be unworried if there is a justified reason to be worried, neither to deny real problems nor suppress negative feelings. Also, people with a cheerful disposition are certainly sad, angry, and worried from time to time, when there is reason for it. That is right and important. But people that are more cheerful take things easier, they recover faster and get back into a positive mood more easily than people with a less cheerful disposition. If it does not correspond to the current situation, an excessively cheerful mood state may in fact be unfavorable. That applies, for instance, to very risky situations in which people with an extremely cheerful and optimistic mood state might underestimate dangers and might not be cautious enough. When having a serious disease, an inappropriate, extremely cheerful and optimistic mood may result in not taking the disease seriously and not complying with the doctor's instructions and may that way have an adverse influence on the course of the disease. However, this only holds for extremely cheerful and relaxed mood in situations in which it is inappropriate. In contrast to that, for the same reasons cheerfulness as a trait (i.e., a cheerful disposition) may be beneficial. People with a more cheerful disposition more likely gather advice and make more effort to recover than people with a depressive disposition (Martin et al., 2002; Moskowitz, 2003). Thus, in particular situations it may be unfavorable to be in a very cheerful mood state. But it is never wrong to have a cheerful disposition. (Here it is again, the difference between a cheerful mood state and cheerfulness as a trait, i.e., as a general disposition of an individual).

WHAT'S THE USE? Cheerfulness as a trait involves being in a cheerful mood more easily, more often, and for longer times and dealing with mischance and adverse circumstances with humorous serenity. That feels good. Positive emotions just feel good. Having that more often is perhaps already the most important reason why it is worth to aim at more cheerfulness. Of all traits that people can have, depression (i.e., the disposition to feel depressed, to have little energy, to notice predominantly the negative aspects of a situation, etc.) and the disposition for cheerfulness are the strongest and most consistent predictors of life satisfaction (within the limits that are

14


given by the personal circumstances, of course). People who are prone to experience more cheerfulness and less depression are more likely to find life beautiful (Diener and Larson, 1993; Schimmack, Oishi, Furr, and Funder, 2004). But that is not nearly everything. Cheerfulness is related to several advantages and to a collection of personal resources that can sustainably promote emotional well-being in the long run. It is associated with robust emotional well-being that can also withstand future challenges. In other words, cheerfulness does not only feel good in the present, but also increases the likelihood that one will feel good in the future (Fredrickson and Joiner, 2002; Steptoe, O'Donnell, Marmot, and Wardle, 2008).

STRESS AND STRAIN Circumstances involving stress or strain are a part of everybody's life. However, how stressful and threatening a situation is perceived depends on a person's appraisal of the situation and his or her ability to cope (Lazarus and Folkman, 1984). Consequently, different people perceive the same situation as differently stressful. What is an overwhelming burden for one person, may be a manageable challenge for another one. There is scientific evidence that people that are more cheerful generally use more successful, more helpful coping strategies, that is, strategies that help them to deal and cope with adversity. Fort instance, when thrown out of balance, they more likely react with positive self-instructions ("I will manage that") than less cheerful people do. They reflect about how they can deal with the difficult situation or minimize the significance of the problem. Less cheerful people are more likely to react to problems in a manner that may even increase the feeling of being stressed. For instance, they ruminate about the problem even when the situation is long over, pity themselves, swear at themselves, or give up. Consequently, individuals that are more cheerful experience the same adverse situations as less awful and less stressful than individuals with a less cheerful disposition, and more likely stand up to stress and adversity (Folkman and Moskowitz, 2000; Fredrickson and Joiner, 2002; Gendolla and Krüsken, 2001a, 2001b; Lazarus and Folkman, 1984; Papousek et al., 2010; Ruch and Zweyer, 2001; Strand et al., 2006). People with negative affective traits, in particular depression, are characterized by a narrowed attentional focus that is very much directed at themselves and burdening issues. Consequently, they may not see or realize potentially helpful things. The same thoughts circulate their minds constantly, and they find it very difficult to interrupt the loop of thoughts, which makes the depressed mood even worse. A positive affect disposition, instead, is related to a broader focus of attention and more flexible thinking, which may additionally facilitate successful coping. The wider scope of attention enables them to perceive and consider more aspects in their environment and of their knowledge, memory etc., and, thus, to escape their thoughts and worries more easily. Cheerful individuals also shift their attention and their strategies more easily. Therefore, they more easily see and find a solution, a way out of difficult circumstances (Ashby, Isen, and Turken, 1999; Compton, Wirtz, Pajoumand, Claus, and Heller, 2004; Derryberry and Tucker, 1994; McLaughlin, Borkovec, and Sibrava, 2007; Rowe, Hirsh, and Anderson, 2007; Wadlinger and Isaacowitz, 2006). These features of


15

cheerfulness may not only reduce the feeling of stress but may also potentially contribute to finding better and faster solutions to problems. Related to that, a cheerful, serene attitude towards oneself and the things one is scared or annoyed of or that are a burden facilitates a change of perspective and a more positive reappraisal of the situation. Looking at problems from a different angle may make them seem less important. For example, if you can laugh at your own shortcomings and mishaps, or at the exam situation of which you are actually afraid of, or at an unpleasant medical examination, because you also see a funny side of the situation, the perspective changes and you gain emotional distance from yourself and your problems. Consequently, difficult circumstances may be experienced less stressful, annoying, or threatening (Kuiper, Martin, and Olinger, 1993; Lefcourt et al., 1995; Martin, 2001; Newman and Stone, 1996; Ventis, Higbee, and Murdock, 2001). It has also been demonstrated that the emotional well-being of people with a cheerful disposition is more robust. That is, there must be more going on to throw cheerful individuals out of balance, to make them depressed or furious or nervous, than is the case with less cheerful persons. Moreover, a disposition to positive affect and a more positive appraisal of difficult situations and circumstances does not only contribute to less experience of stress and to not letting oneself get worked up so easily, but also to faster and more efficient recovery from stressful situations and events (Fredrickson and Levenson, 1998; Kallus, 2002; Newman and Stone, 1996; Ong, Bergeman, Bisconti, and Wallace, 2006; Papousek et al., 2010; Ruch and Köhler, 1999; Tugade and Fredrickson, 2004; Tugade, Fredrickson, and Barrett, 2004; Zautra, Smith, Affleck, and Tennen, 2001). In summary, trait cheerfulness does not only help to keep balance and to experience difficult circumstances less awful and burdening. It also helps to cope with adversities more efficiently and quickly and to regain balance, should it be necessary. The consequence of all this is: Individuals that are more cheerful feel less stressed and strained overall. Scientific studies also demonstrated that persons felt less stressed and tense after their cheerfulness had been enhanced by a professional intervention. In one study, a group of people participated in a professional cheerfulness training (1-2-H Cheerfulness Training®; two-day introductory session plus 15 training sessions lasting 45 min each). The degree to which cheerfulness was enhanced correlated with the reduction of perceived stress in everyday life. The relief of stress was also reflected in a reduction of blood pressure that can be regarded a physiological and objective indicator of stress and tension. In a control group not participating in the training, perceived stress and blood pressure did not change within the same period (Papousek and Schulter, 2008). Another study showed that a professional and systematic cheerfulness training may not only reduce the degree of subjectively experienced stress in daily life, but may also improve several aspects of the ability to recover quickly and efficiently (1-2-H Cheerfulness Training®; two-day introductory session plus several weekly training sessions). As a result, spare time and pauses were experienced as more restorative. The effects exceeded those of autogenous training (an established relaxation technique), which was conducted in a control group (Lederer, 2007). In a further study, a group of high school teachers participated in a cheerfulness-training course (1-2-H Cheerfulness Training®; two-day introductory course plus several weekly training sessions). Several days before the introductory course and again several days after the end of the training period, various aspects of well-being were assessed. The same measures

16


were taken in a control group not participating in the training. The study showed that the effects of improved cheerfulness were also present in the occupational environment. After the training period, the teachers experienced less stress in their jobs than before. On average, the degree of perceived stress was reduced by 14 percent. They felt less overworked, less worn out, less burnt out after the training. Job satisfaction improved, too, that is, satisfaction with work, with the school, with the working conditions, on average by 11 percent. Moreover, the reduced perception of stress and the general improvement of mood had also an effect on the social life. After the training period, they rated the quality of their contacts with colleagues more positively (on average by about 14 percent). They felt more relaxed, more confident, and more open in their social encounters. In the control group not participating in the training, the same aspects did not change within the same period (Papousek, 2008). Efficient coping strategies, adequate recovery after stress and the related feeling to not be under permanent stress, satisfaction with the job and the working conditions, and intact social contacts are considered protective factors that may prevent or slow down the development of burnout symptoms (Graham, Potts, and Ramirez, 2002; Hoyos and Kallus, 2005; Visser, Smets, Oort, and De Haes, 2003). Certainly, the enhancement of cheerfulness can only contribute to making the development of burnout symptoms less likely, it cannot totally prevent them. The risk of burning out does not only depend on the affective traits of an individual, but to a considerable extent on the structural conditions of work. Examples of factors that can contribute to the development of burnout are shortage of staff, unclear requirements, lack of support by superiors, lack of personal control over the environment and others. Certainly, such unfavorable job conditions cannot be changed by the affective dispositions of single employees. However, as a matter of fact, under the same job conditions, only some people develop burnout symptoms, whereas others do not, not so easily, or not so quickly. Thus, there is some scope left that is independent from the structural conditions that can be used to do something for oneself and to counteract the development of burnout and other stress-related conditions.

DON'T TAKE AN X FOR A U Tip 2: Changes Can Materialize on Their Own Suppose that you hear or read that it was observed that a group of people having fever drank a glass of water from the holy well of St. Barbara and on average had much less fever two days later. Does this make you believe that the water from the holy well of St. Barbara has an antipyretic effect (i.e., helps to reduce temperature)? Suppose you hear or read that a patient with a rheumatoid disease watched funny films every day and was cured several months later. Does this make you believe that laughing at funny films brings you back to health? Suppose you hear or read that every year at a given day during winter a village community in an arctic region holds a ceremony during which the village elders sing certain songs and throw frozen fish into the air, in order that it will get warm again. And indeed, every year, several weeks after the ceremony was held, it gets warmer. It never happened that it stayed cold after the village community held their ceremony. The village residents firmly


17

believe that the ceremony causes the cold winter to end and summer to return. Do you believe it, either? Does the fact that it gets warmer again every year after the village community held their ceremony prove that the ceremony is the cause of the return of summer? Does it prove that summer returns every year, because the village community takes care of it? No, you probably do not believe that. You probably think that it may well be that summer follows winter anyway, no matter whether that village community in the Arctic holds a ceremony or not and how many frozen fish are thrown into the air. Of course, the fact that summer returns every year does not prove that the annual ceremony of the arctic village community is the cause for it. All the same, the fall of body temperature in the group who drank holy spring water does not prove that the water was the cause of it. Neither does the recovery of a patient who watched funny films for several months prove that laughing at the films was the cause for his recovery. In all three examples, it is always the same problem: It may be true that summer would have come anyway, also without the ceremony of the arctic village community. It certainly may be true, either, that the fever would have ceased anyway, also without the holy spring water. And it certainly may be true that a patient recovers without watching funny films. What is the point? The arctic village community holds its ceremony every year. For generations there was no year in which the ceremony did not take place. And of course, summer returned every year anew. To find out if the ceremony is the cause of the return of summer, the whole village community had to be locked up during the entire winter season, in order to prevent the ceremony from being held. If it is true that the ceremony is the cause of the return of summer, in this year winter must never end and it must not get warmer. Only then, it could be excluded that summer returns on its own. To be able to attribute an effect to a certain cause, it is essential to also test a control condition. In the example of the arctic village community, the control condition would be that the community cancels the ceremony. One could, for instance, cancel the ceremony every second year for some years and observe in which years summer returns and in which not. Only if summer returns in all years with the ceremony and does not return in the years without the ceremony, it could be concluded that summer does not return by itself, but that the ceremony is the cause for it. (Since the ceremony is totally fabricated, it can be asserted that summer will return in any case, for sure). In the example with the holy well another group of patients had to be observed, who also suffer from fever of approximately the same height and for the same time and who have the same illnesses as the group drinking the holy water. This second group only gets normal tap water (that would be the control condition in this case). It would only be an indication of an antipyretic effect of the water of the holy well of St. Barbara, if the body temperature dropped to a greater extent after drinking holy water than after drinking normal tap water. Without such a control condition, it cannot be decided if the decrease of body temperature is attributable to the holy water or if it is just that time went by, that is, that the fever dropped on its own. (If it would be done carefully, the participants would not be told whether the water they are drinking stems from the well of St. Barbara or from the tap, in order to exclude a placebo effect). The same holds true for the funny films. Without an appropriate control condition, it cannot be excluded that the patient would have recovered anyway. In this case, two groups of patients would be required, with the same diagnoses, the same age, the same states of health, and the same medical treatments. Only one group watches funny films, the other group

18


watches to the same extent films that are not particularly funny. Only then can it be determined whether it is not as likely to recover without as with watching funny films. As different people are different, it has to be taken into account again that there will always be differences between groups of people. (For instance, different people also differ in how fast their body temperature returns to normal). That is why certain rules must be followed in such studies and additional scientific methods must be applied to be able to decide if the observed differences are large enough to assume that they are not merely coincidental, that is, that they are not only there, because different people are different. For this and for the evaluation of studies that were conducted by others, much professional knowledge and experience is needed. But everybody can recognize reports that are by no means serious, that is, reports of studies in which changes were investigated without an appropriate control condition; studies in which it was not evaluated whether the changes also would have materialized on their own (or for another plausible reason). In these cases, someone makes an X for a U.

EMOTIONAL WELL-BEING Having a high degree of cheerfulness does not simply mean that one is prone to be in a positively valenced mood. Cheerfulness is associated with a collection of personal resources that individuals can draw on during adverse circumstances. Resources are tools that can help to cope with certain demands. With the aid of personal resources, one better stands up to stressful events and circumstances and recovers faster and more efficiently. That is so important because stress plays a part in the life of everyone. Even minor annoyances such as that one drops the milk carton on the kitchen floor, has put on another kilo, that the son left his footprints on the freshly polished floor, or all toilets are occupied, may considerably contribute to the feeling of being stressed. Or else may not. It is assumed that the ability to draw on helpful personal resources is even more important to general well-being than the degree of unfavorable affective traits such as anxiety or pessimism (Cohn, Fredrickson, Brown, Mikels, and Conway, 2009; Steptoe et al.. 2008; Tugade et al., 2004; Zautra, Johnson, and Davis, 2005). Resources that are related to trait cheerfulness are, for instance, the already mentioned coping strategies, flexibility, a humorous, serene attitude towards oneself and the given personal circumstances (see "Stress and strain"), but also a cheerful and humorous attitude in social situations with associated beneficial effects on social life and social support (see "Social life"). Thus, for instance, when cheerful individuals are sitting in the waiting room of a doctor for a while, they tend to approach other waiting people with a smile and perhaps make a cheerful, encouraging comment on the long waiting time and their possible causes, instead of quickly falling into despair or staring hostilely at the others and wishing that those who came first may be even more unnerved, give up and go home. In turn, they benefit from the positive reactions of the others and the related positive effects on their own mood. When they notice that they have left the office key at home for the second time within one month, cheerful individuals smile to themselves and ask their colleague or the secretary eyes atwinkle to please help them out, instead of getting furious, kicking the office door, chucking the briefcase into the corner of the secretary's office and ruminating for hours how they can


19

be so stupid. When cheerful persons make a mistake during a speech or a job interview, they do not panic, or hope with their face red as a beetroot that nobody has noticed the mistake, but they calmly take note of their error and correct it with a smirk, perhaps even with an appropriate humorous remark. In the long run, the collection of resources accompanying cheerfulness puts a brake on the development of negative affective traits such as depression, worry, or the permanent feeling of stress. But there is even more to it than that. Cheerfulness directly fosters other positive emotional traits such as vitality, alertness, and relaxation and in the long run contributes to a lasting and robust enhancement of emotional well-being. The resources that are available when having a high degree of cheerfulness are used with success on many occasions. Thereby over time new resources develop. For instance, individuals acquire the attitude of being the architect of their own fortune and face difficulties with composure, because they trust in the ability to cope stress and adversity and that there will always be a way out. In further consequence, they can even better manage upcoming problems. This, in turn, further fosters the development of positive affective traits and resources, and so forth. Thereby a process is set in motion, which sustainably advances the enhancement of emotional well-being like an upward spiral (Fredrickson and Joiner, 2002; Hobfoll, 1989; Kallus, 2002; Salovey, Rothman, Detweiler, and Steward, 2000). With the treatment of negative affect alone all this cannot be achieved. That is why there is more to the training of cheerfulness than, for instance, the removal of depressive symptoms or the reduction of fears and worries, more than the attenuation of a certain negative affect. Cheerfulness sustainably promotes the enhancement of emotional well-being, also and in particular in the future. In various other contexts, too, the promotion of positive characteristics and resources seem to be more effective than only attenuating negative affect. For instance, a high degree of trait positive affect and resources helps to keep balance in stressful situations and also, for instance, in the face of disease or pain, and is related to overall life satisfaction. A relatively lower degree of negative affect alone does not have this effect (Cohn et al., 2009; Zautra, Fasman, et al., 2005). For several aspects of physical wellbeing and health, for which the degree of negative traits like depression, worry or the persistent experience of stress plays an important part, too, there is some evidence that a lack of trait positive affect is even more unfavorable than a high degree of negative affective traits (Benyamini, Idler, Leventhal, and Leventhal, 2000; Cohen, Doyle, Turner, Alper, and Skoner, 2003; Cohen, Alper, Doyle, Treanor, and Turner, 2006; Ostir, Markides, Black, and Goodwin, 2000; Ostir, Markides, Peek, and Goodwin, 2001; Pettit, Kline, Gencoz, Gencoz, and Joiner, 2001; Pressman and Cohen, 2005). Scientific studies demonstrated that after participating in an intervention program with which cheerfulness can be successfully trained, not only the feeling of stress and tension decreased, but that this was also accompanied by a more general improvement of emotional well-being. In a study in which a systematic training was conducted (1-2-H Cheerfulness Training®), some time after the end of the training not only the degree of cheerfulness was higher than before, but the participants were in a generally better mood, they felt considerably more calm, alert, active and less anxious than before. On average, the values in the applied diagnostic instruments were more positive by about 16 percent. In the control group not participating in the training, none of these indicators changed within the same period (Papousek and Schulter, 2008).

20


A program that aims at enhancing cheerfulness as a trait is suited to stimulate the upward spiral towards emotional well-being in healthy individuals. It is suited to attenuate negative affect and to sustainably foster positive emotional traits and the development of successful personal resources. A noticeable benefit can always be achieved, whether positive and negative affective traits balance each other before the training, or the balance is positive, or negative traits predominate (see also "Training of cheerfulness"). However, there are limits to the adequacy and the success that can be expected from such an intervention. A limit is definitely exceeded, when the current emotional state is distinctly disturbed. The training of cheerfulness primarily has potential for improvements in the future. It is appropriate when one aims at achieving sustainable changes in the long run. It is not suitable as a quick help in a crisis. In a crisis, cheerfulness does only help, if one is already able to draw on helpful personal resources, that is, if one already has a sufficiently high degree of trait cheerfulness. Directly in a serious emotional crisis or immediately afterwards and immediately after traumas or blows of fate, a cheerfulness intervention is not appropriate. At the proper time, grief, anxiety, and angriness are right and necessary reactions, for which one should take enough time. When needed, professional psychological counseling or psychotherapy can help to be able to manage. Yet this period should not last too long, and after an appropriate amount of time, one should recover as completely as possible. Some time after periods of severe stress, for instance, after loss of a closely related person, loss of employment, severe illness, and other serious adversities, when one has the feeling that it is time to step back into life, an intervention enhancing cheerfulness may be useful. Cheerfulness also helps to broaden a person's thinking and behavioral repertoires (whereas the repertoire is restricted during grief, anxiety, and anger).That is, more cheerfulness helps to be able to turn to new thoughts and activities again, to let go of entrenched patterns of thinking, to strike new paths, instead of constantly ruminating on the same thoughts and worries and withdrawing from the world (Fredrickson, 2004; Tugade et al., 2004). In the case of major affective disorders and personality disorders (e.g., major depression, anxiety disorders, schizophrenia, addiction, borderline, obsessive-compulsive disorders) a cheerfulness intervention does not help. In these cases, psychiatric and/or psychological or psychotherapeutic treatment is required. Severe mental diseases and disorders are also accompanied by biological changes in the brain that in many cases can be best treated with drugs. An intervention program to enhance cheerfulness can by no means replace necessary drugs and therapies. During acute mental illness, a cheerfulness intervention is also misplaced as a supplementary treatment. Only when patients are completely or largely symptom-free after treatment, one can think of applying an intervention to enhance cheerfulness, in order to help building positive resources. A scientific study showed that in psychiatric rehabilitation, an intervention program for the enhancement of cheerfulness may facilitate advances, but only to a limited extent. In this study a group of in-patients of a psychiatric rehabilitation clinic took part in a cheerfulness training, in addition to their other therapies (1-2-H Cheerfulness Training®; introductory course plus periodic training sessions for five weeks, twice a week; the standard method was slightly modified to adapt it to the special requirements of the sample). The participants had no acute symptoms during their stay at the clinic; diagnoses were predominantly depressive disorders. As compared to a carefully selected control group, the participants of the training showed a more pronounced reduction of subjective impairment by psychological and physical symptoms and a greater feeling of confidence in social situations at the end of their six weeks


21

stay in the clinic. For other indicators that can show marked improvements in healthy individuals within this period, the positive intervention did not show any additional benefits as compared to the effects of the usual therapy program (depression, anxiety, alertness, vitality; Nograsek, 2006). Thus, although there may be some benefits in patients in rehabilitation after mental disease, they are considerably smaller than in healthy individuals. It might also be that further measurable changes would only appear after longer training periods. A prerequisite for the applicability of such an intervention is in any cases a sufficient degree of functionality in the patients.

DON'T TAKE AN X FOR A U Tip 3: Co-Occurrence or Cause and Effect Every week the media publish new stories about things that are said to be "healthy". In the majority of cases, these claims are based on the observation of a simple correlation: In individuals who have a certain characteristic, it is more likely that another characteristic is observed either. Suppose that individuals who are joking more often are compared to individuals who never or rarely joke. Suppose that it is observed that those who joke more often on average have better health than those who never or rarely joke, that they, for instance, have fewer cardiovascular diseases. Can it be concluded from the observation of cooccurrence of frequent joking and a healthier heart that joking is "healthy" and prevents from disease? No, because only a correlation was found; two things frequently co-occur. In order to learn whether something is really "healthy", one also needs to determine what is the cause and what the effect. There are always at least three possibilities for that. In the given example, these are (see Figure 5): First, it might be that frequent joking is the cause and a healthy heart is the effect. That would imply that the frequency with which one jokes causally influences the likelihood to get cardiac disease, for instance, because frequent joking is accompanied by some favorable longterm changes of physiology. Second, the reverse might be true, that is, cardiac health might be the cause and joking the effect. It is just as well possible that some people do not joke so often or not joke at all, because they have cardiac disease and know that or do not feel well and, hence, do not feel like joking. Perhaps this may even be more obvious than the first possibility. Third, it might neither be true that joking causally influences cardiac health, nor that cardiac disease is the cause for less frequent joking. Nevertheless it is possible that it is observed that frequent joking and healthy hearts often co-occur, that is, if there is a third variable that influences both the frequency of joking and cardiac health. In the given case, membership in a well-functioning social group could be such a third variable, which is accompanied by convivial gatherings increasing the likelihood of joking, and also by social support that can play a part in staying healthy and feeling healthier. Thus, in that case it would have been observed that joking and good cardiac health often co-occur, only because the social situation of an individual influences both the frequency of joking and his or her cardiac health. But joking and health are not directly related at all, neither in one nor in the

22


other direction. There may also be several "third variables" (in most cases, there are indeed several).

Figure 5.

The claim that joking is 'healthy' would only be correct if the first of these possibilities was true, that is, if frequent joking would in fact causally influence cardiac health. If one of the other possibilities is true, the claim that joking is healthy, is wrong. How can it be determined what is cause and what effect? An important consideration in that context is that only that can causally influence something else that was there first (the other way round it would not be possible). Suppose, for instance, the traffic lights break down at a busy junction; ten minutes later two vehicles are involved in an accident. Since the traffic lights went out before the accident happened, the accident could have been caused by the break down of the traffic lights. The traffic lights could also have broken down in consequence of the accidence, for instance, because the involved cars crashed the traffic lights. But then the accident would have had to happen first, before the break down of the traffic lights. Therefore, in the given example, we can rule out the possibility that the accident caused the break down of the traffic lights. However, there might be a "third variable", for instance, a thunderstorm could have caused the break down of the traffic lights and at the same time the accident (e.g., because of aquaplaning). In this case, the break down of the traffic lights and the accident would be in no direct relationship to each other. That is, in order to determine what is cause and what effect, studies are essential that do not only examine how often two things co-occur at a fixed point in time, but that also take into account what was there first. That is possible with prospective or with experimental studies. In prospective studies, persons are examined who are healthy at the first time of measurement. To stick to the example above, in a prospective study it would first be evaluated in many healthy individuals, how often they joke during a regular week. Subsequently, it would be observed during the following ten or twenty years which individuals get a cardiac disease and which not. In this case, it would be clear that the frequency of joking was there before the cardiac disease. If individuals who joke more frequently develop cardiac disease less often over the course of the following years, this would be an indication that joking might in fact causally influence health. It cannot be the other way round (cardiac health being the cause of joking more frequently twenty years earlier). However, it cannot be excluded automatically that there are 'third variables'. For this, possible third variables have to be controlled, that is, respective data have to be collected, too. With the help of certain scientific methods, it can be determined, then, whether one or several of these variables are responsible for the observed correlation. In an experimental study, the putative cause is purposefully manipulated. In the given example, a large group of people could be obligated to tell a certain number of jokes every


23

week over an extended time. Another group would be obligated to not tell any jokes at all (over the same period). The time period must be long enough so that cardiac diseases may develop. Afterwards it would be observed which people get ill and which not. In this case, it is also clear which of the two variables was there first, because it is purposefully arranged that way. Should it really be true that joking prevents from cardiac disease, the likelihood to develop cardiac disease must be lower in the joking than in the non-joking group. It is quite difficult and, therefore, a matter for experts, to determine whether studies have been adequately controlled and all scientific rules that are required for reliable conclusions have been followed. But in most cases, it can be recognized very easily whether studies were conducted prospectively or experimentally, often also directly in media reports. If it was only observed that two things co-occur, it is not possible to determine what is the cause and what the effect, and whether the two variables are directly causally related at all. If only such a simple observation of co-occurrence is available and it is nevertheless claimed that something is "healthy", someone makes an X for a U.

PSYCHOSOMATICS Generally speaking, the field of psychosomatics is about how psychological processes and characteristics can influence the functions of body organs. Among the psychological processes and characteristics are thoughts, feelings, moods, personality characteristics, affective traits and so forth. Functions of body organs may be, for instance, functions of the heart, the gastrointestinal system, or the immune system. Psychosomatic processes constantly occur in our daily lives. They are totally normal and harmless and even very important, because through these processes, the body adapts to current demands. In everyday life, the demands on various body functions are changing continuously. They change when a person stands up or goes up a few stairs, and also change when a person is nervous, for instance. Therefore, the heart is not only beating faster when your are climbing stairs, but also when your are nervous and anxious, because your have to take an exam in a few moments or because you hear steps behind yourself, and also when your are excited and on cloud nine, because you kiss your new boyfriend (or girlfriend) for the first time. Psychological processes such as thoughts, feelings, moods, or perceptions are generated in the brain, and brain regions that are involved in it can intervene in the regulation of body functions via complex nervous connections. Therefore, also thoughts or emotions or the sight of the beloved in the distance can change functions of body organs. For this purpose, neurons of the "highest" brain regions (the cerebral cortex) send signals, via several relay stations, down to the organs. In addition, the release of hormones plays a part in it (Cechetto and Saper, 1990; Lovallo, 1997; Mayer, 2000). However, psychological processes do not only cause short-term changes of body functions, such as during temporary emotional stress or excitement. Processes that are related to affective traits such as depression, that last for some time, can also cause longer-lasting changes of processes regulating body functions. When that happens, something in the interplay between psychological and bodily processes will not work as perfectly anymore as it should. The altered processes may be less efficient and less adaptive and, in the long run, unfavorable to the respective organ system (Depue and Monroe, 1986; Sheffield et al., 1998).

24


Therefore, psychosomatic processes may also play an important role in connection with health and disease. The concepts and knowledge about interrelations of the mind and the body, how psychological processes can cause or influence bodily symptoms or can affect well-being, and the approaches to consider psychosomatic processes in medical practice, have changed very much during the past decades. However, in the popular literature the older concepts are often still present. Therefore, we will very briefly contrast them with the contemporary view. If, for instance, a patient suffers from persistent constipation and abdominal pain, it is sensible to check whether there is a tumor, inflammation, damage of the nerves or any other somatic problem. But quite often, nothing abnormal is detected in traditional medical examinations, although the patients suffer from their complaints. This is particularly often the case with gastrointestinal complaints. In up to 50 percent of the patients having gastrointestinal complaints, there is no apparent medical condition that may account for the symptoms experienced. Beyond that, even if there may be a pathological finding in the gut, it often cannot explain the type and strength of the symptoms (Kroenke and Harris, 2001). In historical terms, the possibility that psychological factors play a part in well-being and health, was taken into consideration in different ways. According to the dualistic or "traditional medical" approach that traces back to Decartes (1596-1650), "real" somatic problems on the one hand and psychological factors on the other hand are completely dissociated from each other. First, it is examined whether there is any abnormality of the body. If no somatic problem is found, then it is concluded that there has to be damage to the mind. Consequently, a mental disorder such as hysteria, hypochondria, or somatization disorder is diagnosed. That is, according to the dualistic concept, either the body is affected ("somatic", "physical" or "organic" disorders) or the mind is affected ("psychological" or "mental disorders"). Either the symptoms are attributed to the body, or they are attributed to the mind. If the symptoms are attributed to a somatic problem, they are accepted as "real". If the symptoms are attributed to the mind, they are not accepted as "real". According to this concept, a patient with constipation and intestinal pain in whom no physical abnormality is found in the gut is not "really" ill, does not have "real" complaints; the symptoms, the complaints only exist "in the mind". At least implicitly, this assumption is still widespread both in medicine and in the general population, although it is clear by now that it has to be regarded outdated and unscientific (Lovallo, 1997; Mayer, Munakata, and Chang, 1997; White and Moorey, 1997; Wilhelmsen, 2000). The psychoanalytic approach, which has its origin in the for its time innovative considerations of Sigmund Freud (1846-1939), has been a progress in so far as it includes the possibility that even "real" somatic disorders can develop through psychological processes. Consequently, even when a somatic cause is present, a contribution of psychological factors is not automatically excluded, although the idea of "imagined" illnesses is still present, and the patients are in part blamed for their complaints. In the psychoanalytic approach, attempts to explain psychosomatic processes are characterized by prescientific analogical thinking. Therefore, constipation, for instance, is attributed to characteristics such as parsimony or the attitude "I can't expect anything from others, therefore I don't need to give anything to others" (analogy: that is why I do not give away my excrements, either), or tidiness (analogy: I do not want to cause dirtiness), or "fear of too much overspending" (analogy obvious; Klußmann, 1992). Also still included is the assumption that psychosomatic processes play a part only or predominantly for certain diseases or symptoms, which are denoted "psychosomatic


25

diseases". The psychoanalytic analogical ideas of the development of diseases and complaints have not been empirically confirmed (i.e., through scientific studies), and are untenable from a contemporary scientific perspective. It is clear by now that it is not possible to attribute a certain disease or a certain symptom to a certain personality trait. In modern, contemporary approaches of psychosomatic medicine that are often referred to as "biobehavioral" or "biopsychosocial" concepts, "organic", "mental", and "psychosomatic" diseases are not rigorously distinguished any more. Instead, it is assumed that both aspects (i.e., somatic and psychological) play a role in all diseases and complaints (with sometimes one aspect and sometimes the other on the fore). It is known by now that even in diseases with a clear somatic cause, psychological factors can influence the severity of the disease or the likelihood of a flare-up and can substantially co-determine the severity of pain. Thus, patients with a certain disease may vary in their illness expression from asymptomatic to severely disabled, despite comparable objective medical findings. Moreover, it is assumed that diseases and complaints do never exist exclusively in the mind (or "in one's imagination"), but that complaints that cannot be explained by a distinct somatic cause, too, are related to "real" physiological disorders (disorders of function). In the case of constipation, for instance, they may be related to slightly disturbed motor function or altered sensitivity of the sensory receptors in the gut, which can be due to small alterations of the information transfer in the bidirectional pathways between brain and gut (Mayer, 1999; Naliboff, Chang, Munakata, and Mayer, 2000; Wood, Alpers, and Andrews, 1999). Instead of wrapping the mechanisms how psychological factors can affect well-being and health in a veil of mystery such as "somatization", these mechanisms and processes now are extensively investigated scientifically. As already mentioned, the attempt to link certain diseases or symptoms to certain personality traits failed. But by now, it is very well established by very much scientific work that predominantly three affective traits are related to the development, the course, and the severity of all kinds of somatic complaints and diseases: persistent experience of stress, depression, and anxiety or worry (Hubbard and Workman, 1998). Note that this concerns affective traits, that is, durable characteristics of individuals. Certainly, a person does not become ill when he or she is stressed or sad or worried once or from time to time. Neither do persons become ill when they are often stressed, sad, or worried, if they quickly and completely recover in between. But persistent experience of stress over a long time or persistent depressive mood or anxiety can adversely affect physical well-being and health. In part, the significance of these negative emotional traits for the development, the course, and the severity of complaints and diseases is impressive. That is particularly true for complaints and diseases in which the processes underlying the symptoms take a longer time to develop (Booth-Kewley and Friedman, 1987; Hubbard and Workman, 1998; Pressman and Cohen, 2005). How is it possible that affective traits will affect physical well-being and health? As noted above, the brain adapts all body functions to the current demands. Changing demands may be signaled by the body (e.g., high traffic volume in the gut, but also small changes of all kinds of physiological variables), or by the brain itself (e.g., perception of the voice of the beloved on the phone). Various structures of the brain, the respective body organ or organ system, the nerve connections between the brain and the body organs, and hormonal changes all are participating in these regulation processes, which are essential for the organism to

26


function properly. Normally, the body functions are optimally adapted to the current demands by these constantly occurring regulation processes. Affective traits such as the persistent experience of stress, depression, and worry are also related to certain processes and activation patterns in the brain, which can cause small alterations of adaptation processes (Bremner et al., 1997; Fuchs and Fluegge, 1995; Papousek and Schulter, 2001, 2002). Since the way in which the brain regulates the body functions is slightly changed, the adaptation processes may not work entirely as they should, and the results of the adaptation processes may not optimally correspond to the current demands any more. For instance, neurons may be prompted to send signals to a certain organ that cause a response that is a bit too weak or a bit too strong according to the current demands. A bit too much or too few of a hormone may be released. Receptors in the gut may respond a bit too sensitively or not sensitively enough. The cardiac rhythm may be slightly disturbed, and coagulation of blood platelets may be slightly reduced or enhanced. The immune system may respond a bit too strongly and inflammation processes may exceed the actual demand, and so forth (Friedman and Thayer, 1998; Hughes and Stoney, 2000; Joynt, Whellan, and O'Connor, 2003; Mayer, 1999; Miller, Chen, and Zhou, 2007; Plotsky, Owens, and Nemeroff, 1998; Thayer, Friedman, and Borkovec, 1996). If that remains so for a short time only, it will have no particular effects. But if the disturbances remain for a longer time, such minor dysfunctions of adaptation processes may affect the function of body organs, that is, the organ will not entirely work as it ideally should. Consequently, complaints may occur or diseases may be advanced (Clauw and Chrousos, 1997; Depue and Monroe, 1986; Papousek et al., 2002; Ringel and Drossman, 1999; Sheffield et al., 1998). Beyond that, affective traits cannot only affect physical well-being and health by the direct biological route, but also by pathways that are more indirect. For example, negative affective traits are often accompanied by adverse behavioral patterns such as tobacco smoking, alcohol, drugs, lack of exercise, malnutrition, and lack of compliance with the doctor's recommendations (Brummett et al., 2003; Cohen and Rodriguez, 1995; DiMatteo, Lepper, and Croghan, 2000; Joynt et al., 2003; Kritz-Silverstein, Barrett-Connor, and Corbeau, 2001; Patton et al., 1996). Negative affective traits may also be linked to unfavorable cognitive characteristics. Examples are the degree of attention allocated to the symptoms and the appraisal of symptoms. When a person is anxious and worried, his or her attention is much more directed at the pain, and the pain is perceived as more threatening. Consequently, the pain is experienced as more severe and less tolerable (Miron, Duncan, and Bushnell, 1989; Villemure and Bushnell, 2002). Finally, social factors may play a role. Depression, for instance, is often accompanied by withdrawal from friends and family. At the same time, friends and family often gradually retreat from a depressed person, because communication may be burdensome (Coyne, 1976; Troisi and Moles, 1999). Consequently, depressed people receive less social support that in many cases would be helpful to appropriately interpret symptoms and complaints, to make use of medical facilities, to maintain independent living, and so forth.


27

DON'T TAKE AN X FOR A U Tip 4: Stress Responses Are Not "Unhealthy" When you have to do an exam or a speech, when you are engaged in a passionate kiss, when it is already late and you have to catch the train, when your national team scores a goal at the World Cup, when you are sitting in the dentist's chair waiting for the dentist, when you crack a joke, when your favorite football club has lost the game, when you unwrap a present from a kind friend of yours, when your daughter does not return home as agreed, when you are laughing heartily at a memory with your friends ..., then for a short time all kinds of physiological functions change. Thus, various psychological processes also elicit changes in the body. Since all those examples are accompanied with the activation of strong feelings, many changes are equal or similar in all examples; some changes meet specific requirements of the specific situation. The assumption that physiological responses to psychological processes (so-called stress responses) are unhealthy, is one of the most widespread fallacies that are still persistently spread explicitly or implicitly via popular books, wellness folders, advertising brochures, etc. In every day life, the term "stress" is often used to express that one feels uncomfortably burdened ("I have so much stress!"). From a biological point of view, stress relates to every kind of short-term strain. The strain consists in that changed conditions (physical or mental performance, excitement, etc.) lead to altered demands on somatic (and psychological) functions. It can be elicited, for instance, by running up the stairs, doing a speech, or kissing passionately. Therefore, the strain may also be experienced as positive, desirable, and pleasant. The organism reacts by adapting the functions to the altered demands (e.g., the heart beats a bit faster). This adaptation represents the "stress response". If the body would not permanently adapt its functions to the current demands, an unfavorable situation would arise. As an intuitive example, one may think of a plant that grows best if it gets neither too much nor too little water according to its demands. How much water it needs depends on the current conditions such as sunlight, air temperature, humidity, wind strength, etc. The plant certainly needs more than water to grow optimally. In humans, being a bit more complicated than a plant, it depends on the fine-tuning of hundreds of parameters how optimal the body works under certain conditions. Therefore, all functions must be permanently regulated and adapted to the current conditions and demands. In former times, it was thought that it might be the healthier the less the body responded to emotional strain (and many people still mistakenly believe it even nowadays). It was thought that every stress response of the body would be detrimental. But stress responses are not only totally normal and occur in everyone every day, but they are important and necessary adaptation responses. Today it is assumed that responding flexibly and adaptively to changing demands is important for staying healthy. Flexible means that it is important that the body functions quickly adjust to the changed conditions. Adaptive means that too strong but also too weak stress responses are in the long run unfavorable to health and physical well-being. A quick, distinct response that also quickly returns to baseline when the stress is over is considered a "healthy" stress response (see Figure 6). In rest conditions, too, the body functions should adapt accordingly (Brosschot, Gerin, and Thayer, 2006; Dienstbier, 1989;

28


'h ealthy ': dist inct respons e wit h fast o nset a nd qu ick return to base line af ter ce ssation of the str ess

'unhealthy': r espo nse is too w eak

Time

'unhealth y': re spons e is too str ong and on set is delayed

Ex ampl es for 'healthy' an d 'unh ealthy' stress response s

Figure 6.

Time

S tr ess

Str ess

Time

Stres s

Stress

Ti me

Streng th of re spon se

Str ength of response

Stren th of r espon se

S treng th of r espon se

Friedman and Thayer, 1998; Heponiemi et al., 2007; Hoehn-Saric and McLeod, 1988, 2000; McEwen, 1998; Papousek et al., 2002). The outdated negative view of stress responses is associated with a concept that draws back to Cannon, who lived at the beginning of the twentieth century. His concept, although outdated, can still be found in many books and various kinds of brochures. Cannon believed that the stress response always proceeded in the same way. To put it simply, he thought that the organism always reacted with a general, unspecific activation of the sympathetic nervous system. (The sympathetic nervous system is part of the autonomic nervous system through which the brain sends signals to the body organs). General and unspecific means that not only certain organs or organ systems are addressed but that always the whole organism is activated. According to Cannon's view, the purpose of the stress response is to activate the whole body, in order to prepare it to "fight or flight". Cannon deduced this assumption from observations of animals that were exposed to extreme, acutely life-threatening conditions. What Cannon observed were emergency responses of the body that reflected the attempt to survive in an extreme situation that is a matter of life and death. In normal every day conditions, such a general, unspecific activation of the whole body does not occur. For stress responses in normal conditions (i.e., in conditions that are not acutely life threatening) the concept of Cannon is definitely wrong (Jänig and Häbler, 2000). Today it is known that in conditions of stress, the brain sends differentiated signals to the body organs through specific nerve pathways. By specific nerve pathways, one understands a chain of neurons that are responsible for the regulation of a certain function of a certain organ or organ system. Differentiated signals are signals that are not uniformly sent out to the whole body, but that differ depending on the specific nerve pathway and organ. Both the sympathetic and the parasympathetic branch of the autonomic nervous system are involved in the adaptation processes, as well as a cocktail of hormones the composition of which can also be very specific. With all this, the body functions are precisely adapted to changing demands.

'unhealthy ': pr ol onged resp onse


29

The more flexible and the better the body functions are adapted to the demands of the current situation, the "healthier" the stress response is. Therefore, failing to respond or responding too weakly according to the current demands or responses with a delayed onset is as unfavorable as too strong or prolonged responses. Thus, if someone claims that the body's responses to emotional strain are generally adverse, an X is made for a U. Only then are stress responses "unhealthy", if the results of the regulation processes are not fully in accordance with the current demands. There are numerous reasons why deviations in adaptation processes may occur. Persistent negative emotional traits such as depression, anxiety, and chronic experience of stress are among the factors that can contribute to the development of minor alterations of adaptation processes (Cohen et al., 2000; Fuchs and Fluegge, 1995; Hughes and Stoney, 2000; Oswald et al., 2006; Peeters, Nicholson, and Berkhof, 2003; Plotsky et al., 1998; Thayer et al., 1996).

THE POSITIVE SIDE OF THE PSYCHOSOMATIC COIN There is much more research on the impact of negative than of positive affective traits on well-being and health. Taken together, there are over 20 times more studies on the concomitants of negative affect than there are on health-related aspects of positive affect, although there is even evidence that positive affective traits may be associated with longevity (Danner, Snowdon, and Friesen, 2001; Pressman and Cohen, 2005). The current knowledge about psychosomatic processes has nearly exclusively developed based on investigating the negative side of the psychosomatic coin. Surely, that can be attributed to the general principle that everything that causes disturbances attracts more attention and on the first glance seems to be more interesting than something is that may attenuate adverse processes and, consequently, may prevent disorders. This phenomenon is also reflected in the news culture. (Particularly the bad news and reports of disasters are the most interesting news). Therefore, much more is known about the negative side of the psychosomatic coin. Nevertheless, turning the coin over it seems justified to deduce certain expectations about the psychosomatic sequelae of cheerfulness. The key factor is the lasting beneficial effects of cheerfulness on psychological health. More trait cheerfulness results in feeling less stressed, depressed, worried, and anxious; not only because cheerfulness and negative mood are incompatible, but above all because cheerfulness is associated with the ability to better deal and cope with adversity and, thus, difficult circumstances are experienced less awful and burdening (see "Stress and strain"). Consequently, it can be expected that by enhancing cheerfulness in every day life, the well-known sequelae of stress, depression, and anxiety can be warded off or at least considerably attenuated. Beyond that, a cheerful disposition also contributes to faster and more efficient recovery from adverse circumstances and the associated negative feelings. That way imbalances produced by stress, anger, sadness, worry, etc. are quickly readjusted, and the development of lasting changes that may affect health in the long run is prevented (Tugade and Fredrickson, 2004). That also implies that in order to stay healthy, it is in no way necessary to have never negative feelings, be never sad, angry, or stressed. On the contrary, given the respective circumstances, it is right and important to also react emotionally (to an appropriate extent). What is important is that the negative mood does not last too long and that one sufficiently recovers both emotionally and physically. That is, it

30


is important, for instance, that one does not ruminate and worry about a situation long after it is settled or over, and that the stress-induced physiological changes quickly return to baseline (Brosschot et al., 2006; Heponiemi et al., 2007; Kallus, 2002). Trait cheerfulness facilitates that. That is, if an individual can cope more successfully with stress and adversity in every day life, adequately recovers from stress, anger, sadness, worry, etc. and, hence, does not permanently feel stressed, or worried, or depressed, then adverse consequences of negative affective traits on physical health can be warded off. That is of great value, because the impact of negative affective traits on well-being and health can be substantial. In addition, these relationships are not only interesting for individual persons and their families and friends. Studies indicated that it strongly depends on psychological factors if and to what extent health care facilities are used. Experts estimated that only 12 to 25 percent of utilization of health care services can be explained by objective morbidity or disability alone. In all other cases, the emotional condition of a patient plays at least an important part. Moreover, it was estimated that approximately 50 percent of all visits to doctors can be attributed to so-called functional disorders and diseases, in which psychological factors play a particularly important role for the development, severity, and course of the disorder and in most cases there is no medical diagnosable condition. It was also calculated that systematic programs to improve the emotional condition of patients and their coping with stress could considerably reduce the costs of the health care system (Berkanovic, Telesky, and Reeder, 1981; Cummings and van den Bos, 1981; Sobel, 2000). That is, cheerfulness can play a part in contributing to not letting chronic stress, anger, sadness, depression, worry, or anxiety set processes in motion that in the long run may affect health or may hinder or slow down recovery. This positive side of the psychosomatic coin is of great value. However, there will not be any effects beyond that. It is not to be expected that more cheerfulness will turn you into superman or supergirl, that you will become healthier than healthy, extra-robust, mega potent. That will not be the case for sure. Details of what can be expected from the enhancement of cheerfulness in every day life will be summarized below.

CARDIOVASCULAR HEALTH Particularly convincing evidence for the health-related impact of negative and positive affective traits has been provided for cardiovascular diseases. In well-controlled prospective studies it was repeatedly demonstrated that negative emotional traits have to be regarded as important risk-factors, independently of other known risk-factors such as smoking, lack of exercise, eating habits, etc. (Frasure-Smith and Lesperance, 2005; Gallo, Ghaed, and Bracken, 2004; Kamphuis et al., 2006; Middleton and Byrd, 1996). Thus, negative affective traits are independent risk-factors, that means, that the correlation between chronic stress, depression, worry, anxiety and cardiovascular disease can not be entirely attributed to the fact that people with negative affective traits have a less healthy life-style (e.g., smoke more, exercise less, have a less healthy diet). The affective disposition plays an additional role, in addition to these well-known risk factors (obviously through biological mechanisms). Being a risk-factor means that not everyone with a disposition to negative affect in time develops cardiovascular


31

disease, but just that it is more likely. The same holds for all other risk factors. Not all smokers will die of a heart attack, but the risk to develop heart problems is greater if you smoke. Of course, the significance of all this becomes the greater, the more independent risk factors accumulate in an individual. Besides the psychological factors that are generally important for psychosomatic relationships (chronic stress, depression, worry/anxiety), the disposition to get heavily annoyed at minor events in every day life seems to play an important role for the development of cardiovascular disease. It has been demonstrated in prospective studies that in people with a chronic disposition to be annoyed or angry, the risk to develop cardiovascular disease is twice as high as in people who tend to handle adverse situations and circumstances with serenity. The tendency to brood on the angry thoughts for longer times seems to be a particularly unfavorable disposition (Brosschot et al., 2006; Kawachi, Sparrow, Spiro, Vokonas, and Weiss, 1996; Williams et al., 2000). As opposed to that, there is first evidence that a positive affect disposition can be regarded as a protective factor, that is, as something that makes the development of diseases less likely (Rozanski and Kubzansky, 2005; Steptoe and Wardle, 2005). Positive and negative affective traits also influence the probability of developing cerebral strokes (Jonas and Mussolino, 2000; Ostir et al., 2001). These relationships have also been shown for predisposing factors, that is, for somatic changes that, for their part, promote the development of cardiovascular disease and stroke. Prospective studies demonstrated, for instance, that negative affective traits (chronic experience of stress, depression, anxiety) increase the probability of developing chronic hypertension, also independently of other known risk-factors such as smoking, lack of exercise, etc. That holds true for people at middle age and even for adolescents and young adults who are completely healthy at the time of the first examination (Brady and Matthews, 2006; Davidson et al., 2000; Jonas, Franks, and Ingram, 1997; Jonas and Lando, 2000). Similar holds true for atherosclerosis, which progresses faster in people with a higher disposition for depression, anxiety, or chronic anger (Matthews, Owens, Edmundowicz, Lee, and Kuller, 2006, Matthews, Raikkonen, Sutton-Tyrell, and Kuller, 2004; Paterniti et al., 2001; Raikkonen, Matthews, Sutton-Tyrrell, and Kuller, 2004). It has also been reported that chronic experience of stress, depression, and anxiety is related to certain inflammatory processes in the blood vessels that also play a part in the development of cardiovascular disease (Jain, Mills, von Känel, Hong, and Dimsdale, 2007; Joynt et al., 2003; Kop et al., 2002; Libby, 2003; Miller and Blackwell, 2006; Pitsavos et al., 2006; Ross, 1999). These findings, too, have been shown both for older and for otherwise healthy people at middle age. In addition to that, it has been demonstrated that even individuals with relatively low levels of negative emotional traits are at elevated risk, that is, with levels that are far from abnormity or clinically relevant psychological disorders. Findings also suggest that affective traits may be linked with later disease in a graded manner, that is, cardiovascular diseases, strokes, and respective predisposing factors such as hypertension seem to be more likely the higher is the disposition to negative affect (Gallo et al., 2004; Jonas and Lando, 2000; Kawachi et al., 1996; Kubzansky et al., 1997, Kubzansky, Kawachi, Weiss, and Sparrow, 1998; Kubzansky, Davidson, and Rozanski, 2005; Kubzansky and Kawachi, 2000; Rugulies, 2002; Williams et al., 2000). Taken together, it can be concluded from the body of scientific evidence that the enhancement of cheerfulness as a trait can be a useful preventive measure. Improved coping and the development of successful personal resources enhance emotional well-being

32


enhanced on a lasting basis. One faces adversity with serenity rather than being ferociously angry or devastated. Situations and circumstances are experienced less burdening and can be managed more effectively. One feels confident being able to successfully manage stressful or difficult situations and that there will always be a way out. Consequently, adverse processes induced or augmented by the chronic experience of stress, depression, worry, or anger are warded off in the long run. Transitory states of stress, sadness, worry, or anger, elicited by certain events, are no harm, because a high level of cheerfulness is also associated with faster and more efficient recovery from stress and negative mood, and, thus, these emotional turbulences will not affect health (see "The positive side of the psychosomatic coin"). The scientific findings also indicate that the promotion of cheerfulness may already be useful in completely healthy and young individuals, because the affective disposition that one has when young co-determines the probability of cardiovascular problems at an older age. The processes that are induced or augmented by negative affective traits have their effects only after a longer time, and significant health effects will only occur after many years. With a higher level of cheerfulness, these processes can be warded off or at least attenuated or delayed. Scientific evidence also indicates that the promotion of cheerfulness is useful in individuals who are not seriously depressed or anxious and do not feel heavily stressed. Since affective traits are linked with the likelihood of later cardiovascular disease in a graded manner, improvement is always possible. That is, every improvement of one's dispositional affect may contribute to reducing the risk of developing cardiovascular disease. Improving it from good to even a bit better will reduce the risk just the same as improving it from bad to slightly less bad, but just at a different level. However, it is essential that the enhancement of cheerfulness and serenity is lasting. Transient episodes of cheerful mood, exhilaration, or laughter do not have any effects that may be relevant to cardiovascular health (see "Is exhilaration healthy?"). Certain forms of humor and laughter (that have nothing to do with cheerfulness) such as cynical or aggressive humor or sardonic laughter even belong to a complex of personality characteristics that are linked to a heightened probability of developing cardiovascular disease (Martin, 2001). Another important conclusion follows from the observation that chronic stress, depression, worry, anxiety, and the disposition to being angry are risk-factors that are (at least partly) independent from other risk-factors such as smoking, lack of exercise, etc.: The enhancement of cheerfulness can absolutely not replace other important preventive measures such as giving up smoking, more exercise, healthy eating, etc. But it may be a useful additional measure, and it could perhaps help abandon other "unhealthy" behavior. Thus, a higher level of cheerfulness can help to ward off unfavorable alterations of the cardiovascular system and, hence, to prevent disease. But what about if something has already happened, if a heart attack has occurred or surgery was necessary? Numerous controlled prospective studies indicated that patients with a less depressed and anxious disposition have a better prognosis. More anxious patients, particularly if they lack efficient coping strategies and, thus, feel at the mercy of the situation, are more likely to develop dangerous complications such as ventricular fibrillation (dysrhythmia) or ischemia (impaired myocardial blood flow) during their stay at the hospital directly after an acute heart attack. During the weeks and years after a heart attack or a bypass surgery, patients with a less depressive and anxious or worried disposition are markedly less likely to develop another heart problem or die of one. This is independent from the severity of the first incident and the general health


33

status of the patients. Even a slightly higher negative affect disposition, by far within the normal range, affects the risk for complications, relapses, and mortality (Barefoot et al., 1996; Blumenthal et al., 2003; Bush et al., 2001; Frasure-Smith, Lesperance, and Talajic, 1995; Kubzansky et al., 1997; Lesperance, Frasure-Smith, Talajic, Bourassa, 2002; Middleton and Byrd, 1996; Moser et al., 2007). Therefore, obviously an improvement of affect has the potential to slow down or attenuate adverse processes even when a person has already fallen ill. Selective measures for the enhancement of cheerfulness as a disposition, therefore, could also be useful within the context of rehabilitation after cardiovascular disease and surgery. Of course, it is important to note, again, that the enhancement of cheerfulness can be a useful additional measure, in addition to other proved measures such as systematic exercise programs, but cannot replace them. For severely ill cardiac patients who generally should avoid excitements, for instance, patients with severe angina pectoris, no programs should be selected that include strong emotional arousal through intense exhilaration or hearty laughter. Emotional arousal, no matter if it is experienced negatively or positively, is accompanied by changes of various cardiac parameters, increase of blood pressure, etc. Under certain circumstances, intense exhilaration and hearty laughter could, therefore, (like intense anger, anxiety, etc.) provoke attacks. If excitements do not constitute an acute risk, short episodes of cheerful mood, exhilaration, and laughter do not have any effects that may be relevant to cardiovascular health (Gabbay et al., 1996; Moller et al., 1999; Pressman and Cohen, 2005). In any case, positive effects can only be expected, if a program can provide a lasting enhancement of cheerfulness and serenity in everyday life. Beyond that, it is important to note that the potential of emotional factors to influence bodily processes is of course limited. If the disease is already far advanced, or if the kidney or the heart already fails, not even permanent emotional factors can effect something (Pressman and Cohen, 2005).

FUNCTIONAL COMPLAINTS In European countries, about 75 percent of adults report having at least some subjective health complaints (Eriksen, Svendsrod, Ursin, and Ursin, 1998). About one third of all somatic symptoms reported in primary care fall into the category of so-called functional complaints or functional disorders (Kroenke and Harris, 2001). These terms are used to define symptoms that are the result of organs or organ systems not functioning normally, but not being associated with structural or biochemical abnormalities. Consequently, x-rays, blood tests, CT scans, or endoscopic exams have essentially normal, that is, non-disease results (Drossman, Corazziari, Talley, Thompson, and Whitehead, 2000). Among the most common functional complaints are gastrointestinal symptoms such as abdominal pain, constipation, diarrhea, and bloating, which are subsumed in the term "Irritable Bowel Syndrome". When diagnosed by standardized diagnostic criteria, about 8 to 17 percent of all adults in western countries suffer from this complex of complaints. Single functional gastrointestinal symptoms are much more widespread (Drossman et al., 1993; Leibbrand, Cuntz, and Hiller, 2002). It has been estimated that functional disorders are responsible for 25 to 50 percent of all visits to gastroenterologists, although only a small proportion of patients with these symptoms present to the doctor (Olden, 1998). Thus,

34


functional gastrointestinal complaints have also a major economic impact. Other symptom groups subsuming functional complaints are, for instance, fibromyalgia (widespread muscle pain, enhanced sensitivity to pain, tiredness) or the "chronic fatigue syndrome". But these are only labels, in order to give the patients (and the health insurance companies) a diagnosis. The expression of the illness can vary considerably, and on the other hand, the various syndromes (i.e., symptom-groups) have many symptoms in common. The range of functional complaints is much more multifaceted than a reduction to a small number of syndromes suggests. Many very different complaints can result from functional disorders. Functional disorders are not dangerous, but the symptoms can have a considerable impact on quality of life. Attention is very much focused on one's own feelings and inner sensations, often leaving not much energy for other things of life, and some patients are even restricted in their everyday activities (Tveito, Passchier, Duivenvoorden, and Eriksen, 2004). It is important to note that even when the doctor cannot find anything wrong, functional complaints are not pretended or "all in the head". In contemporary medicine, they are regarded as an expression of disorders of function that are "real" and that can be treated. They develop from slight dysfunction of regulation processes that, in time, can cause symptoms (Clauw and Chrousos, 1997; Depue and Monroe, 1986; Papousek et al., 2002; Ringel and Drossman, 1999; Sheffield et al., 1998; Staud, 2006; see "Psychosomatics"). Psychological factors play a major role for the development and the course of such dysfunctions, and for the extent of complaints and how symptoms are interpreted (Cohen and Williamson, 1991; Papousek and Schulter, 2002; Pennebaker, 1982; Petrie, Moss-Morris, Grey, and Shaw, 2004). Individuals with a higher degree of negative affective traits such as chronic stress, depression, worry, or anxiety are more likely to develop functional complaints and report more complaints than individuals with a more positive affect disposition. Even if a medically diagnosed disease is present, they experience more or more severe complaints than the underlying disease would suggest (Cohen et al., 1995; Hubbard and Workman, 1998; Watson and Pennebaker, 1989). It is also true, of course, that it will negatively influence one's mood if one is affected by somatic symptoms. But controlled prospective studies demonstrated that negative affective traits may indeed increase the likelihood of somatic complaints and may worsen existing complaints (see "Don't take an X for a U, Tip 3"). In contrast, people with a more positive affect disposition generally feel more healthy and have less somatic complaints, even when they are objectively as healthy or ill as others, and they are less likely to develop functional disorders in the future. All this holds for young adults as well as for people at medium or older age (Brosschot et al., 2006; Cohen et al., 1995, 2003; Hirdes and Forbes, 1993; Okun, Stock, Haring, and Winter, 1984; Pettit et al., 2001; Pressman and Cohen, 2005; Thomsen et al., 2004). More cheerfulness in everyday life can attenuate negative emotional characteristics and foster positive ones (see "Emotional well-being"), by which the adverse effects of depression and anxiety on the number and extent of somatic complaints can be warded off. But in connection with somatic complaints it is also particularly important that cheerfulness is accompanied by effective coping strategies (see "Stress and strain"). Therefore, individuals with a more cheerful disposition can better deal with somatic complaints and also tend to behave in a more sensible way: They take their symptoms easier in the first place, they are more likely to consider what they can do about them themselves, to talk to someone who is close to them, and visit a doctor when it is appropriate. Consequently, they more successfully


35

cope with their complaints; they experience them as less awful and frightening, can gain distance and are not worrying so much about their symptoms. Particularly ruminating about the symptoms, envisioning all kinds of terrifying scenarios, and related worries can considerably worsen somatic complaints, also because they prevent an individual from recovering in between times from the emotional strain (Brosschot et al., 2006; Gendolla, Abele, Andrei, Spurk, and Richter, 2005; Thomsen et al., 2004). Effective interventions can help, e.g., interventions that succeed in stopping ruminating on the same thoughts and worries all day. An experimental study in which a large group of people participated in such an intervention demonstrated that the number of somatic complaints was markedly reduced after the intervention, as compared to a control group who did not participate. The improvement involved a wide range of symptoms such as gastrointestinal pain, cough, dizziness, low back and neck pain, heartburn, hot flushs, etc. (Brosschot and van der Doef, 2006). Interruption of rumination and worry is also a concomitant of the enhancement of cheerfulness (see "Stress and strain"). It also has been directly demonstrated that the degree of somatic complaints can be reduced by purposefully training cheerfulness. After a respective training program lasting several weeks, participants in whom cheerfulness was already considerably increased also felt physically better. In a control group not participating in the program, nothing changed in the same period (Papousek and Schulter, 2008). Certainly, all that does not mean that it may be recommended to thin, with unrealistic optimism to be invulnerable and to simply ignore symptoms. Symptoms are not only annoying, but are also important information that something is not as it should be. Thus, it is not a good strategy to simply ignore symptoms that are present. A doctor should clear symptoms that persist or constantly recur. Having more cheerfulness has nothing to do with forcefully suppressing negative thoughts and somatic complaints. Individuals that are more cheerful automatically have more emotional and physical well-being. To just describe one's situation more positively as it is experienced (to "whitewash"), does not help either, it does not improve somatic complaints (Pettit et al., 2001). To worry about one's symptoms and still not visit a doctor is not useful, either. On the contrary, it prolongs the unfavourable loop of thoughts. To keep worrying and ruminating, even after visiting the doctor, and even when the doctor has not found anything (and, thus, it is probably not a dangerous disease but a functional disorder), will probably also increase the problems. But more cheerfulness as a trait can be effective against that. Therefore, more cheerfulness in every day life can contribute to feeling physically better and to developing less somatic symptoms. But miracles are of course not to be expected. Particularly if someone has already serious and persistent problems, the enhancement of cheerfulness might provide some relieve; but to get rid of them, additional measures will definitely be required.

CHRONIC PAIN Chronic pain is usually defined as persistent or recurring pain that lasts for six months or longer. It is wide spread. In European countries, for instance, about 20 to 25 percent of the adult population have chronic low back, shoulder, or neck pain (Bergman et al., 2001; Picavet

36


and Schouten, 2003). That psychological factors strongly influence chronic pain is beyond doubt (Campbell, Clauw, and Keefe, 2003; Janssen, 2002). In fact, it has been found that the severity of pain and how much a patient needs help depends more on the affective disposition of an individual than on the extent of the anatomical damage determined by radiography (Salaffi, Cavalieri, Nolli, and Ferraccioli, 1991). Chronic pain can have a clear medical cause (e.g., injury or degeneration) or not (functional disorder). In both cases, the same psychosomatic processes co-determine the duration and the severity of the pain and the associated emotional strain. To understand the influence of feelings, thoughts and affective traits on pain, it is important to know that certain groups of neurons in the brain produce the experience of pain. If we, for instance, cut our finger with the kitchen knife, neurons send a message from the finger to the brain that damage has happened. Only when these signals have arrived and are processed at certain locations in the brain, we feel pain. Due to the arriving signals, the brain also "knows" where they come from. Therefore, it feels like the finger would hurt. But in fact, the brain feels the pain (and not the finger). The finger alone is not able to convey the experience of pain. The severity of the pain we experience certainly depends on the size of the injury we caused with the kitchen knife. But it is at least as important what happens in the brain at that moment. For various parts of the brain intervene in the perception of pain. They send out signals on their part that can attenuate, inhibit, or also reinforce the transfer of the report on damages from the finger into the brain. Other parts of the brain determine whether a message from the body is experienced as pain at all and determine the appraisal of the pain, for instance, as threatening, intolerable, burdening, unimportant, etc., sometimes even as erotic. The activity of these intervening parts of the brain, in turn, is related to the affective dispositions and mood states of an individual and to the other activities, the brain is occupied with at the moment (Fields, 2000; Jasmin, Rabkin, Granado, Boudak, and Ohara, 2003). As psychological processes such as feelings, thoughts, etc. can strongly influence the perception of pain, because various parts of the brain intervene in the pain experience, intriguing things are possible, such as that after an accident and severe injury one experiences pain only after having fled the danger-zone or help has arrived; or that some people voluntarily dangle themselves from a meat hook or can pierce their cheeks with a spear. (Talented people can practice to reinforce the required pain-inhibiting processes in the brain). The intervening processes of the brain are also the reason why "medication" that is expected (or believed) to alleviate pain, has a certain pain-alleviating effect, even when it does not contain any active ingredients, but, for instance, only consists of dextrose ('Placebo-effect'; Levine and Gordon, 1984; Petrovic, Kalso, Pettersson, and Ingvar, 2002; Sauro and Greenberg, 2005). The other way round, pain is perceived as more severe during depressed, anxious, or tense mood states, and the pain is less bearable and more burdening the more threatening it is perceived and the more a person is worried and frightened of it (Campbell et al., 2003; Janssen, 2002; Ochsner et al., 2006; Sharp, 2001). Chronic pain is associated with durable but reversible alterations in the brain and in the function of nerve cells in the spinal cord that cause hypersensitivity of the pain perception system. Consequently, even weak stimuli and stimuli that the brain normally would not interpret as pain (e.g., slight pressure) may produce a strong experience of pain. Emotional factors can reinforce these alterations and can contribute to the prolongation of respective processes (Staud, 2006). In prospective studies, a depressed disposition was even identified as the most important predictor of the development and maintenance of chronic pain. Permanent


37

worry and ruminating about the pain or possible disease also plays an important part, because it makes people extremely focus on themselves and their pain, which may also reinforce the perception of pain (Brosschot, 2002; Campbell et al., 2003; Forseth, Forre, and Gran, 1999; Severeijns, Vlaeyen, Van den Hour, and Weber, 2001; Sharp, 2001). Taken together, it can be deduced from the existing evidence that a high degree of cheerfulness can help to prevent the development of chronic pain. In case of existing chronic pain, it may bring some relief. Various factors play a part in that. The above-mentioned adverse effects of negative affective traits such as depression, anxiety, and chronic experience of stress are prohibited, because trait cheerfulness implicates that they are only present to a smaller degree (see "Emotional well-being" and "Stress and strain"). The processes that are responsible for the development and maintenance of chronic pain are not brought forward, and the perception of pain is not additionally reinforced. Consequently, patients with chronic diseases such as rheumatism or fibromyalgia who have a generally more positive affect disposition suffer less pain, also in the future (Zautra, Johnson, et al., 2005). In addition to that, individuals that are more cheerful tend to use more effective coping strategies (see "Stress and strain"). Thus, they can also better cope with chronic pain. They experience the pain as less burdening and threatening, they worry less, and do not catastrophize and fall into despair so quickly, should the pain return or become more intense. They also recover faster and more efficiently after periods of intense pain (Strand et al., 2006; Zautra et al., 2001; Zautra, Johnson, et al., 2005). Moreover, cheerfulness promotes a change of perspective and, consequently, helps to gain distance from oneself and one's pain (see "Stress and strain"). This also helps to appraise the pain as less threatening. And the less threatening the pain is perceived and the less worries and fears are related to it, the less severe the pain is experienced and the better a person can bear up against it (Ochsner et al., 2006; Sharp, 2001). An additional effect is that individuals that are more cheerful do not think at the pain all the time and do not permanently concentrate on it. Pain is experienced less severe and intolerable if the attention is not only focused on the aching body part, but if one occupies oneself (i.e., the brain) with other things. Neuroscientific studies have shown that that is due to altered activity of those parts of the brain that are participating in the processing and in the reinforcement and attenuation of pain perceptions (Miron et al., 1989; Nouwen, Cloutier, Kappas, Warbrick, and Sheffield, 2006; Petrovic, Petterson, Ghatan, Sone-Elander, and Ingvar, 2000; Tracey et al., 2002; Villemure and Bushnell, 2002). By way of exception, in connection with pain even the short-lived concomitants of exhilaration have some worth (see "What is meant by cheerfulness" for the difference between cheerfulness and exhilaration). Scientific studies showed that during exhilaration (e.g., watching a funny film, comedy, etc.) pain sensitivity may decrease for a short while (Cogan, Cogan, Waltz, and McCue, 1987; Weisenberg, Raz, and Tener, 1998; Zweyer, Velker, and Ruch, 2004). This effect can probably be attributed to distraction, that is, to the fact that less attention is directed to the pain or the aching body part; possibly also to some unspecific effect of emotional arousal, i.e., of strong feelings. Films that are comparably interesting and elicit a comparably strong emotional response but are not exhilarating have essentially the same effect as exhilaration (e.g., horrified feelings during a disaster film). It is known that a transitory inhibition of pain perception also occurs during the state of shock after an accident. If the elicited feeling is not really intense, pain perception is only slightly

38


altered or not altered at all (Martin, 2001; Ruch and Ekman, 2001; Weisenberg, Tepper, and Schwarzwald, 1995; Zillmann, Rockwell, Schweitzer, and Sundar, 1993). There is also evidence that the short-lived inhibitory effect of exhilaration (or other strong emotions) is only effective with less severe pain. With severe pain, when strong medication is required to bear it, the effect of exhilaration is not observable any more (Rotton and Shats, 1996). But perhaps it is just more difficult to exhilarate patients suffering from severe pain with films and comedy. Cheerfulness as a temporally stable disposition also plays a part in the short-term effect of exhilaration. As individuals that are more cheerful get into an exhilarated mood more easily, they are more likely to reach the required intensity of exhilaration. People with a low degree of trait cheerfulness may not be sufficiently exhilaratable, also with a supposedly very funny film (Ruch and Zweyer, 2001). Certainly, this reduction of pain sensitivity as a concomitant of exhilaration and other intense feelings is only a short-lived and transitory effect. It is only there at the time one is exhilarated, perhaps also for some minutes afterwards. Then everything is as it was before. However, for patients suffering from chronic pain it can also be a relief to have less pain for a short while. Therefore, some worth can be ascribed to the short-term concomitants of exhilaration. It would be better, of course, if the pain could be alleviated more permanently, if it would be less severe also when one is not exhilarated at the moment. But such a durable effect cannot be achieved by watching comedy films twice a week instead of once a month, that is, by just being exhilarated more often (see "Is exhilaration healthy"). A distinct sense of humor and the frequency of laughter are not related to pain sensitivity and tolerance, either (Martin, 2001). For a durable alleviation of chronic pain, a sustainable enhancement of affect with associated improved coping and recovery processes is required. That can only be accomplished with more cheerfulness and more serenity in every day life. However, although it can be assumed that a high degree of cheerfulness may have favorable effects on the development and progress of chronic pain, no miracles are to be expected. It does not make you invulnerable. Even the most cheerful people may be hit, because certainly many factors play a part in the developing of chronic pain. However, a high degree of cheerfulness makes it a bit less likely to get chronic pain. If you already suffer from chronic pain, the attempt to enhance cheerfulness alone will surely not be sufficient to get rid of it. It might be promising as an additional measure, complementing medication, physiotherapy, etc. There are also a number of established psychological intervention methods that in part also use one or the other of the above-mentioned mechanisms and have been used successfully for a long time in the therapy of chronic pain (e.g., classical relaxation methods, biofeedback, imagination techniques, cognitive pain management, various techniques of distraction). Ideally, a pain specialist should tie up a comprehensive package of various measures. Training cheerfulness could be a useful component of it or could complement the package.


39

DON'T TAKE AN X FOR A U Tip 5: What Can Changes of Immune Parameters Say From time to time studies have been reported that showed that under some condition (e.g., while watching a funny film) some parameter of the immune system (e.g., immunoglobulin A) increased a little bit for a few seconds. The media have often used such reports to claim that exhilaration or laughter may "boost the immune system". But can the slight increase of a single immune parameter, lasting for a few seconds, really be denoted as "boost of the immune system"? And above all: Does this really have anything to do with health, that is, with whether one stays or becomes healthy? The human immune system is a highly complex system, where a number of different components and processes must intertwine to successfully accomplish its numerous complicated tasks. Therefore, there are a number of possible immune parameters that can be measured, which are related to different components fulfilling different functions. In the majority of cases researchers count how many white blood cells of a certain type are in the blood, for instance, natural killer cells, T-cells, or B-cells (just to mention a few), or they determine the amount of a certain type of immunoglobulin. Immunoglobulins are protein molecules that bind to a certain "enemy" (e.g., a virus) and, for example, mark it for destruction (which then is accomplished by other components of the immune system). There are various types of immunoglobulins fulfilling different specific functions. Cytokines are substances that are secreted by specific cells of the immune system. They mediate, reinforce, or stop various other processes of the immune response. Of these also different types exist, including various kinds of interleukins. There are also several types of parameters with which it is attempted to quantify the functional capacity of immune cells. This is done outside the body (in vitro). It is determined, for instance, how effectively certain cells proliferate (i.e., divide), or how many natural killer cells are required to destroy a certain number of target cells. And there are many other components of the immune system beyond that. If, for instance, differences are found between groups of people (e.g., between depressed and less depressed individuals), it is never the case that these differences are equally present in all immune parameters. The groups will only differ in some parameters and in others not, and in one group some parameters may be higher than in the other group while at the same time others may be lower. Due to the large number of different components, it is impossible to make a general conclusion on how well "the immune system" works by measuring one or a few parameters. But single parameters themselves are difficult to interpret, as well. The measures vary greatly within an individual, that is, if a parameter is repeatedly obtained in the same person, the results will always differ from each other; they are not temporally stable. Therefore, with one single measurement of an immune parameter, it is hard to tell how high the score of the respective individual is in general. Moreover, it is far from unequivocal of which functional significance differences in the number of immune cells are. It is true that a certain minimum number is required of each type of immune cells to enable the organism to respond to threats. But in healthy individuals, the numbers far exceed the required minima, and the numbers very much vary between individuals. The numbers of immune cells (if above the minimum) do not

40


necessarily correlate with the functional capacity of the immune system. It is also important that the different types of cells be in a certain proportion to each other. The health consequences of small changes in the numbers of immune cells in the blood are unknown. Moreover, changes in the number of a specific cell type may be due to a variety of different mechanisms that have different functional significance. For instance, the concentration in the blood may be higher because more cells migrate from the lymph nodes to some place in the body where they are needed, or more cells may migrate back to the lymph nodes. Interpreting the meaning of the total levels of immunoglobulins is also difficult, because only a small proportion of a certain type of immunoglobulin is effective against a certain disease. It is also doubtful whether the relative small differences and changes in the levels of immunoglobulins that are typically observed in studies have any relevance to health at all. Moreover, a higher value is not always beneficial. Higher values of immune parameters may also indicate that an infection is insufficiently controlled or may indicate systemic inflammation that can reinforce diseases or symptoms. Allergies and autoimmune diseases are the consequence of an overreactive immune system (Ershler and Keller, 2000; Herbert and Cohen, 1993; Papanicolaou, Wilder, Manolagas, and Chrousos, 1998; Segerstrom, 2005; Stein, Miller, and Trostman, 1991; Stiles and Terr, 1991; Weisse, 1992). Transient changes of immune parameters lasting several seconds that may be observed in laboratory studies after stress, exhilaration etc. cannot have any significant health consequences anyway (see "Is exhilaration healthy"). Moreover, the short-term effects of emotional arousal on the immune system are essentially the same when it is experienced negatively (e.g., in a stressful situation) as when it is experienced positively (e.g., during exhilaration). In addition, the responses to temporary changes of mood are always complex; some functions are activated, at the same time other functions are inhibited or turned off (Herbert and Cohen, 1993; Segerstrom and Miller, 2004; Stein et al., 1991; Weisse, 1992). In those studies that are readily cited by providers of laughter- or humor-related courses or events, it was only observed, if at all, that during exhilaration individual immune parameters changed very little for a very short time. Moreover, these are exactly the same changes that can be observed during every emotional activation, that is, also during shortlived negative stress, for example. Added to this are often serious methodological flaws (Martin, 2001; Pressman and Cohen, 2005). For the mentioned reasons, existing studies do not justify the claim that exhilaration or laughter might "boost the immune system". Only in connection with completely differently constructed studies, such investigations could be meaningfully interpreted and indeed be conclusive. Even if there might be longer lasting differences and changes of immune parameters: Before significant conclusions can be made, it must be verified that these differences or changes are of some relevance for staying healthy or becoming ill; and if so, whether these consequences are positive or negative. If it is claimed that something may "boost the immune system", only referring to slightly higher values of individual immune parameters, somebody tries to make an X for a U. Examples of a group of studies from which more unequivocal conclusions can be drawn are the studies of Cohen's group (Cohen, Tyrell, and Smith, 1991; Cohen et al. 2003, 2006). In these studies not only changes of individual immune parameters lasting a few seconds, but the consequences of durable affective traits, in fact, their relevance to staying healthy or becoming ill, were examined. For this purpose, healthy volunteers were individually


41

quarantined. On the second day, they were given nasal drops containing a certain amount of rhinovirus. Only part of the infected participants became ill during the following days, that is, developed symptoms of the common cold, determined by objective criteria. In the other participants, the immune system responded to the infection in a way that prevented the illness from developing. Participants with a habitual tendency to feel stressed and experience situations as stressful were more likely to become ill. A greater disposition to positive affect, in line with trait cheerfulness, was associated with greater resistance to developing a cold. However, cheerfulness does not protect from infection by the virus. The greater resistance of more cheerful individuals does not relate to whether one gets infected by the rhinovirus or not, but to the likelihood of developing illness symptoms when infected. There is some evidence that this may be due to the level of certain components of the immune system mediating inflammation (cytokines). In the noses of more cheerful individuals and individuals that are less prone to feel stress, a lower level of a certain type of cytokines is present when they are infected with rhinovirus (Cohen, Doyle, and Skoner, 1999; Doyle, Gentile, and Cohen, 2006). These intriguing findings are related to particular processes that are obviously mediated by particular components of the immune defence. Therefore, these findings only hold for coughs and sneezes and cannot be transferred to other infectious diseases, neither of course to diseases that are not infectious. They also only hold for durable affective traits and have nothing to do with temporary mood swings. It is also important to note that the resistance against the common cold depends on various factors affecting the likelihood of becoming ill independently from the affective traits of an individual. Thus, individuals with a high level of cheerfulness are not invulnerable. It is only that within the boundary conditions given by other factors, more cheerful individuals seem to be less prone to colds when exposed to the virus.

SOCIAL LIFE Negative affective traits such as depression are not only related to the tendency towards disengaging from social interaction and to increasingly withdrawing from friends and family. Others retreat from depressed people, because they experience them as unpleasant, little inviting and burdening and sense signals of rejection. People with negative affective traits also notice the difficult atmosphere in their social environment, which can contribute to reinforce and perpetuate their condition - a vicious cycle that is hard to break (Coyne, 1976; Troisi and Moles, 1999). As opposed to that, if someone's behavior (facial expression, posture, gestures, language) radiates positive affect, others interpret this as a signal that this person is open to make contact or is willing to continue the social interaction. Making friends with people radiating a positive affect disposition is more attractive, because people expect them to have also other desirable characteristics such as emotional stability and safety. In existing relationships, shared laughter is believed to be a signal of reassuring relationship partners of mutual emotional support when needed. In groups and teams, the reciprocal signaling of positive mood increases the cohesiveness. However, all this only works if the smile or laughter of others is perceived as authentic, that is, as elicited by cheerful mood. Observers are able to

42


distinguish very quickly and accurately between smiles and laughter devoid of cheerful mood and the genuine expression of a positive affective state. Therefore, it is not the pure behavior (smiles, laughter) that is crucial to the positive effects on social life, but the affective traits and mood states of the respective individual (Harker and Keltner, 2001; Keltner and Bonanno, 1997; LaFrance and Hecht, 1995; Otta, Abrosio, and Hoshino, 1996; Provine, 2000; Reis et al., 1990; Ruch, 1993a; Szameitat et al., 2009; Vinton, 1989). Beyond that, people with a more cheerful disposition socialize more often themselves, and they maintain more and higher quality social ties. Consequently, positive affective traits are associated with greater social connectedness and more social support, and the relationships are perceived as more rewarding by both the more cheerful individuals and their friends than it is the case in relationships in which a person with a less positive affect disposition is involved (Berry and Hanssen, 1996; Berry, Willingham, and Thayer, 2000; Steptoe et al., 2008; Watson, Clark, McIntyre, and Hamaker, 1992). That individuals that are more cheerful have more close social contacts and relationships is promoted by the fact that people radiating cheerful mood also induce positive feelings in their interaction partners: Cheerful mood is contagious. Others are drawn to form attachments with cheerful people, and the social contacts are perceived as particularly attractive and inviting. That, too, only works if the expression of positive mood is perceived as authentic. Simulated cheerful mood, faked smiles or laughter devoid of cheerful mood are recognized as such and do not have the same effects (Harker and Keltner, 2001; Hatfield, Cacioppo, and Rapson, 1994; Kashdan and Roberts, 2004; Keltner and Bonanno, 1997; Provine, 1992). As emotional expressions and moods are "contagious", the presence of people expressing cheerful mood via their behavior is one of the most powerful elicitors of exhilaration at all. In part, this is attributed to the fact that people automatically and very quickly mimic the facial expression and other behavior of people with which they are in direct contact, at least a bit. One does not even have to be consciously aware of looking at a worried or cheerful face; the own facial expression will still change towards that of the person one faces. If the facial expression of the other person is authentic, imitating the behavior will advance, again completely automatically, the same mood state in the observer. That is, the observer is also infected with the mood state of the other person. That is why people being with depressed persons are likely to become somewhat depressed themselves. If one is with cheerful people, one becomes a bit more cheerful oneself. Moreover, individuals with a more cheerful disposition are more easily infected with the cheerful mood of others than less cheerful people (Botvinick et al., 2005; Chapman, 1976, 1983; Chartrand and Bargh, 1999; Dimberg, 1990; Dimberg, Thunberg, and Elmehed, 2000; Hatfield et al., 1994; Hess and Blairy, 2001; Hietanen, Surakka, and Linnankonski, 1998; Neumann and Strack, 2000; Ruch, 1997; Ruch and Zweyer, 2001; Wild, Erb, and Bartels, 2001). There is also neuroscientific evidence for automatic emotional contagion processes. It was demonstrated that while looking at a face expressing a certain feeling, those parts of the observer's brain are automatically activated that are active when this person is experiencing the respective feeling him or herself. Moreover, it has been shown that when a person hears someone laughing heartily, parts of the brain that control the movements of the voice box are automatically pre-activated. That is, once people look at or hear other people expressing a certain mood state, their own brain prepares for the experience of this mood and its expression. The relevant parts of the brain are pre-activated, which advances respective changes of their own mood. The same mechanisms are operating with negative feelings and


43

mood states, e.g., disgust (Hennenlotter et al., 2005; Meyer, Zysset, vonCramon, and Alter, 2005; Wicker et al., 2003). Thus, if cheerfulness can be durably enhanced by some intervention, it can be expected that, by improving the level of mood, in time beneficial effects on social life will develop, too. Evidence for that is provided by the already mentioned study in teachers, which showed that after a few weeks of cheerfulness training, the quality of social contacts was rated more positively (Papousek, 2008). Apparently, the enhancement of cheerfulness and the related improvement of emotional well-being are also accompanied by positive experiences in social life. The social benefits of cheerfulness can also reinforce other positive effects. Being embedded in a well functioning social network belongs to the most important pathways by which positive affective traits can contribute to health maintenance and physical well-being (see "Psychosomatics"). Prospective studies showed that individuals with positive social relations were less likely to become ill; this holds in particular for the development of cardiovascular disease (Berkman, Glass, Brissette, and Seeman, 2000; Berkman, LeoSummers, and Horwitz, 1992; Frasure-Smith et al., 2000; House, Landis, and Umberson, 1988; Kaplan et al., 1988; Orth-Gomer, Rosengren, and Wilhelmsen, 1993; Pressman and Cohen, 2005; Williams et al., 1992). The social support of friends and family is often helpful to judge symptoms appropriately, to utilize health care facilities, and to remain independent longer; added to this is the emotional support in difficult situations. This can play a part in contributing to experience adverse circumstances as less burdening, which in turn slows down the negative effects of chronic stress on physical health (see also "The positive side of the psychosomatic coin" and "Cardiovascular health"). Of course, these things can only affect health in the long run; the beneficial effects of social support of friends and family virtually add up over the years. That is why correlations between the quality of social life and health indicators are stronger in older than in younger people. For instance, primarily in older people, the height of blood pressure, which develops over many years, is correlated to the degree of social support. Though blood pressure generally increases with age, the increase is stronger in individuals who are less embedded in a well functioning social life. Thus, a cheerful disposition may be beneficial for health also because it is a component of a protective portfolio of social characteristics (Cohen and Wills, 1985; Steptoe et al., 2008; Uchino, 2006; Uchino, HoltLunstad, Uno, Betancourt, and Garvey, 1999).

70 PLUS Older people often have to face multiple burdens. With advancing age, natural aging processes and the accumulation of risk factors lead to an increasing incidence of chronic disease. Added to this are physical impairments that can make everyday life a challenge. With the passing of years, strokes of fate such as threatening illness or death of near relatives and friends become increasingly likely. However, many older individuals succeed in maintaining their emotional well-being in spite of the daily challenges and adversities, or are able to restore it each time. That is supported by the availability of positive personal resources associated with cheerfulness, by

44


successful coping strategies and recovery processes, by making it easier to escape the alwayssame thoughts and worries. That more cheerfulness in every day life can help to counteract social isolation and loneliness that often gradually occurs with increasing age, is also part of it. Positive social contacts themselves contribute to the quality of life and help to feel better and stay healthier (see "Stress and strain" and "Social life"). Scientific studies demonstrated that the maintenance of positive well-being late in life helps to protect against age-related morbidity and to slow down the progress of physical impairments. Older individuals who have a cheerful and serene attitude also feel healthier overall, they recover faster and better from serious diseases such as stroke, heart attacks, or hip fractures, stay independent longer, and even have an increased life expectancy (Fredman et al., 2006; Okun et al., 1984; Ostir et al., 2000, 2002; Pressman and Cohen, 2005; Steptoe and Wardle, 2005; see also "Cardiovascular health", "Functional complaints", "Chronic pain"). Therefore, cheerfulness seems to be especially valuable for older people; and for the purpose of emotional and social well-being and the associated higher quality of the remaining lifetime, it is never too late to try for a bit more cheerfulness. As for physical health, cheerfulness and other psychological factors can only help up to a certain point. In the case of an "end stage disease" or acutely life threatening illness, that point is clearly exceeded, because emotional factors can only influence long-term processes (Pressman and Cohen, 2005).

DON'T TAKE AN X FOR A U Tip 6: What's the Use of Laughter Clubs, Clownery, and Funny Films A wide variety of courses, seminars, evening events, and workshops which include clownery, jokes, or laughter is offered, using various different names such as laughter club, laughter training, laughter yoga, laughter seminar, laughter workshop, laughter day, laughter school, laughter presentation, laughter principle, laughter event, laughter therapy, laughter coaching, humor seminar, humor therapy, happy mind, and many more. Often the same things are hidden under different names; on the other hand, a "laughter seminar" can be everything from joke telling to comedy, clownery, and breathing exercises to lectures and mediation according to Osho (Bhagwan). Those offers, which are often heavily promoted via the media and the internet, typically last from one hour to a few hours, sometimes one day or two days. Also typically, the providers very often hold out the prospect or try to suggest directly or indirectly that participating in their seminar, course, evening event, or workshop will give all that can be desired. As in most cases the promises are identical or nearly identical, the assumption suggests itself that the same things are unscrupulously copied from the internet again and again without ever calling them into question. Who cares whether it is true or at least possible, if it sounds so pleasant: It allegedly makes you happy, successful, healthy, never ill again, beautiful, creative, sometimes even cured from cancer and other serious diseases, alleviates stress, boosts the immune system, and develops potentials of some sort, in companies the productivity is allegedly increased, and you become one with the universe.


45

Sometimes it is even claimed that by participating in a laughter workshop or club one can improve the world, prevent wars, or contribute to global peace or the protection of nature! Thus, the providers nearly always promise all-embracing happiness and health. But which benefits can laughter, clownery, humor seminars, courses, events, or workshops really have? The answer has already been given in the previous sections of this chapter. One thing should be obvious in any case: Lasting effects that remain, which ever they may be, cannot be achieved by a workshop or a seminar lasting one hour or one or two days, for sure. To expect that a workshop or a seminar lasting one hour or two days could make you healthy or at least healthier, or more successful, or what ever, is absurd. But even attending laughter, clownery, humor seminars, courses, events or workshops every week for several months does by far not imply that any effects will be achieved that are relevant to health or anything else that might be desired (see "Is laughter healthy", "Is exhilaration healthy", and "Training of cheerfulness"). As explained extensively above, taken by itself, neither the motor action of laughing, nor the perception of something as funny, nor the ability to make other people laugh have any benefits that are relevant to health or well-being. Only cheerfulness, a cheerful disposition that is also present in every day life and in stressful and adverse conditions has the potential to slow down adverse developments and perhaps to contribute to the alleviation of certain problems. But typical laughter and humor courses or events do not equip the participants with cheerfulness (see above for the definition of cheerfulness). The use of typical laughter and humor courses is quickly told: Entertainment, a nice experience, short-term distraction. If the provider succeeds in inducing very intense exhilaration, a strong reward effect can arouse the desire to let oneself be exhilarated also on other occasions. That is it; more is not possible. However, amusement, a nice experience, and short-term distraction are not bad either; on the contrary. Very intense exhilaration that is accompanied by a really hearty laugh can give a euphoric feeling, a sense of pleasure. The crucial neurophysiological basis for that experience is the mesotelencephalic dopamine system. It is composed of several brain structures, one of the most well-known being the nucleus accumbens. The system is active when one experiences euphoria. That acts as a strong reward, that is, what ever has triggered activation of the system, one wants to do it again. Therefore, the euphoric state that is mediated by activation of the mesotelencephalic dopamine system also plays an important part in the development of addiction. In an experiment that is particularly well known in that context, rats could directly activate this system by pressing a lever via electrodes in their brain that were connected to the lever. The rats were pressing the lever over and over again in quick succession and did not stop doing it until they were completely exhausted. Humans who (as opposed to rats) can talk about their condition immediately report euphoric feelings when this brain region is directly electrically stimulated (Okun et al., 2004; Olds and Milner, 1954). Like the rats that cannot stop pressing the lever over and over again, humans, too, want to get the euphoric feeling that is mediated by the mesotelencephalic dopamine system again and again. Very few people have electrodes in their brain, however. But the system can also be activated, and, thus, euphoric, sensual feelings can also be induced (in varying degrees) by, e.g., sex, consumption of heroin, alcohol and other drugs, a great meal - or exhilaration. That is, also during exhilaration, the activity of the mesotelencephalic dopamine system increases, and the more intense the exhilaration, the larger is the increase (Mobbs, Greicius, AbdelAzim, Menon, and Reiss, 2003; Pfaus et al., 1990).

46


Really intense exhilaration accompanied by a euphoric feeling is a special experience, which is in any case worth attending a respective course or seminar. There is no need to always try to better oneself or the world. However, not every seminar that promises exhilaration and a hearty laugh can keep the promise. For a great experience, really intense exhilaration is required. That is, one has to be convulsed with laughter, to laugh oneself to tears, to split one's sides laughing, to be rolling in the aisles ... Good laughter courses can induce that to a much higher degree than, for instance, a funny film or comedy. The short-term distracting effect is not to be sneezed at, either. For this purpose, clownery in hospitals has been proved to be successful, particularly for children who are more easily distractable than adults are (Clinic Clowns). The temporary distraction can reduce the anxiety of children that they have, e.g., when an operation is about to happen or they are waiting for anaesthesia (Vagnoli, Caprilli, Robiglio, and Messeri, 2005). The distracting effect of the clowns and perhaps also the strong emotional activation by exhilaration can also effect a temporary alleviation of pain (see "Chronic pain"). But the diversion and distraction from the dreary hospital routine alone, which most children gratefully appreciate, justifies sending clowns into the hospitals. Surely most adult patients would appreciate a little amusement distracting them from their worries and pain and thus making their hospital stay a bit less dreadful, either. Not least, the funny events provide a welcome diversion for family members and nursing staff. However, one must not expect more from it than those temporary effects (see "Is laughter healthy" and "Is exhilaration healthy"). Thus, typical laughter, clownery, or humor related courses or events (in case they are good and meet one's own taste) can provide entertainment, a nice experience, and temporary distraction. But they are not "healthy". Apart from that, there is no scientific or otherwise reliable evidence suggesting that the participation (also the repeated participation) in such courses or events might help to become more resistant, successful, beautiful, happy, or the like. Most certainly, not one bomb less will be constructed, not one tree less will be cut down and not one soldier less will be shot. Whoever claims such things, wants to make an X for a U; in most cases also those who claim that participating in their laughter or humor course or event leads to more cheerfulness as a habitual disposition. As affective traits, that is, the disposition to certain moods and certain response patterns to stress can only be changed by systematic training, the typical laughter and humor seminars, events, courses, and workshops are surely not qualified to sustainably enhance cheerfulness (see also "Training of cheerfulness"). But also not everything what is done repeatedly or for a longer time qualifies as training. It must be the right things, and they must be trained in the right way. No matter if sport, music, or affective characteristics are concerned: The purpose of training is always to reach lasting and stable effects. For instance, you will not become a good saxophone player, if you blow into a saxophone once; neither, if you do it once every week. You will not become a good saxophone player either, if you listen to one or several lectures on playing the saxophone, or if you practice singing in the local church choir every week. You will only become a good saxophone player if you train properly, that is, if you practice the right things regularly, systematically, and consequently for a long time. Similar applies to cheerfulness (see "Ways to enhance cheerfulness"). Providing theoretical information on how it would work if one did it will not change anything. Laughing more frequently about jokes or without jokes has nothing to do with training cheerfulness. Learning and practicing to make others laugh has nothing to do with training cheerfulness. Neither does it suffice to practice seeing the funny sides of things (see


47

"Ways to enhance cheerfulness"). The labels are not necessarily helpful. If something is called "cheerfulness training" or "humor training", it does not necessarily mean that cheerfulness or some aspect of cheerfulness will be really trained with it. Now how to recognize good and useful courses? First, to systematically and regularly practice is definitely a basic requirement for acquiring more cheerfulness. Thus, courses or events that last one hour, one evening, half a day or one or two days might be suited to provide amusement, a nice experience, and temporary distraction. But they are a priori ineligible if one aims at sustainable benefits. If one is interested in durable changes, one should look for courses that extend over several weeks. If you want to strengthen your back muscles, you also go for a longer training, and do not just participate in a single session, all the same if you want to learn dancing or playing the piano. Second, nowhere near everything what is offered as a more extended course is indeed suitable to enhance cheerfulness in everyday life, as a durable disposition. To be able to teach people to train the right things in the right way, very much expert knowledge is necessary. It is advisable, therefore, to make sure that professionals with an appropriate qualification (psychologists or psychotherapists with an accredited qualification) instruct the courses. These persons have learnt how emotional processes and ways of thinking can be changed by training; they are able to activate the crucial psychological processes, to plan the training program in an appropriate manner, to judge for whom and for which purpose the program is suitable, and much more. But particularly important is that they have learnt and are able to intervene and do the right things, if something undesired happens with a participant. That can always happen when strong feelings are evoked, also when they are positive. It may not always be easy to determine if providers of laughter or humor related courses have an appropriate and accredited qualification. But one is always free to ask the provider for his or her exact qualification. Masseurs, journalists, life consultants, teachers, clowns, colour and style consultants, actors, etc., but also alternative practitioners and medical doctors without additional accredited psychotherapeutical education are normally not qualified to develop, plan, and instruct a training program for the enhancement of cheerfulness successfully and safely. Also, do not let the label "therapist" mislead you. In most countries, it is not legally protected. Therefore, labels such as singing bowl therapist, colour therapist, painting therapist, laughter therapist, reiki therapist, laughter yoga therapist, ayurveda therapist, zen therapist, sex therapist, aroma therapist, energy therapist, gem therapist, breathing therapist, bioresonance therapist, body therapist, dance therapist, etc. do not reliably indicate that people have any successfully completed professional education or even some professional competence. Third, even professional knowledge and competence alone do not guarantee that a training program is indeed suitable to successfully equip the participants with more cheerfulness or (e.g., in the case of humor training) with some important aspect of cheerfulness. To be sure, you can ask the provider which scientific studies do exist that verify that cheerfulness or the respective aspect of cheerfulness may be enhanced with the applied method, and exactly that method which is used by the provider and exactly that way the provider uses it. Fourth, courses can be immediately identified as dubious, if laughter or cheerfulness is touted as a cure-all or a miracle cure; that also applies if someone with an accredited education is behind it. What can be expected and cannot be expected has been extensively

48


explained above. Another type of courses that must be seen as problematical from the outset are courses in which the participants are urged to weep, to be angry, or to think or speak about their sorrows. In those cases, the course is definitely not a matter of enhancing cheerfulness. If a psychotherapist with an accredited training is behind it, it is all right, but it is not a cheerfulness program, but, e.g., a self-awareness group or psychological group therapy. If people without appropriate qualification offer something like that, it is sensible to refrain from it. For instructors without psychotherapeutical qualification are usually not sufficiently educated to be able to deal with the churned-up emotions in a way to ensure that no harm is done to the participants. For the typical laughter and humor related courses and events with which cheerfulness cannot be trained but that can provide short-term amusement, a nice experience, and distraction, no academic degree and no accredited psychotherapy training is required. Neither for programs with which one can learn and practice to make others laugh. As for the latter, clowns and other comedy pros are much more apt than most psychologists and psychotherapists. However, even if a course is only suitable or intended for amusement or distraction, one should make sure that the minimum standards of quality are met, because even such programs may be associated with certain risks. In seminars and workshops in which intense exhilaration is induced, mood swings including strong negative emotions may sometimes occur. In physically ill people (also in those who perhaps do not know being ill yet), the strong emotional arousal during exhilaration may elicit problems, in rare cases even dangerous events (see "Cardiovascular health"). It belongs to the responsibilities of the seminar or workshop facilitator to not leave the affected person alone or let him or her depart on her own, but to look after him or her and to call medical or psychological emergency help, if necessary. But the remaining group must not be left to take care of themselves, either. They have the right to an orderly continuation of the program, for which they have paid. Therefore, a quality criterion is that in seminars and workshops in which intense exhilaration is induced, a second responsible person is present. Then, whatever problems may arise, one person can take care of it, while the other one carries on with the program or brings it to an orderly end. But not only intense exhilaration can be associated with risks. Not properly or not carefully enough applied, humor and comicality may also do harm (see "Ways to enhance cheerfulness"). The seminar or workshop facilitators must not only be able to avoid problematic humor styles themselves, but also to monitor and control the humor of the participants. For that, relevant basic knowledge is required, and it is a matter of responsibility. Finally yet importantly, the desire for emotional and social well-being is also misused by sect-like groups and self-proclaimed "gurus". Consequently, among the spectrum of laughter and humor related courses and seminars, there are also some that must be rated as dangerous. It is a warning sign, if it is suggested to stop thinking or to "turn off the intellect". Those who stop thinking for themselves thoughtlessly follow a leader. Caution should also be exercised, if additional spiritual elements or lay psychological elements such as "personality building" are included. Methods with which susceptible people can be made dependent could be hidden behind them. Special caution is required if the dissemination of an "idea" or the propagation of a "movement" is involved, if the provider promises peace and happiness around the world, if the participants are prompted to connect to higher powers or to abandon themselves to a higher power (instead of thinking), if it is about unfolding the participants' unlimited potential, or if the glorification of a leader or "guru" is shining through. Most often, these


49

things show up on the homepage of the provider. In such cases, even an academic degree or an accredited job title does not justify to be more trusting or less cautious.

WAYS TO ENHANCE CHEERFULNESS The advice to aim for more cheerfulness is not very helpful, if one has no idea how to tackle it. Neither does it help to tell oneself to instantaneously have at least one component of trait cheerfulness, that is, to approach difficult situations and circumstances with humorous serenity, to let one get in a cheerful mood more easily, more often, and for longer times, or to adopt a humorous attitude in social situations (see "What is meant by cheerfulness"). It is not as simple as that. If one wants to have more cheerfulness for the longer term or more of the one or other element of cheerfulness, one must really train that. Training cheerfulness means a lot more than simply trying to cheer oneself up, to relax, or to improve one's mood, more than reducing negative feelings. Most of all, it means to improve and expand one's repertoire of psychological resources in a certain direction. Then one can draw on these resources under stressful circumstances, also in the future, without any need to think about it or to make an effort. Consequently, a robust improvement of well-being can be attained that can also withstand future challenges (see "Emotional well-being"). The most simple and most efficient way to enhance cheerfulness is a professional cheerfulness training course, just as physical relaxation is learnt most easily and efficiently in a professional relaxation-training course, and sailing in a professional sailing course. Those who do not like that or do not have the opportunity can also try to practice the one or other element of cheerfulness on their own. But in any case, it will only work, if one is doing it over a longer period and systematically and consequently. A higher level of positive mood is not everything but it is part of it. However, people that are more cheerful are not continuously in a happy mood, but primarily let themselves be cheered up more easily, more often, and for longer times than people with a less cheerful disposition (see "What is meant by cheerfulness" and "Overdose of cheerfulness"). That feels good, considerably contributes to life satisfaction (see "What's the use"), and advances the development of emotional and social resources (see "Stress and strain", "Emotional wellbeing", and "Social life"). What an individual can do on his or her own is primarily to allow him or herself to be in a cheerful mood, especially after stressful or burdensome events, after he or she has allowed sufficient time for the justified anger, or grief, etc. That applies to small mishaps and shortcomings, but also if one has become ill or unemployed or widowed or after a terrible mistake. That also includes allowing oneself to express one's cheerful mood outwardly, that is, to smile or laugh or to whistle to oneself. In most cases, that will not be inappropriate. It substantially helps to recover and also helps the people around (see "Stress and Strain" and "Social life"). But should it once be inappropriate though, or be considered inappropriate to express exhilaration or cheerful mood outwardly, you can be cheerful, nevertheless: "Man kann ja im Herzen / stets lachen und scherzen / und denken dabei / die Gedanken sind frei!" (Lyrics from an old German folk song; literal translation: "In one's heart one can keep laughing and joking while thinking: Thoughts are free!"). Of course, that applies for the time after one has allowed an appropriate amount of time for the grief, the anger, the sympathy towards others, perhaps also the regret. Everything at

50


the proper time (see also "Overdose of cheerfulness"). And, certainly, to be in a cheerful mood does not mean to make fun of those who are affected by one's mistake or to crack jokes about the person who died. Sarcasm, cynicism, scorn, and hostility have nothing to do with cheerful mood at all (see "What is meant by cheerfulness"). If you allow yourself and have the courage to be in a more cheerful mood again, you will feel the benefits, thereby being rewarded for the courage, making it easier the next time (see "Don't take an X for a U, Tip 6"). An important aspect that contributes to the ability to maintain a positive amount of wellbeing in spite of adversity is to recover fast and efficiently in between times (see "Stress and strain"). A simple way to help yourself recover is to let yourself be infected by the positive mood of others, in particular when your mood is frequently affected by adverse events. It is so simple, because it works completely automatically and there is no effort needed. You only have to go to a place where there are people radiating cheerful mood. For the emotional contagion to work effectively, it is essential to have direct personal contact with someone who is in a cheerful mood state and shows it, and the emotional expression has to be genuine and has to be perceived as such (see "Social life"). Apart from that, it is only required to not fight the emotional contagion with might and main. That is, you have to allow yourself to be cheered up and to show it. However, the rub is that contagion with cheerful mood does not work properly or not at all, if the level of trait cheerfulness is low. For it is one of the features of trait cheerfulness to get cheered up more easily (Ruch, 1997). Thus, the method of emotional contagion will only be promising, if a person has at least some amount of trait cheerfulness (or at the same time trains it otherwise). In any case, only temporary effects can be achieved. Certainly, no permanent improvements of mood and well-being can be reached by letting oneself be infected by the emotions of merry people now and again. But it can help to recover from negative feelings and mood states more quickly, at least if the level of dispositional cheerfulness is not very low. A very important element of cheerfulness is to take mishaps, difficult situations and adverse circumstances in every day life easier and to approach them with humorous serenity. That includes the appraisal and interpretation of situations and circumstances (see "Stress and strain"). In most cases (except for bad disasters), appraisals of situations and events can differ greatly between individuals. For instance, if you are in a team meeting and your boss invites you to give your opinion on the subject that is currently discussed, you may appraise the situation as terribly stressful, your boss as awfully mean, and yourself as horribly exposed. But you may also appraise the situation as a great chance to participate, your boss as admirably fair and yourself as tremendously respected and esteemed. To automatically appraise and interpret situations and circumstances positively or at least a bit more positively can be learned and practiced. You can think of situations that may elicit depressed feelings, anger, or anxiety, and consciously contrive a positive meaning or interpretation of the situation, and picture it to yourself for some time. For instance, you could imagine sitting alone in your flat on a gray, rainy day drinking a cup of coffee, your thoughts wandering ... and then deliberately imagine that your thoughts wander to your last holiday and thereby many happy memories come flooding back. Or you could think of a situation in which you are invited to introduce yourself to a group of people, you are nervous and uncertain what to say ... and then deliberately imagine that everybody congratulates you afterwards and tell you how cool and likeable you appeared. Or, for instance, you could think of walking down a street and catch sight of your usually friendly neighbor, who fails to


51

respond although you shout and wave at her ..., and then deliberately imagine that you know that she is like that just because she is preoccupied in thoughts and thus does not notice you. In order to change something, one certainly has to think of many different situations, and to do it every day for some time. But there is evidence that practicing it systematically may improve a person's mood towards more humorous serenity and the levels of anxiety, worry, and tension will decline. But it is particularly important that you more and more will tend to interpret also other situations and circumstances more positively. Thereby, you will gain a resource that will help you deal with uncertain or negative situations ("Positive interpretation training", Holmes, Mathews, Dalgleish, and Macintosh, 2006; Murphy, Hirsch, Mathews, Smith, and Clark, 2007). Certainly, that, too, is easier with professional instruction. Another skill you can try to practice on your own is to deliberately see a funny side of things, situations and of yourself. By doing it systematically and regularly for some time, elements of cheerfulness may be promoted. A humorous view of oneself and the things one is stressed or scared of helps to change the perspective, to be able to view things also from a different angle, and thereby to gain distance from oneself and one's problems. Consequently, things and circumstances are experienced less stressful and threatening (see "Stress and strain"). By practicing that extensively, a resource may develop that can be used in future stressful situations. In the case of fear of spiders, for instance, examples of exercises would be to list as many uses as you can think of for a deceptively realistic looking rubber spider that squeaks when squeezed, or to imagine what a spider you encounter would think of you, if it could think. In the case of test anxiety, you could imagine the brain and the hand to conduct a dialog in which the hand makes up funny excuses why it trembles so much (Ventis et al., 2001). However, to invent such exercises on one's own and to (appropriately) perform them, and to use humorous views in a beneficial way is not quite easy. Therefore, that, too, works better with professional instruction. If you suffer from very strong specific fears or worries that are a great burden and affect daily living, attempts to deal with them on your own are normally not promising. That would be the case, for instance, if a person does not dare to leave the house any more, if a person must immediately wash his or her hands after touching something that has been used by others, if a person is not able to go to an exam any more, etc. In such cases, it is advisable to visit a specialist who can effectively help. For people who do not have severe problems like that, special humor training is offered with which one can learn and practice to see a funny side of every day situations (mostly of every day work). As using humor may also be problematical, it is important that professionals with an appropriate qualification instruct such training courses (see "Don't take an X for a U, Tip 6"). For only certain forms of humor represent a useful and successful strategy to better cope with stressful situations and adverse circumstances. Bitter, sardonic, cynical, or aggressive humor can do harm, promotes negative affective traits such as depression and anxiety in oneself, and is occasionally used to accentuate hierarchies and keep one's distance to other people. Especially if a person is the target of the humor or believes to be the target, humor can do real harm. But cynical and aggressive forms of humor also do more harm than good to those who make such jokes (Franzini, 2001; Holmes and Marra, 2002; Kubie, 1971; Kuiper, Grimshaw, Leite, and Kirsh, 2004; Lefcourt, Davidson, Prkachin, and Mills, 1997; Martin and Kuiper, 1999). Reliable trainers with an appropriate qualification (ideally experienced psychologists or psychotherapists with an accredited qualification) are mindful of the dangers of humor and can make sure that nothing goes wrong.

52


Thus, finding or seeing the funny side alone does not suffice to attain durable benefits. On its own, an enhanced sense of humor is not automatically linked with greater emotional well-being, neither with greater physical well-being nor with health (Kuiper and BorowiczSibenik, 2005; Kuiper and Martin, 1998; Kuiper et al., 2004; Martin, 2001; Porterfield, 1987; Svebak et al., 2004). Practicing humorous views does only help, if it is associated with the development of favorable and successful coping strategies. Then (and only then), a component of cheerfulness can be enhanced, that is, to approach otherwise frightening or annoying events and circumstances with more humorous serenity. It does not only depend on the kind of humor and how it is used whether successful coping strategies will develop. It is also essential to practice to find a humorous or funny side of events and circumstances on one's own, so that they can be viewed from a different angle and, consequently, one can better cope with them. It is about oneself. It is not about making others laugh. The ability to make other people laugh does not indicate to which extent someone draws on humorous views oneself when exposed to adverse situations and circumstances and is able to use it as a successful coping strategy. Neither do the perception of comicality, listening to jokes, watching humorous films, etc. or laughing by itself have anything to do with favorable coping strategies and, thus, with the training of cheerfulness (Martin and Lefcourt, 1983; Newman and Stone, 1996; Nezu, Nezu, and Blisset, 1988). Those things can only induce temporary exhilaration and distraction, without longer-term consequences (see "Is exhilaration healthy", "Training of cheerfulness", and "Don't take an X for a U, Tip 6"). Finally, you can also try to enhance the third aspect of cheerfulness, that is, the cheerful and humorous attitude in social situations. By practicing it systematically and regularly for some time, one can benefit from the favorable consequences of positive social contacts and social support (see "Social life"). What you can try to practice on your own is mainly to approach other people in a friendly and open manner. The simplest attempt is to smile at the checkout girl in the supermarket or at the bus driver while getting on the bus or at the customer at the counter. The world will immediately change a little. The expression of cheerful and friendly mood has an effect on the interaction partner and will instantaneously bounce back to you (see "Social life"). A humorous attitude in social situation means, for instance, that people are laughing together about mishaps or mistakes instead of being angry or calling the other person names, or to make friendly, humorous comments when meeting each other, instead of just nodding one's head grouchily. For instance, if you are jostled and pushed aside in the crowd at the market, you may get angry and look at the other person furiously or even snap at him or her – or you may smile at him or her, thereby signaling that you know how difficult it is today to get through, or say something along these lines ("There is no getting through today, isn't it, though there is nothing for free here"). However, even that is not without risk. In no case may the other person have the feeling that he or she is laughed at or that jokes are made at his or her expense. Laughing at somebody and jokes with hostile, aggressive, or cynical undertones do never have positive but always only negative consequences (see "Social life"). It is not a matter of how it is meant, but how the person concerned perceives it. Classical jokes are usually hostile and made at other peoples' expense. These are different things that should not be mixed up: Friendly-humorous comments are completely different from cracking jokes. And laughing together about a mishap or a mistake is completely different from laughing at other people.


53

Thus, there are several ways to enhance cheerfulness. If one aims at durable improvements of one or the other element of cheerfulness, the suggested things must be really trained, that is, they must be practiced regularly, systematically, and consequently for some time. Otherwise, nothing will be achieved. Professional instruction will make it easier.

EXAMPLE FOR A SCIENTIFICALLY FOUNDED METHOD FOR THE TRAINING OF CHEERFULNESS The 1-2-H Cheerfulness Training® 2 was developed over several years according to scientific principles and has been systematically tested and further developed at the Karl Franzens University of Graz. It was developed to specifically and sustainably advance and strengthen cheerfulness and associated personal resources, in contrast to most other psychological intervention methods that predominantly aim at reducing stress and negative affect. In the long run, the collection of resources accompanying cheerfulness does not only put a brake on the development of the permanent feeling of stress and other negative affective traits such as depression and worry, but also directly fosters several positive affective traits and thereby may contribute to a lasting and robust enhancement of emotional well-being (see "Stress and strain" and "Emotional well-being"). The training method follows a behavioral therapy approach and is roughly comparable to relaxation training (autogenous training). It is conducted in a group setting. The core of the method is to first learn and practice a technique to efficiently self-induce cheerful mood by one's own behavior, that is, by imagining and voluntarily producing motor and vocal expressions of cheerful mood (facial expression, laughter). Then, in many repetitions, imaginations of personal shortcomings, annoyances, and unpleasant situations are coupled with the positive affective state by conditioning. During the training sessions, the trainers lead the participants to the imagination of the situations by telling a little story of which the participants themselves are the leading character. The story is always different, because the participants partly contribute the used annoying and unpleasant situations by anonymously writing them on cards that can be inserted into a provided box during the whole training period. Additionally, the imaginations are accompanied by small, simple corresponding gestures, while the participants are applying the previously practiced technique to self-induce cheerful mood via their own behavior. For instance, during the imagination that already the third traffic light turns red, the participants illustrate the changing traffic lights with a little gesture. Or while imagining sitting alone at home stirring their tea, they are stirring their imaginary tea with an imaginary spoon. The story may be humorous, but it is essential that the participants do not simply laugh at jokes of the trainers (or of other participants), but learn and practice to self-induce a more cheerful mood, even when they are thinking of situations in which they normally would be angry or worried. In the course of time the imaginations of adversities (conditioned stimuli), and later also corresponding situations in every day life (transfer) automatically trigger a cheerful and composed mood on their own, at least a more positive mood than before (conditioned response). 2 The name is protected as a registered trade mark, in order to ensure that the name can not be misused, that only the scientifically proved and effective method is applied under this name, and courses under this name are exactly conducted in the proved way. Using the name without permission is an offence.

54


Further psychological processes are used to advance the effectiveness of the method and the transfer into every day life. For instance, after an initial learning period most participants experience intense exhilaration during practicing. This is an utmost positive, euphorizing experience, acting as a strong positive reinforcer (Custers and Aarts, 2005) that helps the participants learn the technique and stay motivated (operant conditioning; see also "Don't take an X for a U, Tip 6"). Like classical and operant conditioning, all other processes that are purposefully used in the training program are scientifically founded. The neuroscientific network model of exhilaration (Papousek, Lang, Zitzenbacher, Kogler, 2004; Papousek and Schulter, 2006) provides a theoretical explanation for several elements of the method. Cheerful mood, humor (in the sense of perceiving something as funny), and smiles and laughter can be viewed as components of a network that - after appropriate practice - can promote each other when one or several of the components are activated. Humor, cheerful mood and smiles or laughter can also occur independently of each other, different brain regions are involved in each of the three aspects, and their concomitants differ (see "What is meant by cheerfulness"). But in the course of our lives, the brain structures that are active during humor, cheerful mood, smiles and laughter are often co-activated. It is known from brain research that brain regions that are very often concurrently active, in time will establish connections, so that the activation of one of these brain regions and the respective connections gradually will also automatically favor activation of the other areas (Goodman and Shatz, 1993). That is, in time, network-like connections will be established between the brain structures that are active during humor (perceiving something as funny, cognition), cheerful mood (emotion), and smiles and laughter (behavior). It not necessarily and not always will be the case that, for instance, when someone perceives something as funny, he or she will also be exhilarated and laughing. But the gradually established and strengthened connections increase the likelihood that perceiving something as funny will be accompanied by transient exhilaration and that smiles or laughter will be easier elicited. The network may also be activated by one of the other components. Also through cheerful mood and through one's behavior, that is, through the voluntary expression of cheerful mood (facial expression, laughter) the co-activation of the other two components can be favored. Above all, activation of the connections can be trained, so that, in time, the co-activation of the other components become more and more likely, faster, and stronger. That explains why it is possible to learn and practice to efficiently self-induce cheerful mood via one's own (motor and vocal) behavior (see Figure 7). The assumption that voluntary expressions of emotions can in fact produce or advance genuine feelings of these emotions is supported by the findings of many scientific studies. When a person produces an emotional facial expression, this is accompanied by a stronger experience of the corresponding emotion and by characteristic changes of physiological measures that are associated with these emotions. If the activation has spread to the corresponding mood state, then the respective parts of the brain that mediate the current emotional state are also active (Coan, Allen, and Harmon-Jones, 2001; Duclos et al., 1989; Ekman and Davidson, 1993; Hess, Kappas, McHugo, Lanzetta, and Kleck, 1992; Levenson, Ekman, Friesen, 1983, 1990; Soussignan, 2002). According to the network model, the cheerful affective state and the behavioral elements also promote humor, in the sense of more easily seeing the funny side of things or circumstances. This effect, too, is proven by scientific evidence. It has been shown, for instance, that persons whose facial expression had been manipulated to a smile without their


55

notice perceived cartoons considerably more funny than persons whose facial expression had been manipulated in the direction of a grim, bad tempered expression. In a controlled case study it was reported that during electrical stimulation of a certain spot in the cerebral cortex (in the supplementary motor area), the patient smiled and laughed, before reporting that she found something funny, depending on what she was currently looking at (e.g., "You guys are just so funny standing around"). That is, the patient laughed first and then made up a story that was funny to her. When the respective spot was not stimulated, the patient did not laugh and did not view her current situation and surroundings funny at all (Fried, Wilson, MacDonald, and Behnke, 1998; Strack, Martin, and Stepper, 1988). Those automatic processes additionally advance the exhilaration during the training, but are also purposefully used to promote that the participants meet adverse circumstances with humorous serenity, allowing a change of perspective, greater distance and a more positive reappraisal, and, consequently, helping to view adverse circumstances as less serious and less threatening (see "Stress and strain"). Importance is attached to directing the spontaneously emerging humor in channels that correspond to positive, "healthy" forms of humor (see "Ways to enhance cheerfulness").

Figure 7.

Another psychological process that is purposefully used and promoted in the 1-2-H Cheerfulness Training® is emotional contagion. The presence of other participants showing behavioral expressions of cheerful mood and thereby "infecting" the others with exhilaration additionally facilitates the experience of exhilaration and cheerful mood during the training. This very effective and completely automatic process is also scientifically proven (see "Social life"). It is promoted during the training, for instance, by permanently establishing direct faceto-face contact among the participants and by preventing them from pulling inappropriate faces. Beyond that, the exercises are consequently alternated with short structured breaks, by which the participants also learn to control and regulate their exhilaration. This helps to get a feeling of security and controllability and prevents habituation and exhaustion. Through the special method of the training, the reinforcement by the positive experience, and a balanced proportion of repetition and variation, the potential to induce cheerful mood does not decline

56


over time; it is possible to evoke a substantial degree of cheerful mood repeatedly, over many days and weeks (Papousek and Schulter, 2008). The use of fully automatic processes such as the induction of cheerful mood and humor by behavioral elements, emotional contagion, and conditioning has several advantages over more cognitively oriented intervention methods. The participants do not have to make conscious efforts to change moods and attitudes, find another perspective, etc. Consequently, the method also works for participants in which the readiness to be in a cheerful state of mood is reduced because of the current circumstances and the corresponding social role (e.g., patient, sufferer, failed,). To support abandoning an inhibiting social role (it may also be the role as a teacher, politician, boss, professor, etc.), it is important, among other things, to conduct the training in a protected environment. Consequently, 1-2-H Cheerfulness Training® is never conducted in rooms where the participants can be watched from the outside, neither of course in public space. Beyond that, as opposed to many cognitively oriented methods, the training does not include any cultural, educational, religious, or ideological barriers. The training program starts with an intense introductory session lasting eight to twelve hours that are ideally spread over two consecutive days. In tests of the method, this extensive introductory session turned out to be essential, in order to enable all participants to learn the technique so well from the beginning onwards that they can apply it fast and efficiently in each of the subsequent training sessions. Moreover, this longer introductory session is essential to make sure that all participants have the chance to overcome their possible initial insecurity or embarrassment. Finally, it is important to enable all participants to reach a state of substantial exhilaration and the associated positive experience, which is an important supporting factor for the continuation of the training. A very careful composition of the training in the introductory session ensures that the technique is learnt thoroughly and at the same time cautiously enough so that the participants feel as secure and well as possible. It is also important to take care that nobody is overchallenged. Gaining control of the insecurity of the participants is very important. Tests showed that it does not only depend on the degree of exhilaration how positive the participants perceive the training, but to the same extent on the degree to which they feel insecure (Papousek et al., 2004). Consequently, much importance is attached to prevent feelings of insecurity; by the above-mentioned training of controllability, but also by avoiding excessive demand. Insecure participants are constantly supported, for instance, by permanently involving them actively. That is important, because the other participants tend to withdraw from insecure persons, in order to not become insecure themselves. Thus, insecure participants would be more and more marginalized, by which an unfavorable process would be established that would act counter to the aims of the training. As a result, feelings of insecurity, which (in spite of the unusual character of the training) are rated rather low from the second introductory day onwards, decline even more in the course of the training. Mean ratings dropped from 3.9 on the second day of the introductory session to 2.7 at the end of the whole training course (12point rating scale ranging from "did not feel uneasy at all" to "felt extremely uneasy"; Papousek and Schulter, 2008). In order to reach the aims of the training, that is, to sustainably promote cheerfulness and serenity in everyday life, periodical training sessions must follow the introductory session for several weeks (lasting about one hour each). The sessions can be conducted once or twice a week (Lederer, 2007; Nograsek, 2006; Papousek, 2008). Participation in the introductory


57

session alone without participating in the subsequent regular training sessions is without effect (see also "Don't take an X for a U, Tip 6"). After having attended the training for some time, the participants automatically approach also normally unpleasant or difficult situations in every day life that are accompanied by feelings of anger, tension, depression, or of being overtaxed with more humorous serenity. They act in a composed manner and are able to smile to themselves or even laugh, when they cannot remember what they need to know urgently, when their boss asks them in for afternoon coffee, when already the third traffic light turns red, when the scales show a four pound gain, when a family member spills the milk, when a mile-long to do list is waiting for them, when their partner is again late, when they are sitting alone at home stirring their tea, when they are introduced to an important person, etc. They gain a more cheerful attitude towards themselves, their lives, and the adversities of every day life, and do not lose their balance so quickly any more. It becomes easier to switch to a more cheerful mood, and humorous serenity finds its way into encounters with other people. Those are all features of trait cheerfulness. Scientific studies demonstrated that the 1-2-H Cheerfulness Training® could effectively enhance cheerfulness. Several days after the end of the training period, cheerfulness (as assessed by a standardized questionnaire; Ruch, Köhler, and vanThriehl, 1997) was increased by an average of 30 percent, whereas in a control group not participating in the training cheerfulness did not change during the same period. Beyond that, studies provided scientific evidence that the pronounced enhancement of cheerfulness is accompanied by reduced feelings of stress both in every day life and in the job, by faster and more efficient recovery, and a more general improvement of psychological well-being. (These and other findings have already been reviewed in previous sections of this chapter). Stress and recovery indicators that were considerably improved after the end of the eight-week training period remained unchanged until at least four weeks after the intervention (last measurement). The improvements were even accompanied by characteristic changes in brain activity that objectively confirmed the self-reported ratings of the course participants. Participants who had already reached a pronounced enhancement of cheerfulness and serenity also felt physically better and reported less symptoms. Finally, it was shown that the training of cheerfulness and the associated improvement of emotional well-being was accompanied by positive experiences in social life. The positive effects on social life that in time develop as a consequence of the enhanced level of positive mood (see "Social life") are added to the fact that the training group by itself is perceived as a source of positive social contacts (Lederer, 2007; Papousek, 2008; Papousek and Schulter, 2006; 2008; in preparation). From participants' ratings of the training, it can be concluded that the intervention itself is, on average, positively experienced, and becomes even more enjoyable during the course of the training. On the second day of the introductory session, the participants rated the degree to which they enjoyed the training with an average of 9.6. After 7 / 15 training sessions, the average rating increased to 10.4 / 10.6 (12-point rating scale ranging from "not at all" to "extremely"). The degree to which the participants felt exhilarated during the training sessions remained constantly at a high level over the whole training period. The ratings ranged from 9.1 (second day of introductory session) to 9.7 (after 15 training sessions; Papousek and Schulter, 2008). These findings indicate that the intervention can be conducted over longer periods without losing its effectivity and without difficulties to make the participants hold out to the end.

58


However, it should not go unmentioned that the training method does not suit all people equally. An important prerequisite for beneficial effects of the training is that the participants attend the training voluntarily and without great resistance. Moreover, benefits going beyond the mood enhancement depend on the participants' personality. Individuals with a less "serious" personality are more responsive to the training and, hence, effects are stronger or more rapid (Papousek and Schulter, 2008). Individuals high in trait seriousness are characterized by a preference for reasonable activities and a reserved attitude towards humorrelated matters or doing things "just for fun" (Ruch and Köhler, 1999). In addition, the training method is ineligible for people with a pathological fear of being laughed at or of exposing oneself to ridicule (Gelotophobia; Ruch and Proyer, 2008; Papousek et al., 2009).

REFERENCES Arendt, H. (1986). Communicative power. In: S. Lukes (Ed.), Power (pp. 59-74). New York: New York University Press. Ashby, F. G., Isen, A. M., and Turken, A. U. (1999). A neuropsychological theory of positive affect and its influence on cognition. Psychological Reviews, 106, 529-550. Barefoot, J. C., Helms, M. J., Mark, D. B., Blumenthal, J. A., Califf, R. M., Haney, T. L., et al. (1996). Depression and long-term mortality risk in patients with coronary artery disease. American Journal of Cardiology, 78, 613-617. Benyamini, Y., Idler, E. L., Leventhal, H., and Leventhal, E. A. (2000). Positive affect and function as influences on self-assessments of health: Expanding our view beyond illness and disability. Journal of Gerontology, 55B, 107-116. Bergman, S., Herrstrom, P., Hogstrom, K., Petersson, I. F., Svensson, B., and Jacobsson, L. T. (2001). Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study. Rheumatology, 28, 1369-1377. Berkanovic, E., Telesky, C., and Reeder, S. (1981). Structural and social psychological factors in the decision to seek medical care for symptoms. Medical Care, 21, 693-709. Berkman, L. F., Glass, T., Brissette, I., and Seeman, T. E. (2000). From social integration to health: Durkheim in the new millennium. Social Science and Medicine, 51, 843-857. Berkman, L. F., Leo-Summers, L., and Horwitz, R. I. (1992). Emotional support and survival after myocardial infarction: A prospective, population-based study of the elderly. Annals of Internal Medicine, 117, 1003-1009. Berry, D. S., and Hansen, J. S. (1996). Positive affect, negative affect, and social interaction. Journal of Personality and Social Psychology, 71, 796-809. Berry, D. S., Willingham, J. K., and Thayer, C. A. (2000). Affect and personality as predictors of conflict and closeness in young adults' friendships. Journal of Research in Personality, 34, 84-107. Blumenthal, J. A., Lett, H. S., Babyak, M. A., White, W., Smith, P. K., Mark, D. B., et al. (2003). Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet, 362, 604-609. Booth-Kewley, S., and Friedman, H. S. (1987). Psychological predictors of heart disease: A quantitative review. Psychological Bulletin, 101, 343-362.


59

Botvinick, M., Jha, A. P., Bylsma, L. M., Fabian, S. A., Solomon, P. E., and Prkachin, K. M. (2005). Viewing facial expressions of pain engages cortical areas involved in the direct experience of pain. Neuroimage, 25, 312-319. Brady, S. S., and Matthews, K. A. (2006). Chronic stress influences ambulatory blood pressure in adolescents. Annals of Behavioral Medicine, 31, 80-88. Bremner, J. D, Randall, P., Vermetten, E., Staib, L., Bronen, R.A., Mazure, C., et al. (1997). Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorders related to childhood physical and emotional abuse - a preliminary report. Biological Psychiatry, 41, 23-32. Brosschot, J. F. (2002). Cognitive-emotional sensitization and somatic health complaints. Scandinavian Journal of Psychology, 43, 113–121. Brosschot, J. F., Gerin, W., and Thayer, J. F. (2006). The perseverative cognition hypothesis: A review of worry, prolonged stress-related physiological activation, and health. Journal of Psychosomatic Research, 60, 113-124. Brosschot, J. F. and van den Doef, M. (2006). Daily worrying and somatic health complaints: Testing the effectiveness of a simple worry reduction intervention. Psychology and Health, 21, 19-31. Brummett, B. H., Babyak, M. A., Siegler, I. C., Mark, D. B., Williams, R. B., and Barefoot, J. C. (2003). Effect of smoking and sedentary behavior on the association between depressive symptoms and mortality from coronary heart disease. American Journal of Cardiology, 92, 529-532. Bush, D. E., Ziegelstein, R. C., Tayback, M., Richter, D., Stevens, S., Zahalsky, H., et al. (2001). Even minimal symptoms of depression increase mortality risk after acute myocardial infarction. American Journal of Cardiology, 88, 337-341. Campbell, L. C., Clauw, D. J., and Keefe, F. J. (2003). Persistent pain and depression: A biopsychosocial perspective. Biological Psychiatry, 54, 399-409. Cechetto, D. F., and Saper, C .B. (1990). Role of the cerebral cortex in autonomic function. In A. D. Loewy and K. M. Spyer (Eds.), Central Regulation of Autonomic Functions (pp. 208-223). New York: Oxford University Press. Chapman, A. J. (1976): Social aspects of humorous laughter. In A. J. Chapman, and H. C. Foot (Ed.), Humour and Laughter: Theory, Research and Applications. London: Wiley. Chapman, A. J. (1983): Humor and laughter in social interaction and some implications for humor research. In P. E. McGhee, and J. H. Goldstein, J. H. (Eds.), Handbook of Humor Research. Vol. 1 (pp. 135-157). New York: Springer. Chartrand, T. L., and Bargh, J. A. (1999). The chameleon effect. The perception-behavior link and social interaction. Journal of Personality and Social Psychology, 76, 893-910. Clauw, D. J., and Chrousos, G. P. (1997). Chronic pain and fatigue syndromes: Overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation, 4, 134-153. Coan, J. A., Allen, J. J., and Harmon-Jones, E. (2001). Voluntary facial expression and hemispheric asymmetry over the frontal cortex. Psychophysiology, 38, 912-925. Cogan, R., Cogan, D., Waltz, W., and McCue M. (1987). Effects of laughter and relaxation on discomfort thresholds. Journal of Behavioral Medicine, 10, 139-144. Cohen, S., Alper, C. M., Doyle, W. J., Treanor, J. T., and Turner, R. B. (2006). Positive emotional style predicts resistance to illness after experimental exposure to rhinovirus or influenza A virus. Psychosomatic Medicine, 68, 809-815.

60


Cohen, H., Benjamin, J., Geva, A. B., Matar, M. A., Kaplan, Z., and Kotler, M. (2000). Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: Application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 96, 1-13. Cohen, S., Doyle, W. J., and Skoner, D. P. (1999). Psychological stress, cytokine production, and severity of upper respiratory illness. Psychosomatic Medicine, 61, 175-180. Cohen, S., Doyle, W. J., Skoner, D. P., Fireman, P., Gwaltney, J. M., and Newsom, J. T. (1995). State and trait negative affect as predictors of objective and subjective symptoms of respiratory viral infections. Journal of Personality and Social Psychology, 68, 159169. Cohen, S., Doyle, W. J., Turner, R. B., Alper, C. M., and Skoner, D. P. (2003). Emotional style and susceptibility to the common cold. Psychosomatic Medicine, 65, 652-657. Cohen, S. and Rodriguez, M. S. (1995). Pathways linking affective disturbances and physical disorders. Health Psychology, 14, 374-380. Cohen, S., Tyrrell, D. A. J, and Smith, A. P. (1991). Psychological stress and susceptibility to the common cold. New England Journal of Medicine, 325, 606-612. Cohen, S., and Williamson, G. M. (1991). Stress and infectious disease in humans. Psychological Bulletin, 109, 5-24. Cohen, S., and Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357. Cohn, M. A., Fredrickson, B. L., Brown, S. L., Mikels, J. A., and Conway, A. M. (2009). Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion, 9, 361-368. Compton, R. J., Wirtz, D., Pajoumand, G., Claus, E., and Heller, W. (2004). Association between positive affect and attentional shifting. Cognitive Therapy and Research, 28, 733-744. Coyne, J. C. (1976). Depression and the response of others. Journal of Abnormal Psychology, 85, 186-193. Cummings, N. S., and van den Bos, G. R. (1981). The twenty years Kaiser-Permanente experience with psychotherapy and medical utilization: Implications for national health policy and national health insurance. Health Politics Quarterly, 1, 159-175. Custers, R., and Aarts, H. (2005). Positive affect as implicit motivator: On the nonconscious operation of behavioral goals. Journal of Personality and Social Psychology, 89, 129142. Danner, D. D., Snowdon, D. A., and Friesen, W. V. (2001). Positive emotions in early life and longevity: Findings from the nun study. Journal of Personality and Social Psychology, 80, 804-813. Darwin, C. (1872). The expression of the emotions in man and animals (3rd ed., Ed. P. Ekman, 1997). London: Murray. Davidson, K., Jonas, B. S., Dixon, K. E., and Markovitz, J. H. (2000). Do depression symptoms predict early hypertension incidence in young adults in the CARDIA study. Archives of Internal Medicine, 160, 1495-1500. Davidson, R. J., Jackson, D. C., and Kalin, N. H. (2000). Emotion, plasticity, context, and regulation: Perspectives from affective neuroscience. Psychological Bulletin, 126, 890909.


61

Depue, R. A., and Monroe, S. M. (1986). Conceptualization and measurement of human disorder in life stress research: The problem of chronic disturbance. Psychological Bulletin, 99, 36-51. Derryberry, D. and Tucker, D. M. (1994). Motivating the focus of attention. In: P. M. Neidenthal, and S. Mitoyama (Eds.), The heart's eye: Emotional influences in perception and attention (pp. 167-196). San Diego: Academic Press. Diener, E., and Larsen, R. J. (1993). The experience of emotional well-being. In: M. Lewis, and J. M. Haviland (Eds.), Handbook of emotions (pp. 405-415). New York: Guilford. Dienstbier, R. A. (1989). Arousal and physiological toughness: Implications for mental and physical health. Psychological Reviews, 96, 84-100. DiMatteo, M. R., Lepper, H. S., and Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160, 2101-2107. Dimberg, U. (1990). Facial electromyography and emotional reactions. Psychophysiology, 27, 481-494. Dimberg, U., Thunberg, M., and Elmehed, K. (2000). Unconscious facial reactions to emotional facial expressions. Psychological Science, 11, 86-89. Doyle, W. J., Gentile, D. A., and Cohen, S. (2006). Emotional style, nasal cytokines, and illness expression after experimental rhinovirus exposure. Brain, Behavior and Immunity, 20, 175-181. Drossman, D. A., Corazziari, E., Talley, N. J., Thompson, G., and Whitehead, W. E. (Eds.) (2000). The functional gastrointestinal disorders: Diagnosis, pathophysiology, and treatment: A multinational consensus (2nd ed.). McLean, Virginia: Degnon Associates. Drossman, D. A., Li, Z., Andruzzi, E., Temple, R. D., Talley, N. J., Thompson, W. G. et al. (1993). U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Digestive Diseases and Sciences, 9, 1569-1580. Duclos, S. E., Laird, J. D., Schneider, E., Sexter, M., Stern, L., and vanLighten, O. (1989). Emotion-specific effects of facial expressions and postures of emotional experience. Journal of Personality and Social Psychology, 57, 100-108. Ekman, P., and Davidson, R. J. (1993). Voluntary smiling changes regional brain activity. Psychological Science, 4, 342-345. Eriksen, H. R., Svendsrod, R., Ursin, G., and Ursin, H. (1998). Prevalence of subjective health complaints in the Nordic European countries in 1993. European Journal of Public Health, 8, 294-298. Ershler, W. B., and Keller, E. T. (2000). Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. Annual Review of Medicine, 51, 245-270. Fields, H. L. (2000). Pain modulation: expectation, opioid analgesia and virtual pain. Progress in Brain Research, 122, 245-253. Filippelli, M., Pellegrino, R., Landelli, I., Misuri, G., Rodarte, J. R., Duranti, R., et al. (2001). Respiratory dynamics during laughter. Journal of Applied Physiology, 90, 1441-1446. Folkman, S., and Moskowitz, J. T. (2000). Positive affect and the other side of coping. American Psychologist, 55, 647-654. Forabosco G. (1992). Cognitive aspects of the humor process: The concept of incongruity. Humor, 5, 45-68.

62


Forseth, K. O., Forre, O., and Gran, J. T. (1999). A 5.5 year prospective study of self-reported musculoskeletal pain and of fibromyalgia in a female population: Significance and natural history. Clinical Rheumatology, 18, 114-121. Franzini, L. R. (2001). Humor in therapy: The case for training therapists in its uses and risks. Journal of General Psychology, 128, 170-193. Frasure-Smith, N. and Lesperance, F. (2005). Reflections on depression as a cardiac risk factor. Psychosomatic Medicine, 67, S19-S25. Frasure-Smith, N., Lesperance, F., Gravel, G., Masson, A., Juneau, M., Talajic, M., et al. (2000). Social support, depression, and mortality during the first year after myocardial infarction. Circulation, 101, 1919-1924. Frasure-Smith, N., Lesperance, F., and Talajic, M. (1995). The impact of negative emotions on prognosis following myocardial infarction: Is it more than depression. Health Psychology, 14, 388-398. Frazier, T. W., Strauss, M. E., and Steinhauer, S. R. (2004). Respiratory sinus arrhythmia as an index of emotional response in young adults. Psychophysiology, 41, 75-83. Fredman, L., Hawkes, W. G., Black, S., Bertrand, R. M., and Magaziner, J. (2006). Elderly patients with hip fracture with positive affect have better functional recovery over 2 years. Journal of the American Geriatrics Society, 54, 1074-1081. Fredrickson, B. L. (2004). The broaden-and-build theory of positive emotions. Philosophical Transactions of the Royal Society London, Biological Sciences, 359, 1367-1377. Fredrickson, B. L., and Joiner, T. (2002). Positive emotions trigger upward spirals toward emotional well-being. Psychological Science, 13, 172-175. Fredrickson, B. L., and Levenson, R. W. (1998). Positive emotions speed recovery from the cardiovascular sequelae of negative emotions. Cognition and Emotion, 12, 191-220. Fried, I., Wilson, C. L., MacDonald, K. A., and Behnke, E. J. (1998). Electric current stimulates laughter. Nature, 391, 650. Friedman, B. H., and Thayer, J. F. (1998). Anxiety and autonomic flexibility: A cardiovascular approach. Biological Psychology, 49, 303-323. Fuchs, E., and Fluegge, G. (1995). Modulation of binding sites for corticotropin-releasing hormone by chronic psychosocial stress. Psychoneuroendocrinology, 20, 33-51. Gabbay, F. H., Krantz, D. S., Kop, W. J., Hedges, S. M., Klein, J., Gottdiener, J. S., et al. (1996). Triggers of myocardial ischemia during daily life in patients with coronary artery disease: Physical and mental activities, anger and smoking. Journal of the American College of Cardiology, 27, 585-592. Gallo, L. C., Ghaed, S. G., and Bracken, W. S. (2004). Emotions and cognitions in coronary heart disease: Risk, resilience, and social context. Cognitive Therapy and Research, 28, 669-694. Gendolla, G. H., Abele, A. E., Andrei, A., Spurk, D., and Richter, M. (2005). Negative mood, self-focused attention, and the experience of physical symptoms: The joint impact hypothesis. Emotion, 5, 131-144. Gendolla, G. H. E., and Krüsken, J. (2001a). Mood state and cardiovascular response in active coping with an affect-regulative challenge. International Journal of Psychophysiology, 41, 169-180. Gendolla, G. H. E., and Krüsken, J. (2001b). The joint impact of mood state and task difficulty on cardiovascular and electrodermal reactivity in active coping. Psychophysiology, 38, 548-556.


63

Goel, V., and Dolan, R.J. (2001). The functional anatomy of humor: Segregating cognitive and affective components. Nature Neuroscience, 4, 237-238. Goodman, C. S., and Shatz, C. J. (1993). Developmental mechanisms that generate precise patterns of neuronal connectivity. Cell, 72, 77-98. Graham, J., Potts, H. W., and Ramirez, A. J. (2002): Stress and burnout in doctors. Lancet, 360, 1975–1976. Harker, L. and Keltner, D. (2001). Expressions of positive emotions in women's college yearbook pictures and their relationship to personality and life outcomes across adulthood. Journal of Personality and Social Psychology, 80, 112-124. Hatfield, E., Cacioppo, J. T., and Rapson, R. L. (1994). Emotional Contagion. Cambridge: University Press. Hennenlotter, A., Schroeder, U., Erhard, P., Castrop, F., Haslinger, B., Stoecker, D., et al. (2005). A common neural basis for receptive and expressive communication of pleasant facial affect. Neuroimage, 26, 581-591. Heponiemi, T., Elovainio, M., Pulkki, L., Puttonen, S., Raitakari, O., and KeltikangasJärvinen, L. (2007). Cardiac autonomic reactivity and recovery in predicting carotid atherosclerosis: The cardiovascular risk in young finns study. Health Psychology, 26, 1321. Herbert, T. B. and Cohen, S. (1993). Stress and immunity in humans: A meta-analytic review. Psychosomatic Medicine, 55, 364-379. Hess, U., and Blairy, S. (2001). Facial mimicry and emotional contagion to dynamic emotional facial expressions and their influence on decoding accuracy. International Journal of Psychophysiology, 40, 129-141. Hess, U., Kappas, A., McHugo, G. J., Lanzetta, J. T., and Kleck, R. E. (1992). The facilitative effect of facial expression on the self-generation of emotion. International Journal of Psychophysiology, 12, 251-265. Hietanen, J. K., Surakka, V., and Linnankonski, I. (1998). Facial electromyographic responses to vocal affect expressions. Psychophysiology, 35, 530-536. Hirdes, J. P., and Forbes, W. F. (1993). Factors associated with the maintenance of good selfrated health. Journal of Aging and Health, 5, 101-122. Hobfoll, S.E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44, 513-524. Hoehn-Saric, R., and McLeod, D. R. (1988). The peripheral sympathetic nervous system. Its role in normal and pathological anxiety. Psychiatric Clinics in North America, 11, 375386. Hoehn-Saric, R., and McLeod, D. R. (2000). Anxiety and arousal: Physiological changes and their perception. Journal of Affective Disorders, 61, 217-224. Holmes, E. A., Mathews, A., Dalgleish, T., and Macintosh, B. (2006). Positive interpretation training: Effects of mental imagery versus verbal training on positive mood. Behavioral Therapy, 37, 237-247. Holmes, J., and Marra, M. (2002). Over the edge? Subversive humor between colleagues and friends. Humor: International Journal of Humor Research, 15, 65-87. House, J. S., Landis, K. R., and Umberson, D. (1988). Social relationships and health. Science, 241, 540-545.

64


Hoyos, T., and Kallus, K. W. (2005). Burnout risk factors: Stress-recovery-state and coping among teachers. Research report, Department of Psychology, Karl-Franzens-University, Graz Austria. Hubbard, J. R., and Workman, E. A. (Eds.) (1998). Handbook of stress medicine. An organ system approach. Boca Raton: CRC Press. Hubert, W., Moller, M., and deJong-Meyer, R. (1993). Film-induced amusement changes in saliva cortisol levels. Psychoneuroendocrinology, 18, 265-272. Hughes, J. W., and Stoney, C. M. (2000). Depressed mood is related to high-frequency heart rate variability during stressors. Psychosomatic Medicine, 62, 796-803. Iwase, M., Ouchi, Y., Okada, H., Yokoyama, X., Nobezawa, S., Yoshikawa, E., et al. (2002). Neural substrates of human facial expression of pleasant emotion induced by comic films: A PET study. Neuroimage, 17, 758-768. Jain, S., Mills, P. J., von Känel, R., Hong, S., and Dimsdale, J. E. (2007). Effects of perceived stress and uplifts on inflammation and coagulability. Psychophysiology, 44, 154-160. Jänig, W., and Häbler, H. J. (2000). Specificity in the organization of the autonomic nervous system: A basis for precise neural regulation of homeostatic and protective body functions. Progress in Brain Research, 122, 351-367. Janssen, S. A. (2002). Negative affect and sensitization to pain. Scandinavian Journal of Psychology, 43, 131-137. Jasmin, L., Rabkin, S. D., Granado, A., Boudak, A., and Ohara, P. T. (2003). Analgesia and hyperalgesia from GABA-mediated modulation of the cerebral cortex. Nature, 424, 316320. Jonas, B. S., Franks, P., and Ingram, D. D. (1997). Are symptoms of anxiety and depression risk factors for hypertension? Longitudinal evidence from the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Archives of Family Medicine, 6, 43-49. Jonas, B. S., and Lando, J. F. (2000). Negative affect as a prospective risk factor for hypertension. Psychosomatic Medicine, 62, 188-196. Jonas, B. S. and Mussolino, M. E. (2000). Symptoms of depression as a prospective risk factor for stroke. Psychosomatic Medicine, 62, 463-471. Joynt, K. E., Whellan, D. J., and O'Connor, C. M. (2003). Depression and cardiovascular disease: Mechanisms of interaction. Biological Psychiatry, 54, 248-261. Kallus, K. W. (2002). Impact of recovery in different areas of application. In M. Kellman (Ed.), Enhancing recovery: Preventing underperformance in athletes (pp. 283-300). Champaign, IL: Human Kinetics. Kamphuis, M. H., Kalmijn, S., Tijhuis, M. A., Geerlings, M. I., Giampaoli, S., Nissinen, A., et al. (2006). Depressive symptoms as a risk factor of cardiovascular mortality in older European men: The Finland, Italy and Netherlands Elderly (FINE) study. European Journal of Cardiovascular Prevention and Rehabilitation, 13, 199-206. Kaplan, G. A., Salonen, J. T., Cohen, R. D., Brand, R. J., Syme, S. L., and Puska, P. (1988). Social connections and mortality from all causes and from cardiovascular disease: Prospective evidence from Eastern Finland. American Journal of Epidemiology, 128, 370-380. Kashdan, T. B., and Roberts, J. E. (2004). Trait and state curiosity in the genesis of intimacy: Differentiation from related constructs. Journal of Social and Clinical Psychology, 23, 792-816.


65

Kawachi, I., Sparrow, D., Spiro, A., Vokonas, P., and Weiss, S. T. (1996). A prospective study of anger and coronary heart disease. The Normative Aging Study. Circulation, 94, 2090-2095. Keltner, D. and Bonanno, G. A. (1997). A study of laughter and dissociation: Distinct correlates of laughter and smiling during bereavement. Journal of Personality and Social Psychology, 73, 687-702. Klußmann, R. (1992). Psychosomatische Medizin. Berlin: Springer. Kop, W. J., Gottdiener, J. S., Tangen, C. M., Fried, L. P., McBurnie, M. A., Walston, J., et al. (2002). Inflammation and coagulation factors in persons > 65 years of age with symptoms of depression but without evidence of myocardial ischemia. American Journal of Cardiology, 89, 419-424. Korotkov, D. and Hannah, T. E. (1994): Extraversion and emotionality as proposed superordinate stress moderators: A prospective analysis. Personality and Individual Differences, 16, 787-792. Kritz-Silverstein, D., Barrett-Connor, E., and Corbeau, C. (2001). Cross-sectional and prospective study of exercise and depressed mood in the elderly: The Rancho Bernado study. American Journal of Epidemiology, 153, 596-603. Kroenke, K., and Harris, L. (2001). Symptoms research: A fertile field. Annals of Internal Medicine, 134, 801-802. Kubie, L. (1971). The destructive potential of humor in psychotherapy. American Journal of Psychiatry, 172, 861-866. Kubzansky, L. D., Davidson, K. W., and Rozanski, A. (2005). The clinical impact of negative psychological states: Expanding the spectrum of risk for coronary artery disease. Psychosomatic Medicine, 67, S10-S14. Kubzansky, L. D., and Kawachi, I. (2000). Going to the heart of the matter. Do negative emotions cause coronary heart disease. Journal of Psychosomatic Research, 48, 323-327. Kubzansky, L. D., Kawachi, I., Spiro, A., Weiss, S. T., Vokonas, P. S., and Sparrow, D. (1997). Is worrying bad for your heart? A prospective study of worry and coronary heart disease in the Normative Aging Study. Circulation, 95, 818-824. Kubzansky, L. D., Kawachi, I., Weiss, S. T., and Sparrow, D. (1998). Anxiety and coronary heart disease: A synthesis of epidemiological, psychological, and experimental evidence. Annals of Behavioral Medicine, 20, 47-58. Kuiper, N. A., and Borowicz-Sibenik, M. (2005). A good sense of humor doesn't always help: Agency and communion as moderators of psychological well-being. Personality and Individual Differences, 38, 365-377. Kuiper, N. A., Grimshaw, M., Leite, C., and Kirsh, G. (2004). Humor is not always the best medicine: Specific components of sense of humor and psychological well-being. Humor, 17, 135-168. Kuiper, N., and Martin, R. (1998). Laughter and stress in daily life: Relation to positive and negative affect. Motivation and Emotion, 22, 133-153. Kuiper, N. A., Martin, R. A., and Olinger, L. J. (1993). Coping humor, stress, and cognitive appraisals. Canadian Journal of Behavioral Sciences, 25, 81-96. LaFrance, M., and Hecht, M. A. (1995). Why smiles generate leniency. Personality and Social Psychology Bulletin, 21, 207-214. Lazarus, R. S. and Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

66


Lederer, F. (2007). Heiterkeitstraining als Methode der betrieblichen Gesundheitsförderung [Cheerfulness training as a method of workplace health promotion]. Unpublished master's thesis, Interuniversitary College for Health and Development, Graz / Seggau. Lefcourt, H. M., Davidson, K., Prkachin, K. M., and Mills, D. E. (1997). Humor as a stress moderator in the prediction of blood pressure obtained during five stressful tasks. Journal of Research in Personality, 31, 523-542. Lefcourt, H. M., Davidson, K., Shepherd, R., Phillips, M., Prkachin, K., and Mills, D. E. (1995). Perspective-taking humor: Accounting for stress moderation. Journal of Social and Clinical Psychology, 14, 373-391. Levenson, R. W., Ekman, P., and Friesen, W. V. (1983). Autonomic nervous system activity distinguishes among emotions. Science, 221, 1208-1210. Levenson, R. W., Ekman, P., and Friesen, W. V. (1990). Voluntary facial action generates emotion-specific autonomic nervous system activity. Psychophysiology, 27, 363-384. Leibbrand, R., Cuntz, U., and Hiller, W. (2002). Assessment of functional gastrointestinal disorders using the Gastro-Questionnaire. International Journal of Behavioral Medicine, 9, 155-172. Lesperance, F., Frasure-Smith, N., Talajic, M., and Bourassa, M. G. (2002). Five-year risk of cardiac mortality in relation to initial severity and one-year chances in depression symptoms after myocardial infarction. Circulation, 105, 1049-1053. Levi, L. (1965). The urinary output of adrenalin and noradrenalin during pleasant and unpleasant emotional states: A preliminary report. Psychosomatic Medicine, 27, 80-85. Levine, J. D., and Gordon, N. C. (1984). Influence of the method of drug administration on analgesic response. Nature, 312, 755-756. Liangas, G., Yates, D. H., Wu, D., Henry, R. L., and Thomas, P. S. (2004). Laughterassociated asthma. Journal of Asthma, 41, 217-221. Libby, P. (2003). Vascular biology of atherosclerosis: Overview and state of the art. American Journal of Cardiology, 91, 3A-6A. Lovallo, W. R. (1997). Stress and Health. Biological and Psychological Interactions. Thousand Oaks: Sage. Mahony, D. L., Burroughs, W. J., and Lippman, L. G. (2002): Perceived attributes of healthpromoting laughter: A cross-generational comparison. Journal of Psychology, 136, 171181. Martin, R. A. (2001): Humor, laughter, and physical health: Methodological issues and research findings. Psychological Bulletin, 127, 504-519. Martin, L. R., Friedman, H. S., Tucker, J. S., Tomlinson-Keasey, C. Criqui, M. H., and Schwartz, J. E. (2002). A life course perspective on childhood cheerfulness and its relation to mortality risk. Personality and Social Psychology Bulletin, 28, 1155-1165. Martin, R. A., and Kuiper, N. A. (1999). Daily occurrence of laughter: Relationships with age, gender, and Type A personality. Humor: International Journal of Humor Research, 12, 355-384. Martin, R. A., and Lefcourt, H. M. (1983). Sense of humor as a moderator of the relation between stressors and moods. Journal of Personality and Social Psychology, 45, 13131324. Matthews, K. A., Owens, J. F., Edmundowicz, D., Lee, L., and Kuller, L. H. (2006). Positive and negative attributes and risk for coronary and aortic calcification in healthy women. Psychosomatic Medicine, 68, 355-361.


67

Matthews, K. A., Raikkonen, K., Sutton-Tyrrell, K., Kuller, L. H. (2004). Optimistic attitudes protect against progression of carotid atherosclerosis in healthy middle-aged women. Psychosomatic Medicine, 66, 640-644. Mayer, E. A. (1999). Emerging disease model for functional gastrointestinal disorders. American Journal of Medicine, 107(5A), 12-19. Mayer, E. A. (2000). The neurobiology of stress and gastrointestinal disease. Gut, 47, 861869. Mayer, E. A., Munakata, J., and Chang, L. (1997). Does mind-body medicine have a role in gastroenterology. Current Opinion in Gastroenterology, 13, 1-4. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338, 171-179. McLaughlin, K. A., Borkovec, T. D., and Sibrava, N. J. (2005). The effects of worry and rumination on affect states and cognitive activity. Behavioral Therapy, 38, 23-38. McMahon, C., Mahmud, A., and Feely J. (2005): Taking blood pressure - no laughing matter. Blood Pressure Monitor, 10, 109-10. Meyer, M., Zysset, S., vonCramon, D. Y., and Alter, K. (2005). Distinct fMRI responses to laughter, speech, and sounds along the human peri-sylvian cortex. Cognitive Brain Research, 24, 291-306. Middleton, R. A., and Byrd, E.K. (1996). Psychosocial factors and hospital readmission status of older persons with cardiovascular disease. Journal of Applied Rehabilitation Counseling, 27, 3-10. Miller, G. E., and Blackwell, E. (2006). Turning up the heat. Inflammation as a mechanism linking chronic stress, depression, and heart disease. Current Directions in Psychological Science, 15, 269-272. Miller, G. E., Chen, E., and Zhou, E. S. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychological Bulletin, 133, 25-45. Miron, D., Duncan, G. H., and Bushnell, M. C. (1989). Effects of attention on the intensity and unpleasantness of thermal pain. Pain, 39, 345-352. Mobbs, D., Greicius, M. D., Abdel-Azim, E., Menon, V., and Reiss, A. L. (2003). Humor modulates the mesolimbic reward centers. Neuron, 40, 1041-1048. Moller, J., Hallqvist, J., Diderichsen, F., Theorell, T., Reuterwall, C., and Ahlbom, A. (1999). Do episodes of anger trigger myocardial infarction? A case-crossover analysis in the Stockholm Heart Epidemiology Program (SHEEP). Psychosomatic Medicine, 61, 842849. Mori, H., Yamamoto, H., Kuwashima, M., Saito, S., Ukai, H., Hirao, K., et al. (2005). How does deep breathing affect office blood pressure and pulse rate. Hypertension Research, 28, 499-504. Moser, D. K., Riegel, B., McKinley, S., Doering, L. V., An, K., and Sheahan, S. (2007). Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction. Psychosomatic Medicine, 69, 10-16. Moskowitz, J. T. (2003). Positive affect predicts lower risk of AIDS mortality. Psychosomatic Medicine, 65, 620-626. Murphy, R., Hirsch, C. R., Mathews, A., Smith, K., and Clark, D. M. (2007). Facilitating a benign interpretation bias in a high socially anxious population. Behavior Research and Therapy, 45, 1517-1529.

68


Naliboff, B. D., Chang, L., Munakata, J., and Mayer, E. A. (2000). Towards an integrative model of irritable bowel syndrome. Progress in Brain Research, 122, 413-423. Neumann, R., and Strack, F. (2000). 'Mood contagion': The automatic transfer of mood between persons. Journal of Personality and Social Psychology, 79, 211-223. Neumann, S. A., and Waldstein, S. R. (2001): Similar patterns of cardiovascular response during emotional activation as a function of affective valence and arousal and gender. Journal of Psychosomatic Research, 50, 245-253. Newman, M. G., and Stone, A. A. (1996). Does humor moderate the effects of experimentally-induced stress. Annals of Behavioral Medicine, 18, 101-109. Nezu, A. M., Nezu, C. M., and Blisset, S. E. (1988). Sense of humor as a moderator of the relation between stressful events and psychological distress: A prospective analysis. Journal of Personality and Social Psychology, 54, 520-525. Nograsek, J. (2006). Positive Intervention in der psychiatrischen Rehabilitation [Positive intervention in psychiatric rehabilitation]. Unpublished master's thesis, Karl-Franzens University, Graz. Nouwen, A., Cloutier, C., Kappas, A., Warbrick, T., and Sheffield, D. (2006). Effects of focusing and distraction on cold pressor-induced pain in chronic back pain patients and control subjects. Journal of Pain, 7, 62-71. Ochsner, K. N., Ludlow, D. H., Knierim, K., Hanelin, J., Ramachandran, T., Glover, G. C., et al. (2006). Neural correlates of individual differences in pain-related fear and anxiety. Pain, 120, 69-77. Okun, M. A., Stock, W. A., Haring, M. H., and Winter, R. A. (1984). Health and subjective well-being: A meta-analysis. International Journal of Aging and Human Development, 19, 111-132. Okun, M. S., Bowers, D., Springer, U., Shapira, N. A., Malone, D., Rezai, A. R., et al. (2004). What's in a smile. Intra-operative observations of contralateral smiles induced by deep brain stimulation. Neurocase, 10, 271-279. Olden, K. W. (1998). Stress and the gastrointestinal tract. In J. R. Hubbard, and E. A. Workman (Eds.), Handbook of stress medicine. An organ system approach. Boca Raton: CRC Press. Olds, J., and Milner, P. (1954). Positive reinforcement produced by electrical stimulation of septal area and other regions of rat brain. Journal of Comparative Physiological Psychology, 47, 419-427. Ong, A. D., Bergeman, C. S., Bisconti, T. L., and Wallace, K. A. (2006). Psychological resilience, positive emotions, and successful adaptation to stress in later life. Journal of Personality and Social Psychology, 91, 730-749. Orth-Gomer, K., Rosengren, A., and Wilhelmsen, L. (1993). Lack of social support and incidence of coronary heart disease in middle-aged Swedish men. Psychosomatic Medicine, 55, 37-43. Ostir, G. V., Goodwin, J. S., Markides, K. S., Ottenbacher, K. J., Balfour, J., and Guralnik, J. M. (2002). Differential effects of premorbid physical and emotional health on recovery from acute events. Journal of the American Geriatrics Society, 50, 713-718. Ostir, G. V., Markides, K. S., Black, S. A., and Goodwin, J. S. (2000). Emotional well-being predicts subsequent functional independence and survival. Journal of the American Geriatrics Society, 48, 473-478.


69

Ostir, G. V., Markides, K. S., Peek, M. K., and Goodwin, J. S. (2001). The association between emotional well-being and the incidence of stroke in older adults. Psychosomatic Medicine, 210-215. Oswald, L. M., Zandi, P., Nestadt, G., Potash, J. B., Kalaydjian, A. E., and Wand, G. S. (2006). Relationship between cortisol responses to stress and personality. Neuropsychopharmacology, 31, 1583-1591. Otta, E., Abrosio, F. F. E., and Hoshino, R .L. (1996). Reading a smiling face: Messages conveyed by various forms of smiling. Perceptual and Motor Skills, 82, 1111-1121. Overeem, S., Lammers, G. J., and van Dijk, J. G. (1999). Weak with laughter. Lancet, 354, 838. Overeem, S., Taal, W., Ocal, G. E., Lammers, G. J., and van Dijk, J. G. (2004): Is motor inhibition during laughter due to emotional or respiratory influences. Psychophysiology, 41, 254-258. Papanicolaou, D. A., Wilder, R. L., Manolagas, S. C., and Chrousos, G. P. (1989). The pathophysiologic roles of interleukin-6 in human disease. Annals of Internal Medicine, 128, 127-137. Papousek, I. (2008). Heiterkeit und Gelassenheit trainieren mit Lachen [Training cheerfulness and serenity with laughter]. In H. Effinger (Ed.), Die Wahrheit zum Lachen bringen Humor als Medium in der Sozialen Arbeit [To make the truth laugh - use of humor in social work]. Weinheim: Juventa. Papousek, I., Lang, S., Zitzenbacher, A., and Kogler, E. (2004). Entwicklung und Evaluation eines wissenschaftlich fundierten Heiterkeitstrainings [Development and evaluation of a scientifically founded cheerfulness training]. Research report, Karl-Franzens-University, Graz, Austria. Papousek, I., Nauschnegg, K., Paechter, M., Lackner, H. K., Goswami, N., and Schulter, G. (2010). Trait and state positive affect and cardiovascular recovery from experimental academic stress. Biological Psychology, 83, 108-115. Papousek, I., Ruch, W., Freudenthaler, H. H., Kogler, E., Lang, B., and Schulter, G. (2009). Gelotophobia, emotion-related skills and responses to the affective states of others. Personality and Individual Differences, 47, 58-63. Papousek, I., and Schulter, G. (2001). Associations between EEG asymmetries and electrodermal lability in low versus high depressive and anxious normal individuals. International Journal of Psychophysiology, 41, 105-117. Papousek, I., and Schulter, G. (2002). Brain asymmetry and stress: New perspectives in psychophysiologically oriented psychosomatic research. Psychology Science Quarterly, 44, 535-544. Papousek, I., and Schulter, G. (2006). Heiterkeit trainieren: Subjektive und psychophysiologische Wirkungen [Cheerfulness training: Subjective and psychophysiological effects]. Paper, presented at the 7th Scientific Conference of the Austrian Psychological Society, Klagenfurt, Austria. Papousek, I., and Schulter, G. (2008). Effects of a mood enhancing intervention on subjective well-being and cardiovascular parameters. International Journal of Behavioral Medicine, 15, 293-302. Papousek, I., and Schulter, G. (In preparation). Alterations in EEG laterality produced by a mood enhancing intervention.

70


Papousek, I., Schulter, G., and Premsberger, E. (2002). Dissociated autonomic regulation during stress, and physical complaints. Journal of Psychosomatic Research, 52, 257-266. Paterniti, S., Zureik, M., Ducimetiere, P., Touboul, P. J., Feve, J. M., and Alperovitch, A. (2001). Sustained anxiety and 4-year progression of carotid atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology, 21, 136-141. Patton, G. C., Hibbert, M., Rosier, M. J., Carlin, J. B., Caust, J., and Bowes, G. (1996). Is smoking associated with depression and anxiety in teenagers. American Journal of Public Health, 86, 225-230. Peeters, F., Nicholson, N. A., and Berkhof, J. (2003). Cortisol responses to daily events in major depressive disorder. Psychosomatic Medicine, 65, 836-841. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer. Petrie, K. J., Moss-Morris, R., Grey, C., and Shaw, M. (2004). The relationship of negative affect and perceived sensitivity to symptom reporting following vaccination. British Journal of Health Psychology, 9, 101-111. Pettit, J. W., Kline, J. P., Gencoz, T., Gencoz, F., and Joiner, T. E. (2001). Are happy people healthier? The specific role of positive affect in predicting self-reported health symptoms. Journal of Research in Personality, 35, 521-536. Petrovic, P., Kalso, E., Pettersson, K. M., and Ingvar, M. (2002). Placebo and opioid analgesia. Imaging a shared neuronal network. Science, 295, 1737-1740. Petrovic, P., Petterson, K. M., Ghatan, P. H., Sone-Elander, S., and Ingvar, M. (2000). Painrelated cerebral activation is altered by a distracting cognitive task. Pain, 85, 19-30. Pfaus, J. G., Damsma, G., Nomikos, G. G., Wenstern, D. G., Blaha, C. D., Phillips, A. G., et al. (1990). Sexual behavior enhances central dopamine transmission in the male rat. Brain Research, 530, 345-348. Picavet, H. S. and Schouten, J. S. (2003). Musculoskeletal pain in the Netherlands: Prevalences, consequences and risk groups, the DMC(3) study. Pain, 102, 167-178. Pitsavos, C., Panagiotakos, D. B., Papageorgiou, C., Tsetsekou, E., Soldatos, C., and Stefanadis, C. (2006). Anxiety in relation to inflammation and coagulation markers among healthy adults: The ATTICA study. Atherosclerosis, 185, 320-326. Plotsky, P. M., Owens, M. J., and Nemeroff, C. B. (1998). Psychoneuroendocrinology of depression. Hypothalamic-pituitary-adrenal axis. Psychiatric Clinics of North America, 21, 293-307. Porterfield, A. (1987). Does sense of humor moderate the impact of life stress on psychological well-being. Journal of Research in Personality, 21, 306-317. Pressman, S. D., and Cohen, S. (2005). Does positive affect influence health. Psychological Bulletin, 131, 925-971. Provine, R. R. (1992). Contagious laughter: Laughter is a sufficient stimulus for laughs and smiles. Bulletin of the Psychonomic Society, 30, 1-4. Provine, R. R. (2000). Laughter: A scientific investigation. New York: Viking Putnam. Raikkonen, K., Matthews, K. A., Sutton-Tyrrell, K., and Kuller, L. H. (2004). Trait anger and the metabolic syndrome predict progression of carotid atherosclerosis in healthy middleaged women. Psychosomatic Medicine, 66, 903-908. Reis, H. T., Wilson, I. M., Monestere, C., Bernstein, S., Clark, K., Seidl, E., et al., (1990). What is smiling is beautiful and good. European Journal of Social Psychology, 20, 259267.


71

Ring, C., Harrison, L. K., Winzer, A., Carroll, D., Drayson, M., and Kendall, M. (2000): Secretory immunoglobulin A and cardiovascular reactions to mental arithmetic, cold pressor, and exercise: Effects of alpha-adrenergic blockade. Psychophysiology, 37, 63443. Ringel, Y., and Drossman, D.A. (1999). From gut to brain and back - a new perspective into functional gastrointestinal disorders. Journal of Psychosomatic Research, 47, 205-210. Ritz, T., George, C., and Dahme, B. (2000): Respiratory resistance during emotional stimulation: Evidence for a nonspecific effect of experienced arousal. Biological Psychology, 52, 143-160. Ritz, T., and Steptoe, A. (2000): Emotion and pulmonary function in asthma: Reactivity in the field and relationship with laboratory induction of emotion. Psychosomatic Medicine, 62, 808-815. Ross, R. (1999). Atherosclerosis. An inflammatory disease. New England Journal of Medicine, 340, 115-126. Rotton, J., and Shats, M. (1996). Effects of state humor, expectancies, and choice on postsurgical mood and self-medication: A field experiment. Journal of Applied Social Psychology, 26, 1775-1794. Rowe, G., Hirsh, J. B., and Anderson, A. K. (2007). Positive affect increases the breadth of attentional selection. Proceedings of the National Academy of Sciences, 104, 383-388. Rozanski A., and Kubzansky, L. D. (2005). Psychologic functioning and physical health: A paradigm of flexibility. Psychosomatic Medicine, 67, 47-53. Ruch, W. (1993a). Exhilaration and humor. In M. Lewis and J. M. Haviland (Eds.), The handbook of emotion (pp. 605-616). New York: Guilford Press. Ruch, W. (1993b): Die Emotion Erheiterung: Eine Übersicht über den Forschungsbestand [The emotion exhilaration: Overview over the scientific evidence]. In Montada, L. (Ed.), Proceedings of the 38th Congress of the German Psychological Society (pp. 277-285). Göttingen, Hogrefe. Ruch, W. (1997). State and trait cheerfulness and the induction of exhilaration. A FACS study. European Psychologist, 2, 328-341. Ruch, W., and Ekman, P. (2001). The expressive pattern of laughter. In A. W. Kaszniak (Ed.), Emotion, qualia, and consciousness (pp. 246-443). Tokyo: World Scientific Publisher. Ruch, W., and Köhler, G. (1999). The measurement of state and trait cheerfulness. In I. Mervielde, I. Deary, F. De Fruyt, and F. Ostendorf (Eds.), Personality psychology in Europe: Theoretical and empirical developments, Vol. 7 (pp. 67-83). Tilburg: University Press. Ruch, W., Köhler, G., and vanThriel, C. (1997). To be in good or bad humor: Construction of the state form of the State-Trait-Cheerfulness-Inventory STCI. Personality and Individual Differences, 22, 477-491. Ruch, W., and Proyer, R. T. (2008). The fear of being laughed at: Individual and group differences in Gelotophobia. Humor: International Journal of Humor Research, 21, 4767. Ruch, W., and Zweyer, K. (2001). Heiterkeit und Humor: Ergebnisse der Forschung [Cheerfulness and humor: Scientific findings]. In R. D. Hirsch, J. Bruder, and H. Radebold (Eds.), Heiterkeit und Humor im Alter. Schriftenreihe der Deutschen Gesellschaft für Gerontopsychiatrie und -psychotherapie, Band 2 [Cheerfulness and

72


humor in old age. Series of the German Society of Gerontopsychiatry and psychotherapy, Vol. 2] (pp. 9-43). Bornheim-Sechtem: Chudeck-Druck. Rugulies, R. (2002). Depression as a predictor for coronary heart disease. A review and metaanalysis. American Journal of Preventive Medicine, 23, 51-61. Salaffi, F., Cavalieri, F., Nolli, M., and Ferraccioli, G. (1991). Analysis of disability in known osteoarthritis: Relationship with age and psychological variables but not with radiographic score. Journal of Rheumatology, 18, 1581-1586. Salovey, P., Rothman, A. J., Detweiler, J. B., and Steward, W. T. (2000). Emotional states and physical health. American Psychologist, 55, 110-121. Sauro, M. D., and Greenberg, R. P. (2005). Endogenous opiates and the placebo effect. A meta-analytic review. Journal of Psychosomatic Research, 58, 115-120. Schimmack, U., Oishi, S., Furr, R. M., and Funder, D. C. (2004). Personality and life satisfaction: A facet-level analysis. Personality and Social Psychology Bulletin, 30, 10621075. Segerstrom, S. C. (2005). Optimism and immunity: Do positive thoughts always lead to positive effects. Brain, Behavior and Immunity, 19, 195-200. Segerstrom, S. C. and Miller, G. E. (2004). Psychological stress and the immune system: A meta-analytic study of 30 years of inquiry. Psychological Bulletin, 130, 601-630. Severeijns, R., Vlaeyen, J. W., Van den Hout, M. A., and Weber, W. E. (2001). Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clinical Journal of Pain, 17, 165–172. Sharp, T. J. (2001). Chronic pain: A reformulation of the cognitive-behavioural model. Behaviour Research and Therapy, 39, 787-800. Sheffield, D., Krittayaphong, R., Cascio, W. E., Light, K. C., Golden, R. N., Finkel, J. B., et al. (1998). Heart rate variability at rest and during mental stress in patients with coronary artery disease: Differences in patients with high and low depression scores. International Journal of Behavioral Medicine, 5, 31-47. Sobel, D. S. (2000). The cost-effectiveness of mind-body medicine interventions. Progress in Brain Research, 122, 393-412. Soussignan, R. (2002). Duchenne smile, emotional experience, and autonomic reactivity. Emotion, 2, 52-74 Staud, R. (2006). Biology and therapy of fibromyalgia: Pain in fibromyalgia syndrome. Arthritis Research and Therapy, 8, 208-214. Stein, M., Miller, A. H., and Trostman, R. I. (1991). Depression, the immune system, and health and illness. Archives of General Psychiatry, 48, 171-177. Steptoe, A., O'Donnell, K., Marmot, M., and Wardle, J. (2008). Positive affect and psychosocial processes related to health. British Journal of Psychology, 99, 211-227. Steptoe, A. and Wardle, J. (2005). Positive affect and biological function in everyday life. Neurobiology of Ageing, 26, 108-112. Stiles, D. P., and Terr, A. I. (1991). Basic and clinical immunology. San Mateo: Appleton and Lange. Strack, F., Martin, L. L., and Stepper, S. (1988). Inhibiting and facilitating conditions of the human smile: A nonobtrusive test of the facial feedback hypothesis. Journal of Personality and Social Psychology, 54, 768-777.


73

Strand, E. B., Zautra, A. J., Thoresen, M., Odegard, S., Uhlig, T., and Finset, A. (2006). Positive affect as a factor of resilience in the pain-negative affect relationship in patients with rheumatoid arthritis. Journal of Psychosomatic Research, 60, 477-484. Svebak, S., Martin, R. A., and Holmen, J. (2004). The prevalence of sense of humor in a large, unselected county population in Norway: Relations with age, sex, and some health indicators. Humor: International Journal of Humor Research, 17, 121-134. Szameitat, D. P., Alter, K., Szameitat, A. J., Darwin, C. J., Wildgruber, D., Dietrich, S., et al. (2009). Differentiation of emotions in laughter at the behavioral level. Emotion, 9, 397405. Thayer, J. F., Friedman, B. H., and Borkovec, T. D. (1996). Autonomic characteristics of generalized anxiety disorder and worry. Biological Psychiatry, 39, 255-266. Thomsen, D. K., Mehlsen, M. Y., Olesen, F., Hokland, M., Vidik, A., Avlund, K., et al. (2004). Is there an association between rumination and self-reported physical health. A one year follow-up in a young and an elderly sample. Journal of Behavioral Medicine, 27, 215-231. Tracey, I. Ploghaus, A., Gati, J. S., Clare, S., Smith, S., Menon, R. S., et al. (2002). Imaging attentional modulation of pain in the periaqueductal gray in humans. Journal of Neuroscience, 22, 2748-2752. Troisi, A., and Moles, A. (1999). Gender differences in depression. An ethological study of nonverbal behavior during interviews. Journal of Psychiatric Research, 33, 243-250. Tugade, M. M., and Fredrickson, B. L. (2004). Resilient individuals use positive emotions to bounce back from negative emotional experiences. Journal of Personality and Social Psychology, 86, 320-333. Tugade, M. M., Fredrickson, B. L., and Barrett, L. F. (2004). Psychological resilience and positive emotional granularity: Examining the benefits of positive emotions on coping and health. Journal of Personality, 72, 1161-1190. Tveito, T. H., Passchier, J., Duivenvoorden, H. J., and Eriksen, H. R. (2004). Subjective health complaints and health related quality of life in a population of health care workers. Psychology and Health, 19, 247-259. Uchino, B. N. (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29, 377-387. Uchino, B. N., Holt-Lunstad, J., Uno, D., Betancourt, R., and Garvey, T. S. (1999). Social support and age-related differences in cardiovascular function: An examination of potential mediators. Annals of Behavioral Medicine, 21, 135-142. Vagnoli, L., Caprilli, S., Robiglio, A., and Messeri, A. (2005). Clown doctors as a treatment for preoperative anxiety in children: A randomized, prospective study. Pediatrics, 116, 563-567. Van Hooff, J. A. (1972). A comparative approach to the phylogeny of laughter and smiling. In R. A. Hinde (Ed.), Nonverbal communication (pp. 209-237). Cambridge: Cambridge University Press. Ventis, W. L., Higbee, G., and Murdock, S. A. (2001). Using humor in systematic desensitization to reduce fear. Journal of General Psychology, 128, 241-253. Villemure, C. and Bushnell, M. C. (2002). Cognitive modulation of pain: How do attention and emotion influence pain processing. Pain, 95, 195-199.

74


Vinton, K. L. (1989). Humor in the work place: Is it more than telling jokes. Small Group Behavior, 20, 151-166. Visser, M. R., Smets, E. M., Oort, F. J., and De Haes, H. C. (2003). Stress, satisfaction and burnout among Dutch medical specialists. Canadian Medial Association Journal, 168, 271-275. Wadlinger, H. A., and Isaacowitz, D. M. (2006). Positive mood broadens visual attention to positive stimuli. Motivation and Emotion, 30, 89-101. Watkins, L. L., Grossman, P., Krishnan, R., and Sherwood, A. (1998). Anxiety and vagal control of heart rate. Psychosomatic Medicine, 60, 498-502. Watson, D., Clark, L. A., McIntyre, C. W., and Hamaker, S. (1992). Affect, personality, and social activity. Journal of Personality and Social Psychology, 63, 1011-1025. Watson, D., and Pennebaker, J. W. (1989). Health complaints, stress, and distress: Exploring the central role of negative affectivity. Psychological Reviews, 96, 234-254. Weisenberg, M., Raz, T., and Tener, T. (1998). The influence of film-induced mood on pain perception. Pain, 76, 365-375. Weisenberg, M., Tepper, I., and Schwarzwald, J. (1995). Humor as a cognitive technique for increasing pain tolerance. Pain, 63, 207-212. Weisse, C. S. (1992). Depression and immunocompetence: A review of the literature. Psychological Bulletin, 111, 475-489. White, P. D. and Moorey, S. (1997). Psychosomatic illnesses are not 'all in the mind'. Journal of Psychosomatic Research, 42, 329-332. Wicker, B., Keysers, C., Plailly, J., Royet, J. P., Gallese, V., and Rizzolatti, G. (2003). Both of us disgusted in my insula: The common neural basis of seeing and feeling disgust. Neuron, 40, 655-664. Wild, B., Erb, M., and Bartels, M. (2001). Are emotions contagious? Evoked emotions while viewing emotionally expressive faces: Quality, quantity, time course and gender differences. Psychiatry Research, 102, 109-124. Wild, B., Rodden, F. A., Rapp, A., Erb, M., Grodd, W., and Ruch, W. (2006). Humor and smiling: Cortical regions selective for cognitive, affective, and volitional components. Neurology, 66, 887-893. Wilhelmsen, I. (2000). Brain-gut axis as an example of the bio-psycho-social model. Gut, 47, 5-7. Williams, J. E., Paton, C. C., Siegler, I. C., Eigenbrodt, M. L., Nieto, F. J., and Tyroler, H. A. (2000). Anger proneness predicts coronary heart disease risk: Prospective analysis from the atherosclerosis risk in communities (ARIC) study. Circulation, 101, 2034-2039. Williams, R. B., Barefoot, J. C., Califf, R. M., Haney, T. L., Saunders, W. B., Pryor, D. B., et al. (1992). Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease. Journal of the American Medical Association, 267, 520-524. Wood, J. D., Alpers, D. H., and Andrews, P .L. R. (1999). Fundamentals of Neurogastroenterology. Gut, 45, II6-II16. Zautra, A. J., Fasman, R., Reich, J. W., Harakas, P., Johnson, L. M., Olmsted, M. E., et al. (2005). Fibromyalgia: Evidence for deficits in positive affect regulation. Psychosomatic Medicine, 67, 147-155.


75

Zautra, A. J., Johnson, L. M., and Davis, M. C. (2005). Positive affect as a source of resilience for women in chronic pain. Journal of Consulting and Clinical Psychology, 73, 212-220. Zautra, A. J., Smith, B., Affleck, G., and Tennen, H. (2001). Examinations of chronic pain and affect relationships: Applications of a dynamic model of affect. Journal of Consulting and Clinical Psychology, 69, 786-795. Zillmann, D., Rockwell, S., Schweitzer, K., and Sundar, S. S. (1993). Does humor facilitate coping with physical discomfort. Motivation and Emotion, 17, 1-21. Zweyer, K., Velker, B., and Ruch, W. (2004). Do cheerfulness, exhilaration, and humor production moderate pain tolerance? A FACS study. Humor: International Journal of Humor Research, 17, 67-84.

In: Psychological Well-Being Editor: Ingrid E. Wells, pp. 77-113


Chapter 2

PSYCHOLOGICAL WELL-BEING, ASSESSMENT TOOLS AND RELATED FACTORS Jesús López-Torres Hidalgo1,2, Beatriz Navarro Bravo1,2, Ignacio Párraga Martínez1, Fernando Andrés Pretel1, José Miguel Latorre Postigo2 and Francisco Escobar Rabadán1,2 1.Health Care Service of Castilla-La Mancha (SESCAM). 2. University of Castilla-La Mancha.

1. ABSTRACT The positive psychological functioning has received several approaches along the history. We must distinguish between the hedonic approach, which speaks of the ―subjective well-being‖ relating it to happiness, and the eudaemonic approach, which relates the ―psychological well-being‖ to human potential development. In this second thinking trend we find authors like Maslow and Rogers. These authors focused on selfactualization and on the view of the fully functioning person respectively, as ways to achieve well-being and personal fulfillment. More recently, Carol Ryff has divided this construct in 6 dimensions: Selfacceptance, Positive relations with others, Autonomy, Environmental Mastery, Purpose in Life and Personal Growth. In order to asses the 6 dimensions mentioned, Ryff created the ―Psychological well-being scales‖, with 20 items each. After that, shorter versions have been proposed, due to the 120 items of the original ones. Psychological well-being positively correlates to factors as satisfaction with life, self-esteem or internal control, and negatively to depression or the powerful others. Likewise, the health levels positively correlates to the 6 factors of the psychological well-being above. When we speak about psychological well-being by sex, women have higher scores in ―relations with others‖ and in ―personal growth‖, even though men get better scores in self-esteem and self-concept. As for differences by ages, literature speaks about higher scores in the group of aged people on some factors, like ―autonomy‖ and ―environmental mastery‖. In other factors like, ―personal growth‖ and ―purpose in life‖, young people have higher scores.

78 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. Regarding the differences by education and occupation level, the psychological wellbeing positively relates to a higher educational and occupational level. Maintaining a good psychological well-being level can be an important protective factor when it comes to suffer several physical or psychological problems, and it is interesting to investigate the extent to which influences the development and evolution of certain health problems.

2. INTRODUCTION 2.1. Historic Introduction to Positive Psychological Functioning Throughout history, psychologists have offered different descriptions of positive psychological functioning, or well-being, in the context of the different branches of psychology, such as developmental or clinical psychology. From the perspective of developmental psychology, Erikson [1950] presented the concept of a ―healthy personality‖ in the context of Freudian theory. Erikson perceives development of the personality as a process in which each personality factor is related with the others, in such a way that the personality as a whole depends on the correct development of each of its components. In his analysis of the growth process, this author talks about how the components of mental health develop over the following series of sequential stages: a sense of basic trust, a sense of autonomy, a sense of initiative, a sense of industry, a sense of ego identity, geniality, generativity and integrity. During each of these stages a conflict takes place, and the person‘s development will be more or less healthy, depending on how this conflict is resolved. According to Erikson‘s vision, development of the ego is a continuous growth process, which progresses, throughout a person‘s lifespan, towards a superior capacity. This same perspective of continuous growth throughout the lifespan can be found in Bühler‘s theory [1935], which speaks of the so-called ―curve of life‖. Buhler concluded that, in spite of individual differences, there is a regular sequence in which events, experiences and achievements appear in peoples‘ lives, and that improvement or deterioration in psychological well-being does not necessarily occur at the same rate as changes in physical well-being. From the perspective of clinical psychology, authors such as Maslow, Allport and Rogers have offered other descriptions of well-being. In his well-known pyramid, Maslow [1958] includes 5 basic needs that a person must fulfill to become fully-functioning. A person begins by satisfying the most basic needs and after fulfilling the first one, then moves on to the next, on the level immediately above. Firstly, the most basic needs for an organism are considered to be physiological ones. These are, undoubtedly, the most important in the pyramid, in that when a person loses everything in life, his strongest desire is to satisfy this type of need. The most important goal in a person without food, love or safety, will most certainly be to find food before anything else. When none of the needs are satisfied and the organism is dominated by physiological requirements, the other needs cease to exist or become less important.

Psychological Well-Being, Assessment Tools and Related Factors

79

In second place, when the physiological needs are satisfied the need for safety takes over. When a person is in this stage, safety becomes more important than anything else, even than the physiological needs that are already covered. Maslow‘s third need concerns the requirement to belong to a group, and for affection and love, which comes into play when the previous two needs have been satisfied. The person is now interested in forming relationships with others and becoming part of a group, and will work hard to achieve this. The person is now more interested in doing this than in anything else and forgets the little importance he attributed to this when he was hungry. Maslow‘s fourth need corresponds to a person‘s self-esteem. This author considers that everyone (with the exception of some mental illnesses) needs a positive opinion of himself, self-respect and self-esteem and also to be valued by others. These needs can be classified into two sub-groups: on the one hand, a desire for fortitude, achievements, independence and freedom and, on the other hand, a desire to earn a good reputation or prestige, defined as having gained the respect or esteem of others. Finally, we come to the need for self-actualization, defined as a person realizing his full potential, which comes into play when all the other needs are satisfied. According to Maslow ―what a man can be, he must be‖, and he calls this need, selfactualization. If a person has the talent to do something, he will be unsatisfied or unhappy if he cannot fully develop this part of himself, in other words, a musician must make music and a poet must write poems. This need refers to the desire for a person to develop his full potential, to seek personal growth and to become everything he is capable of being. Clearly, these desires vary greatly from one person to the next. Some people may feel self-fulfilled by becoming top sportsmen, while others will acquire a feeling of self-fulfillment by being good parents. Allport [1952] described a mature personality as a form of positive functioning. In his study on maturity, this is partly achieved through marriage, during which the need for affiliation reaches adulthood. A mature person would be defined as having ―an extended ego, a self-objectification related to a sense of humor and some sort of integrative philosophy of life‖. This maturity would be acquired through a series of stages of emotional maturation. Rogers [1963] introduces the concept of ―the fully functioning person‖ to refer to people who can live fully with all of their own feelings and reactions. These people trust their own organism and its functioning, not because this is infallible, but because they can accept the consequences of their own actions and can correct them if they consider them to be unsatisfactory. They can experience all their feelings and are not afraid of them. They are open to evidence and are fully implicated in the process of being themselves. These people live life to the full and are aware of themselves through their own experiences. To summarize, the integration of studies on mental health, clinical aspects and life-span theories have many converging aspects of positive psychological functioning. Historically, research into mental health has tended to focus on psychological dysfunction, instead of studying more positive aspects of human functioning. This perspective is rather limiting, since definitions of mental health as an absence of illness ignore the human capacities, needs to prosper and the protective traits associated with their well-being [Ryff and Singer, 1996].

80 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. When we refer to psychological well-being, we are talking about a construct associated with the optimum or positive functioning of a person [Ryan and Deci, 2001]. For more than 20 years, the study of psychological well-being has been guided by two essential concepts. We can find the first of these in the work of Bradburn [1969], which distinguishes between positive affect and negative affect, and defines happiness as achieving a balance between the two. The second formulation, which has acquired importance among sociologists, regards satisfaction with life as being a key indicator of well-being. Considered as a cognitive component, satisfaction with life was interpreted as a complement to happiness, the most affective dimension of positive functioning [Andrews and McKennel, 1980; Andrews and Withey, 1976]. Waterman [1993] distinguishes between the hedonic and the eudemonic facets of wellbeing. The hedonic facet mainly focuses on happiness and defines well-being as an indicator of quality-of-life, based on the relationship between environmental characteristics and a person‘s level of satisfaction [Campbell, Converse and Rodgers, 1976]. This perspective focuses on achieving pleasure and avoiding pain [Ryan and Deci, 2001]. The eudemonic approach is orientated towards life having a meaning and a person‘s degree of selffulfillment. It defines well-being as the extent to which someone becomes a fully functioning person, [Ryan and Deci, 2001]. On the basis of this previous classification, some authors [Keyes, Shmotkin and Ryff, 2002] have used the construct of subjective well-being (SWB) as the main representative of hedonic tradition, taking special interest in studies of affections and satisfaction with life [Diaz, Rodriguez-Carvajal, Blanco et al., 2006]. The construct of psychological well-being (PWB) is taken to represent eudemonic tradition, focusing on the development of skills and personal growth, both conceived as key indicators of positive functioning [Diaz, RodriguezCarvajal, Blanco et al., 2006]. If we consider the construct of subjective well-being as happiness, Wilson [1967] concluded that a happy person would be ―young, healthy, well-educated, well-paid, extrovert, optimistic, free from worries, religious, married with a high self-esteem, job morale, with modest aspirations, of either sex and within a broad interval of intelligence‖. Michalos [1985] explains in his multiple discrepancy theory of satisfaction that an individual compares himself with many standards; these include other people, past conditions, ambitions and ideal levels of satisfaction and his own needs or goals. The conclusions he reaches about his level of satisfaction will be based on the differences between current conditions and these standards. Wilson reached this definition some time ago, and since then research into subjective well-being has advanced significantly. Wilson believed that a happy person would be wellpaid, young, educated, religious and married, among other factors [Wilson, 1967]. Now, three decades later, Diener, Suh, Lucas et al., [1999] consider that a happy person is someone with a positive temperament, who tends to see the good side of things and does not ponder over negative events, he lives in an economically-developed society, has social confidants, and has sufficient resources to advance towards his most important goals. According to Diener‘s [1984] so-called telic theories, a person‘s behavior can be best understood by studying his goals: what a person tries to do in life [Austin and Vancouver, 1996] and the extent to which he achieves these goals. The types of goals one has, the structure of these, the extent to which one is successful in attaining them, and the speed of progress towards them, can all potentially affect one‘s emotions and degree of satisfaction. According to this model, overall, a person reacts positively when he progresses towards his


81

goals, and negatively when he fails to attain them. The basic concept is that goals serve as an important standard of reference for the system of affects. Other authors such as Cantor and Sanderson [1999] also emphasize the importance of having goals, and explain that the commitment of trying to attain these gives a person a sense of personal agency and a structure and meaning to daily life. When different philosophical and scientific lines of thinking are compared, they are found to converge in their descriptions of a good and healthy life as one that encompasses processes of setting and then pursuing goals, which are used to try to develop a person‘s potential of experiencing significant connections with other people, managing demands and opportunities, practicing self-management and having a positive self-regard. Studies on life events/experiences have found these life experiences and individual interpretations of these experiences to be essential factors of psychological well-being [Heidrich and Ryff, 1993a; Heidrich and Ryff, 1993b; Ryff and Essex, 1992]. Collectively, these studies showed that life experiences and how these are interpreted can help to understand human variations in well-being [Ryff and Singer, 1996]. Happiness cannot be guaranteed by simply having goals or having the resources to attain them. These goals can act as standards or as aspirations and, according to this perspective, subjective well-being is a criterion or a rule that measures the proximity of a person to the goals he is striving to reach. Carver and Scheier [1998] suggested that the difference between a person‘s goals and current life situation affects the amount of positive or negative affect that a person feels. Hsee and Abelson [1991] found that the speed of progress towards these goals, rather than attainment of the goals itself, had a greater influence on the differences in affect. Moreover, Emmons [1986] found that having valued goals, regardless of past success, was associated with a greater satisfaction with life. Also, happy people would tend to choose goals for which they already had the appropriate resources [Diener and Fujita, 1995]. The achievement of these goals would, therefore, be the result, rather than the cause, of a high subjective well-being.

2.2. Multidimensional Model of Psychological Well-Being In relation to the concept of psychological well-being, Ryff [1989a] proposes a multidimensional model composed of 6 different dimensions: Self-acceptance, Positive relations with others, Autonomy, Environmental mastery, Purpose in life and Personal growth. These 6 dimensions of psychological well-being can be defined as follows: Self-acceptance: This is a key part of well-being and concerns the positive opinion a person has of himself. It does not refer to narcissistic self love or superficial selfesteem, but instead to a constructed self-regard that includes both positive and negative aspects [Ryff and Singer, 2003]. Other authors spoke about this previously, [Jung 1933; Von Franz, 1964] emphasizing that only a fully-individuated person can accept his own failures. The concept of ego integrity introduced by Erikson [1959], also refers to a person coming to terms with his own triumphs and failures in past life. This acceptance of self is constructed with an honest self-assessment; the person

82 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. is aware of his personal failings and limitations, but has the love to accept and embrace himself as he is.  High scores in this factor are indicators of people with a positive attitude, who recognize and accept the multiple aspect of the self, including their good and bad qualities, and can look at the past with positive feelings [Ryff and Keyes, 1995].  Low scores in this factor appear in people who are largely unsatisfied with themselves; they are uncomfortable with what has happened in their past life, are concerned about some of their personal qualities and want to change [Ryff and Keyes, 1995]. Positive relationships with others: These include the fortitude, pleasures and human delights that come from close contact with others, from intimacy and love [Ryff and Singer, 2003]. Theories about the stages of adult development also emphasize close relationships with others (intimacy) and the guidance and care of others (generativity). The importance of having positive relationships with other people is repeatedly emphasized in definitions of psychological well-being [Ryff and Singer, 1996].  High scores appear in people who have warm, satisfactory and trusting relationships with others, who are concerned about the well-being of others and have the capacity to feel empathy, affect and intimacy and understand the give and take in human relationships [Ryff and Keyes, 1995].  Low scores indicate that a person has few close and trusting relationships with other people, finds it difficult to be warm, open and to feel concern for the wellbeing of others. They feel isolated and frustrated with social relationships. These people do not want an important commitment with others [Ryff and Keyes, 1995]. Autonomy: This refers to a person‘s ability to march to his own drum and to pursue personal convictions and beliefs, even if these go against accepted dogma or conventional wisdom. It also refers to the ability to be alone if necessary and to live autonomously [Ryff and Singer, 2003]. Also, in theories about self-actualization, the self-actualizers are described as functioning autonomously and as being resistant to enculturation. In studies into the concept of a fully functioning person, this person is someone with an internal frame of assessment, who is mainly uninterested in what others think of him, but will evaluate himself according to his own personal standards [Ryff and Singer, 1996].  High scores in this factor show people who are self-determined and independent, capable of resisting social pressure and of acting by regulating their behavior from an internal frame of assessment. These people self-evaluate according to personal standards [Ryff and Keyes, 1995].  Low scores indicate people who are concerned about the expectations of others, they depend on other peoples‘ judgments before making important decisions, and


83

their thoughts and actions are influenced by social pressures [Ryff and Keyes, 1995]. Environmental mastery: This is another essential factor in well-being and concerns the challenge of a person mastering the environment around him. This ability requires the skills of creating and sustaining environments that are beneficial to a person [Ryff and Singer, 2003]. The ability of an individual to choose or to create environments appropriate for his mental state is defined as a characteristic of mental health. According to life-span developmental theories, for a person to adequately master his environment, he needs the ability to manage and to control complex surroundings, emphasizing from this perspective the need to move forwards in the world and to change it creatively with physical and mental activities [Ryff and Singer, 1996].  High scores in this factor are obtained by people with a sense of mastery and competence of their surroundings, who can make effective use of opportunities that arise and can choose or create contexts appropriate for their needs and personal values [Ryff and Keyes, 1995].  Low scores indicate a difficulty in managing daily affairs, or changing or improving their environment and making the most of opportunities that arise, and a lack of control about the world around them [Ryff and Keyes, 1995]. Purpose in life: This is a person‘s ability to find a meaning and a direction in his own experiences, and to propose and set goals in his life [Ryff and Singer, 2003]. The definition of maturity also clearly emphasizes an understanding of the purpose of life and the presence of a sense of direction and intentionality. A positively functioning person has goals, intentions and a sense of direction, and all of this helps to give a meaning to life [Ryff and Singer, 1996].  High scores in this factor appear in people who have goals in life and a sense of direction; they feel that both the past and the present of their lives has a meaning, they hold beliefs that give their lives a purpose and have goals and reasons to live [Ryff and Keyes, 1995].  Low scores appear in people who feel their life has no meaning and have no goals or sense of direction; they can‘t see any point in their past experiences [Ryff and Keyes, 1995]. Personal growth: This factor concerns a person‘s ability to realize his own potential and talent and to develop new resources. It also frequently involves encounters with adversity that require one to dig deeply to find one‘s inner strength [Ryff and Singer, 2003]. It is associated with being open to new experiences, which is a key characteristic of the fully functioning person. Life-span theories also explicitly emphasize the importance of continuing to grow and to tackle new tasks or challenges in the different stages of one‘s life [Ryff and Singer, 1996].

84 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al.  High scores indicate people who want to continue to develop. They regard themselves as growing and expanding, are open to new experiences, feel they are fulfilling their potential, they can see improvements in the self and in their behavior over time, and change towards ways that improve their self-knowledge and effectiveness [Ryff and Keyes, 1995].  Low scores appear in people with a sense of personal stagnation, with no improvement or growth over a period of time, they feel bored and lack interest in life. They feel incapable of developing new attitudes or behaviors [Ryff and Keyes, 1995]. This model was studied in a representative sample of 1108 adults over 25 years old. In the confirmatory analysis of the factors, it was found that the results supported the multidimensional model proposed, and was the model which best fitted the six factors combined together to form a factor of higher order, called psychological well-being [Ryff and Keyes, 1995]. In this same study, it was found that the factors self-acceptance and environmental mastery were highly correlated, so it was proposed to combine these factors to obtain a model with 5 factors. In any case, the authors concluded that well-being is more than simply feeling happy or satisfied with life; nor is it merely an absence of negative emotions or experiences which define the well-lived. Instead it entails having a rich perception of these experiences and successfully managing the challenges and difficulties that may arise [Ryff and Singer, 2003].

3. MEASURES OF PSYCHOLOGICAL WELL-BEING 3.1. Bradburn Affect Balance Scale One of the first scales that could be used to measure psychological well-being, which later served as a reference to validate subsequent scales is the BABS (Bradburn Affect Balance Scale) [Bradburn, 1969]. This is a ten-item scale divided into two subscales, one that evaluates positive affect and the other that evaluates negative affect. Each of these subscales has 5 items. These items refer to pleasant or unpleasant experiences over the past few weeks which are intentionally treated with a degree of ambiguity [Bartlett and Coles, 1988]. The score is obtained by adding one point for every yes answer and summarizing separately the responses to the positive and negative subscales, respectively. After this, the difference between the scores is calculated and a constant is added to eliminate possible negative results. The test-retest reliability was evaluated by Bradburn [1969], and in a sample of 200 people with an interval of 3 days the reliability calculated for positive affect, negative affect and the affect balance were 0.83, 0.81 and 0.76, respectively.


85

3.2. The Short Form 36 The Short Form 36 (SF-36) was developed to measure the services provided by different health departments in the United States [Ware, Snow, Kosinski et al. 1993]. It is a self-administered scale comprised of 8 different subscales that contain Likert-type items. The 8 different concepts are each evaluated by their own scale: Physical functioning. Role limitations because of physical health problems. Bodily pain. Social functioning. General mental health (psychological distress and psychological well-being). Role limitations because of emotional problems. Vitality (energy/fatigue). General health perceptions. Both the General mental health and the Vitality subscales have psychological implications. The authors of the SF-36 scale understand mental health (measured by the General mental health scale) as part of a construct of psychological well-being with a positive pole and another negative pole [Bartlett and Coles, 1998]. This scale has received some criticism, such as that from Hunt and McKenna [1993] who question the design of the scale, both in the selection of its items and also its objective. For example, Hunt asks how many British people could answer the question ―Does your health limit you in your ability to do vigorous activities, such as sports, running, lifting heavy objects?” when most of them don‘t even do this kind of activity. Hunt uses another example with the question “Does your health limit you in your ability to walk a mile?”. He considers this question is complicated with the factor of necessity. He explains that some people won‘t walk a mile even if they are in good health, while others, from necessity, because they live in the outskirts or for other reasons, will walk the mile in spite of having poor health. McHorney, Ware and Razcek [1993] provided evidence to support the validity of SF-36, showing that the mental health scale can discriminate between groups by using the mean scores. A group with minor medical conditions has a mean score of 83, a group with a serious medical condition would have a mean score of 78 and a group with a serious medical condition with psychiatric comorbidity would obtain a mean score of around 53.

3.3. Satisfaction with Life Scale (Swls) This is a self-administered scale with 5 items relating to level of satisfaction with life. The possible responses are 1 to 7, where 1 indicates that the person strongly disagrees with the statement and 7 that they strongly agree [Diener, Emmons, Sem et al. 1985]. The score is the total of the responses to these 5 items and can be used to classify the person into one of the following categories: 30-35: extremely satisfied, well above average.

86 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. 25-29: very satisfied, above average. 20-24: quite satisfied, average for adult United States citizens. 15-19: slightly dissatisfied, a little less than average. 10-14: dissatisfied, clearly below the average. 5-9: extremely dissatisfied, far below the average. The test-retest correlation was carried out with 2 months difference and gave a result of 0.82. The alpha coefficient of the scale is 0.87 [Diener, Emmons, Sem et al. 1985]. This is a scale to measure subjective well-being and in its original validation the authors calculate the correlation existing between SWLS and other scales to measure subjective wellbeing, including the Bradburn scale (BABS) described previously. The coefficient of correlation for Bradburn‘s positive affect subscale is 0.5 and that for the negative affect subscale is -0.37.

3.4. Psychological General Well-Being Index Short (PGWB-S) The PGWBI scale is a 22-item scale that evaluates self-perceived psychological wellbeing, each item is evaluated on a 6 point scale. The scale assesses 6 dimensions of quality of life relating to health: anxiety, depression, positive well-being, self-control, general health and vitality [Grossi, Groth, Mosconi et al. 2006]. There is a considerable amount of information about the original scale since it was used widely in studies in the United States and worldwide, and has been translated and validated in several languages, for example to Spanish by Badia, Gutierrez, Wiklund et al. [1996]. The short version of the PGWBI aims to reduce the number of items but to maintain the validity and reliability of the scale. In its final version, the PGWB-S has only 6 items that reflect 5 of the 6 items assessed in the original version (except for general health) and reproduces 90% of the variation in the result of the PGWBI. The high Cronbach alpha value (between 0.8 and 0.92) indicates a good reliability when compared with the original scale.

3.5. Psychological aWell-Being Scales (PGWB) One of the most widely used scales to measure psychological well-being is Ryff‘s scale [1989a]. This scale breaks down the construct into 6 different dimensions [Ryff, 1989b] that are analyzed separately, each with their own subscale. The dimensions analyzed are: Self-acceptance, Positive relations with others, Autonomy, Environmental mastery, Purpose in life and Personal growth. Each of these subscales has 20 likert-type items in which the patient self-assesses himself by choosing from the six possible responses, from strongly agree to strongly disagree. This test has a high test-retest reliability and a high internal consistency. Moreover, its convergent and discriminate validity with other measures have also been studied.


87

The test-retest coefficients per subscale (with a retest of 6 weeks) were self-acceptance 0.85, relations with others 0.83, autonomy 0.88, environmental mastery 0.81, purpose in life 0.82 and personal growth 0.81. The alpha coefficients for the subscales were: self-acceptance 0.93, relations with others 0.91, autonomy 0.86, environmental mastery 0.90, purpose in life 0.90 and personal growth 0.87. Ryff‘s article gives an in-depth explanation of convergent validity [1989a]. Here, we indicate the convergent validity values for the different dimensions with Bradburn‘s Affect Balance Scale: self-acceptance 0.55, relations with others 0.30, autonomy 0.36, environmental mastery 0.62, purpose in life 0.42 and personal growth 0.25. The fact that this covers 6 scales (120 items), combined with its good psychometric qualities has given rise to the development of shorter versions, which still maintain good fits and consistency. These versions include the one by van Dierendonck [2004] which, with only 39 items, obtains a goodness of fit indicator (GFI) of 0.88 and Cronbach‘s alpha between 0.84 and 0.70 (depending on the subscale).

4. PSYCHOLOGICAL WELL-BEING RELATED TO SOCIODEMOGRAPHIC FACTORS Psychological well-being is influenced by the nature of one‘s subjective experiences and is related to different aspects of physical, mental and social functioning. We can refer to wellbeing as the result of the balance between a person‘s expectations and achievements in the different spheres of action of the human being, such as work, the family, health, the material conditions of life, and interpersonal and affective relationships [Garcia-Viniegras and Gonzalez Benitez, 2000]. One of the components of well-being is personal satisfaction with life, which is influenced by an individual‘s relationship with their social environment, together with current and historical elements. It is recommendable to study the context in which a person‘s experiences develop to determine the influence of external circumstances that could affect this well-being (economic development, the existence of friendships and the availability of adequate resources to be able to achieve the goals set) [Diener, Suh, Lucas et al., 1999]. One of the ways to get closer to understanding the concept of psychological well-being is to study the factors associated with it, bearing in mind that these will have some cultural variation. Several authors [Diener and Suh, 2000] suggest that the emotions are good predictors of well-being in so-called individualistic cultures, while in collectivist cultures well-being is more closely associated with behaviors of respect and compliance with the social rules in force. Therefore, taking into consideration the broader concept of culture, wellbeing should be studied from a sociocultural level (individual level of income, life expectancy, unemployment) and a personal level (beliefs, opinions and attitudes). According to Triandis and Harry [2000], culture is to society what memory is to individuals, and this culture influences each of the six dimensions of psychological well-being. Sociodemographic differences not only produce different levels of well-being and health [Organización Panamericana de la Salud, 1993a], but also different ways of finding psychological well-

88 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. being. The causes of well-being can be expected to differ in relation to age, conditions of life, educational level, occupation or social class. Well-being is not determined by any single factor, but has a multidimensional character [Martire, Stephens and Townsend, 2000]. Culture and personal influence have been shown to have an important effect on well-being. Type of personality has also been found to be significant, especially in the tendency to adapt to negative events, without ignoring the influence of other demographic variables such as gender or occupation. This latter factor has more of a temporary nature and is related to the person‘s stage of life at the time. One of the main objectives of epidemiological research is to identify and describe the different variables associated with psychological well-being. For this reason, we describe here the influence of some sociodemographic factors.

4.1. Psychological Well-Being and Age Well-being can vary greatly in relation to age, gender and culture. When we study changes in the elements of well-being, some factors change significantly with age, while others remain stable [Villar, Triado, Resano et al., 2003]. Some authors, such as Ryff and Keyes [1995] consider that elderly people experience less personal growth, and also suggest that mastering the environment and autonomy increase as people reached the older stages of life. Mastering the environment tends to be better in the middle-aged and elderly than in young people, but remains stable from middle-age to older ages. A similar pattern can be observed with the dimension autonomy, but in this case the increase in this parameter from young people to middle age is less acute. According to these authors, the dimensions self acceptance and positive relations with others do not seem to vary with age. Ryff [1989a] also claims that standard dimensions of well-being, such as purpose in life and personal growth, tend to become less important with age, with this situation becoming most extreme in elderly people. An individual‘s perception of himself changes with time, becoming more related to temporary differences as he grows older and less related to interpersonal comparisons. Young people, the middle-aged and the elderly all have different perspectives of themselves, depending on whether they are evaluating or describing the present, the past or the future. All these perceptions are important to fully understand psychological well-being. Hence, the experience an individual acquires during a lifetime can change the ideals to which he aspires and the way he assesses his own well-being [Birren and Renner, 1980]. Young people perceive themselves as making significant progress since their adolescence and having great expectations for the future, so the scores in their self-assessments for the dimensions purpose of life and personal growth are higher [Ryff, 1991]. People in middle age tend to remain in a continuous process of improvement from the past to the present and maintain high levels of well-being in the different dimensions that constitute this well-being. Finally, elderly people constantly consider themselves in relation to the past and do not perceive sensations of developing towards the future. From a positive perspective, elderly people tend to master the environment better than other age groups. To summarize, research such as that conducted by Ryff [1991] observed that as people grow older the difference between their ideals and their perception of reality seems to diminish.


89

4.2. Psychological Well-Being and Gender It has already been described how psychological well-being can be positively related to factors such as satisfaction with life and self-concept or self-esteem. Several studies have assessed the differences in psychological well-being and self-concept between the genders, although the different measures used and the discrepancies between the results obtained make it difficult to draw any clear conclusions [Pinquart and Sörensen, 2001]. Some of the studies in the meta-analysis by Pinquart and Sörensen [2001], which included participants ranging from adolescence to old age, concluded that there was no difference in well-being between the genders. In some case, self-esteem and well-being was found to be slightly higher among men than women. It was also found in all the studies included in this meta-analysis that older women present lower levels of satisfaction with life, happiness and self-esteem than men. On the other hand, other researchers have observed that the protagonism of gender issues as a predictor of psychological well-being, often diminishes as other factors come into play [Inglehart, 2002]. Hence, the differences observed between men and women in well-being and self-esteem are less significant in younger stages of life, since this is when there are also less differences between the genders in financial situation, state of health and other factors referred to previously [Pinquart and Sörensen, 2001]. Similarly, if we take into account that the differences between aspirations and success achieved have been proposed as an important source of psychological well-being [Brandtstädter, Wentura, and Greve, 1993], gender differences in well-being could be greater in older people because women experience a greater decline in their ambitions as they grow older. Another possible explanation for the difference between the genders is the existence of different sources of psychological well-being and self-esteem in both cases. Women are more closely associated with events in social systems, while men are more affected by their professional environment [Whitbourne and Powers, 1994]. Women, therefore, are more socially integrated and have higher scores in positive relationships with others than men [Pinquart and Sörensen, 2000]. The increased differences between the genders with age could also be due to differences in their circumstances, such as the greater risk of suffering from chronic illnesses in older women or the higher risk of being widowed. In a series of studies reviewed by Pinquart and Sörensen [2001] in his meta-analysis, the influence of men and women‘s marital status on well-being was studied. It was found that well-being and self-esteem were higher in married men, while the opposite was true in unmarried men. However, in this same research the authors reported that reliable conclusions could not be drawn about marital status and wellbeing. One possible explanation for the tendency observed could be the effect of solitude and its repercussions on social relationships, and the presence in the studies analyzed of only a small proportion of unmarried people. It has been argued that this disadvantage of the women is associated with the differences between sociodemographic variables such as social integration or financial independence [Pinquart and Sörensen, 2000]. In general, women still have less opportunities than men in the job market and lower rates of stable employment, resulting in women having lower incomes throughout their lives and lower pensions when they are older. The concept of gender is known to incorporate social factors associated with the different patterns of socialization of men and women, in relation to family roles, professional expectations, types of occupation and social culture, and also affects the processes of health

90 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. and illness [Rohlfs, Borrell and Fonseca, 2000]. It is, therefore, important to take these characteristics into consideration when evaluating the psychological well-being of any person. In spite of an increase in women‘s participation in remunerated work in recent years, they still have most of the family responsibilities, and an unequal share of the domestic tasks and the care of children. To have to fit in this double workload, in other words to be a mother (with the domestic tasks this entails) and at the same time to have a paid job, can affect their health and well-being [Rohlfs Borrell and Fonseca, 2000; Artazcoz, Borell and Benach 2001]. Research by Martire, Stephens and Townsend [2000], studied the influence of gender on well-being in almost 300 women. It was found that well-being was affected by age, and that this effect increased with the women‘s social role. A woman‘s family and professional responsibilities can represent an important overload if considered simultaneously. The traditional role of the woman as a carer of children, the elderly and the ill, contributes to this overload in the family environment. These relationships of responsibility that develop in the family are considered as important determinants of psychological well-being [Kowal, Kramer, Krull et al., 2002; Wright and Cropanzano, 2000]. The study by Escriba-Agüir and Tenias-Burillo [2004] analyzed the effect of gender and the work environment on the psychological well-being of the staff in two hospitals. The results showed that being a woman and spending more than 30 hours on domestic tasks had a negative effect on psychological well-being. Also, in this study women had a lower level of well-being than men. In relation to the influence of a woman‘s professional life on levels of well-being, a strong association was found between women‘s satisfaction with their work and their satisfaction with life, although it was not established which caused the other. In fact, unemployment was associated with low levels of well-being and also conflict at the work place. Being close to retirement was also considered to have stressful effects and to influence well-being in women. Similarly, the study by Sanchez-Uriz, Gamo, Godoy et al. [2006], on the psychological well-being of healthcare staff found a higher prevalence of psychological discontent in women than men. Another study carried out in Australia [Dennerstein, Lehert and Guthrie, 2002] on 226 women assessed the level of satisfaction and other variables during one period of life, the menopausal process. They found that well-being increased significantly after passing from initial stages of the menopause to the later stages. The factor with the greatest effect on wellbeing was high levels of well-being at the start of this transition stage. They observed during this transition period that well-being varied greatly with other factors such as changes in marital status, satisfaction with work, day-to-day problems and life events. The authors concluded that psychological well-being improves as women enter the final stages of the menopausal transition, and that this is significantly affected by psychosocial effects.

4.3. Psychological Well-Being and Marital Status In relation to this socio-demographic variable, it was found that being part of a family situation with equal status in the decision-making and a good conjugal relationship had a favorable overall influence on health and psychological well-being. The results of the study by Escriba-Agüir and Tenias-Burillo, 2004] confirm this, and show that a good relationship with one‘s partner improves psychological well-being. They even claimed that persons who proved to have had a good conjugal relationship are less likely to have poor mental health.


91

Other studies also focus on possible interrelations between different factors, such as the study by Mroczek and Kolarz [1998], which described the importance of some sociodemographic variables and personality factors in relation to age and well-being. More specifically, these authors found higher incidences of well-being in older married adults, compared with those who were single.

4.4. Psychological Well-Being and Socioeconomic Level Another aspect with important repercussions on psychological well-being is socioeconomic situation, which also includes some objective conditions such as access to housing, a healthcare system, education, employment and recreational activities [Diener, 2000]. A more precarious lifestyle was associated with higher levels of psychological anxiety [Kaplan, Roberts, Camacho et al. 1987], although there are few results about the impact of a possible socioeconomic benefit with time on the more positive aspects of psychological functioning. In spite of this, it could be suggested that financial success or failure in combination with environmental resources, could have an important effect on a person‘s feelings of achievement, mastery of the environment and self-acceptance, and these tend to develop as a person gets older [Haan, Kaplan and Syme, 1989]. The research by Ryff [2001] on the impact of economic level on the degree of well-being showed a clear relationship between socioeconomic level and some dimensions of well-being, such as self-acceptance and personal growth. This was also found to be clearly linked to an individual‘s goals and objectives (purpose in life). The results of several studies show that people with a lower socioeconomic level, determined both by educational characteristics (level of studies) and by a person‘s usual work activity, have a lower level of psychological well-being [Marmot, Fuhrer, Ettner et al., 1998]. The analysis of several works by this author showed that, in general, health is poorer in people at the lower end of the population‘s economic distribution. There was also evidence for a social gradient in the whole population, with lower levels of psychological well-being associated with lower social status. These conclusions suggest that there is a combination of factors, such as working environment, social conditions outside the working environment, health and individual behavior that can be related with general state of health and the level of psychological well-being. In a recent study by Kaplan, Shema and Leite [2008], data collected over several years of follow-up provided information about the association between average level of income, the rate at which income changes, and a series of indicators of the financial situation of the population studied and the different measures of psychological well-being. The author suggested that these results are consistent with the financial situation, except for the case of autonomy. As a whole, when the financial situation is more favorable, represented by a positive economic balance, psychological well-being also improves. When this financial situation becomes worse, and with it the perceived amount of income, the level of psychological well-being also becomes worse. These results provide information about the impact of the economic situation on psychological well-being at a given moment, and how this changes with time. It was observed that a higher level of income and increases in this income with time, were associated with higher scores in dimensions of well-being such as: purpose in life, self-acceptance, personal growth and mastery of the environment. Also, scores were found to be lower for these same dimensions in people with a lower average

92 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. income and less financial benefits over time. A correlation was even observed between periods when the benefits were more numerous and a higher level of psychological wellbeing. Ultimately, this research showed that psychological well-being was strongly influenced by financial income and by changes in income over the years. Research carried out by Diener and Diener [1995] showed that changes in a person‘s income were more important for their psychological well-being than absolute levels of income. It was also observed that levels of satisfaction are higher in people with incomes above the average income for the reference population [Diener and Diener, 1995; Diener and Suh, 1997]. These authors conducted studies on psychological well-being in 29 different countries in different continents and found a correlation between average level of satisfaction and people‘s purchasing power. Other studies have also observed a positive association between the level of education, the income and psychological well-being of elderly people [Cheng, Chi, Boey et al., 2002]. If we consider that a person‘s job is usually closely related to his socioeconomic level, the characteristics of each job, which are correlated with social class, have an increasing influence on psychological well-being over time [Kohn and Schooler, 1978]. Hence, in the study of Sanchez-Uriz, Gamo, Godoy et al. [2006] it was observed that members of staff working shifts had a higher prevalence of psychological distress. A feeling of stagnation in the same work post, with little opportunity to change and the absence of a professional career linked to promotion at work, were other variables related with increased psychological stress. Another factor with important repercussions on socioeconomic level is a person‘s house or place of residence. The impact of a person‘s residential area on their health is being increasingly acknowledged, and there is evidence for the effects of neighborhood, independently of the individual characteristics of the residents. In the study by Phillips, Siu, Yeh et al. [2005], the authors suggest that living conditions can constitute an important factor affecting psychological well-being in the elderly. More specifically, these authors studied the effect of a person‘s degree of satisfaction with their housing (conditions of the accommodation and the district they live in) on psychological well-being. The results showed this to be influenced by internal conditions of the accommodation (characteristics of the rooms, habitability, comfort), and also by external conditions (environment). Hence, Steptoe and Feldman [2001] observed that the presence of negative environmental conditions in the neighborhood were associated with a perception of poor health and with psychological anxiety, independently of age, gender and social capital.

4.5. Psychological Well-Being and Social Relations One of the dimensions of psychological well-being is the ability to maintain positive relationships with other people [Ryff and Singer, 1998]. People need to have stable social relationships and to have friends they can trust. In fact, numerous studies carried out over the past few years [Berkman, 1995; Davis, Morris and Graus, 1998] have found that social isolation, loneliness and a loss of social support are associated with an increased risk of illness or reduced life expectancy. Well-being is clearly influenced by social contact and interpersonal relationships. It has also been shown to be associated with contacts in the community and active patterns of friendship and social participation [Blanco and Diaz, 2005]. Finally, there is also an association between well-being and positive relationships with others


93

[Keyes, Shmotkin, and Ryff, 2002]. In summary, we can conclude that a degree of interaction does exist between social and psychological factors. Social aspects influence psychological ones through the meaning these have for an individual, and psychological aspects can affect social aspects through the stance a person adopts [Breilh, 1989]. This is a theoretical concept that should be taken into consideration when studying and evaluating quality of life and wellbeing. Regarding the social factor, Ryff [2001] considers that there is sufficient evidence to assert that positive social relationships can predict a specific psychological functioning. He observed that the presence of positive relationships was associated with pleasure and a positive mood. In studies by Kevin, Hershberger, Russell et al. [2001] and Cutrona, Russell, Hessling et al. [2000] demonstrated a relationship between social integration, health, social support and well-being. These authors insist on the importance of being able to count on consistent sources of support. Similarly, research by Diener and Diener [1995], show the importance of social and cultural context in a person‘s assessment of his own well-being. As mentioned previously, the degree of individualism and collectivism of a society is a cultural variable that can affect the relationships between well-being and sociological variables. Although there are few clear data about this, possibly in collectivist cultures there is a better sense of group cohesion and social support that improves well-being. However, in the more individualist cultures, people value more their own well-being and the freedom to choose how to achieve [Diener, Diener and Diener, 1995; Suh, Diener, Oishi et al., 1998]. When examining the relationship between gender and well-being we have already mentioned that social and environmental characteristics are closely associated with life and with happiness in men, while in women this association can be found with social relationships or integration with others [Piquart and Sörensen, 2001]. Another important factor, especially in elderly populations is the influence of social environment and support. It has been shown that the presence of family and social networks to support old people contribute to increasing their levels of well-being [Litwin, 2006]. In this sense, previous studies, such as the one carried out by Beyene, Becker and Mayen [2002], in elderly Hispanic populations, showed clear repercussions of the extent and quality of social support on the level of psychological wellbeing. Another study carried out on an elderly population in Hong Kong, also refers to the contribution that family support of elderly people makes to increasing the level of psychological well-being [Weng, 1998]. Another important factor in the level of well-being in elderly people is satisfaction with the people they live with. This aspect is very important for the health and well-being of the elderly, for whom the family becomes a protective factor for their health [Krause, 1988). The family acquires an important role at this time in life and becomes an essential source of wellbeing [Parreño, 1990; Organización Panamericana de la Salud, 1994b]. From the perspective of a person‘s relationships with others, their religious beliefs also play an important cultural role. Different types of participation in religious activities are associated, to varying degrees, with all the dimensions of psychological well-being (positive relations with others, self-acceptance, autonomy, mastery of the environment, purpose in life and personal growth) [Frazier, Mintz and Mobley, 2005].

94 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al.

5. PSYCHOLOGICAL WELL-BEING AND HEALTH In parallel with the considerable economic and social development in Western countries, there has been a growing interest in studying the determinants of quality of life. It has been shown that economic development alone is not a good indicator of progress, since the latter must be able to respond to the need people have for satisfaction with life over their whole life-span, to have the ability and competence to achieve this satisfaction, and to have the power to control their environment and life conditions. Quality of life is not only manifest through objective conditions of social well-being, but also includes other subjective aspects. From this perspective, it is an integrating concept that incorporates happiness, well-being, satisfaction with life, health etc. as evaluable dimensions [Martinez Garcia and Garcia Ramirez, 1994]. When the World Health Organization established a definition for health that went beyond merely health as an absence of illness, it introduced a modern concept, constructed on the presence of well-being, and the meaning of human development, in relation to factors such as: purpose in life, quality relationships with others and opportunities to develop one‘s potential. Although it is well known that negative emotions and distress can cause declines in levels of physical and physiological health, little importance has been attributed to the protective and beneficial effects of positive emotions and well-being on health [Howell, 2009]. If directional influences are also taken into account, the relationship between well-being and health is even more complicated. Being healthy makes people happy and being happy strengthens a person‘s health. There are numerous studies in the literature, including longitudinal observational studies and also experimental ones, which focus on the possible impact of well-being on objective health results and can help us to discern these causal influences. In a work that integrates the findings of 150 studies, Howell, Kern and Lyubomirsky [2007], evaluated the impact of well-being on objective health results, and concluded that well-being has a positive impact on these. Well-being is positively related to the short and long-term results, and to the control of illnesses and symptoms. The probability of survival was higher in the group with a higher level of well-being and mortality was higher in the group with a low level of well-being. A comparison of the different effects of distress and well-being on health results produced similar findings: high levels of well-being were more likely to result in an improved functioning and high levels of distress negatively affected functioning. A similar magnitude of effects was found in both longitudinal observational and experimental studies and for different health results (in the short term, the long term and in the control of illness/symptoms). These results show that the effect of subjective well-being on health is not only due to a negative effect of distress, but also because well-being has a positively health-inducing effect. A reduction in illness associated with well-being has significant implications for medical and psychological interventions, and an important aspect of improving health should focus on increasing happiness and the frequency of positive emotions. Lyubomirsky, Sheldon and Schkade [2005] consider it possible to permanently increase a person‘s level of happiness. These authors propose that chronic happiness in a person depends on three main types of factors: genetic, circumstantial and practical factors, and activities significant for happiness. The latter type of factors gives a person the chance to maintain an increased level of happiness.


95

As Friedman, Hayney, Love et al. [2007] pointed out, both hedonic and eudaimonic wellbeing have been associated with health results. Positive feelings have been associated with a low morbidity, and with an increased longevity [Pressman and Cohen, 2005; Lyubomirsky, King, and Diener, 2005]. More specifically, they have been found to be associated with a reduced incidence of stroke [Ostir, Markides, Peek et al., 2001], of general functional independence [Ostir, Markides, Black et al., 2000], or less acute rises in stress-induced fibrinogen levels [Steptoe, Wardle and Marmot, 2005], lower levels of cortisol in saliva, a lower heart rate and systolic blood pressure [Steptoe and Wardle, 2005]. Higher levels of eudaimonic well-being are associated with lower cortisol levels and less musculoskeletal symptoms [Lindfors, 2002]. Some measures of eudaimonic well-being are positively associated with levels of HDL-cholesterol and with healthy sleeping patterns, and negatively associated with the diurnal cortisol gradient in saliva, body weight, waist-hip ratio, glycosylated hemoglobin and total cholesterol and plasma levels of soluble interleukin-6 receptors [Ryff, Singer and Love, 2004]. Although there is a degree of conceptual and statistical overlap in hedonic and eudaimonic indices of well-being, significant differences between them have been demonstrated empirically. Purpose-of-life scales measure the degree of meaning people assign to daily activities and life changes, which have been related to lower levels of cortisol in saliva, lower waist-hip ratio and higher levels of HDL cholesterol [Ryff, Singer and Love, 2004]. As Steptoe and ez Roux [2008] mentioned, the mechanism by which happiness affects future health has not been well established. We explained previously that happiness has been associated with a reduced release of diurnal cortisol, with attenuated inflammatory responses and patterns of heart rate variability indicative of a healthy autonomic heart rate control. These associations are independent of socioeconomic characteristics and negative affective states. One possibility is that frontal and limbic cerebral mechanisms, which regulate the neuroendocrine and autonomous functions, could be involved. Happiness is also associated with a better social cohesion and strong social support.

5.1. Well-Being and Society If happiness, as Fowler and Christakis [2008] suggested, is transmitted by social connections, this could indirectly contribute to a social transfer of health, in other words, some psychosocial determinants of health could be spread by social contact. Social links, especially of friendship, are often established between individuals with a lot in common, including personal attributes and also living and work environments. Many of these characteristics are associated with health results and psychological states. These patterns of behavior can disseminate with time to different people through both nearby and more distant social contacts. Social epidemiology has established the importance of social communication for health, and both beneficial and adverse effects on health can be transmitted through the social network [Steptoe and ez Roux, 2008]. This inter-relationship is especially important in the family environment. For example, chronic diseases are often painful and in the long-term can affect the family and the home environment. The spouses of chronic patients have also been found to suffer more problems in their physical health than the spouses of healthy individuals. However, as Bigatti and

96 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. Cronan [2002] pointed out, studies in this area have mainly focused on spouses who act as carers, in other words, those who assist their husbands or wives in activities of daily living (bathing, feeding, dressing, toileting). They demonstrated that spouses play a crucial role in the level of adaptation of chronic patients to their condition, especially in relation to the reversal of roles and life patterns established in the couple with time. This impaired physical health among the spouses of chronic patients has been widely reported in the literature, and was also observed in those functioning as informal carers. They tend to have a higher prevalence of chronic illnesses, infections and physical problems such as backache, arthritis, impaired hearing, insomnia, diabetes, ulcers, anemia, hypertension, cataracts and heart disease than would be expected in this population. Consequently, the population group corresponding to spouses of chronic patients have an above-average use of the services. The literature has suggested that the spouses of chronic patients suffer from emotional discontent, resulting from the burden associated with their stressful situation, in this case their partner‘s chronic illness. Their emotional reactions to the spouse‘s illness can range from anger and resentment, insecurity, incompetence, guilt, anxiety, despondency, worry, physical and emotional stress, fatigue and many more, which lead to an overall dissatisfaction with life. Bigatti and Cronan (2002) compared the physical and mental health and the use of healthcare services among the husbands of patients with fibromyalgia, compared with the husbands of healthy women. Participants from the fibromyalgia group reported poorer levels of health and emotions, and had higher scores in depression, loneliness and subjective stress than members of the control group. The husbands in the fibromyalgia group who reported an increased impact of illness, and whose wives had a worse quality of sleep and lower levels of self-efficiency, presented more psychological difficulties. No differences were found in the costs of healthcare incurred by both groups. These findings suggest that chronic illnesses can have a negative impact on the physical and mental health of the spouses.

5.2. Biological Relationships between Well-Being and Health It is very important to identify the physiological substrate of this association. In fact, the core hypothesis to positive health is that the experience of well-being contributes to the effective functioning of multiple biological systems, which can help the body to avoid illness or, when illness appears, can help it to recover quickly [Ryff, Singer and Love, 2004]. On the other hand, it is not clear if hedonic and eudaimonic well-being have similar or different biological correlations. Both imply positive psychological functioning and would therefore be expected to have similar biological connections. However, eudaimonic well-being evokes an active and hard-working organism, often striving against adversity, which could promote a greater biological activation of the organism than hedonic well-being. The key to positive health is that well-being is accompanied by an optimum functioning of multiple biological systems. In the long term, this biopsychosocial interaction will prevent illnesses and will help the body to maintain its functional capacities and, hence, prolong periods of quality-of-life. One initial step to testing this hypothesis is to study whether individuals with well-being have lower levels of biological risk for multiple physiological systems, and higher levels of ―good‖ biological markers, such as HDL cholesterol. Although the influence of psychosocial factors on cardiovascular, neuroendocrine and immune function have been studied for some time, research has mainly focused on negative effects, showing


97

how psychosocial adversity increases biological risk. The work by Ryff, Singer and Love, [2004], however, focuses on the opposite perspective question, whether well-being is associated with reduced biological risk. The findings of this study carried out on a sample of 135 women over 60 years old, show that high levels of eudaimonic well-being are associated with lower diurnal levels of cortisol in saliva, of proinflammatory cytokines, less cardiovascular risk and longer periods of REM sleep compared with individuals with lower levels of eudaimonic well-being. On the other hand, hedonic well-being was only minimally correlated with biological markers. The study by Howell, Kern and Lyubomirsky [2007] revealed potential biological pathways that could explain the association between well-being and health, suggesting that it could directly strengthen the immune system and neutralize stress. Well-being had a greater impact on health promotion due to its effects on the immune system and tolerance to pain, and was not significantly related to increases in cardiovascular and physiological reactivity. These findings indicate the existence of potential biological pathways, through which wellbeing could directly reinforce immune functioning and neutralize the impact of stress. These authors propose a model that could give a simplified explanation for the connection between emotions and health. When a physically or emotionally stressful factor comes into play this produces a disagreeable situation. However, this can activate the central nervous system and trigger a response characterized by physiological changes, such as increases in blood glucose levels, heart rate and blood pressure, and the release of stressrelated hormones, such as cortisol and epinephrine. This response can directly or indirectly affect the functioning of the immune system, which can continue activating the central nervous system, leading to a chronic state of tension and an increased susceptibility to illness. Hence, the cardiovascular, neuroendocrine and immune systems can work together and mutually influence each other. Some evidence for this model comes from research into animals, supported to some degree by a few studies in humans. However, it is a relatively simple model and the real situation is undoubtedly much more complex. While stress activates the sympathetic nervous system an opposite reaction can diminish its activity and promote optimum functioning. Negative personality traits such as neuroticism and hostility, are related to an increased risk of mortality and poor health results, while positive traits, such as optimism, extroversion, conformity and awareness are associated with a reduced mortality and a better health. Pressman and Cohen [2005] proposed two models which correlate positive feelings with illness. In the direct effects model, positive feelings can directly affect healthy practices, reducing the activity of the autonomous nervous system, controlling the release of stress hormones, influencing the opioid system and immune responses and also affective social networks, with a consequent impact on health and illness. In the stress neutralization model, positive feelings can improve the effects of stressful events, increasing resistance and reinforcing fight responses. Consequently, well-being can affect health by reinforcing short-term responses (such as the immune response and tolerance to pain) and long-term functioning (such as an improved cardiovascular profile and longevity), or by neutralizing the stressful effects in the short-term (marked by high level stress responses and cardiac reactivity), and illness in the long-term (for example by slowing down disease progression and increasing survival). These two mechanisms probably operate together, depending on the individuals and the situation in each case [Friedman, Hayney, Love et al., 2007].

98 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. The possibility of a relationship between plasma levels of antiinflamatory cytokines and psychological well-being has been studied. Plasma levels of interleukin-6 (IL-6) were lower in women with a higher score for positive relationships, while levels of soluble interleukin-6 receptors (sIL-6R) were lower in women with higher scores for purpose of life, even after controlling for a series of sociodemographic and health factors. These results, together with a lack of significant connections with other measures of well-being or distress, suggest that selective patterns of association exist between inflammatory processes in advanced stages of life and psychological factors, especially those related to positive bonds with others and a degree of commitment. IL-6 belongs to a family of inflammatory factors involved in agerelated disorders, such as Alzheimer‘s disease, osteoporosis, rheumatoid arthritis, cardiovascular disease and some forms of cancer. Since concentrations of this cytokine in peripheral blood also increase with age, it has become a key focus for research into agerelated inflammatory diseases. IL-6 regulation is sensitive to a wide range of psychological influences: negative psychological experiences can be a risk factor for high levels of circulating IL-6 in at-risk elderly individuals [Friedman, Hayney, Love et al. 2007]. The study by Friedman, Hayney, Love et al. [2007] examined the relationship between different measures of psychological well-being or distress and cytokine levels in older women. On the basis of previous research into circulating IL-6 levels, the authors try to prove the hypothesis that distress could be associated with high levels of IL-6 and sIL-6R, and that well-being could be associated with low levels. In fact, the only measures that were significantly associated with IL-6 and sIL-6R were levels of eudaimonic well-being; neither hedonic well-being nor distress were associated with inflammatory factors after controlling for health and sociodemographic factors. These results suggest that, in general, in healthy older women biological markers of inflammation are more closely related to some aspects of eudaimonic well-being than to differences in positive or negative affective states. This suggests that some aspects of well-being in the elderly could be related to a series of illnesses associated with ageing. The finding that plasma levels of IL-6 were lower in women with higher scores for positive relationships with others is consistent with studies showing that social integration and support predict a reduced morbidity and mortality, and can provide a buffer against the repercussions of stressful life events on health. By contrast, plasma levels of sIL-6R have a significant negative association with scores on the purpose of life and mastery of the environment scales.

5.3. Physical Activity and Well-Being There is an abundance of evidence in the literature to support the popular belief that physical activity is associated with psychological health. This was shown in a meta-analysis by Netz, Wu, Becker et al. [2005], which included 36 studies that analyzed the relationship between organized physical activity and well-being in elderly adults without clinical alterations. These authors found an effect size three times greater in study groups compared to the control. Aerobic exercise and moderately intense physical activity were the most beneficial to psychological well-being. Physical activity had marked effects on self-efficiency and improved cardiovascular condition, strength and functional capacity were all associated with a general improvement in well-being.


99

5.4. Psychological Well-Being and Illness There is increasing interest in the desire to study psychological adaptation to situations of illness, especially in more serious situations such as cancer. Although in the past this disease was almost always considered to be a terminal illness, an improvement in treatment and techniques for early diagnosis have increased survival in many patients. However, since both diagnosis and treatment can cause considerable distress in many people, it is easy to explain the interest in studying the psychological adaptation of these individuals [Manne and Schnoll, 2001]. Special emphasis in this area has focused on establishing the psychosocial preoccupations of individuals who survive cancer. Both diagnosis and treatment of cancer and its sequelae are adverse experiences. For most individuals, it causes important degrees of stress and for some a diagnosis of cancer is traumatic. Cancer survivors present a greater degree of psychological distress caused by emotional problems and a poorer social well-being, compared to those without a history of cancer. However, a model has been described [Carver, 1998] in which survival with impairment occurs after the initial decline in functioning following the adverse experience, as a continuation of compromised functioning, but that these individuals can also manifest a degree of resistance, with a return to normal or even a thriving functioning, exceeding the original level of functioning. Costanzo, Ryff and Singer [2009] set themselves the goal of studying psychological affectation, resistance or thriving in cancer survivors among the general population, comparing them with individuals without a history of cancer. They studied 4 psychological domains: distress, defined as symptoms of mental health and mood, psychological wellbeing, social well-being and spirituality. Data were obtained from the National Survey of Midlife Development in the United States (MIDUS) [2009], designed to study health and well-being in middle age. MIDUS is a national study of the combined influence of numerous factors (behavioral, social, psychological, biological, neurological) on health and well-being as people pass from early adulthood to middle-age and then to old age. In the first stage, MIDUS I, from 1995-1996, 7108 adults aged between 25 and 74 years old participated. One member, aged between 25 and 74 years old, was randomly chosen from each household contacted, and was invited to carry out a telephone interview and to fill in 2 self-administered questionnaires. Around 70% agreed to participate in the telephone interview and 89% of these also completed the selfadministered questionnaires. These patients were followed up in 2005-2006 (MIDUS II), 4963 of them carried out another telephone interview and 81% of these also completed 2 self-administered questionnaires. The individuals participating in MIDUS also completed a broad battery of psychological tests, thus making it possible to compare individuals with a history of cancer and those without a history of cancer for a range of psychological results. There was also the opportunity to compare psychological functioning, before and after the diagnosis, in individuals diagnosed with cancer between the two evaluations. Psychological well-being was evaluated with 4 of the 6 domains of well-being considered to be the most relevant to cancer: mastery of the environment, personal development, positive relationships with others and self-acceptance. Changes in patients‘ psychological state before and after diagnosis were evaluated in patients who had survived cancer between the two interviews. Individuals surviving cancer had more negative feelings and less positive feelings both before and after

100 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. diagnosis. Positive feelings were affected by time: both cancer survivors and the control group showed an increase in positive feelings with time. There were no interactions between a diagnosis of cancer and time elapsed, implying that cancer did not affect the trajectory of feelings over time. Similarly, survivors of cancer had poorer well-being than controls both before and after diagnosis. Time also significantly affected 3 out of 4 of the domains of wellbeing: mastery of the environment, personal development and positive relations with others. Mastery of the environment and positive relations with others increased significantly for both groups, while personal development decreased for both groups. There was no difference in this pattern between the groups with or without cancer. However, this deterioration in psychological state reflects only a partial view, since the results also show that cancer survivors function as well as the control group in several psychological domains, including social well-being, spirituality and personal development. Moreover, neither the measures of social well-being nor the measures of spirituality were reduced after the diagnosis. In fact, the survivors had higher levels of spirituality and social progress and a belief that society is improving, both for themselves and for others. However, the control group also improved in these areas, supporting a model of resistance rather than ―thriving‖. This study did not observe a better functioning of cancer survivors compared to controls in any domain. The longitudinal study shows an increase in positive feelings, mastery of the environment and positive relationships with others after the diagnosis, combined with an improvement in social actualization and spirituality. However, the group without cancer showed the same improved trajectory, suggesting therefore that these changes are more likely to be associated with the passing of time or external events than with the cancer itself. The findings in this study verify important areas of psychological affectation and resistance among cancer survivors. Although the data do not support the existence of posttraumatic development after a diagnosis of cancer, with higher levels of personal development, social well-being or spirituality, some degree of resistance among survivors can be found. Cancer survivors are not only resistant in spite of the cancer, but also against greater mood alteration and psychiatric symptoms. Moreover, although cancer survivors show a poorer function in these measures of distress, these reduced levels of well-being tend to be found more among young survivors. Older cancer survivors seem to cope as well, or even better, than those without cancer, so age can be considered as an important factor of resistance against cancer. When other health problems are taken into consideration, the effect of obesity on psychological well-being is perhaps one of the most interesting. In this sense, community studies suggest that, in spite of these individuals experiencing moderate levels of dissatisfaction with their bodies, few obese children are depressed or have low self-esteem. However, individuals seeking treatment do present lower levels of well-being than the general population, or controls of normal weight [Wardle and Cooke, 2005]. On the other hand, successful weight-reducing treatments have been shown to increase self-esteem [Blaine, Rodman and Newman, 2007]. Changes in psychological well-being have been studied in other endocrine diseases such as diabetes [Debono and Cachia, 2007], or rheumatic diseases such as rheumatoid arthritis [Treharne, Lyons, Booth et al., 2007], and emphasize the importance of educating patients to increase self-empowerment and to develop coping strategies.


101

5.5. Ageing, Health and Well-Being Provided that the elderly maintain the functional capacity to be independent and to perform daily activities, they regard themselves as healthy. Similarly, some psychosocial characteristics, such as the possibility of receiving help from their surroundings and the availability of natural social networks help to improve this perception, to some degree independently of the illness. The way in which the elderly evaluate their satisfaction with life depends on certain life situations and the individual‘s psychosocial characteristics. Hence, the perception of satisfaction with life is not only linked to the concept of attaining goals and achieving one‘s expectations, but also to the life events characteristic of this age. Ultimately, the quality of life perceived by the elderly depends on the life satisfaction they manifest, and their own selfassessment of their health. Therefore, a positive mood, perceiving oneself as having the capacity and competence to solve problems, having the skills and an adequate level of health to maintain one‘s lifestyle, to evaluate positively what one has achieved in life and to know how to be of use to oneself and to others, are all factors that help a person to assess his life in terms of good quality [Martinez Garcia and Garcia Ramirez, 1994].

5.6. Well-Being and Mortality A recent meta-analysis of longitudinal observational studies found that measures of happiness, joy and related concepts were associated prospectively with reduced mortality, both in initially healthy individuals and also in those with an established illness [Chida and Steptoe, 2008]. These effects were independent of the initial state of health, age, demographic factors and risk factors, and persisted after negative affective states, such as anxiety and depression had been controlled for. These results indicate that happiness is more beneficial than merely an absence of these afflictions. A two year cohort study on 2282 Mexican subjects, aged between 65 and 99, without functional limitations, showed a direct association between positive sentiments at the start of the study and morbidity, functional state and survival at two years, independently of functional state, sociodemographic variables, chronic illnesses, body mass index, smoking and alcohol consumption and negative feelings at the start of the study. Individuals with strong positive sentiments had half the probability of suffering alterations in activities of daily life (OR: 0.48; 95% CI: 0.28-0.93) and of dying during the two year follow-up (OR: 0.53; 95% CI: 0.30-0.93), compared with those with lower scores in positive affects. These results support the idea that positive feelings, or emotional well-being, is different to an absence of depression or negative feelings. Positive feelings seem to protect individuals against physical deterioration in older ages.

102 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al.

6. PSYCHOLOGICAL WELL-BEING AND PERSONALITY FACTORS On the whole, the concept of psychological well-being is linked to the subjective perception a person has of his own achievements and the extent to which he is satisfied with his past, present and future actions. In this sense, it refers to the positive opinion and constructive thoughts a person has about himself [Diener, Suh, Lucas et al. 1999]. Taking into account that psychological well-being entails accepting one‘s self, maintaining positive relationships with other people, being autonomous, adequately managing the environment, having clear priorities and goals in life, and the feeling of undergoing a continuous process of personal development [Ryff and Keyes, 1995] we may, therefore, wonder whether personality influences psychological well-being. There has been repeated evidence over the past few decades that personality variables are closely related with psychological well-being [Costa and McCrae, 1996]. Neuroticism and extrovertism are associated with negative and positive affect, respectively. In other words, people with neurotic tendencies (emotionality, impulsivity, rage and fear) are more predisposed to negative affect. By contrast, people who regard themselves as extrovert (vigor, tempo, sociability), experience more positive effect in a wider range of circumstances and situations, are more content, laugh more and feel happier than introverts [Diener, Sandvik, Pavot et al. 1992]. Research studies based on the Big Five personality factors tend to replicate the original results reported by Costa and McCrae [1984], in both correlational and experimental studies [Larsen and Ketelaar, 1991]: the neuroticism factor is a strong predictor of negative affect, while positive effect is predicted by the dimension of extroversion and agreeableness [DeNeve and Cooper, 1998]. Generally, people with neurotic tendencies are systematically more distressed. By contrast, extroversion affects positive emotions, while neuroticism independently influences negative emotions. Therefore, people who frequently express feelings of well-being will tend to be characterized by emotional stability and extroversion. Indeed, in people who were classified in relation to these two personality factors, it was possible to predict their future levels of well-being ten years later [Costa and McCrae, 1980]. Moreover, it was found that extroverts experience more events objectively classified to be positive than introverts. The correlation between extroversion and subjective well-being ranged from 0.40 to 0.60 [Diener and Diener, 1996]. Why is this the case? Firstly, a genetic explanation has been proposed and assumes that extroverts are more sensitive than introverts towards signals of reward, which are regulated by the Behavioral Activation System. On the other hand, people with neurotic tendencies are more sensitive to signals of punishment, regulated by the Behavioral Inhibition System. Extroverts learn to be happy more quickly, but not so readily to become sad. The opposite can be observed in people with neurotic tendencies: they quickly become sad but find it more difficult to become happy. Ultimately, depending on the circumstances extroverts are prepared to react with intense positive affect and neurotics with intense disagreeable emotions [Larsen and Ketelaar, 1991]. A second explanation for the increased psychological well-being of extroverts is that they have a greater ability to create situations that will make them happy. There is some evidence


103

to suggest that extroverts do tend to chose environments that they can later enjoy [Diener, Sandvik, Pavot et al., 1992] and that they feel better in the social settings they have selected, but not in others imposed upon them [Emmons, Diener and Larsen, 1986]. Clearly, it is easier for the extrovert to experience positive emotions, but he is also more likely to be involved in situations that facilitate these positive emotions. This has been demonstrated in recent studies into the relationship between social interaction and well-being in long-lived people [Landau and Litwin, 2001]. In addition to extroversion, other personality variables also affect psychological wellbeing. Friendly and conciliatory people have higher levels of satisfaction than antagonistic people who are easily offended. People who are responsible and meticulous seem to be more satisfied than people who couldn‘t care less, although these factors have less of an influence on well-being and extroversion and neuroticism. These results have come from the Big Five model which studies five personality factors: neuroticism, extroversion, openness, agreeableness and conscientiousness. Three of these are associated with well-being (extroversion, friendliness and responsibility), another is associated with unhappiness (neuroticism), and the last factor is not associated with either [Avia and Vazquez, 1998]. In addition to the above-mentioned personality factors, we cannot ignore the fact that over the past decade there has been consistent evidence for a relationship between a greater Emotional Intelligence, understood as the ability to understand and manage one‘s own emotional states, and a higher level of psychological well-being and a better psychological adjustment to the environment [Mayer, Roberts and Barsade, 2008]. People with a greater emotional intelligence have a better mastery of the tasks they are set and as a result experience a higher level of psychological well-being. These people also experience less negative and more positive feelings, are more agreeable, have less difficulty identifying and describing their feelings, are less likely to present somatic symptoms, and are better at tolerating stress. The ability to manage one‘s emotions appears to be an effective way of preventing some emotional alterations. Moreover, people with high emotional intelligence find it easier to express their emotions and show higher degrees of empathy or the ability to understand emotions felt by other people [Davies, Stankov and Roberts, 1998]. Ultimately, the ability to manage emotions adequately is associated with a better psychological adjustment to the environment and, hence, to a higher level of well-being. On the other hand, less emotional intelligence is related with a lower personal level of well-being and depression [FernándezBerrocal and Ramos, 2002].

7. FUTURE RESEARCH Over the past few years, a wide range of research studies have focused on psychological well-being in different professional and scientific settings. In the health sciences, progress in medicine has led to a significant increase in life-span, but has also given rise to the appearance of numerous chronic illnesses. This has resulted in a special relevance being assigned to the term ―Health-Related Quality of Life‖. Numerous scientific research studies use the term today to refer to the patient‘s perception of the effects of a given illness, or the administration of a treatment, in different life settings, and especially the consequences this

104 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. may have on their physical, emotional and social well-being. Thanks to these studies, healthcare professionals now have a better all-round perspective of individuals afflicted with disorders as diverse as Alzheimer‘s disease, patients with terminal cancer or AIDS, disabilities or traumatic disorders caused by violent situations. Traditionally, research into mental health has focused more on psychological dysfunction, than on other more positive aspects of human functioning. However, this view is very narrow, since defining mental health as an absence of illness ignores human needs and abilities to prosper and the protective effects associated with living well [Ryff and Singer, 1996]. Being well-lived is not defined as a lack of negative experiences, but instead as living these experiences to the full, and successfully managing the challenges and difficulties that arise [Ryff and Singer, 2003]. It is well known that negative emotions and distress cause a decline in levels of physical and physiological health but, until recently, little emphasis was placed upon the protective and beneficial effects of positive emotions and well-being on health [Howell, 2009]. A reduction in illness, and its association with well-being, has important implications for possible psychological and medical interventions, hence an important approach for health promotion would be to increase an individual‘s happiness and the frequency of positive emotions. As mentioned previously, positive feelings are associated with a low morbidity and increased longevity [Pressman and Cohen, 2005; Lyubomirsky, King, and Diener, 2005]. Measures of physical and psychological functioning, and in general those of health and quality of life, are more interesting to researchers than doctors, and used more by them [Valderas, Kotzeva, Espallargues et al. 2008]. In spite of the fact that these measures may be comparable, in terms of the reliability and viability with the clinical measures usually used in practice [Patrick and Chiang, 2000], healthcare professionals are still skeptical about their significance and applicability. There is some evidence that these measures could improve the diagnosis and recognition of problems, and communication between professionals and patients, but there is no evidence to support their systematic use [Marshall, Haywood and Fitzpatrick, 2006]. In spite of this, the usual measures of morbidity are being replaced by new ways of evaluating the results of interventions, and the goals of healthcare today focus on improving the patient‘s quality of life, and not merely eliminating or curing illness. Some important research in this line has been carried out in people with cancer, AIDS, asthma, multiple sclerosis and many other diseases. Also, from the perspectives of psychiatry and psychology, studies into quality of life are being carried out in order to evaluate the results of programs and treatments for chronic patients, such as those with schizophrenia or major depression. In some of these studies into specific diseases, the importance of a person‘s degree of autonomy on their well-being has not been emphasized sufficiently. Today, it is important to move the concept of psychological well-being closer to that of functional capacity. If satisfaction with life is considered as being closely associated with the possibility of taking decisions and choosing between different options, opportunities will arise to study how individuals with disabilities can improve their level of satisfaction by being able to express their preferences, wishes, goals and aspirations, and by participating more in the decisions that affect them. Regarding the elderly population, they consider themselves to be healthy if they can maintain the functional capacity to be autonomous and to perform daily activities on their own. Similarly, some psychosocial characteristics such as the ability to help the environment and the availability of natural social


105

networks help to improve this feeling of being to some extent independent of processes of illness. The needs, aspirations and ideals associated with well-being vary depending on the developmental stage, so the perception of satisfaction is influenced by several age-related factors. Because of this, studies have tended to focus on specific periods in the developmental cycle, especially on childhood and old age. Research focusing on childhood and adolescence study the repercussions of special situations (for example, chronic illnesses such as asthma or diabetes) on perceived satisfaction with life. In these cases, contrary to the usual situation, emphasis must be placed on the point of view held by the child himself and not by his parents, teachers or carers. Research into the elderly has mainly focused on the influence degree of well-being has on physical health and the services received by the elderly, although less importance has perhaps been given to the influence of social support, or recreational or leisure activities. One of the dimensions of psychological well-being is the ability to maintain positive relationships with other people [Ryff and Singer, 1998], and people‘s need to maintain stable social relationships. On the whole, people‘s well-being reflects complex social processes, with multiple components, which must be measured by a system of indicators of variable validity in different times and contexts. From both conceptual and operative frames of reference, more research is required over the next few years into the psychological well-being of people from an all-round perspective. Researchers must endeavor to overcome conceptual ambiguities and to investigate more operative formulas that can identify, with greater precision, human or social aspects with a decisive involvement in the condition of psychological well-being, such as education, health, satisfaction with work, work and family relationships, life expectancy and, among other aspects, people‘s moral values and aspirations. The search for desirable and sustainable levels of psychological well-being, although with variable interests and points of view, is a widespread concern in our society. There is increasing interest and attempts to conceive and measure it from an all-round perspective. Analysis of the factors associated with psychological well-being is one of the ways of moving closer to the concept, taking into consideration that these factors vary in relation to cultural differences. Well-being has a multidimensional character [Martire, Stephens and Townsend, 2000] and the identification and description of the different variables associated with it, especially sociodemographic and personality variables, are among the main objectives of epidemiological research. The concept of psychological well-being must focus on the most essential aspects of human existence, especially in the area of health, where it almost undoubtedly acquires its greatest operativity. In this context, in spite of some partial and rather inconclusive definitions, not always emerging with the expected significance, psychological well-being is being increasingly used upon as a powerful instrument to analyze and implement public policies. It is being employed to articulate, from an all-round perspective, the approaches of social inclusion and equity, human development and sustainable development. Moreover, it could also help to guide the provision of services towards more people-focused practices. This can be found within a context of increasingly well-informed citizens, with a greater capacity to demand and to manage, guided by positive values and legitimate social aspirations, striving to improve their quality of life. The area of subjective well-being must be significantly developed in several directions. In the first place, an attempt must be made to approach the concept of psychological well-

106 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. being with standardized and valid, but also more sophisticated, instruments. It is also necessary to recognize the multifactorial nature of emotions and well-being. Scales have been obtained with good psychometric properties, but these have hardly incorporated any non selfinformed measures [Diener, Suh, Lucas et al. 1999]. It would, therefore, be desirable, and certainly much more complicated, to complement the evaluation of well-being with more objective measures of biological determinations, facial expressions, life experiences, cognitive states etc. The central hypothesis to positive health is that the experience of wellbeing contributes to the effective functioning of multiple biological systems, which can help to protect the individual from illness or, when illness appears, to help him to recover rapidly [Ryff, Singer and Love, 2004]. Although it has sometimes been considered that well-being in individuals can only be studied through the replies they themselves make, arguing that it is an internal and subjective phenomenon, there are no solid reasons to exclude other kinds of variables. As these other measures converge towards self-reported ones, the conclusions will be reinforced. If, however, these tend to diverge the researchers must formulate hypotheses to explain these tendencies. Psychological well-being is highly influenced by the nature of subjective experiences, but is also related to measurable aspects of physical, mental and social functioning. An attempt should be made to expand on knowledge in the area, to include factors related to both objective and subjective aspects of well-being in individuals, groups, communities and societies. From the different interpretations of psychological well-being, there is an underlying, and so far unresolved, argument about the types of relationships that exist between objective and subjective factors of well-being in people. On the other hand, it would be desirable to carry out more longitudinal and experimental studies into the determinants of psychological well-being, rather than always resorting to the transversal types of studies used to date. In this way, instead of just basing our knowledge on mere associations or correlations between variables, we can move closer to the causal factors of well-being, to prognostic factors and also to verifying the efficacy of different interventions to improve well-being.

REFERENCES Allport, G. W. (1952). The mature personality. Pastoral Psychology., 2, 19-24. Andrews, F. M. and Withney, S. B. (1976). Social indicators of well-being: America´s perception of life quality. New York.: Plenum. Andrews, F. M. and McKennell, A. C. (1980). Measures of self-reported well-being. Social Indicators Research., 8, 127-156. Artazcoz, L., Borrell, C., and Benach, J. (2001). Gender inequalities in health among workers: the relation with family demands. J. Epidemiol.Community Health, 55, 639-647. Austin, J. T. and Vancouver, J. F. (1996). Goal constructs in psychology: Structure, process, and content. Psychological Bulletin, 120, 338-375. Avia, M. D. and Vazquez, C. (1998). Optimismo inteligente. Madrid: Alianza Editorial. Badia, X., Gutierrez, F., Wiklund, I., and Alonso, J. (1996). Validity and reliability of the Spanish Version of the Psychological General Well-Being Index. Quality of Life Research, 5.


107

Bartlett, C. J. and Coles, E. C. (1998). Psychological health and well-being: why and how should public health specialists measure it? Part 2:stress, subjetive well-being and overall conclusions. Journal of Public Health Medicine, 20, 288-294. Berkman, L. F. (1995). The role of social relations in health promotion. Psychosom. Med, 57, 245-254. Beyene, Y., Becker, G., and Mayen, N. (2002). Perception of aging and sense of well-being among Latino elderly. J. Cross. Cult. Gerontol, 17, 155-172. Bigatti, S. M. and Cronan, T. A. (2002). An examination of the physical health, health care use, and psychological well-being of spouses of people with Fibromyalgia Syndrome. Health Psychology, 21, 157-166. Birren, J. E. and Renner, V. J. (1980). Concepts and issues of mental health and aging. In J.E.Birren and R. B. Sloane (Eds.), Handbook of mental health and aging. (pp. 3-33). Englewood Cliffs, NJ: Prentice-Hall. Blaine, B. E., Rodman, J., and Newman, J. M. (2007). Weight loss treatment and psychological well-being: a review and meta-analysis. J. Health Psychol., 12, 66-82. Blanco, A. and Diaz, D. (2005). El bienestar social: su concepto y medicion. Psicothema, 17, 582-589. Bradburn, N. M. (1969). The structure of psychological well-being. Chicago.: Aldine. Brandtstädter, J., Wentura, D., and Greve, W. (1993). Adaptive resources of the aging self: Outlines of an emerging perspective. International Journal of Behavioral Development, 16, 323-349. Breilh, J. (1989). Epidemiologia, economia, medicina y politica. Buenos Aires, Argentina. Bühler, C. (1935). The curve of life as studied in biographies. Journal of Applied Psychology., 19, 405-409. Campbell, A., Converse, P. E., and Rodgers, W. L. (1976). The quality of American life: Perceptions, evaluations, and satisfactions. New York: Russell Sage Foundation. Cantor, N. and Sanderson, C. A. (1999). Life task participation and well-being: The importance of taking part in daily life. In D.Kahneman, E. Diener, and N. Schwarz (Eds.), Well-being: The foundation of hedonic psychology. (pp. 230-243). New York, US.: Russell Sage Foundation. Carver, C. S. and Scheier, M. F. (1998). On the self-regulation of behavior. New York: Cambridge University Press. Carver, C. S. (1998). Resilience and thriving: Issues, models, and linkages. Journal of Social Issues, 54, 245-266. Cheng, Y. H., Chi, I., Boey, K. W., Ko, L. S., and Chou, K. L. (2002). Self-rated economic condition and the health of elderly persons in Hong Kong. Soc. Sci. Med, 55, 1415-1424. Chida, Y. and Steptoe, A. (2008). Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom. Med, 70, 741-756. Costa, P. and McCrae, R. (1984). Personality as life long determinant of well-being. In Malatesta and Izard (Ed.), Affective process in adult development and aging. (pp. 141156). Beverly Hills: Sage. Costa, P. T., Jr. and McCrae, R. R. (1980). Influence of extroversion and neuroticism on subjective well-being: happy and unhappy people. J. Pers. Soc. Psychol., 38, 668-678. Costa, T. P. and McCrae, R. R. (1996). Mood and personality in adulthood. In C.Magai and S. H. MacFadden (Eds.), Handbook of emotion, adult development and aging. (pp. 369383). San Diego: Academic Press.

108 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. Costanzo, E. S., Ryff, C. D., and Singer, B. H. (2009). Psychosocial adjustment among cancer survivors: findings from a national survey of health and well-being. Health Psychol., 28, 147-156. Cutrona, C. E., Russell, D. W., Hessling, R. M., Brown, P. A., and Murry, V. (2000). Direct and moderating effects of community context on the psychological well-being of African American women. J. Pers. Soc. Psychol., 79, 1088-1101. Davies, M., Stankov, L., and Roberts, R. D. (1998). Emotional intelligence: in search of an elusive construct. J. Pers. Soc. Psychol., 75, 989-1015. Davis, M. H., Morris, M. M., and Kraus, L. A. (1998). Relationship-specific and global perceptions of social support: associations with well-being and attachment. J. Pers. Soc. Psychol., 74, 468-481. Debono, M. and Cachia, E. (2007). The impact of diabetes on psychological well being and quality of life. The role of patient education. Psychol. Health Med, 12, 545-555. DeNeve, K. M. and Cooper, H. (1998). The happy personality: a meta-analysis of 137 personality traits and subjective well-being. Psychol. Bull., 124, 197-229. Dennerstein, L., Lehert, P., and Guthrie, J. (2002). The effects of the menopausal transition and biopsychosocial factors on well-being. Arch Womens Ment. Health, 5, 15-22. Diaz, D., Rodriguez-Carvajal, R., Blanco, A., Moreno-Jimenez, B., Gallardo, I., Valle, C. et al. (2006). [Spanish adaptation of the Psychological Well-Being Scales (PWBS)]. Psicothema, 18, 572-577. Diener, E. (1984). Subjetive well-being. Psychological Bulletin, 95, 542-575. Diener, E., Sandvik, E., Pavot, W., and Fujita, F. (1992). Extroversion and subjective wellbeing in a U.S. national probability sample. Journal of Research in Personality, 26, 205215. Diener, E. and Diener, M. (1995). Cross-cultural correlates of life satisfaction and selfesteem. J. Pers. Soc. Psychol., 68, 653-663. Diener, E., Diener, M., and Diener, C. (1995). Factors predicting the subjective well-being of nations. J. Pers. Soc. Psychol., 69, 851-864. Diener, E. and Fujita, F. (1995). Resources, personal strivings, and subjective well-being: a nomothetic and idiographic approach. J. Pers. Soc. Psychol., 68, 926-935. Diener, E. and Diener, C. (1996). Most people are happy. Psychological Science, 7, 181-185. Diener, E. and Suh, E. (1997). Measuring quality of life: economic, social, and subjective indicators. Social Indicators Research., 40, 189-216. Diener, E., Suh, E. M., Lucas, R. E., and Smith, H. L. (1999). Subjective Well-Being: Three Decades of Progress. Psychological Bulletin, 125, 276-302. Diener, E. and Suh, E. (2000). Culture and subjective well-being. Cambridge, MA, US: The MIT Press. Diener, E. (2000). Subjective well-being. The science of happiness and a proposal for a national index. Am. Psychol., 55, 34-43. Diener, E. D., Emmons, R. A., Sem, R. J. L., and Griffin, S. (1985). The Satisfaction With Life Scale. Journal of Personality Assessment, 49. Emmons, R. A. (1986). Personal strivings: An approach to personality and subjective wellbeing. Journal of Personality and Social Psychology., 51, 1058-1068. Emmons, R. A., Diener, E., and Larsen, R. J. (1986). Choice and avoidance of everyday situations and affect congruence: Two models of reciprocal interactionism. Journal of Personality and Social Psychology, 51, 815-826.


109

Erikson, E. H. (1950). Growth and crises of the "healthy personality". In M.J.E.Senn (Ed.), Symposium on the healthy personality. (pp. 91-146). Oxford, England.: Josiah Macy, Jr. Foundation. Erikson, E. (1959). Identity and the life cycle. Psychological Issues, 1, 1-171. Escriba-Agüir, V. and Tenias-Burillo, J. M. (2004). Psychological well-being among hospital personnel: the role of family demands and psychosocial work environment. International Journal of Occupational and Environmental Health, 77, 401-408. Fernández-Berrocal, P. and Ramos, N. (2002). Inteligencia emocional y ajuste psicologico. In P.Fernandez-Berrocal and N. Ramos (Eds.), Corazones inteligentes. (pp. 147-162). Barcelona: Editorial Kairos. Fowler, J. H. and Christakis, N. A. (2008). Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ, 337, a2338. Frazier, C., Mintz, L. B., and Mobley, M. A. (2005). A multidimensional look at religious involvement and psychological well-being among urban elderly african americans. Journal of Counseling Psychology., 52, 583-590. Friedman, E. M., Hayney, M., Love, G. D., Singer, B. H., and Ryff, C. D. (2007). Plasma interleukin-6 and soluble IL-6 receptors are associated with psychological well-being in aging women. Health Psychol., 26, 305-313. Garcia Viniegras, C. R. and Gonzalez Benitez, I. (2000). La categoria bienestar psicologico. Su relacion con otras categorias sociales. Revista cubana de medicina general integral, 16, 586-592. Grossi, E., Groth, N., Mosconi, P., Cerutti, R., Pace, F., Compare, A. et al. (2006). Development and validation of the short version of the Psychological General WellBeing Index (PGWB-S). Health and Quality of Life Outcomes, 4. Haan, M. N., Kaplan, G. A., and Syme, S. L. (1989). Socioeconomic status and health: old observations and new thoughts. In D.S.Bunker, D. S. Gomby, and B. H. Kehrer (Eds.), Pathways to Health: The Role of Social Factors. (pp. 76-135). Menlo Park. Heidrich, S. M. and Ryff, C. D. (1993a). The role of social comparisons processes in the psychological adaptation of elderly adults. J. Gerontol, 48, 127-136. Heidrich, S. M. and Ryff, C. D. (1993b). Physical and mental health in later life: the selfsystem as mediator. Psychol. Aging, 8, 327-338. Howell, R. T., Kern, M. L., and Lyubomirsky, S. (2007). Health benefits: Meta-analytically determining the impact of well-being on objective health outcomes. Health Psychology Review, 1, 1-54. Howell, R. T. (2009). Review: positive psychological well-being reduces the risk of mortality in both ill and healthy populations. Evid. Based. Ment. Health, 12, 41. Hsee, C. K. and Abelson, R. P. (1991). Velocity relations: satisfaction as a function of the first derivate of outcome over time. Journal of Personality and Social Psychology., 60, 341-347. Hunt, S. and McKenna, S. (1993). SF-36 misses the mark. BMJ, 307, 125. Inglehart, R. (2002). Gender, aging and subjective well-being. International Journal of Comparative Sociology., 43, 391-408. Jung, C. G. (1933). Modern man in search of a soul. New York: Harcourt, Brace and World.

110 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. Kaplan, G. A., Roberts, R. E., Camacho, T. C., and Coyne, J. C. (1987). Psychosocial predictors of depression. Prospective evidence from the human population laboratory studies. Am. J. Epidemiol., 125, 206-220. Kaplan, G. A., Shema, S. J., and Leite, C. M. (2008). Socioeconomic determinants of psychological well-being: the role of income, income change, and income sources during the course of 29 years. Ann. Epidemiol., 18, 531-537. Kevin, E., Hershberger, P. J., Russell, R. K., and Market, R. J. (2001). Stress, negative social exchange and health symptoms in university students. Journal of American College Health., 50, 75-80. Keyes, C. L., Shmotkin, D., and Ryff, C. D. (2002). Optimizing well-being: the empirical encounter of two traditions. J. Pers. Soc. Psychol., 82, 1007-1022. Kohn, M. L. and Schooler, C. (1978). The reciprocal effects of the substantive complexity of work and intellectual flexibility: A longitudinal assessment. Americal Journal f Sociology, 84, 24-52. Kowal, A., Kramer, L., Krull, J. L., and Crick, N. R. (2002). Children's perceptions of the fairness of parental preferential treatment and their socioemotional well-being. J. Fam. Psychol., 16, 297-306. Krause, N. (1988). Stressful life events and physician utilization. J. Gerontol, 43, S53-S61. Landau, R. and Litwin, H. (2001). Subjective well-being among the old-old: the role of health, personality and social support. International Journal of Agin and Human Development, 52, 265-280. Larsen, R. J. and Ketelaar, T. (1991). Personality and susceptibility to positive and negative emotional states. J. Pers. Soc. Psychol., 61, 132-140. Lindfors, P. (2002). Positive health in a group of Swedish white-collar workers. Psychological Reports, 91, 839-845. Litwin, H. (2006). The path to well-being among elderly Arab Israelis. J. Cross. Cult. Gerontol, 21, 25-40. Lyubomirsky, S., Sheldon, K. M., and Schkade, D. (2005). Pursuing happiness: The architecture of sustainable change. Review of General Psychology., 9, 111-131. Lyubomirsky, S., King, L., and Diener, E. (2005). The benefits of frequent positive affect: does happiness lead to success?. Psychol. Bull., 131, 803-855. Manne, S. and Schnoll, R. (2001). Measuring cancer patients' psychological distress and wellbeing: a factor analytic assessment of the Mental Health Inventory 5. Psychol. Assess, 13, 99-109. Marmot, M. G., Fuhrer, R., Ettner, S. L., Marks, N. F., Bumpass, L. L., and Ryff, C. D. (1998). Contribution of psychosocial factors to socioeconomic differences in health. Milbank Q., 76, 403-48, 305. Marshall, S., Haywood, K., and Fitzpatrick, R. (2006). Impact of patient-reported outcome measures on routine practice: a structured review. J. Eval. Clin. Pract., 12, 559-568. Martinez Garcia, M. F. and Garcia Ramirez, M. (1994). La autopercepcion de la salud y el bienestar psicologico com indicador de calidad de vida percibida en la vejez. Revista de Psicologia de la Salud, 20, 272-284. Martire, L. M., Stephens, M. A., and Townsend, A. L. (2000). Centrality of women's multiple roles: beneficial and detrimental consequences for psychological well-being. Psychol. Aging, 15, 148-156.


111

Maslow, A. H. (1958). A Dynamic Theory of Human Motivation. In C.L.Stacey and M. DeMartino (Eds.), Understanding human motivation. (pp. 26-47). Cleveland, OH, US.: Howard Allen Publishers. Mayer, J. D., Roberts, R. D., and Barsade, S. G. (2008). Human abilities: emotional intelligence 18. Annu. Rev. Psychol., 59, 507-536. McHorney, C. A., Ware, J. E., and Raczek, A. (1993). The MOS 36-item Short Form Health Survey (SF-36): II Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med. Care, 31, 247-263. Michalos, A. C. (1985). Multiple discrepancies theory (MDT). Social Indicators Research., 16, 347-413. Mroczek, D. K. and Kolarz, C. M. (1998). The effect of age on positive and negative affect: a developmental perspective on happiness. J. Pers. Soc .Psychol., 75, 1333-1349. National Survey of Midlife Development in the United States (MIDUS) (2009). MIDUS [Online]. Available: http://www.midus.wisc.edu/ Netz, Y., Wu, M. J., Becker, B. J., and Tenenbaum, G. (2005). Physical activity and psychological well-being in advanced age: a meta-analysis of intervention studies. Psychol. Aging, 20, 272-284. Organizacion Panamericana de la Salud (1994a). Analisis de la salud-enfermedad segun condiciones de vida. Honduras. New York. Organizacion Panamericana de la Salud (1994b). Las condiciones de salud de las Americas. (Rep. No. 1). Washington DC. Ostir, G. V., Markides, K. S., Black, S. A., and Goodwin, J. S. (2000). Emotional well-being predicts subsequent functional independence and survival. J. Am. Geriatr. Soc., 48, 473478. Ostir, G. V., Markides, K. S., Peek, M. K., and Goodwin, J. S. (2001). The association between emotional well-being and the incidence of stroke in older adults. Psychosom. Med, 63, 210-215. Parreño, J. (1990). Tercera edad sana. (2 ed.) Madrid: ARTEGRAF. Patrick, D. L. and Chiang, Y. P. (2000). Measurement of health outcomes in treatment effectiveness evaluations: conceptual and methodological challenges. Med. Care, 38, II14-II25. Phillips, D. R., Siu, O. L., Yeh, A. G., and Cheng, K. H. (2005). The impacts of dwelling conditions on older persons' psychological well-being in Hong Kong: the mediating role of residential satisfaction. Soc. Sci. Med, 60, 2785-2797. Pinquart, M. and Sörensen, S. (2000). Influences of socioeconomic status, social network, and competence on subjective well-being in later life: a meta-analysis. Psychol. Aging, 15, 187-224. Pinquart, M. and Sörensen, S. (2001). Gender differences in self-concept and psychological well-being in old age: a meta-analysis. J. Gerontol. B Psychol. Sci. Soc. Sci., 56, 195-213. Pressman, S. D. and Cohen, S. (2005). Does positive affect influence health?. Psychol. Bull., 131, 925-971. Rogers, C. R. (1963). The concept of the fully functioning person. Psychotherapy: Theory, Research and Practice., 1, 17-26. Rohlfs, I., Borrell, C., and Fonseca, M. (2000). Genero, desigualdaes y salud publica: conocimientos y desconocimientos. Gaceta Sanitaria, 14, 60-71.

112 Jesús López-Torres Hidalgo, Beatriz Navarro Bravo, Ignacio Párraga Martínez et al. Ryan, R. M. and Deci, E. L. (2001). On happiness and human potentials: a review of research on hedonic and eudemonic well-being. Annu. Rev. Psychol., 52, 141-166. Ryff, C. (1989a). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology., 57, 1069-1081. Ryff, C. (1989b). Beyond Ponce de Leon and life satisfaction: New directions in quest of successful aging. International Journal of Behavioral Development, 12, 35-55. Ryff, C. and Singer, B. (1998). The contours of positive health. Psychological Inquiry, 9, 128. Ryff, C. (2001). Electives affinities and uninvited agonies. New Cork: Oxford University press. Ryff, C. D. (1991). Possible selves in adulthood and old age: a tale of shifting horizons. Psychol.Aging, 6, 286-295. Ryff, C. D. and Essex, M. J. (1992). The interpretation of life experience and well-being: the sample case of relocation. Psychol. Aging, 7, 507-517. Ryff, C. D. and Keyes, C. L. (1995). The structure of psychological well-being revisited. J. Pers. Soc. Psychol., 69, 719-727. Ryff, C. D. and Singer, B. (1996). Psychological well-being: meaning, measurement, and implications for psychotherapy research. Psychother. Psychosom., 65, 14-23. Ryff, C. D. and Singer, B. (2003). Ironies of the human condition: Well-being and health on the way to mortality. In L.G.Aspinwal and U. M. Staudinger (Eds.), A psychology of human strengths: Fundamental questions and future directions for a positive psychology. (pp. 271-287). Washington, DC, US.: American Psychological Association. Ryff, C. D., Singer, B. H., and Love G. (2004). Positive health: connecting well-being with biology. Philos. Trans. R. Soc. Lond B Biol. Sci., 359, 1383-1394. Sanchez-Uriz, M. A., Gamo, M. F., Godoy, F. J., Igual, J., and Romero, A. (2006). ¿Conocemos el bienestar psicologico de nuestro personal sanitario? Revista de Calidad Asistencial, 21, 194-198. Steptoe, A. and Feldman, P. J. (2001). Neighborhood problems as sources of chronic stress: development of a measure of neighborhood problems, and associations with socioeconomic status and health. Ann. Behav. Med, 23, 177-185. Steptoe, A., Wardle, J., and Marmot, M. (2005). Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proc. Natl. Acad. Sci. USA, 102, 6508-6512. Steptoe, A. and Wardle, J. (2005). Positive affect and biological function in everyday life. Neurobiol. Aging, 26 Suppl 1, 108-112. Steptoe, A. and ez Roux, A. V. (2008). Happiness, social networks, and health. BMJ, 337, a2781. Suh, E., Diener, E., Oishi, S., and Triandis, H. C. (1998). The shifting basis of life satisfaction judgments across cultures: Emotions versus norms. Journal of Personality and Social Psychology, 74, 482-493. Treharne, G. J., Lyons, A. C., Booth, D. A., and Kitas, G. D. (2007). Psychological wellbeing across 1 year with rheumatoid arthritis: coping resources as buffers of perceived stress. Br. J. Health Psychol., 12, 323-345. Triandis, H. C. and Harry, C. (2000). Cultural syndromes and subjetive well-being. In E.Diener and E. M. Suh (Eds.), Culture and subjective well-being. (pp. 13-36). Cambridge, MA, US: The MIT Press.


113

Valderas, J. M., Kotzeva, A., Espallargues, M., Guyatt, G., Ferrans, C. E., Halyard, M. Y. et al. (2008). The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. Qual. Life Res., 17, 179-193. Van Dierendonck, D. (2004). The construct validity of Ryff's Scale of Psychological WellBeing and its extension with spiritual well-being.. Personality and Individual Differences, 36, 629-644. Villar, F., Triado, C., Resano, C. S., and Osuna, M. J. (2003). Bienestar, adaptacion y envejecimiento: cuando la estabilidad significa cambio. Revista Multidisciplinar de Gerontologia, 13, 152-162. Von Franz, M. L. (1964). The process of individuation. In C.G.Jung (Ed.), Man and his symbols. (pp. 158-229). New York: Doubleday. Wardle, J. and Cooke, L. (2005). The impact of obesity on psychological well-being. Best. Pract. Res. Clin. Endocrinol. Metab, 19, 421-440. Ware, J. E., Snow, K. K., Kosinski, M., and Gandek, B. (1993). SF-36 Health Survey: Manual and interpretation guide 111. Boston: The Health Institute, New England Medical Center. Waterman, A. S. (1993). Two conceptions of happiness: Contrast of personal expressiveness (eudaimonic) and hedonic enjoyment. Journal of Personality and Social Psychology., 64, 678-691. Weng, B. K. (1998). Social network and subjective well-being of the elderly in Hong Kong. Asia Pacific Journal of Social Work., 8, 5-15. Whitbourne, S. K. and Powers, C. B. (1994). Older women's constructs of their lives: a quantitative and qualitative exploration. Int. J. Aging Hum. Dev., 38, 293-306. Wilson, W. (1967). Correlates of avowed happiness. Psychol. Bull., 67, 294-306. Wright, T. A. and Cropanzano, R. (2000). Psychological well-being and job satisfaction as predictors of job performance. J. Occup. Health Psychol., 5, 84-94.

In: Psychological Well-Being Editor: Ingrid E. Wells, pp.115-134


Chapter 3

SEXUAL SATISFACTION AS A FUNCTION OF PARTNERSHIP ATTRIBUTES AND HEALTH CHARACTERISTICS: EFFECT OF GENDER Ann-Christine Andersson Arntén and Trevor Archer Department of Psychology, University of Gothenburg, Göteborg, Sweden

ABSTRACT Two hundred and fourteen employees, 136 men and 78 women, responded to Subjective Stress Experience Questionnaire, Stress and Energy Scale, Hospital Anxiety and Depression Scale, Job Stress Survey, Partnership Relations Quality Tests (e.g. Sexual life Satisfaction, and Partnership Relation Quality), and Positive and Negative Affect Scale. Health-promoting advantages of sexual life satisfaction in counteracting illhealth associated with different types of stress were observed. Men participants‘ Sexual life Satisfaction was predicted by intercourse frequency, accordance with desired frequency, intercourse satisfaction, frequency of sexpartners, women‘s participants‘ Sexual life Satisfaction was predicted by intimate communication, caressing and cuddling, and desire. Level of Sexual life Satisfaction and gender influenced coping (e.g. cognitive, emotional, social), depression anxiety, Partnership Relation Quality, thoughts of divorce, negative affect, general stress, and dispositional optimism. Regression analyse showed that work-stress was predictive and sexual life satisfaction was counter-predictive for depression, anxiety, general stress and psychological stress and thereby buffering the negative effects of work stress.

Keywords: Sexuality, stress, affect, anxiety, depression, partnership relation, gender, health.

116

Ann-Christine Andersson Arntén and Trevor Archer

INTRODUCTION Current notions of individuals‘ lives would appear to revolve, to a significant extent, around three major domains: interpersonal (love) relations (here conceptualized as sexuality), work and health. Sexuality, long since accepted as an essential feature of life, has critical importance for health, quality of life and general well-being (Nusbaum et al., 2000; Howard 2006; Lauman et al., 1994; Ventgodt, 1998). Additionally, sexuality influences also our perceptions and relations to partners, meaningful others and ourselves (Nusbaum et al., 2000). There exists a reciprocal deterministic relationships between high levels of intimacy and high levels of adaptation and attachment within a couple, i.e. partnership quality (Moore et al., 2001; Howard et al., 2006; Fasching et al., 2007), over both genders. Beutel et al. (2002; 2008) have confirmed these associations indicating a strong positive correlation between sexual enjoyment and partnership satisfaction, and a less strong correlation of the latter with sexual activity. Andersson Arntén et al. (2008a, 2008b) found significant links between inferior partnership relation quality and certain health markers, including anxiety, depression and stress, as well as with high quality of sexuality predicting almost 50% of partnership relation quality (Andersson Arntén et al., 2008c). Sprecher et al. (1995), in citing several studies indicating that partners enjoying high levels of sexual activity and/or a satisfied sexuality together express greater satisfaction with their entire relationship, concluded from their own results that communication, sexual expression and companionship were important factors predicting satisfaction. Taken together, these findings underline the strong associations between couples‘ sexuality and the quality of their partnership relations. One essential aspect of sexuality pertains to which factors mediate individuals‘ experiences of their own sexuality and sexual enjoyment. Addis et al. (2006), in a study of women between 40-69 years, defined three areas: sexual frequency, sexual satisfaction and sexual problems. There are several advantages linked to a positive and active sexuality, including pleasure and physical relaxation, a feeling of coherence, opportunity for intimate communication, increased feelings of self-worth and contribution to individuals‘ self-identity (Nusbaum, 2000). Self-identity is associated with personality characteristics. For example, it follows that ―openness‖ contributes to a higher level of sexuality and partnership satisfaction while interpersonal problems reduced both (Beutel et al., 2002; Beutel et al., 2007). In adults, there is a correlation between marital stability, good mental and physical health and positive personality characteristics, all of which protect against mortality risk (Blair et al., 1989). Sexuality, or rather problems associated with it, appears to provide a marker for different forms of health/illhealth, with sexual distress linked to forms of illhealth (Addis, 2006). Sexual problems often coexist with depression, lack of self-respect, relationship problems or unpleasant sexual experiences (Ventgodt, 1998). Thus, Howard (2006) implies that the best predictors for sexual distress are general lack of emotional well-being and the lack of emotional relationship between individuals participating in the sexual act. Beutel et al. (2002) has shown that both sexual satisfaction and satisfaction with partner relationship were at risk in cases where men were dissatisfied with own health, reporting somatoform (physical) complaints and interpersonal problems. There exist marked gender differences pertaining to sexuality and sexually-related problems, e.g. men report greater sexual desire than women (Beutel et al. 2007). On the other hand, several studies indicate gender differences pertaining to lack of sexual interest, wherein

Sexual Satisfaction as a Function of Partnership Attributes…

117

women indicate a greater lack of sexual desire than men (Laumann, 1994; Ventgodt, 1998; Beutel et al. 2007), the most common sexual problem among women incremental with age. Premature ejaculation, the most common sex-related problem among men, appears not to be age-related (Ventgodt, 1998). It appears likely that men report sexually-related problems more frequently than women (Clayton 2001). Nevertheless, sexual dysfunction is more common among women than men (Addis et al. 2006). Sexual dysfunction among women significantly affects womens‘ self-confidence, quality-of-life, and causes emotional distress that may culminate in relationship problems (Lauman et al. 1994), an association that exists for men too. In addition to this, it appears likely that sexual behaviour promotes health thereby contributing also to general well being. Among men, frequency of intercourse is inversely related to mortality whereas among women enjoyment of intercourse was inversely related to mortality (Smith 1997) and sexual dissatisfaction was linked to increased mortality risk. In general, the risk of mortality among individuals with high rate of orgasm was halved in relation to those with a low rate, over death from all causes. Men with a higher frequency of orgasm had 50% lower risk of mortality than men with lower frequency of orgasm (Smith 1997). Furthermore, Palmore (1982) found a direct, positive relationship between sexuality activity and longevity and that men‘s intercourse frequency and women‘s earlier enjoyment of intercourse were predictors for increased longevity. This relationship was confirmed by Seldin et al. (2002), who found too that frequency of orgasm for married women was moderately protective against mortality risk. Brody et al. (2000) reported a direct physiological association with sexual activity, e.g. the link between penile-vaginal intercourse (FSI) and lower diastolic blood pressure. Moreover, some results indicate a positive correlation between sexual activity and positive effects on the immune system (Stein, 2000; Charentski and Brennan 2001) as well as reduction of cancer risk, breast cancer in women (Murell, 1995; Petriodu et al. 2000; Le, et al. 1989;Janerich, 1994; Rossing, et al. 1996) and in men (Petridou, et al 2000), prostate cancer (Giles, et al. 2003; Leitzmann et al. 2004). Another factor that is strongly connected with well being and health is sleep. Sexual activity, e.g. sexual release and orgasm, positively correlates with better sleep (Crooks and Baur, 1983; Odent 1999; Ellison 2000). Psychological health is linked strongly with sexual functioning. For example, Ferguson, (2001) observed that reduced sexual functioning was associated with clinical depression: 5090% of the depressed patient group, with or without medication, expressed some form of sexual dysfunction. Only 50% of the depressed women and 75% of the depressed men had been sexually active during the previous month and within the depressed patient group 40% of the men and 50% of the women expressed reduced sexual desire. Other psychological faxctors, such as stressors, interpersonal relations, body image and sexual self-awareness are linked to sexual functioning (Clayton, 2001; Addis et al. 2006). Subjective health selfperceptions may exert critical effects in deciding sexual and partnership satisfaction (Beutel et al., 2002; Fasching et al., 2007). On the other hand, individuals expressing sexual activeness appear to enjoy a higher quality-of-life than those less active and the population average (Ventgodt, 1998). Both men and women who had partners expressed a quality-of-life that was over the population mean (ibid). Other dimensions that do not require that individuals having a partner, such as well-being, satisfaction with life and happiness, appear higher in individuals having an active sexuality (ibid).

118


In summary, an active sexual life ensures several positive effects that may be directly or indirectly associated with physical and psychological well-being.

Stress Marked associations between general stress and sex-related factors, such as intimate comunication, intercourse frequensy and satisfaction, have been described (Andersson Arntén et al., 2008c). Beutel et al. (2007) indicated that emotional problems, stress and poor health, in turn, influenced women‘s sexual desire. Andersson Arntén et al. (2008c) described marked associations between ‖work-stress‖ and sexually-related factors, whereby elevated workrelated stress reduced ―own-initiative‖, ―satisfaction and orgasm during intercourse‖ and ―partner‘s initiative‖. Collins et al. (1992) showed correlations between success rates and psychological stress as well as coping styles during fertilization. Finally, Fasching et al. (2007) demonstrated that anxiety due to difficulties such as coping with lethal illness, physical dysfunction and altered body image exerts a critical influence upon partnership and sexual situations.

Positive and Negative Affect Positive and negative affect influences sexual processes. Among men, positive or negative affect is considered to be a factor influencing whether or not sexual performance is successful or unsuccessful (Barlow, 1986; Meisler and Cary, 1991; Hartmann, 2005). Level of positive affect was shown to be higher among sexually well-functioning men compared with sexually dysfunctional men, possibly due to the former responding with positive mood in the sexual situation (Rowland et al., 1995). Mitchell et al. (1998) found that positive and negative mood induction has differential effects on sexual function (functioning). Positive mood was associated with penile-enlargement and subjective sexual arousal whereas negative was linked to a significant reduction of penile-enlargement. The authors imply that mood influences arousal which in turn influences sexual physiological responses. Thus, elevation in negative mood may constitute a key component of dysfunctional sexual performance and ability, concurrent with the facilitatory role of positive mood on arousal and successful sexual performance (Mitchell et al., 1998). Arguably, sexuality is direct or indirectly associated with well being and positive affect whereas the work place is linked to stress and potential threat to health and well-being, one purpose of the present study is to examine whether or not the endowment of positive qualities from sexuality may provide a ‗buffering‘ effect against negative affective states or tendencies toward illhealth that may be generated by stress at the work place. In the present study, it is hypothesised that:(i) there exists a positive association between degree of sexual life satisfaction (SLS) and different markers for health/illhealth (e.g. positive affect, energy/negative affect, subjective stress reactions, anxiety, depression). (ii) there exists a positive association between degree of SLS and individuals‘ personal profiles (e.g. dispositional optimism, coping strategies).


119

(iii) There exists a negative association between general stress and work stress and quality of sexuality. Against these hypotheses, the presence of gender effects and which particular sex-related factors are linked to ―sexual satisfaction‖ in men and women is investigated.

METHODS AND MATERIALS Participants One two hundred and fourteen participants (136 men and 78 women) equally divided between four different occupational categories, sales personnel, construction foremen, teachers, administrative personnel, took part. The response rate among participants was about 80 percent at each workplace, resulting in 214 subjects. The mean age of the whole population of participants was 39.55 years (SD = 8.43), with men aged 37.86 years (SD = 7.31) and women aged 42.90 years (SD = 9.62). The mean amount of education after basic school was 4.92 years (SD = 2.88), with 5.1% of the men and 2.6% of the women not receiving any education after basic school. Among men, 41.9% had high school education and 53.0% further education whereas the equivalent for women was 20.6% and 77.8%, respectively.

Design The study consisted of independent variables: ―Work Stress (JSS)‖, ―Sexual life satisfaction (SLS)‖, and ―Gender‖, and the dependent variables ―Subjective Stress Experience (SSE): psychological (SSPSYK) and somatic (SSSOM) stress‖, ―Stress and Energy‖ (SE), ―Anxiety‖ and ―Depression‖, and ―Positive (PA) and Negative (NA) affect‖ as well as dispositional optimism (LOT). The dependent variables were chosen from the perspective of examining the effects of experienced work stress from the notion that health/illhealth may be manifested through several different expressions: affect (PANAS), emotion (Stress and Energy), psychological and somatic stress reactions (SSE), anxiety and depression (HAD) as well as the influence of dispositional optimism (LOT). Analyses were performed accordingly: 1) regression analysis in order to study which factors predicted SLS, 2) one-way ANOVA with SLS divided into three groups, i.e. ―Low‖, ―Medium‖ and ―High‖, to confirm that SLS influences health and individuals‘ personal profiles, and 3) regression analysis with application of hierarchical method, to examine the extent SLS may buffer the effects of JSS on health factors, was used.

Instruments Positive affect and negative affect scale (PANAS). The PANAS-instrument provides a self-estimation of ‖affect‖, both positive and negative. It consists of 10 adjectives for the NA

120


dimension and 10 adjectives for the PA dimension. The test manual (Watson, Clark, and Tellegen, 1988) postulates that the adjectives describe feelings (Affect) and mood level. Participants were instructed to estimate how they felt during the last few days. The response alternatives were presented on a five-grade scale that extended from where 1 = not at all to 5 = very much. For each participant the responses to the 10 negatively-charged adjectives were summated to provide a total NA-result for NA affect, and similarly the responses to the positively-adjectives were summated to provide a total PA-result for PA affect. The PANAS instrument has been validated through studies analyzing conditions associated with general aspects of psychopathology (Huebner and Dew, 1995), as well as a multitude of other expressions of affect (Watson and Clark, 1984). Cronbach´s testing for the total scale indicated Alpha = 0.83. Cronbach´s testing for PA indicated Alpha = 0.83. . Cronbach´s testing for NA indicated Alpha = 0.83. Hospital Anxiety and Depression (HAD). The instrument is derived to measure depressive and anxiety symptoms (Zigmond and Smith; 1983; Herrman, 1997). It consists of 14 statements to which participants respond by marking one of either three or four response alternatives. For example, ―I can sit still and feel relaxed‖ with response alternatives: ―Definitely‖, ―Generally‖, ―Seldom‖, ―Never‖, or, ―I look forward with gladness towards this and that‖ with response alternatives: ―As much as before‖, ―Less than before‖, ―Hardly ever‖. Half of the statements were constructed to illustrate depressive symptoms whereas the other half to illustrate anxiety-related symptoms. Participants´ responses thereby provided two results, one pertaining to depressive symptoms, the other to symptoms of anxiety. Cronbach´s testing for the total scal indicated Alpha = 0.69. Cronbach´s testing for depression indicated Alpha = 0.68. Cronbach´s testing for anxiety indicated Alpha = 0.80. Subjective Stress Experience (SSE). The instrument is derived from a diagnostic manual designed to assess different reactions to stress (Lopez-Ibor, 2002). Participants were required to estimate the extent to which different statements concurred with how they felt on an ordinary working day. The first part of the instrument consisted of 23 statements wherein participants were required to respond to the extent to which they experienced, for example, ―Nausea or abdominal pain‖ or ―Overreaction to inconsequential inner stimuli/easily frightened‖, or, ―Muscle tension‖, or, ―Sleep problems caused by worry‖. The test contained statements concerning symptoms implicating autonomic activation, mood changes, tension as well as other non-specific symptoms associated with stress responses. Participants‘ estimations were carried out using a Visual Analogue Scale (VAS) whereby they marked a cross on a 10-cm line (1 at one end and 10 at the other) whereby 1 = ―do not agree at all 2‖ and 10 = ―agree completely‖. The results of the test provided a total estimation for somatic stress (SSSOM) and one for psychological stress (SSPSYK). Cronbach´s testing for the total scale indicated Alpha = 0.95. Cronbach´s testing for SSPSYK indicated Alpha = 0.92. Cronbach´s testing for SSSOM indicated Alpha = 0.89. Partner relationship questionnaire. The questionnaire consists of 45 questions regarding individuals‘ partner relationships that are designed to provide a comprehensive outline of these relationships, including sexual relations. The questionnaire contains two types of scales, multiple choice alternatives and an estimation scale from 1 – 10. Examples of questions are, as follows: ―How often do you and your partner discuss current events?‖ with response alternatives provided in those cases as multiple choice alternatives that vary from ―Never or Almost never‖, ―Seldom‖, ―Sometimes‖, ―Often‖, to ―Very often‖, and ―How often does petting and stroking occur between you and your partner?‖, with multiple choice response


121

alternatives that vary from ―Never‖, ―Seldom‖, ―Less than once a week‖, ―More than once a week‖ to ―Everyday‖ (Möller, 2004). Examples of questions applying an estimation scale from 1 – 10 are, as follows: ―How much enjoyment do you get out of sexual intercourse?‖ whereby 1 represents ―No enjoyment at all‖ to 10 ―Very intensive enjoyment‖. This study was built upon 12 of the questions from the questionnaire, including items concerning: intercourse frequency; accordance with desired frequency; intercourse orgasm; intercourse satisfaction; intimate communication; caressing and cuddling; sexual desire; sexual pleasure; partners and own sexual initiative; frequency of sex-partners last month; and sexual life satisfaction. Other aspects of the questionnaire, family set-ups, housing, and question related to the couples‘ experience of partnership relation quality factors not directly connected to sexual satisfaction were left outside the scope of the present study. Cronbach´s testing indicated Alpha = 0.84. Stress and Energy (SE). The SE-instrument is a self-estimation scale that assesses individuals‘ experience of their own stress and energy (Kjellberg and Iwanowski, 1989). The test is divided into two sub-scales that express each participant‘s level of mood in the two dimensions: ―experienced stress‖ and ―experienced energy‖. Response alternatives are ordered within six-graded scales that extend from 0 = ―not at all‖ to 5 = ―very much‖. The instrument has been validated through studies concerning occupational burdens and pressures (Kjellberg and Iwanowski, 1989). The SE-scale has been constructed from the earlier used checklist, Mood Adjective Check-List (Nowlis, 1965), which was modified by Kjellberg and Bohlin (1974) and Sjöberg, Svensson and Persson (1979). Kjellberg and Iwanowski (1989) reduced the list to 12 adjectives in the two dimensions, stress and energy, which provides the latest version applied here. Cronbach‘s testing for the total scale indicated Alpha = 0.76. Cronbach´s testing for energy indicated Alpha = 0.77. Cronbach´s testing for stress indicated Alpha = 0.92. Job Stress Survey (JSS). The JSS instrument presents a general measure of stress at work. In the test, participants are questioned about the level of seriousness of certain stressors according to how individuals perceive them and how often these stressors have been experienced during the last six months (Spielberger and Vagg, 2002). Through the expediency of assessing the level of seriousness of the stressors as well as their frequency a distinction is made between condition and characteristic under measurement. The participants first estimate the level of seriousness of certain stressors on a 9-graded scale. Following this, they were instructed to assess on a scale from 0 to 9+ how often each incident had occurred during the last six months. The result was tabulated on nine different scales: three of these being index scales, three grading scales and three frequency scales. These scales were summon up in to a total score but can also be separated into three different stress sources: work stress (ASI), work burden (ABI) and lack of organisational support (BSI). Cronbach´s testing indicated Alpha = 0.90 Life orientation Test (LOT). The LOT-instrument is a self-estimation instrument that assesses an individual‘s degree of dispositional optimism. The instrument is based on a general model, regarding self-regulated behaviour, that indicates that optimism exerts meaningful behavioural consequences based on the model (Scheier, and Carver, 1982b; 1985). It was constructed originally to study the extent to which the personality trait optimism was associated with the ability to develop suitable ‗coping strategies‘ in connection with severe psychological and physical handicaps (e.g. tinnitus). The instrument consists of 12 statements from which each participant is instructed to assess the extent to which each of

122


these statements fits in with him/her as an individual. The response alternatives are presented on a five-graded scale extending from 0 = ―strongly disagree‖ to 4 = ―strongly agree‖. LOT is a suitable scientific instrument with an estimated internal consistency of 0.76 (Cronbach‘s alpha) and a Test-Retest reliability of 0.79 (Pearson‘s r), indicating that the test result is stable over time. The LOT test requires about 5 minutes for completion. Testing has provided separate norms for men and women: men show a mean of 21.30 (SD = 4.56) and women 21.41 (SD = 5.22). Cronbach‘s testing indicated Alpha = 0.65. Health and Background questionnaire. The questionnaire is used to assemble background data regarding health and health-related information about the participants. It consists of questions regarding gender, age, education, smoking habit, exercise, aches and pains, sleep problems, time spent watching TV, and amount of activity associated with occupation. Examples of questions include: ―How often have you experienced sleep problems during the past year?‖ Response alternatives in this case provided for a choice between five different options including: ―Constantly‖, ―2-3 times a week‖, ―Once a week‖, ―Once a month‖, or ―Never‖. Each participant was instructed to mark the alternative that was most appropriate for himself/herself.

Procedure Five places of work, both private and public, were contacted with regard to participation of employees in an investigation upon aspects of health. Four places of work, representing both private and public sectors, accepted to allow the study. Permission to carry out the study was sought through Heads of personnel, union representatives and persons in positions of responsibility who adjudged whether or not the material could compromise the integrity of the personnel. One place of work choose not to allow the investigation provided the following reasons: ―This compromises personal integrity‖, and ―We don‘t have the time‖. Employees at each respective place of work were informed first by their respective Heads about the study and then asked whether or not they wished to participate. All participation was on a volunteer basis and took place at the usual work place during working hours. Most of the participants were tested in groups of maximally five persons although some were tested singly. Prior to testing, participants were ensured total anonymity as well as the fact that each set of responses was unidentifiable among all the other sets of responses. In order to avoid the possible effects of ordering of each instrument, the order in which each instrument/questionnaire occurred was randomly distributed in each envelop. Each participant picked an envelop randomly out of the box containing them. The maximum amount of time allocated for subjects to complete all the questionnaires was 45 minutes (all participants were finished before the allocated time). At the start of testing, participants were informed about the purpose and background of the study and that it was above all on a volunteer basis. It was emphasis that all details of work place and personal identity were to be omitted since total anonymity was essential. On completion of all the instruments, each participant was instructed to replace all questionnaires in the envelope. All the envelopes were collected and stored until the employees from each of the places of work had completed the tests.


123

Analyse In order to analyse whether or not different degrees of SLS affected the self-reported measures of coping strategies, health/illhealth, thoughts of divorce, and personality factors as positive and negative affect and together with dispositional optimism, the individual scores on this variable were assigned to three groups on the basis of subjects‘ own responses to the questionnaire:- Group 1 (―Low SLS‖) reported low levels on the sexual related questions on the PRQ instrument, Group 2 (―Medium SLS‖) reported intermediate levels and Group 3 (―High SLS‖) reported high levels. The distributions within these groups was performed through applications of SPSS procedures ‖rank cases‖ whereby the number of groups was confined to three.

RESULTS Sexual Life Satisfaction A descriptive analysis of sexual life satisfaction between men and women shows that women, in general, have a lower degree of sexual life satisfaction (m = 6.02, sd = 2.94) compared to men (m = 6.67, sd = 2.43) giving a Cohen‘s d of -0.24. This result implies a minor difference between the groups of gender. Linear regression analysis was performed to examine the extent to which intercourse frequency, accordance with desired frequency, intercourse orgasm, intercourse satisfaction, intimate communication, ‗caressing and cuddling‘, desire, pleasure, partners and own initiative, frequency of sex-partners last month may predict Sexual life satisfaction (SLS). The result indicated that SLS (F(10,174) = 32,67, p |4.0| SD‘s away from the mean) evident across multiple variables. Both the Variance Inflation (1.09-8.76) and Tolerance (0.15-0.91) values indicated that multicollinearity was a plausible concern within the data. Further inspection of the Variance Proportion Values (VPV) for each Condition Index (CI) exceeding 10.00 revealed that no pair of VPV‘s exceeded 0.50 in model 1 yet competence (VPV = 0.99), autonomy (VPV = 0.73), and balanced psychological need satisfaction (VPV = 0.88) all exceeded 0.50 with a CI of 57.99 in model 2 (c.f., Pedhazur, 1997). These observed VPV values in conjunction with an elevated CI suggest the results derived from model 2 of the regression analyses should be interpreted with caution.

164

Virginia L. Lightheart, Philip M. Wilson and Kristen Oster

Table 1. Descriptive statistics, internal consistency, and bivariate correlation coefficients 1. Competence 2. Autonomy 3. Relatedness 4. Balanced Need Satisfaction 5. Global SelfEsteem

M 5.56 3.52 3.97 3.46

SD 0.83 0.81 0.72 1.58

Skew. -1.14 -0.05 -0.15 0.22

Kurt. 2.06 -0.12 -0.76 -0.30

1 α = 0.88 0.46 0.29 -0.66

2

3

4

α = 0.73 0.14 0.23

α = 0.73 0.05

-

5.70

0.28

-1.22

1.56

0.43

0.34

0.26

-0.15

5

α = 0.58

Note: The initial reliability estimate for the responses to the autonomy items comprising the BNSSAUT was 0.55. Final reliability estimates following item retention/deletion within this study are placed along the principal diagonal. Balance scores after transformation from the total divergence score ranged from 0 to 8 in the present sample. All r-values greater than |0.10| are statistically significant (two-tailed significance) at p < .01 in this sample (n = 175; Sample size is consistent across each element in the lower diagonal and principal diagonal of the matrix).

Table 2. Hierarchical multiple regression analysis predicting global self-esteem from psychological need satisfaction Model 1 (F = 17.37; df = 3, 174) Competence Autonomy Relatedness Model 2 (F = 12.96; df = 4, 174) Competence Autonomy Relatedness Balanced Need Satisfaction

R2adj 0.22

0.22

B

SE

β

t-values

ry,x1(x2)

rs

0.11 0.06 0.06

0.03 0.03 0.03

0.31 0.18 0.15

3.94 2.39 2.12

0.07 0.03 0.02

0.90 0.71 0.55

0.11 0.06 0.06 0.00

0.07 0.05 0.03 0.03

0.33 0.17 0.14 0.02

1.65 1.20 1.71 0.12

0.01 0.01 0.01 0.00

0.90 0.71 0.55 -0.31

Note. R2adj = Adjusted R-squared value from each regression model. B = Unstandardized Beta Coefficients. SE = Standard Error for each Unstandardized Beta Coefficients. β = Standardized Beta Coefficients. t-values = Observed t-statistic for each predictor variables included per model in the regression analyses. ry,x1(x2) = Estimate of unique variance per predictor variable in the regression models where values represent the square of the part-correlation coefficients for each predictor (Hair et al., 2006). rs = Structure coefficients for each predictor variable included in the regression models estimated with the following formula: r/R (where r is the bivariate correlation and R is the Multiple Regression Coefficient per model in the model).

The results of the HMRA (see Table 2) revealed several interesting patterns in the data. First, perceptions of competence, autonomy, and relatedness were all predictive of variance in global self-esteem although the magnitude of these contributions varied. Specifically, across both regression models estimated, perceived competence was the dominant predictor of global self-esteem while perceptions of autonomy and relatedness demonstrated comparably weaker albeit positive effects within model 1. Second, the combination of predictor variables across both models 1 and 2 in the regression analyses accounted for 22.00 percent of the global self-esteem variance which is consistent with a medium-to-large effect size (Cohen, 1992). Finally, balanced psychological need satisfaction accounted for no additional variance

Strength Versus Balance: The Contributions of Two Different Models …

165

in global self-esteem beyond the contributions attributable to individual needs for competence, autonomy, and relatedness in sport.

DISCUSSION The purpose of this study was to test the relationship between fulfilment of BNT‘s psychological needs within a sample of athletes competing in adapted sport contexts and well-being indexed by omnibus feelings of self-esteem. Overall, the results of this investigation support the notion that feeling self-directed in one‘s actions (autonomy), effective in mastering challenging tasks within sport (competence), and a bond with other athletes (relatedness) was linked with higher levels of global self-regard about oneself in adapted sport athletes. Closer inspection of the evidence derived from the multiple regression analyses indicates that feelings of competence appear to be the dominant source of global self-esteem in this sample of adapted sport athletes in comparison to both relatedness and autonomy which demonstrated weaker albeit significant associations with global well-being. Further scrutiny of the data support the a priori hypotheses concerning the role of fulfilling each psychological need forwarded by Deci and Ryan (2002) within SDT in terms of associations with well-being and no support for the role of balanced psychological need satisfaction across perceptions of competence, autonomy, and relatedness in adapted sport athletes. Consistent with past research within the SDT tradition (c.f., Deci and Ryan, 2002) and applications of the theory to the study of motivational issues within sport (c.f., Gagné and Blanchard, 2007), the a priori hypothesis that satisfaction of competence, autonomy, and relatedness needs via experiences from adapted sport was associated with higher levels of global self-esteem was supported in this study. Such observations are wholly consistent with Deci and Ryan‘s (2002) longstanding assertion that fulfillment of these psychological needs is a necessary condition for better psychological thriving along with a secure and stable sense of well-being. Inspection of the effect sizes (see Tables 1 and 2) indicated considerable variation in the magnitude of the relationship between BNT‘s constructs and global self-esteem in this sample of adapted sport athletes. Notably feelings of effectance and skill mastery defining perceived competence within sport exhibited the strongest relationships while experiences of close and secure bonds (relatedness) and volitional self-direction (autonomy) were less potent. Deci and Ryan (2002) make no claims regarding the magnitude of relationships anticipated between BNT‘s psychological needs in relation to markers of adjustment and well-being such as global self-esteem. Accumulating evidence however across diverse physical activity contexts implicates feelings of competence as fundamental to positive selfperceptions such as global self-esteem which is likely derived from the salience of physiquerelevant and performance-based evaluations that permeate the physical domain (Fox and Wilson, 2008). The observation that perceived autonomy and relatedness retained significant relationships with global self-esteem despite the strength of perceived competence‘s link with this index of well-being further substantiates Deci and Ryan‘s (2002) assertion that these experiential inputs represent the cornerstone of a healthy self-regulatory system. Autonomy has long been advocated be Deci and Ryan (2002) as fundamental for well-being to flourish

166


in an authentic fashion despite critical scrutiny of this psychological need on the basis of cultural relativism which often equates autonomy erroneously with independence rather than self-directed volition (c.f., Deci and Ryan, 2002; 2008). Alternatively, the role of perceived relatedness seems less controversial particularly as friendships and social networks likely play a salient role in the development and sustenance of a person‘s well-being (c.f., McDonough and Crocker, 2005). While the results of this study imply that BNT‘s needs may contribute differentially to well-being markers in adapted sport athletes, the findings reported herein do nothing to undermine the importance of autonomy and relatedness in conjunction with competence such that thwarting any of these psychological needs is most likely to result in illbeing rather than flourishing. Building upon work by Sheldon and Niemiec (2006) and Perreault et al. (2007), this study also examined the hypothesis that balanced fulfillment across the candidate psychological needs espoused by Deci and Ryan (2002) would predict variance in well-being beyond the contributions of the ‗additive‘ model within the BNT framework. Conceptualizing the role of psychological need satisfaction in terms of thwarting or enhancing well-being in a ‗balanced‘ rather than ‗additive‘ model is a novel approach that holds considerable potential for understanding the deleterious effects of within person disharmony (c.f., Shedlon and Niemiec, 2006) or cross-contextual variability pertaining to BNT‘s psychological needs (Milyavaskaya et al., 2009). The ‗balanced‘ model implies that well-being is a function of the absolute level of each psychological need satisfied within a given context (the ‗additive‘ model) combined with the degree to which fulfillment of competence, autonomy, and relatedness needs operate synergistically in a state of ―equilibrium‖ (Perreault et al., 2007, p.446) within or across contexts. Observations from the present study in the bivariate correlations and multiple regression analysis did not support our a priori hypothesis that balanced psychological need satisfaction would make a unique contribution to predicting well-being above and beyond the contributions of each individual need espoused within the ‗additive‘ model. The findings concerning ‗balanced‘ psychological need satisfaction are inconsistent with past research originating with the work of Sheldon and Niemiec (2006) and replicated with an index of ill-being conceptualized as athlete burnout in young athletes by Perrault et al. (2007). A number of plausible explanations could account for the lack of support for the ‗balanced‘ model with the ‗additive‘ model of psychological need satisfaction in relation to well-being in this study. First, it is conceivable that this result is attributable to statistical artefacts stemming from considerable overall in the sample data resulting in multicollinearity that was not reported in previous studies (Perreault et al., 2007; Sheldon and Niemiec, 2006). It is likely that the operationalization of balance amongst the psychological needs was the key contributor to this statistical issue given that multicollinearity was not evident in model 1 (namely the ‗additive‘ model) tested in this study. Pedhazur and Pedhazur-Schmlekin (1991) questioned the use of multiple indicators of the same concept within multiple regression analyses which can result in model specification problems leading to multicollinearity which implies that an important future research direction will concern the optimal way to assess concepts within both ‗balanced‘ and ‗additive‘ models. Although multicollinearity seems the most compelling data-driven explanation for the observations made in this study, it seems reasonable to speculate about other issues that could explain this anomalous finding given the relative infancy of ‗balanced‘ models of psychological need satisfaction within the SDT literature (c.f., Milyavkaya et al., 2009;


167

Perrault et al,. 2007). One alternative explanation for the inability of balanced psychological need satisfaction to predict well-being within this study concerns the nature of the sample combined with the assessment of well-being. Extrapolating from the work of Milyavkaya et al. (2009), it seems reasonable to assert that for adapted sport athletes the central issue concerns balance across life domains and task roles rather than within-person stability across experiences of context-specific need satisfaction that impacts feelings of global self-regard. Such an assertion is wholly consistent with other self-perception models that posit mechanisms influencing omnibus self-esteem (c.f., Fox and Wilson, 2008) that warrant careful inquiry to appraise the merit of ‗balanced‘ and ‗additive‘ models with reference to BNT‘s constructs. Future studies may wish to address these issues carefully in longitudinal designs by examining the extent to which equilibrium (and disparity) between important life domains (such as sport, work, school, and relationships for example) contribute to well-being markers including but not limited to global self-esteem (e.g., stress, anxiety, vitality, happiness, etc). Despite the informative nature of these findings for both theory development and coach education, a number of limitations should be recognised and future directions outlined to advanced the study of both SDT in general and BNT in particular within the context of adapted sport. First, this study used a cross-sectional design that relied upon self-report data which limit the interpretations that can be extrapolated from this investigation. Future studies could extend this line of inquiry by examining variation in psychological need fulfilment from adapted sport engagement over time in relation to a broader array of well-being indicators that can be measured using methods other than self-report (e.g., salivary cortisol to index stress). Second, even though the instrument used in this study contained items pertaining to ‗typical feelings‘ experienced by adapted sport athletes it is plausible that time of assessment within the competitive season which was not standardized in this study could have impacted the participant‘s responses. Future studies would do well to address this limitation by examining the fulfillment of basic psychological needs in relation to well-being at meaningful time points throughout the competitive season to test issues of stability and change in relation to BNT constructs and well-being. Third, the nature of the sampling protocol used in the present study relied on a non-probability based approach that limits the external validity of the inferences made from this study. Additional studies drawing welldefined samples from accessible populations would be an advantage in future SDT research within the realm of competitive sport to determine the extent to which these findings are generalizable beyond the confines of a single study. Finally, additional research investigating the optimal manner in which to measure the construct of balanced psychological need satisfaction is required to advance this new line of research using BNT in sport psychology. In summary, the results of the present investigation support the central role played by experiences of psychological need satisfaction derived from adapted sport in relation to levels of well-being indexed by global self-esteem amongst competitive athletes. The observation within this study that balanced psychological need satisfaction conferred no additional information beyond the ‗additive‘ model warrants caution prior to replication. This anomalous albeit interesting observation further reinforces the importance of developing a research agenda that identifies the manner in which experiential inputs in the form of fulfilling basic psychological needs work synergistically in relation to changes in level and stability of well-being. On the basis of this investigation, it appears reasonable to contend that assessment issues germane to both perceived autonomy and balanced psychological need

168


satisfaction represent two pivotal areas ripe for future adapted sport research to explore within the SDT framework. The results of this study do nothing to undermine Deci and Ryan‘s (2002) longstanding assertion regarding the basic features of psychological needs within the SDT framework: That such experiential inputs within the self-system are directly linked with well-being. It would appear on the basis of the present findings that social contexts (such as adapted sport) which permit athletes to satisfy all basic psychological needs outlined within the BNT subcomponent of SDT seem likely to encourage athletes to report higher levels of well-being. The application of BNT and SDT to the study of relevant issues within adapted sport contexts seems justified and further examination of these theory-based approaches is recommended.

AUTHORS’ NOTES The authors‘ gratefully acknowledge the time and assistance provided by Mr. Dave Greig from the Ontario Cerebral Palsy Sports Association who assisted and supported recruitment efforts for this investigation. This project was completed in partial fulfillment of an undergraduate honors thesis at Brock University by the first author under the supervision of the second author. The second author was supported by funds from the Social Sciences and Humanities Research Council of Canada at the time of data collection and manuscript preparation. Our gratitude is extended to those athletes that took the time to participate in this project and share their adapted sport experiences with us.

REFERENCES Ahlberg, M., Mallett, C.J. and Tinning, R. (2008) Developing autonomy supportive coaching behaviors: An action research approach to coach development. International Journal of Coaching Science, 2, 3-22. Baumesieter, R. F., and Leary, M. R. (1995). The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117, 497-529. Bouchard, C., Blair, S. N., and Haskell, W. L. (2007). Physical activity and health. Champaign, IL: Human Kinetics. Canadian Paralympic Committee. (2007). Para-Sport Audit: National Report. Ottawa, Canada. Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychomtricka, 16, 297-234. deCharms, R. (1968). Personal causation: The internal affective determinants of behavior. New York, NY: Academic Press. Deci, E. L., and Ryan, R. M. (2008). Facilitating optimal motivation and psychological wellbeing across life‘s domains. Canadian Psychology, 49, 14-23. Deci, E. L., and Ryan, R. M. (2002). Handbook of self-determination research. Rochester, NY: University of Rochester Press. Eklund, R. C., and Cresswell, S. L. (2007). Athlete burnout. In G. Tenenbaum and R. C. Eklund (Eds.), Handbook of sport psychology (pp. 621–641). Hoboken, NJ: Wiley.


169

Gagné, M., Ryan, R. M., and Bargmann, K. (2003). Autonomy support and need satisfaction in the motivation and well-being of gymnasts. Journal of Applied Sport Psychology, 15, 372-390. Gagné, M., and Blanchard, C. (2007). Self-determination theory and well-being in athletes: It‘s the situation that counts. In M. S. Hagger and N. l. D. Chatzisarantis (Eds.), Handbook of intrinsic motivation and self-determination in exercise and sport (pp. 243254). Champaign, IL: Human Kinetics. Gray, C. E., and Wilson, P. M. (2008). The relationship between organizational commitment, perceived relatedness, and intentions to continue in canadian track and field officials. Journal of Sport Behavior, 31, 44-63. Fox, K. R., and Wilson, P. M. (2008). Self-perceptual systems and physical activity. In T. S. Horn (Ed.), Advances in sport psychology (3rd Edition) (pp. 49-64). Champaign, IL: Human Kinetics. Glass, G. V., and Hopkins, K. D. (1996). Statistical methods in education and psychology (3rd Edition). Boston, MA: Allyn and Bacon. Hodge, K., Lonsdale, C., and Ng, J. Y. (2008). Burnout in elite rugby: Relationships with basic psychological needs fulfillment. Journal of Sports Science, 26, 835-844. Kowal, J., and Fortier, M. S. (1999). Motivational determinants of flow: Contributions from self-determination theory. Journal of Social Psychology, 139, 355-368. Marsh, H. W. (1997). The measurement of physical self-concept: A construct validation approach. In K. R. Fox (Ed.), The physical self: From motivation to well-being. Champaign, IL: Human Kinetics. Marsh, H. W., Richards, G. E., Johnson, S., Roche, L., and Tremayne, P. (1994). Physical Self-Description Questionnaire: Psychometric properties and a multitrait-multimethod analysis of relations to existing instruments. Journal of Sport and Exercise Psychology, 16, 270-305. Martens, R. (1978). Joy and sadness in children‟s sports. Champaign, IL: Human Kinetics. McAuley, E., Duncan, T., and Tammen, V. V. (1989). Psychometric properties of the Intrinsic Motivation Inventory in a competitive sport setting: A confirmatory factor analysis. Research Quarterly for Exercise and Sport, 60, 48-58. McDonough, M. H., and Crocker, P. R. E. (2005). Sport participation motivation in young adolescent girls: The role of friendship quality and self-concept. Research Quarterly for Exercise and Sport, 76, 456-467. Milyavskaya, M., Gingras, I., Mageau, G. A., Koestner, R., Gagnon, H., Fang, J., Boiché, J. (2009). Balance across contexts: Importance of balanced need satisfaction across life domains. Personality and Social Psychology Bulletin, 35, 1031-1045. Morris, J.D. (1979). A comparison of regression prediction accuracy on several types of factor scores. American Educational Research Journal, 16, 17-24. Pedhazur, E. J. (1997). Multiple regression in behavioral research: Explanation and prediction. Orlando, FL: Harcourt Brace. Pedhazur, E. J., and Pedhazur-Schmelkin, L. (1991). Measurement, design, and analysis: An integrated approach. Hillsdale, NJ: Lawrence Erlbaum. Perreault, S., Gaudreau, P., Lapointe, M. C., and Lacroix, C. (2007). Does it take three to tango? psychological need satisfaction and athlete burnout. International Journal of Sport Psychology, 38, 437-450.

170


Podlog, L., and Eklund, R. C. (2009). High-level athletes‘ perceptions of success in returning to sport following injury. Psychology of Sport and Exercise, 10, 534-544. Ryan, R.M. (1982). Control and information in the interpersonal sphere: An extension of cognitive evaluation theory. Journal of Personality and Social Psychology, 43, 450-461. Ryan, R. M., and Deci, E. L. (2007). Active human nature: Self-determination theory and the promotion and maintenance of sport, exercise, and health. In M. S. Hagger and N. l. D. Chatzisarantis (Eds.), Handbook of intrinsic motivation and self-determination in exercise and sport (pp. 1-20). Champaign, IL: Human Kinetics. Sarrazin, P., Boiché, J. C. S., and Pelletier, L. G. (2007). A self-determination theory approach to dropout in athletes. In M. S. Hagger and N. l. D. Chatzisarantis (Eds.), Handbook of intrinsic motivation and self-determination in exercise and sport (pp. 229242). Champaign, IL: Human Kinetics. Sheldon, K. M., and Bettencourt, B. A. (2002). Psychological needs and subjective wellbeing in social groups. British Journal of Social Psychology, 41, 25-38. Sheldon, K. M., and Niemiec, C. (2006). It's not just the amount that counts: Balanced need satisfaction also affects well-being. Journal of Personality and Social Psychology, 91, 331-341. White, R. W. (1959). Motivation reconsidered: The concept of competence. Psychological Review, 66, 297-333. Winnick, J. P. (2005). Adapted physical education and sport (4th Edition). Champaign, IL: Human Kinetics.



Chapter 6

ASPERGER SYNDROME, HUMOR, AND SOCIAL WELL-BEING Ka-Wai Leung1, Sheung-Tak Cheng2 and Siu-Siu Ng2 1. Department of Applied Social Studies, City University of Hong Kong, Hong Kong 2. Department of Psychological Studies, Hong Kong Institute of Education, Hong Kong

ABSTRACT Asperger Syndrome (AS) is marked by severe social impairments. Despite a rising prevalence of AS (Edmonds and Beardon, 2008), there are few studies of these individuals, especially those concerning their social well-being. This paper reviews studies on humor and discusses its role in the social functioning of people with AS. Although studies are few, research generally suggests that individuals with AS are somewhat impaired in their ability to process humorous materials due to fragmented cognitive processes. Because humor plays an essential role in social interactions in everyday life, these findings suggest that the lack of ability to appreciate humor may be partly responsible for the social deficits in people with AS. There is a need for more research into the social competence of individuals with AS, especially in relation to the use of humor in regulating social behaviors.

INTRODUCTION The earliest understanding about Asperger syndrome (AS) could be traced back to Hans Asperger‘s work in 1944. He identified a group of children who exhibited social peculiarities and social isolation, nonetheless with average cognitive and language development. In later Address correspondence to Sheung-Tak Cheng, 10 Lo Ping Road, Tai Po, N.T., Hong Kong. E-mail: [email protected].

172

Ka-Wai Leung, Sheung-Tak Cheng and Siu-Siu Ng

years, Wing (1981) brought the Asperger syndrome to the attention of clinical professionals when she published a paper in which she discussed the syndrome based on her work with 35 individuals aged 5 to 35. In 1994, the American Psychiatric Association added the syndrome to its list of pervasive developmental disorders identified in the Diagnostic-and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Between the years, researchers have gained more knowledge about the syndrome. The diagnostic criteria for AS are qualitative impairment in social interaction in terms of the use of non-verbal behavior, unable to maintain peer relationship appropriately, difficulty with social or emotional reciprocity, occupational impairment, and repetitive and stereotyped motor movements, among others. Throughout the years, researchers have put increasing effort on studying AS, and they continue to discover discrepancies between autism and AS. McLaughlin-Cheng (1998) performed a meta-analysis on the literature on autism and AS and concluded that, children and adolescents with AS perform better than those with autism on intelligence and cognitive measures as well as measures of adaptive behavior functioning. Their language comprehension is within normal limits, and their performance in comprehension tasks is stable but they often miss the hidden meaning in language (Green, 1990). Because people with autistic features suffer from a restricted range of expression and emotions, the experience of psychological well-being in this population has been a neglected topic in this literature. Nevertheless, contrary to popular belief, sadness and depression are commonly reported by individuals with autistic spectrum disorders, except in those who have severe language impairment (Ghaziuddini, 2005). It has been reported that about 30% of people with AS and aged 5-35 are diagnosable with major depression (Wing, 1981; Ghaziuddin, Weidmer-Mikhail, and Ghaziuddin, 1998). Other than sadness, these individuals are characterized by irritability, angry outbursts, anxiety, self-injurious behaviors, and sleep and appetite disturbance (Tse, Strulovitch, Tagalakis, Meng, and Fombonne, 2007). From these preliminary data, one can reasonably argue that the study of well-being is a neglected, yet relevant, topic for this population. This chapter focuses on the potential role of humor in the well-being of persons with AS. Humor is not only a contributor to personal well-being (Lefcourt, 2002), but also plays an important role in facilitating social interactions (Neziek and Derks, 2001). Because AS is typically associated with serious social skills deficits, individuals with AS often feel being isolated and edged out (Tse et al., 2007). Given the potential benefits of humor, a missing piece in the literature therefore concerns the potential contribution of humor to the personal well-being of individuals with AS, through the promotion of social competence. Before we discuss this important issue, let us first take a more in-depth look at the social deficits of persons with AS. Following this, we will review the literature on humor and social competence, and discuss further the application of this literature to persons with AS. Specifically, we will address the extent to which individuals with AS are able to appreciate and use humor, and discuss the need to consider humor training as a means to improve the social and personal well-being of such individuals.

Asperger Syndrome, Humor,and Social Well-being

173

ASPERGER SYNDROME AND SOCIAL COMPETENCE Social competence refers to the skills and strategies that allow individuals to have meaningful friendships, engage in close and emotion-based relationships, maintain social well-being, involve others to form groups, teams, and work partners, manage public social settings, and participate in family functioning (Gutstein and Whitney, 2002). Denham et al. (2001) emphasized that social competence is a critical variable predicting success in life. Social competence is defined in terms of (a) secure attachment to other people, (b) instrumental social learning, and (c) experience-sharing relationships. Any significant deficits in any of these areas would result in eventual social failure (Bruner, 1983; Emde, 1989; Fogel, 1993; Gottman, 1984; Gutstein and Whitney, 2002). People with AS are clumsy as well as peculiar in their social interactions patterns. This syndrome has been described as the foremost social disorders by many researchers (Asperger, 1944; Frith, 1991; Green, 1990; Kerbeshian, Burd, and Fisher, 1990; McLaughlin-Cheng, 1998; Myles and Adreon, 2001; Myles and Simpson, 2001; Szatmari, 1991; Wing, 1981). Although they may be able to pick up some social skills over time, their social difficulties continue well into adulthood. A study conducted by the National Autistic Society of Great Britain (Bernard, Harvey, Potter, and Prior, 2001) on the adult outcomes of individuals with AS showed that they were far less socially active than typically developing individuals. Over one-third (37%) had no participation at all in social activities, while only 50% reported going out no more than once or twice a month. Their social impairment is even more severe than other children known to have major social problems, such as those with conduct disorders (Green, Gilchrist, Burton, and Cox, 2000). However, compared with people with autism, people with AS are different in terms of their desire for social interactions with others (Wing, 1981), though their relationships with peers are often ad hoc or ―shallow‖. Church et al. (2000) suggested that, children with AS aged 8-12 have highly variable social skills. In their study, none of their participants, as reported by their parents, teachers, and health-care providers, had deep, reciprocal relationships with other children, but several had superficial relationships with other children. Most of them never asked to have a friend or asked to make telephone calls to other children. Friendship often starts with two individuals exploring each other‘s thoughts, feelings, attitudes and behaviors. Hence self-disclosure as well as taking an interest in others are fundamental to relationship formation. However, Hobson (1993) noted that people with AS ―do not fully understand what it means for people to share and coordinate their experiences‖ (p.5). Mundy et al. (1993) commented that individuals with AS are in lack of the desires to share their interests and happiness with others. In fact, compared with typically developing ones, they have less interest in exploring their own self, let alone sharing their thoughts and feelings with others (Gutstein and Whitney, 2002). Frith, Happé and Siddons (1994) have asserted that the inability to interpret the mental states, whether those of others or their own, is the primary reason why individuals with AS remain impaired in their everyday social interactions. The inability to share experiences makes it difficult for people with AS to build reciprocal relationships with friends. Wimpory, Hobson, Williams and Nash (2000) reported significantly less emotional engagement and ability to express themselves in individuals with AS than in their typical peers. They take fewer social initiations. Even if they start the

174


conversation with peers, it would be mostly about providing information to peers on topics in which they are deeply interested. Concerning gestures, they have limited eye gaze shifting, and do not point to or show objects to partners for the sake of sharing their feelings and experiences with them. Church, Alisanski and Amanullah (2000) identified two distinct patterns of interaction among children with AS: They are either quiet, unassuming, demanding less from peers, or they are active, energetic, violating social boundaries (adopting the ―in your face‖ style of interacting). These awkward social styles are believed to make typical peers uncomfortable, thus becoming obstacles for them to develop good peer relationships. Although these are promising research directions, given the nature of AS, the social difficulties experienced by these individuals are likely to be contributed by many factors. This paper considers one such factor in detail: humor.

HUMOR AND SOCIAL COMPETENCE One of the factors that may lead to problems in social functioning is the lack of humor. Humor is an element in social interaction, and applying it can facilitate the growth of interpersonal relationships. Humorous people are more confident in interacting with others. (Nezlek and Derks, 2001). Sometimes being humorous brings joyfulness between friends. Paulos (1980) defined humor as ―a complex and human phenomenon, any understanding of it will necessarily enrich our understanding of thought in general‖ (p. 102). Humor also plays a major role in human life and it facilitates our communication of feelings, line of thinking, and ideas (Brownell and Gardner, 1988). Nahemow (1986) considered humor to be a defining human attribute. In a diary study, college students with more efficacious use of humor reported more pleasurable interactions as well as spending more time in interactions on a daily basis (Nezlek and Derks, 2001). Humor is an under-studied element that may have farreaching implications for the social competence of AS individuals. If persons with AS have difficulty understanding humor, they may withdraw from interaction simply because they misinterpret other people‘s humorous messages as intending to tease or make fun of them. Cognitive theories are the main perspectives to explain humor appreciation. Cognitive approaches emphasize the structure of the humorous stimuli and the cognitive processes involved in humor appreciation. Researchers stressed the concept of solving incongruity as the key element throughout the cognitive processes of humor appreciation. Incongruity is defined as inconsistency between (at least) two potential meanings in a humor stimulus; one of them is normal and congruent to what the person perceives or expects, whereas the other is comparatively out of expectation. The person could only solve the incongruity by accepting the sudden perception of the unexpected meaning, and realize it as ―fit‖ for the situation (Dixon, 1980; Paulos, 1980). The incongruity resolution model (Suls, 1972) postulates a twostage process in humor appreciation. In the first stage, the person finds that his or her expectation about the text is inconsistent with the ending, and incongruity is encountered. In the second stage, because of incongruity, the person engages in a problem-solving process in order to solve the inconsistency and reconcile the incongruent part of the humor. Martin, Puhlik-Doris, Larsen, Gray and Weir (2003) developed the humor styles questionnaire, and conceptualized four dimensions of humor styles, what were believed to


175

have different uses or functions in everyday life. Two of these dimensions are conducive to psychosocial well-being: self-enhancing and affiliative humor styles. In a similar vein, Klein and Kuiper (2006) noted that these are ―positive‖ humor styles, which are characterized by self-enhancement and expressing the need for affiliation. Self-enhancing humor styles serve to buffer and protect the self, but not at the expense of others. Affiliative humor styles are intended to arouse amusement in the target and reduce tension or conflict in social situations. Applying these humor styles may help individuals cope with everyday difficulties, minimize negative emotions, and maintain harmony with others. On the contrary, self-defeating and aggressive humor styles are potentially damaging (Martin et al., 2003). People with self-defeating humor styles hide negative feelings and avoid contribution to problem-solving. Those with aggressive humor styles tease, ridicule, or make sarcastic remarks of others, resulting in negative social outcomes because they make others uncomfortable and are not perceived to be friendly. Humor can be positive or negative, depending on whether they are appropriately used to facilitate interaction. For example, the same humor used in an improper situation can cause much embarrassment and negative reactions from others. Hence the effective use of humor requires tact and accurate social perception which may be disadvantages for people with AS. Judging from this perspective, research which does not differentiate functional versus dysfunctional humor styles may be missing the target, because a person might be displaying a great sense of humor, but in a dysfunctional way. Whether persons with AS are in lack of certain humor styles, or whether they have no sense of humor at all, is an issue yet to be resolved. Nevertheless, it is generally believed that some degree of humor deficit is responsible for the social difficulties that these individuals experience on a day-to-day basis. In order to fully understand the role of humor in the social problems of AS individuals, research should assess both functional and dysfunctional humor tasks in the future.

ASPERGER SYNDROME AND HUMOR Asperger (1944) and Frith (1991, p. 82) described people with AS as ―rarely relaxed and carefree‖ and they ―never achieve that particular wisdom and deep intuitive human understanding that underlie genuine humor.‖ However, Lyons and Fitzgerald (2004) argued that people with AS could understand and appreciate simple forms of humor (i.e., slapstick humor and simple jokes), both verbal and non-verbal, although they are not as competent as typically developing individuals. Some people with AS are gifted, and this might facilitate their sense of humor because of their outstanding ability in comprehension, especially in their areas of interest, such as scientific and mathematical humor. Moreover, their advanced and well-developed linguistic and computational abilities are advantages for grasping and appreciating humor in some ways. A very good example would be Patricia Highsmith, a wellknown American crime writer. Despite suffering from AS, she was gifted in writing ability. Using her black humor, Patricia received high achievement in the writing career. Yet, some of the readers did not appreciate her writing because it did not show a warm sense of humor. This kind of dark, cruel sense of humor where theory of mind was usually missing is a typical form of Asperger humor (Lyons and Fitzgerald, 2005).

176


Some individuals with AS are able to master to some extent the cognitive processing of humor (i.e., incongruity and its resolution) and the switching of meanings in relatively complex humorous word games (Lyons and Fitzgerald, 2004). Individuals with AS, however, tend to comprehend humor from a more intellectual perspective, such as by logical inference using surface meanings, which are often motivated by their own obsessive interest areas. For instance, they understand humor simply by the surface meaning of the language rather than the hidden/implied meaning of the words. This is the reason why they often fail to understand humor as they are unable to realize the incongruity embedded in messages. Adams and Earles (2003) reported the inconsistent pattern in which children with AS respond to humor comic stories too. Referring to their study, participant 1 smiles to three comic episodes, participant 2 did not respond positively to any episodes, and participant 3 laughed at all five episodes. Werth et al. (2001), nevertheless, described a case study with a lady, Grace, with high-functioning autism, which may also be treated as AS. Grace had a great sense of humor, which was considered by the authors to be a kind of obsessive creativity. For instance, she loves to frequently invent humorously incongruous and often irrelevant word plays. She was positively reinforced by the reactions of her audiences who found her ―inventions‖ funny. Grace also has a predominant form of humor, which was based on the acoustic properties of word plays. Her great sense of humor also enhances her ability to answer riddles, jokes, and in teasing and sneering. However Werth et al. (2001) perceived Grace‘s self-generated ―humorous products‖ to be structured and nonetheless clumsy, which might have been largely self-stimulating. Although the above studies were based on case studies or small samples, there was some preliminary evidence that people with AS are humorous in some ways, rather than lacking humor totally. Thus it is important for research to specify the nature of humor deficits and how such deficits can be improved, thereby enhancing the well-being of individuals with AS. A problem in considering this literature is the variation across studies in terms of the methods or stimuli to test humor appreciation ability. Sometimes cartoons were used; at other times, it was simply joke tasks (in words). Different stimuli require different types of cognitive processing, which may in turn generate discrepant results because individuals with AS may have different abilities in comprehending both visual tasks (cartoons) and semantic tasks (jokes). A study by Emerich et al. (2003) was revealing. These authors adopted Garfield cartoons and jokes to examine the comprehension of humorous materials by adolescents with AS and those developing normally, aged 11-17. The two groups were matched on age and gender. Cartoon comics and jokes were given to participants, who were asked to pick the funniest endings. Participants with AS tended to choose straightforward endings as the funniest for cartoon comic tasks, though their number of errors were not significantly different from typically developing participants. For joke tasks, however, persons with AS performed significantly worse, making almost three times as many errors as typically developing children. On the whole, the literature suggests that persons with AS are more capable of processing humorous materials when the messages are more concrete and fall into their areas of interest, and when visual aids are available. However, the results appear to depend to a large extent on the methods and stimuli used. Further research may reveal in more specific terms the exact nature of the deficit in humor processing ability of AS individuals.


177

HUMOR AND SPECIFIC COGNITIVE AND SOCIAL DEFICITS Tanguay, Robertson and Derrick (1998) factor analyzed the Autism Diagnostic Interview (Revised) items, and identified three factors, which were (i) affective reciprocity, (ii) joint attention, and (iii) theory of mind. These factors reflect the primary cognitive and social deficits in autistic-spectrum disorders that might have relevance for understanding the ability to comprehend and use humor by individuals with AS.

Affective Reciprocity Affective reciprocity is the quality by which a person is responsive to others‘ affections or emotions. This quality can usually be seen in infants before one year of age. It is the tendency to produce responses in order to get social interactions and social cues from others. Such deficits may be seen in AS individuals in terms of the lack of responsiveness to others‘ emotions such as distress (Bacon, Fein, Morris, Waterhouse, and Allen, 1998) and the absence of empathy (Travis and Sigman, 1998). This quality is different from joint attention and theory of mind (to be described below) which are related to the pragmatics for social communication through facial expressions, gestures, and identifying and taking considerations of other people‘s view (Tanguay, Robertson, and Derrick, 1998). AS individuals with deficits in affective reciprocity may not be able to realize others‘ affections when people are using humor on them. For instance, a person is trying to make fun on them humorously, and people with AS may misunderstand the act as an attempt to tease them, and feel offended.

Joint Attention Joint Attention is the process of sharing one‘s experience of observation, by following gaze or pointing gestures. This ability starts to appear within the first year of life. Tanguay et al. (1998) reported that, at two to four months of age, 30% of children are capable of following their mother‘s line of sight or to follow a moving object automatically. By 14 months, most typically developing children can do so without prompting verbally or by gestures. Children with autism, however, do not seem to recognize the emotional and contextual meaning of facial expressions and gestures as well as the non-verbal expressions of emotion by others (Hobson, 1986). Reddy, Williams and Vaughan (2002) said they sometimes appear to be ―deaf‖ in social interactions, in that they do not give appropriate responses to other people‘s facial expression (e.g., give laughter to a funny face, show anger when being teased). Mundy, Sigman and Kasari (1993) noted that, the infrequent initiations of joint attention by children with AS is also an indication of their inability to integrate their object world with their own social world. It can be expected that AS individuals who are not fluent, or even lacking, in joint attention ability are unable to appreciate humor because of their insensitivity towards others‘ emotions. This is a major obstacle in developing social relationships.

178


Theory of Mind Theory of mind refers to the ability to think about and act on the information about one‘s own and others‘ mental states, that is, to take the perspective of others when it is different from one‘s own (Lyons and Fitzgerald, 2004). Because humor appreciation requires one to discern the intentions of the other party, a deficit in theory of mind can lead to profound impairments in understanding humorous materials. Children with AS are relatively competent in nonverbal concept formation tasks, perceptual organization and spatial visualization (Ehlers et al., 1997), but comparatively poorer in understanding social mores, social judgment, and interpreting interpersonal situations. Hence, in appreciating humor, they may be more capable of grasping meaning in comics (visual) than understanding humorous jokes or conversation, because the former is more concrete, requiring a lower level of cognitive processing, whereas the latter is more abstract and requires perspective taking. Individuals with AS also have difficulties in showing empathy and appreciating the feelings and thoughts of others (Barnhill, 2001; Baron-Cohen, Leslie, and Frith, 1985). Many researchers argued that the lack of theory of mind is the core deficit in autism (Baron-Cohen, 1988; Happé, 1993; Tager-Flusberg, 1993). Researchers gave children AS first-order and second-order tasks assessing theory of mind. The first-order tests assess the ability to recognize that people can have different thoughts even in the same situation. The secondorder tests examine the ability to interpret the mental states of others, such as making inferences or predictions about other people‘s thoughts, beliefs, desires, emotions, and intentions (Papp, 2006). Research on theory of mind suggests that individuals with AS can perform first-order ToM tests, but not the second-order tests. In other words, they are able to understand that other people can have different thoughts from them, but less able in anticipating thoughts of others. (Baron-Cohen, 1995). Thus, even if they are aware that other people have their own thoughts and feelings, they may not be able to tell what they are thinking in a particular situation. However, not all children are incapable of second-order theory-of-mind tasks. Williams (2004) presented findings from an interpretative phenomenological analysis of ten published autobiographical accounts written by individuals diagnosed with either high-functioning autism or Asperger syndrome. His analysis suggested that less than half of the subjects could finish second-order tests. However, even for this subgroup, which was seemingly without apparent deficits in theory of mind, there was still a deficit in mind-reading ability. For instance, they may not realize irony from a person‘s voice but take instead the surface meaning of the message. Also, they may misinterpret a lie as a joke, or deception as sarcasm. According to Ozonoff, Rogers and Pennington (1991), although children and youth with AS may be able to complete theory-of-mind exercises, they encounter difficulties in applying those skills in real-life situations. In ordinary life circumstances, persons with AS are observed to display deficits across a range of tasks, including difficulties in inferring the intentions and perspectives of others, a lack of understanding of how their own behaviors affect others, and difficulties with turn-taking and other reciprocal skills. A total lack of theory of mind would result in a condition in which the person shuts down his or her perception towards the outside world, and show minimal or even no interaction with their surroundings at all (Happé, 2003).


179

DISCUSSION AND CONCLUSION Humor, or the ability to appreciate humor is, to a certain extent, one of the key components in successful interpersonal relationships. Across cultures, sense of humor is one of the essential social skills. Positive humorous exchanges are vital and valuable, as it encourages playfulness (Bruner and Sherwood, 1976). Those with a positive sense of humor are much more able to form alliances with others (Gest, Graham-Bermann, and Hartup, 2001). Asperger syndrome is a heterogeneous disorder, and so it is no wonder that studies have shown substantial variations in the humor ability of individuals with AS. For obvious reasons, studies have relied on small samples, which increase the errors of estimation. Nevertheless, some preliminary conclusions from this literature are possible. First, the ability to process humor is not totally absent in people with AS. Because of their mastery of linguistic abilities, they appear to be able to appreciate humor by processing the surface meaning of sentences or jokes, although they tend to have difficulty in actually realizing the hidden meaning. As their abilities to interpret social surroundings are qualitatively different from those of typically developing people in terms of affective reciprocity, joint attention, and also theory of mind, they appear to have difficulty in achieving intuitive understanding of humor. Moreover as people with AS are fluent in topics in which they have deep interest, they are more capable of understanding humor if the materials match their interests or obsessions, and if the materials come in visual form. The above observations lead us to the question of whether individuals with AS should be given training on the use of humor in social interactions. Although controlled studies are lacking, preliminary research on social skills training has yielded inspiring results. A study by Tse et al. (2007) at the Montreal Children‘s Hospital suggested that social skills training was useful in improving the social competence and reducing the problematic behaviors of adolescents with AS and high-functioning autism. Social skills were taught over 12 weeks through role plays based on the psychoeducational and experiential methods. Parents of the participants responded to measures of the adolescents‘ social adjustment and problem behaviors. Though without a control group, the pre- and post-treatment ratings by the parents suggested improvement in social competence and reduction in problem behaviors. The parents also reported that the social skills learned in the group could be generalized to real life. Although this study did not include humor training, it conveyed an initial enthusiasm about the utility of social skills training. In view of the potential contributions of the use of humor to social well-being, the incorporation of humor training to such interventions should be considered in the future. Other than humor training, a number of issues need to be addressed in future research. First, research should assess humor in more comprehensive ways so that the relative strengths and weaknesses of AS individuals in response to different kinds of humor stimuli can be discerned. Second, research should distinguish between positive (functional) and negative (dysfunctional) humor, and examine if AS individuals are capable of using both kinds of strategy. Third, research should go beyond assessing humor in laboratories and actually examine the contribution of humor deficit to social difficulties in AS individuals. In this connection, the issues of generalizability and ecological validity must be addressed. The issue of sample size aside, the humorous stimuli used in most studies may not have any bearing on

180


the use of humor in social interactions in real life. For instance, the ability to pick a humorous ending for a cartoon may not mean better ability in using humor to develop and maintain relationships with peers. Finally, studies have focused on humor appreciation; empirical data on how humor is used by persons with AS, as compared with typically developing persons, in actual social situations, and the effect on social relationships, are lacking. These are all important issues that need to be addressed before we can draw definitive conclusions regarding the role of humor in the social difficulties of people with AS. In conclusion, research on humor with reference to AS is a new and promising direction for furthering our understanding of the social difficulties faced by these individuals. Inabilities to understand humor hinder them from social well-being development. Humor provides a new perspective into why these individuals, despite relatively normal language development, are still incapable of forming social relationships. Such knowledge may eventually lead to the development of new intervention approaches for this population.

REFERENCES Adams, L., and Earles, W. (2003). Humor and children with Asperger syndrome. Retrieved from http://l-adams.asp.radford.edu/HANDOUTS.htm, on 15, December, 2006. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: Author. Asperger, H. (1944). Autistic psychopathy in children. In U. Frith (Ed.), Autism and Asperger‟s syndrome (pp. 37-92), Cambridge, Great Britain: Cambridge University Press. Bacon, A. L., Fein, D., Morris, R., Waterhouse, L., and Allen, D. (1998). The responses of autistic children to the distress of others. Journal of Autism and Developmental Disorders, 28(2), 129-142. Barnhill, G. P. (2001). Social attribution and depression in adolescents with Asperger syndrome. Focus on Autism and Other Developmental Disabilities, 16, 46-53. Baron-Cohen, S. (1988). Social and pragmatic deficits in autism: Cognitive or affective? Journal of Autism and Developmental Disorders, 18, 379-402. Baron-Cohen, S., (1995). Mindblindness: An essay on autism and theory of mind. Cambridge, MA: MIT Press. Baron-Cohen, S., Leslie, A. M., and Frith, U. (1985). Does the autistic child have a ―theory of mind‖? Cognition, 21, 37-46. Bernard, J., Harvey, V., Potter, D., and Prior, A. (2001). Ignored or ineligible? The Reality for Adults with Autism Spectrum Disorders (Report for Autism Awareness Week 2001). London: The National Autistic Society. Brownell, H., and Gardner, H. (1988). Neuropsychological insights into humor. In J. Durant and J. Miller (Eds.). Laughing matters: A serious look at humor (pp. 17-34). New York: Longman. Bruner, J., and Sherwood, V. (1976). Early rule structure: The case of peekaboo. In J. Bruner, A. Jolly and K. Sylva (Eds.). Play: Its role in evolution and development (pp. 277-285). Harmondsworth: Penguin.


181

Bruner, J. S. (1983). Child‟s talk. Oxford, England: Oxford University Press. Church, C., Alisanski, S., and Amanullah, S. (2000). The social, behavioral, and academic experiences of children with Asperger syndrome. Focus on Autism and Other Developmental Disabilities, 15(1), 12-20. Denham, S., Mason, T., Caverly, S., Schmidt, M., Hackney, R., Caswell, C., and Demulder, E. (2001). Preschoolers at play: Co-socializers of emotional and social competence. International Journal of Behavioral Development, 4, 290-301. Dixon, N. F. (1980). Humor: A cognitive alternative to stress? In I. Sarason and C. Spielberger (Eds.), Stress and Anxiety, 7, 281-289. New York: Hemisphere. Edmonds, G., and Beardon, L. (Eds.) (2008). Asperger syndrome and social relationships: Adults speak out about Asperger syndrome. London: Jessica Kingsley. Ehlers, S., Nyden, A., Gillberg, C., Sandberg, A. D., Dahlgren, S., Hjelmquist, E., and Oden, A. (1997). Asperger syndrome, autism and attention deficits disorders: A comparative study of cognitive profiles of 120 children. Journal of Child Psychology and Psychiatry and Allied Disciplines, 38, 207-217. Emde, R. N. (1989). The infant‘s relationship experience: Developmental and affective patterns. In A. Sameroff and R. Emde (Eds.), Relationship Disturbances in early Childhood: A Developmental Approach (pp. 33-51). New York: Basic Books. Emerich, D. M., Creaghead, N. A., Brether, S. M., Murray, D., and Grasha, C. (2003). The comprehension of humorous materials by adolescents with high-functioning autism and Asperger‘s syndrome. Journal of Autism and Developmental Disorders, 33(3), 253-257. Fogel, A. (1993). Developing through relationships. Chicago: The University of Chicago Press. Frith, U. (1991). Autism and Asperger syndrome. Cambridge, UK: Cambridge University Press. Frith, U., Happé, F., and Siddons, F. (1994). Autism and theory of mind in everyday life. Social Development, 3, 108-124. Gest, S. D., Graham-Bermann, S. A., and Hartup, W. W. (2001). Peer experience: Common and unique features of number of friendships, social network centrality, and sociometric status. Social Development, 10(1), 23-40. Ghaziuddin, M. (2005). Mental health aspects of autism and Asperger syndrome. London: Jessica Kingsley. Ghaziuddin, M. Weidmer-Mikhail, E. and Ghaziuddin, N. (1998). Comorbidity of Asperger syndrome. A preliminary report. Journal of Intellectual Disability Research , 4, 279-83. Gottman, J. M. (1984). How children become friends. Monographs of the Society for Research in Child Development, 3, Number 201. Green, J. (1990). Is Asperger‘s a syndrome? Developmental Medicine and Child Neurology, 32, 743-747. Green, J., Gilchrist, A., Burton, D., and Cox, A. (2000). Social and psychiatric functioning in adolescents with Asperger syndrome compared with conduct disorder. Journal of Autism and Developmental Disorders, 30, 279-293. Gutstein, S. E., and Whitney, R. K. (2002). Relationship development intervention with young children: Social and emotional developmental activities for Asperger syndrome, autism, PDD and NLD. London: Jessica Kingsley. Happé, F. (1993). Communicative competence and theory of mind in autism: A test of relevance theory. Cognition, 48, 101-119.

182


Happé, F. (2003). Theory of mind and the self. Annals of New York Academy of Sciences, 1001, 134-144. Hobson, R. P. (1986). The autistic child‘s appraisal of expressions of emotion. Journal of Child Psychology and Psychiatry, 27, 321-342. Hobson, R. P. (1993). Autism and the development of mind. Hillsdale, NJ: Erlbaum. Kaplan, S. (1987). Aesthetics, affect, and cognition: Environmental preference from an evolutionary perspective. Environment and Behavior, 19, 3-32. Kaplan, S., and Kaplan, R. (1982). Cognition and environment: Functioning in an uncertain world. New York: Praeger. Kerbeshian, J., Burd, L., and Fisher, F. (1990). Asperger‘s syndrome: To be or not to be? British Journal of Psychiatry, 156, 721-725. Klein, D. N., and Kuiper, N. A. (2006). Humor styles, peer relationships, and bullying in middle childhood. Humor, 19(4), 383-404. Lefcourt, H. M. (2002). Humor. In C. R. Syner and S. J. Lopez (Eds.), Handbook of positive psychology. (pp.619-631). New York: Oxford University Press. Lyons, V., and Fitzgerald, M. (2004). Humor in autism and Asperger syndrome. Journal of Autism and developmental Disorders, 34(3), 521-531. Lyons, V., and Fitzgerald, M. (2005). Asperger syndrome: A gift or a curse? New York: Nova Biomedical. Martin, R. A., Puhlik-Doris, P., Larsen, G., Gray, J., Weir, K. (2003). Individual differences in uses of humor and their relation to psychological well-being: Development of the Humor Styles Questionnaire. Journal of Research in Personality, 37, 48-75. McLaughlin-Cheng, E. (1998). Asperger syndrome and autism: A literature review and metaanalysis. Focus on Autism and Other Development Disabilities, 13(4), 234-245. Mundy, P., Sigman, M., and Kasari, C. (1993). The theory of mind and joint-attention deficits in autism. In S. Cohen, H. Tager-Flusberg and D. Cohen (Eds.), Understanding other minds: Perspectives from autism (pp. 181-203). Oxford, England: Oxford University Press. Myles, B. S., and Adreon, D. (2001). Asperger syndrome and adolescence: Practical solution for school success. Shawnee Mission, KS: Autism Asperger Publishing. Myles, B. S., and Simpson, R. L. (2001). Understanding the hidden curriculum: An essential social skill for children and youth with Asperger syndrome. Intervention in School and Clinic, 36, 279-286. Nahemow, L. (1986). Humor as a data base for the study of aging. In L. Nahemow, K. A. McCluskey-Fawcett and P. E. McGhee (Eds.). Humor and aging (pp.3-26). Orlando, FL: Academic Press. Nezlek. J. B., and Derks. P. (2001). Use of humor as a coping mechanism, psychological adjustment, and social interaction. Humor: International Journal of Humor Research, 14, 395-413. Ozonoff, S., Rogers, S., and Pennington, B. (1991). Asperger‘s syndrome: Evidence of an empirical distinction from high-functioning autism. Journal of Child Psychology and Psychiatry, 32, 1107-1122. Papp, S. (2006). A relevance-theoretic account of the development and deficits of theory of mind in normally developing children and individuals with autism. Theory and Psychology, 16(2), 141-161. Paulos, J. A. (1980). Mathematics and humor. Chicago: University of Chicago Press.


183

Reddy, V., Williams, E., and Vaughan, A. (2002). Sharing humour and laughter in autism and Down‘s syndrome. British Journal of Psychology, 93, 219-242. Suls, J. M. (1972). A two-stage model for the appreciation of jokes and cartoons: An information-processing analysis. In J. H. Goldstein and P. E. McGhee (Eds.) The psychology of humor: Theoretical perspectives and empirical issues (pp. 81-100). New York: Academic Press. Szatmari, P. (1991). Asperger‘s syndrome: Diagnosis, treatment, and outcome. Pediatric Clinics of North America, 14(1), 81-92. Tager-Flusberg, H. (1993). What language reveals about the understanding of minds in children with autism. In S. Baron-Cohen, H., Tager-Flusberg and D. J. Cohen (Eds.), Understanding other minds: Perspectives from autism. Place?Oxford University Press. Tanguay, P., Robertson, J., and Derrick, A. (1998). A dimensional classification of autism spectrum disorder by social communication domains. Journal of American Academy of Child and Adolescent Psychiatry, 37, 271-277. Travis, L. L., and Sigman, M. (1998). Social deficits and interpersonal relationships in autism. Mental Retardation and Developmental Disabilities Research Review, 2, 65-72. Tse, J., Strulovitch, J., Tagalakis, V., Meng, L., and Fombonne, E. (2007) Social skills training for adolescents with Asperger syndrome and high-functioning autism. Journal of Autism and Developmental Disorders, 30, 1960-1968. Werth, A., Perkins, M., and Boucher, J. ―Here‘s the weavery looming up‖. Autism: The International Journal of Research and Practice, 5(2), 111. Williams, E. (2004). Who really needs a ‗theory of mind‘? An interpretative phenomenological analysis of the autobiographical writings of ten high-functionong individuals with an Autism Spectrum Disorder. Theory and Psychology, 14, 704-724 Wimpory, D. C., Hobson, R. P., Williams, J. M., and Nash, S. (2000). Are infants with autism socially engaged? A study of recent retrospective parental reports. Journal of Autism and Developmental Disorders, 30, 525-536. Wing, L. (1981). Asperger syndrome: A clinical account. Psychological Medicine, 11, 115129.



Chapter 7

BIG FIVE PERSONALITY TRAITS AS PREDICTORS OF EUDAIMONIC WELL-BEING IN IRANIAN UNIVERSITY STUDENTS Mohsen Joshanloo1 and Samaneh Afshari2 1. Department of Psychology, Chonnam National University, Gwangju, South Korea 2. Department of Psychology and Education, Allameh Tabatabai University, Tehran, Iran

ABSTRACT This study examined the relation between the Big Five personality traits and eudaimonic well-being in Iran, which is an understudied country in the well-being literature. Participants were 240 undergraduates at the University of Tehran. In this study, purpose in life, personal growth, and social well-being scales were used to assess eudaimonic well-being, given the central role these constructs play in the existing models of eudaimonic well-being. Findings revealed that, among the Big Five personality traits, conscientiousness and neuroticism were the most vigorous predictors of eudaimonic wellbeing. Results also revealed that male students scored significantly higher than female students on social well-being. Furthermore, gender moderated the relation between eudaimonic well-being and two traits of extraversion and agreeableness. These relations were significantly stronger for male students than female students. Implications of the results are discussed.

Keywords: Eudaimonic well-being; Social well-being; Big Five; Iran

Corresponding author: [email protected].

186

Mohsen Joshanloo and Samaneh Afshari

INTRODUCTION The distinction between hedonic and eudaimonic aspects of well-being has repeatedly proved meaningful and informative (for example see Delle Fave and Bassi, 2009; Keyes and Annas, 2009; Keyes, Shmotkin, and Ryff, 2002; Ryan and Huta, 2009; Ryan, Huta, and Deci, 2008; Vittersø et al., 2010). On the hedonic view, well-being is equated with hedonic pleasure or happiness. ―Indeed, the predominant view among hedonic psychologists is that well-being consists of subjective happiness and concerns the experience of pleasure versus displeasure broadly construed to include all judgments about the good/bad elements of life‖ (Ryan and Deci, 2001, p. 144). Most research in the so-called ―hedonic‖ psychology has used assessment of subjective well-being. Subjective well-being is generally operationalized as both a predominance of positive over negative affect (affect balance) and a global satisfaction with life (Diener, 1984). In other words, if a person reports that her life is satisfying, that she is experiencing frequent pleasant affect, and that she is infrequently experiencing unpleasant affect, she is said to have high subjective well-being (Diener and Lucas, 1999). Eudemonistic view, on the other hand, maintains that well-being cannot be equated with hedonia (Ryan and Deci, 2001). According to Keyes and Annas (2009), eudaimonia is the person‘s activity that is explicated in terms of living virtuously. In other words, as Solomon and Martin (2004) put it, eudaimonia is a life of activity in accordance virtue. Virtue ethics can be traced back to ancient Greek philosophers, including Aristotle. Psychologists adhering to the eudemonistic view consider well-being to consist of more than just hedonic pleasure, suggesting that people‘s reports of being happy (or of being positively affective and satisfied), although beneficial in its turn, do not necessarily mean that they are functioning psychologically and socially well. Instead, eudaimonic view is concerned with living well and actualizing one‘s human potentials (Deci and Ryan, 2008). Ryff‘s (1989) model of psychological well-being falls into the eudaimonic tradition. Her model stems from extensive literature aimed at defining positive psychological functioning (e.g., the mental health and lifespan developmental theories, humanistic and existential views). She tried to integrate these scattered formulations into a multidimensional model of positive psychological functioning, which encompasses the points of convergence in the previous formulations. The model resulted from this distillation contains six components: ―positive evaluations of oneself and one's past life (Self-Acceptance), a sense of continued growth and development as a person (Personal Growth), the belief that one's life is purposeful and meaningful (Purpose in Life), the possession of quality relations with others (Positive Relations With Others), the capacity to manage effectively one's life and surrounding world (Environmental Mastery), and a sense of self-determination (Autonomy)‖ (Ryff and Keyes, 1995, p. 720). Like Keyes (2006) who believes that eudaimonism animates human concerns with developing nascent abilities and capacities toward becoming a more fully functioning person and citizen, Ryff and Singer (2008) also believe that the central point in Aristotle‘s definition of eudaimonia is that the ultimate aim in life is to strive to realize one‘s true potential (selffulfillment or self-realization). Following this logic, Ryff and Singer (2008) argue that of all the aspects of psychological well-being, it is personal growth that comes closest in meaning to Aristotle‘s eudaimonia.

Big Five Personality Traits as Predictors…

187

As noted earlier, existential and humanistic views were among the sources that Ryff (1989) drew on to formulate her model of positive human functioning. Humanistic and existential views suggest that it is sometimes difficult to find meaning and purpose in life in the modern times. Ryff and Singer (2008) believe that considering existential views are advantageous to the formulation of eudaimonia, as they bring eudaimonia face-to-face with adversity, something on which, they believe, Aristotle is surprisingly silent. Ryff and Singer (2008) consider purpose in life and personal growth as the ―two most eudaimonic aspects of well-being‖ (p. 27). Likewise, Keyes, Shmotkin, and Ryff (2002) point out that these two aspects better reflect the self-fulfillment meanings of psychological well-being than other aspects. Indeed, purpose in life and personal growth play central roles in the work of other researchers of eudaimonic well-being. Waterman and colleagues (Waterman, Schwartz, and Conti, 2008) argue that eudaimonia refers to the feelings present when one is moving toward self-realization. Waterman (1993) maintains that ―activities giving rise to feelings of personal expressiveness will be those in which an individual experiences self-realization through the fulfillment of personal potentials in the form of the development of one's skills and talents, the advancement of one's purposes in living, or both‖ (p. 679). In other words, eudaimonia can be obtained through developing one‘s unique individual potentials and furthering one‘s purposes in living (Waterman, Schwartz, and Conti, 2008). Meaning in life is considered essential to a well-rounded assessment of well-being by many other researchers (e.g., Huta and Ryan, in press; McGregor and Little, 1998; Ryan, Huta, and Deci, 2008). Personal growth also has been considered a central component of eudaimonic well-being by many researchers (e.g., Compton, Smith, Cornish, and Qualls, 1996; Ryan and Deci, 2001; Vittersø et al., 2010). All in all, it can be concluded that purpose in life and personal growth are among the most central aspects of psychological well-being which are considered to be most related to eudaimonia.

SOCIAL COMPONENT OF EUDAIMONIC WELL-BEING According to Keyes and Shapiro (2004), what has been missing in the well-being literature is the recognition that individuals may evaluate the quality of their lives and personal functioning against social criteria. Keyes‘s (1998) brief review shows that the distinction between public and private sides of life has pervaded social psychological theory. Keyes (1998) argues that the private and public sides of life are two potential sources of life challenges, with possibly distinct consequences for judging a well-lived life. Despite this distinction, the ―leading conceptions of adult functioning portray well-being as a primarily private phenomenon‖ (Keyes, 1998, p.121) and emphasize private features of well-being. That is, according to Keyes (2002), measures of hedonic well-being often identify individuals‘ satisfaction or positive affect with ―life overall‖, but rarely with facets of their social lives. Keyes (2002) points to the fact that dimensions of psychological well-being are also intrapersonal reflections of an individual‘s adjustment to and outlook on their life. Only one of the six scales of psychological well-being (positive relations with others) reflects the ability to build and maintain intimate trusting interpersonal relationship (Keyes, 2002). But ―individuals remain embedded in social structures and communities, and face countless social

188


tasks and challenges‖ (Keyes, 1998, p. 122). Accordingly, Keyes (1998) asserts that there is more to functioning than psychological well-being and believes that to understand optimal functioning and mental health, social scientists should also investigate individuals‘ social well-being. Keyes‘s (1998) multidimensional model of social well-being is an attempt to conceptualize and assess the social aspect of well-being. This model falls into the eudaimonic perspective and addresses social aspects of human functioning. This model consists of five dimensions that indicate whether and to what degree individuals are functioning well in their social world. ―Social Acceptance is a favorable view of human nature and a feeling of comfort with other people; Social Actualization is the belief in the evolution of society and the sense that society has potential that is being realized through its institutions and citizens; Social Contribution is the evaluation of one‘s value to society; Social Coherence is the perception of the quality, organization, and operation of the social world and includes a concern for knowing about the world; and Social Integration is the extent to which people feel they have something in common with others who constitute their social reality (e.g., their neighborhood), as well as the degree to which they feel that they belong to their communities and society.‖ (Robitschek and Keyes, 2009, p. 323). These new measures are distinct from extant measures of social well-being that reflect the interpersonal (e.g., aggression) and the societal levels (e.g., poverty and social capital) of analysis (Keyes and Shapiro, 2004). Since the area of social well-being is so important to the quality of life of the people, researchers have made several attempts to search for the correlates and predictors of social well-being in different cultures. For example, social well-being has been found to correlate with anomie, community involvement, generativity, neighborhood heath, life satisfaction, happiness, and dysphoria in United States (Keyes, 1998). It is related to social participation in United States, Italy, and Iran (Cicognani et al., 2008). Social well-being is related to perceived social support, psychological sense of community, identification with community, self-esteem, and self-efficacy in Iranian university students (Joshanloo, Rostami, and Nosratabadi, 2006). Keyes and Ryff (1998) also found that overall social well-being was correlated with measures of civic engagement and prosocial behavior. Using an Iranian student sample, Joshanloo and Ghaedi (2009) found that social well-being was correlated with life satisfaction, affect balance, and psychological well-being. In that study, it was also found that four basic human values (power, self-direction, conformity, and benevolence) were related to social well-being. Research also shows that society is a source of social wellness. Social well-being increases with education and, in general, with age (Keyes, 1998). Using a national American sample, Keyes and Shapiro (2004) found that social well-being is highest among high status persons, males, and those who are married or never married. In contrast, females, those who are previously married, and those who have low occupational status have the lowest level of overall social well-being.


189

RELATION BETWEEN THE BIG FIVE PERSONALITY TRAITS AND ASPECTS OF WELL-BEING The new trait psychology heralded by the Big Five (i.e., five personality traits most commonly labeled extraversion, neuroticism, conscientiousness, agreeableness, and openness to experience; see Costa and McCrae, 1994) ―is arguably the most recognizable contribution personality psychology has to offer today to the discipline of psychology as a whole and to the behavioral and social sciences‖ (McAdams and Pals, 2006, p. 204). Personality traits are important for a wide range of applications (e.g., in the filed of industrial/organizational psychology and predicting problem behaviors, see McCrae, 2004). Related to the scope of this study, they also have been found to be linked to different facets of well-being. Research has shown that external factors (e.g., health, income, etc.) have only a modest impact on subjective well-being reports (Diener et al., 1999). Research instead shows that subjective well-being is often strongly correlated with stable personality traits (Diener, Oishi, and Lucas, 2003). In terms of the Big Five personality traits, extraversion and neuroticism have been found to be the strongest predictors of subjective well-being in many countries (see Schimmack et al., 2002 for a very brief review). However, in the late 1990s, the meta-analysis by DeNeve and Cooper (1998) indicated that two other personality traits, namely agreeableness and conscientiousness also predispose individuals towards subjective wellbeing. Openness to new experiences does not appear to be a strong and consistent predictor of subjective well-being. Schmutte and Ryff‘s study (1997) revealed consistent linkages between the domains of personality and psychological well-being. Environmental mastery demonstrated strong negative links with neuroticism, as did purpose in life and autonomy, to a lesser degree. Selfacceptance, environmental mastery, and purpose in life were related to extraversion and conscientiousness. Personal growth was related to openness. Positive relations with others was associated with agreeableness and to a lesser degree with extraversion. Finally autonomy was linked with extraversion, conscientiousness, and openness but most strongly with neuroticism. Schmutte and Ryff concluded that the dimensions of psychological well-being are ―distinct from, yet meaningfully influenced by, personality‖ (p. 557). To our knowledge, the only examination of the relation between the Big Five personality traits and social well-being is that of Joshanloo, Rastegar, and Bakhshi (unpublished manuscript). Participants of this study were 236 university students at the University of Tehran. Findings revealed that, among the Big Five personality domains, neuroticism was negatively related to social acceptance, social contribution, and social coherence. Conscientiousness was positively related to social contribution. Openness was positively related to social contribution and social coherence. Agreeableness also was related to social acceptance and social contribution. Finally, no significant correlation was observed between extraversion and facets of social well-being. The brief review presented above shows that all five personality traits are related to at least one aspect of hedonic or eudaimonic well-being. One important point is that openness to experience tends to correlate only with eudaimonic aspects of well-being. This is in line with Keyes, Shmotkin, and Ryff‘s (2002) finding that those with high levels of eudaimonic wellbeing (as assessed by psychological well-being scales) but low levels of subjective well-being

190


were distinguished from their opposite counterpart (high subjective well-being/low psychological well-being) by their high levels of openness to experience.

WELL-BEING RESEARCH IN IRAN Research on well-being is scant in Iran. However, a few studies have examined the relation between personality traits and some aspects of well-being. For example, Joshanloo and Nosratabadi‘s study (2009), using an Iranian student sample, showed that extraversion, neuroticism, conscientiousness, and agreeableness could significantly discriminate among the three levels of mental health continuum (i.e., flourishing, moderately mentally healthy, and languishing). In that study mental health was operationalized and assessed based on the Keyes‘s (2002) comprehensive model of mental health, which unlike most of the existing models of mental health, takes all aspects of well-being (emotional, psychological, and social) into account (see Joshanloo and Nosratabadi, 2009; Keyes, 2002). Joshanloo and Afshari (in press) also found that four of the Big Five traits (extraversion, neuroticism, agreeableness, and conscientiousness) were significantly correlated with life satisfaction in a sample of Iranian university students. Findings of that study revealed that there were some gender differences in the level of life satisfaction and its relation to personality traits. These findings, together with those of other studies conducted in Iran (as mentioned earlier) which are in line with the findings from other countries, give initial support to the applicability of the relatively new constructs (such as different aspects of well-being) and their measures, recently introduced by positive psychologists, to Iranian samples. In addition, these studies confirm the importance and relevance of all five personality traits in predicting different aspects of well-being in Iranian samples.

THE PRESENT STUDY The present study, which is an exploratory one, sought to examine the relation between the Big Five personality traits and eudaimonic well-being in an Iranian sample. Based on the brief review provided above, a composite score produced by summing up the scores of purpose in life, personal growth, and social well-being was used to assess overall eudaimonic well-being in this study, given the central role of these three aspects in eudaimonic well-being models. Based on the past studies in Iran (as reviewed above) and all over the world, we expected that all five personality traits would correlate with eudaimonic well-being. Given that significant gender differences have been documented in the aspects of psychological well-being (e.g., Ryff, 1989; Ryff et al., 1994) and social well-being (Keyes, 2008; Keyes and Shapiro, 2004; Joshanloo, Rastegar, and Bakhshi, unpublished manuscript), we were also interested to examine the gender differences and moderating effect of gender on the relation between personality traits and eudaimonic well-being. A sample of Iranian university students was used for the purposes of this study.


191

METHOD Participants Participants were 240 undergraduates at the University of Tehran. Groups of varying size completed the questionnaires in classrooms. The sample consisted of 151 female (62.9%) and 88 male (37.1%) students who were recruited from different fields of study. Average age was 21.60 years (SD =2.28). Ninety six (40%) of the participants were from Teheran (the capital of Iran) and 142 (59.2%) of them were from different areas of Iran (including villages). Two students did not report their cities.

Measures All scales were translated from English into Persian using the method of back-translation. The following scales were employed: Big Five personality traits. Big Five Inventory (John, Donahue, and Kentle, 1991) was used to measure the Big Five personality traits. It consists of 44 items to measure extraversion (8 items), agreeableness (9 items), conscientiousness (9 items), neuroticism (8 items), and openness to experience (10 items). The items are rated on a 5-point scale (1 = disagree strongly, 5 = agree strongly). Social well-being. Keyes‘s (1998) 33-item scale of social well-being was used. On a scale from 1 to 7, respondents indicated whether they agreed or disagreed strongly, moderately, or slightly that an item described them. This scale assesses the five dimensions of social wellbeing (social-acceptance, social actualization, social contribution, social coherence, and social integration). Psychological well-being. Purpose in life and personal growth subscales of Ryff‘s (1989) scale of psychological well-being were used to assess purpose in life and personal growth. Each subscale contains nine items. Items are scored on a 7-point scale ranging from strongly disagree to strongly agree. Giving all the measures equal presence in the overall eudaimonic score, scores of three scales of social well-being, purpose in life, and personal growth were first transformed to zscores and then summed up to obtain an overall score of eudaimonic well-being for each student.

RESULTS Preliminary Analysis Table 1 presents bivariate intercorrelations, means, standard deviations, and Cronbach‘s alphas for all scales used in the study. Independent t test was used to examine the gender differences in the three dimensions of eudaimonic well-being. The results showed that male students scored significantly higher than female students on social well-being (t(198) = -

192


2.358, p < .05). No significant gender difference was found for personal growth (t(225) = 1.404, p = .162) and purpose in life (t(226) = -.135, p = .893).

Regression Analysis To examine the relationship between the Big Five personality traits and overall score of eudaimonic well-being, a multiple regression analysis was conducted. Eudaimonic well-being was entered as the dependent variable and all five personality traits were entered as potential predictors. Results of the regression analysis are summarized in Table 2. Table 1. Descriptive statistics, alphas, and intercorrelations among the scales used in the study 1 1. Purpose in life

1

2. Personal growth

2

3

4

5

6

7

8

9

.68

.47

.87

.13

.20

.42

-.26

.19

1

.46

.86

.17

.19

.39

-.26

.33

1

.77

.18

.30

.30

-.38

1

.22

.30

.46

-.40

3. Social well-being 4. Eudaimonic wellbeing 5. Extraversion

1

.04

6. Agreeableness

1

7. Conscientiousness

.10

.14 .24

.001

.13

.17

-.34

.16

1

-.37

.26

1

-.21

8. Neuroticism 9. Openness

1

Mean

46.53

47.92

146.19

.02

25.20

32.63

30.86

22.97

36.66

SD

8.58

7.84

26.56

2.53

4.96

4.98

5.73

6.70

5.37

.72

.80

.63

Alpha

.71

.68

.90

-

.61

.62

* p

Psychological Well-Being

Boundaryless Careers and Occupational Wellbeing

Promoting Health and Wellbeing through Schools

Psychological Assessment

Psychological Atlas

Psychological Types

The CSIRO Total Wellbeing Diet (Book 2)

Beliefs: Pathways to Health and Wellbeing

Explaining psychological statistics

Autism (Psychological Disorders)

Psychological Foundations of Culture

Pain: Psychological Perspectives

Suicide (Psychological Disorders)

Psychological Testing: An Introduction

Essentials of Psychological Testing

Materialism and Psychological Continuity

On Psychological Prose

Psychological Assessment of Dyslexia

Forbidden Psychological Tactics

Autism (Psychological Disorders)

Tourette Syndrome (Psychological Disorders)

Psychological Commentaries Vol.4

Perdurance and Psychological Continuity

Feminists and Psychological Practice

Essentials of Psychological Testing

Explaining Psychological Statistics

Contemporary Social Psychological Theories

Addiction (Psychological Disorders)

Philosophical and Psychological Pragmatics

Psychological Research in Prisons

Psychological Well-Being

Boundaryless Careers and Occupational Wellbeing

Promoting Health and Wellbeing through Schools

Psychological Assessment

Psychological Atlas

Psychological Types

The CSIRO Total Wellbeing Diet (Book 2)

Beliefs: Pathways to Health and Wellbeing

Explaining psychological statistics

Autism (Psychological Disorders)

Psychological Foundations of Culture

Pain: Psychological Perspectives

Suicide (Psychological Disorders)

Psychological Testing: An Introduction

Essentials of Psychological Testing

Materialism and Psychological Continuity

On Psychological Prose

Psychological Assessment of Dyslexia

Forbidden Psychological Tactics

Autism (Psychological Disorders)

Tourette Syndrome (Psychological Disorders)

Psychological Commentaries Vol.4

Perdurance and Psychological Continuity

Feminists and Psychological Practice

Essentials of Psychological Testing

Explaining Psychological Statistics

Contemporary Social Psychological Theories

Addiction (Psychological Disorders)

Philosophical and Psychological Pragmatics

Psychological Research in Prisons

Recommend Documents