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1
 Positively Positive
M O DULE 1 1

Frates B, Bonnet JP, Joseph R, Peterson JA. Positively Positive. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning;
2021:371-396.
Disclaimer
• ACLM abides by strict professional and clinical standards with published
evidence-based positions and guidelines on the therapeutic approaches that
make up Lifestyle Medicine. These standards are posted for public review at
[Link]/aclm-standards.
• Members and certified professionals are authorized to use ACLM branding,
presentations and approved messaging for the enhancement of our stated
mission and vision. ACLM is not responsible nor accountable for individual
deviations, misrepresentations and misinterpretations.
• Faculty members utilizing this slide deck must acknowledge any slides or
content that have been added as it may represent the viewpoint of the
presenter and not the viewpoint of ACLM.

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 Acknowledgements
We gratefully acknowledge Dr. Beth Frates for her generous donations of slides and
content, derived from decades of her esteemed work in the field and educational contributions
at Harvard Extension School.

Editors: Kaitlyn Pauly MS, RDN; Shannon Worthman; Monami Brierley

Reviewers: Brenda Rea MD, DrPH, PT, RD; Wayne Dysinger MD, MPH, FACLM; Amanda McKinney
MD; Susan Benigas, MS

This PowerPoint was created under the umbrella of the

Lifestyle Medicine Pre-Professional Member Interest Group

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Learning Objectives
By the end of this module, participants will be able to:
• Distinguish the basic forms of positivity
• Recall the evidence-based information on laughter
• Recognize the benefits of having an attitude of gratitude
• Identify the attributes of happy people
• Formulate an understanding of the barriers to feeling joy

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 Guiding Questions
• What is positive psychology?
• Why is it important that people develop a more positive attitude
toward life?
• What are appropriate ways to cultivate an attitude of gratitude?
• What are the obstacles to being happy?
• How can people find more joy in their lives?
• How can laughter have a positive impact on health?

Frates B, Bonnet JP, Joseph R, Peterson JA. Positively Positive. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy Learning;
2021:371.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 6

 Important Terms
• Attitude • Laughter
• Gratitude • Optimism
• Happiness • Positive Psychology
Positivity
• Hope
• Well-being
• Humor
• Joy

Frates B, Bonnet JP, Joseph R, Peterson JA. Positively Positive. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA:
Healthy Learning; 2021:372.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 7

RESEARCH SPOTLIGHT

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 Optimism and Pessimism
OPTIMISTS PESSIMISTS
•Expect positive outcomes to •Expect negative outcomes in
occur in the future and expect their future and do not expect to
to cope successfully. cope successfully.

Goodin BR, Bulls HW. Optimism and the experience of pain: benefits of seeing the glass as half full. Current pain and headache reports. 2013;17(5):329.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 9

 Optimism and the
Experience of Pain
• People with high levels of optimism are hypothesized
to demonstrate enhanced resilience and greater
physical and psychological well-being
• Compared to people with low levels of optimism

Goodin BR, Bulls HW. Optimism and the experience of pain: benefits of seeing the glass as half full. Current pain and headache reports. 2013;17(5):329.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 10

Optimism and Pain
• Last review in 2000 with scant
evidence
• 2013 review more research
available
• Optimism benefits pain and its
course of treatment.

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 Optimism and Recovery from Disease
Optimism is linked to improved
physiological recovery and
psychosocial adjustment to
coronary artery bypass surgery,
bone marrow transplantation,
postpartum depression,
traumatic brain injury,
Alzheimer’s disease, lung
cancer, breast cancer, and
failed in vitro fertilization

Goodin BR, Bulls HW. Optimism and the experience of pain: benefits of seeing the glass as half full. Current pain and headache reports. 2013;17(5):329.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 12

RESEARCH SPOTLIGHT

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 Mistakes and the Growth Mindset
• Is intelligence malleable or fixed?
• Malleable— “If I make a mistake, I try to learn and
figure it out.”
• Fixed—mindset that people can’t get smarter and
do not work to learn from mistakes.

Moser JS, Schroder HS, Heeter C, Moran TP, Lee Y-H. Mind your errors: Evidence for a neural mechanism linking growth mind-set to adaptive posterior adjustments. Psychological
Science. 2011;22(12):1484-1489.

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 Methods
• TOI (Dweck’s Theories of
Intelligence) Scale
• 6 point Likert Scale
• “You have a certain amount of
intelligence and you really cannot
do much to change it.”
• Scored so that the higher score
was most compatible with a
growth mindset.
Moser JS, Schroder HS, Heeter C, Moran TP, Lee Y-H. Mind your errors: Evidence for a neural mechanism linking growth mind-set to adaptive posterror adjustments. Psychological
Science. 2011;22(12):1484-1489.
Dweck CS. Mindset: The new psychology of success. Random House Digital, Inc.; 2008.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 15

 Methods Continued
• 25 students were given a test • Electrical activity in the brain was
measured.
• Click a mouse button to correctly
identify the center letter of a five- • With a mistake, there are 2 signals
letter string of letters within a quarter of a second
• (MMMMM) or (NNMNN) generated by the brain and
recorded in electrical activity.
• Easy to make a mistake • 1. Initial “Oh, crap!” response.
• Check belief system about • 2. Second-indicated the person is
aware of mistake and trying to fix it.
mistakes
Moser JS, Schroder HS, Heeter C, Moran TP, Lee Y-H. Mind your errors: Evidence for a neural mechanism linking growth mind-set to adaptive posterror adjustments. Psychological
Science. 2011;22(12):1484-1489.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 16

 Anterior Cingulate Cortex (ACC) and
Event Response Potentials (ERPs)
• ACC- monitors behavior and
signaling the need for increased
cognitive control.
• Error-related negativity (ERN)
• Fronto-centrally maximal
negative ERP
• Error Positivity (Pe) a centro-
parietally maximal positive ERP

Moser JS, Schroder HS, Heeter C, Moran TP, Lee Y-H. Mind your errors: Evidence for a neural mechanism linking growth mind-set to adaptive posterror adjustments. Psychological
Science. 2011;22(12):1484-1489.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 17

 Electrical Potentials Measured from
Scalp Electrodes in a Lycra Cap
• The difference between the
brain’s second response to an
error—the what can I do to correct
this in the future
• A larger difference between the
incorrect and correct answers =
growth mindset
Key:
• Orange >Difference in Voltage
Green-yellow< Difference in Voltage
Moser JS, Schroder HS, Heeter C, Moran TP, Lee Y-H. Mind your errors: Evidence for a neural mechanism linking growth mind-set to adaptive posterror adjustments. Psychological
Science. 2011;22(12):1484-1489.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 18

 Results
• People who believed that they • It seems that people who have a
could learn from their mistakes growth mindset have brains that
did better after making a are tuned to pay more attention to
mistake. mistakes.
• Their brains created a larger
second signal by electrical
activity recording, noting the
mistake and telling the brain to
pay more attention.
Moser JS, Schroder HS, Heeter C, Moran TP, Lee Y-H. Mind your errors: Evidence for a neural mechanism linking growth mind-set to adaptive posterror adjustments. Psychological
Science. 2011;22(12):1484-1489.

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 Mood Interacts with Cognitive
Processing
• Executive functioning might be • Category learning is associated
the source of this interaction with cognitive flexibility.
• Positive mood leads to • Depressed subjects have
enhanced cognitive flexibility difficulty with learning rule
• Negative mood may reduce described categories but not
cognitive flexibility impaired in learning non rule
described categories.

Busemeyer JR. Book Review: Multidimensional Models of Perception and Cognition: Edited by F. Gregory Ashby Hillsdale NJ: Erlbaum, 1992, 523 pp., Applied Psychological
Measurement. 1994;18(4):383-384.

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RESEARCH SPOTLIGHT

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 Benefits of Positive Emotions
Positive mood allows human brain
to think more creatively.

Nadler RT, Rabi R, Minda JP. Better mood and better performance: Learning rule-described categories is enhanced by positive mood. Psychological Science. 2010;21(12):1770-1776.

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 Watching and listening
• Subjects 87 university students
• Music clips and video clips to
create affective states
• Positive state
• Mozart: “Eine Kleine Hachtmusik”, Laughing
baby
• Negative state
• Schindler’s list, Chinese earthquake news
report
• Neutral state
• Mark Salona: “One Angel’s Hands,” Antiques
Road Show
Nadler RT, Rabi R, Minda JP. Better mood and better performance: Learning rule-described categories is enhanced by positive mood. Psychological Science. 2010;21(12):1770-1776.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 23

 Theories of mood and its effect on
cognitive processing
• Positive mood accounts for
increased cognitive flexibility
associated with the prefrontal
cortex and the anterior cingulate
cortex.
• These areas play an important role
in hypothesis testing and rule
selection in rule described
categorization learning.

Nadler RT, Rabi R, Minda JP. Better mood and better performance: Learning rule-described categories is enhanced by positive mood. Psychological Science. 2010;21(12):1770-1776.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 24

Nadler RT, Rabi R, Minda JP. Better mood and better performance: Learning rule-described categories is enhanced by positive mood. Psychological Science. 2010;21(12):1770-1776.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 25

 Results
• Volunteers who listened to the positive music and watched the
positive video were better at learning a rule to classify sets of
pictures with visually complex patterns, compared to neutral and
negative states.
• Rule selection and hypothesis testing were involved in this task.
• For non-category learning or non rule-described category learning,
there was no difference in the groups (positive, negative or
neutral)

Nadler RT, Rabi R, Minda JP. Better mood and better performance: Learning rule-described categories is enhanced by positive mood. Psychological Science. 2010;21(12):1770-1776.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 26

RESEARCH SPOTLIGHT

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 Do people perform better after
receiving a compliment?
• The striatum is activated when a
person is rewarded a compliment
or cash

Sugawara SK, Tanaka S, Okazaki S, Watanabe K, Sadato N. Social rewards enhance offline improvements in motor skill. PLoS One. 2012;7(11):e48174.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 28

 Methods
• 48 subjects • 1) Individual watches evaluator
• Learn and perform finger compliments the participant
pattern on a keyboard in a individually
particular sequence as fast • 2) individual watches an evaluator
as possible in 30 seconds. compliment another participant
• Three groups • 3) individuals evaluated their own
performance

Sugawara SK, Tanaka S, Okazaki S, Watanabe K, Sadato N. Social rewards enhance offline improvements in motor skill. PLoS One. 2012;7(11):e48174.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 29

 Results
• Next day (after sleep which • The lead researcher reports
was recorded and noted so that there seems to be validity
that it could be taken into behind the message ‘praise to
account), the participants encourage improvement.’
repeated the finger exercise.
• Compliments could be an easy
• The participants who received and effective strategy to use in
a compliment directly from the the classroom and during
evaluator performed better rehabilitation.
than other participants.

Sugawara SK, Tanaka S, Okazaki S, Watanabe K, Sadato N. Social rewards enhance offline improvements in motor skill. PLoS One. 2012;7(11):e48174.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 30

 3-1 RATIO

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 Positivity Ratio

Fredrickson B. Positivity. Harmony; 2009.

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Ten Forms of Positivity
•Joy •Gratitude
•Serentiy •Interest
•Hope •A Sense of Pride
•Amusement •Inspiration
•Awe •Love

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 33

The Effect of Positive Emotions on Our Health. Fractal Enlightenment. [Link] Accessed
July 17, 2020.

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Between 3:1 and 11:1

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 Updated Thinking on Positivity Ratios
• In response to: • Critique of the application of
nonlinear dynamics and
• “The Complex Dynamics of
differential equations in results
Wishful Thinking: The Critical
Positivity Ratio” sections.

• Critique of Marcial Losada’s • Critique of numbers and

precision with decimal places.
foundational papers and
Frederickson’s 2005 paper on
positivity ratio.

Brown NJ, Sokal AD, Friedman HL. The complex dynamics of wishful thinking: The critical positivity ratio. 2013.

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Which Figure Most Resembles the One
on the Top?
• Left (triangles) resembles it
most in general configuration:
which means seeing the big
picture--- positivity

• Right (squares): resembles

top figure in its local details
(all squares)

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 Adam Anderson’s Lab in Toronto
• Question-is the photo of a male or
female? Ignore the background
• When people were feeling positive
emotions, the people could not
help but pick up on the
background house.
• When they were feeling negative
or neutral, they just focused on
the face.

Interview with Barbara Frederickson, PhD: 6/21/2011, [Link]

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 Conclusions leading to broaden and
build with Barbara Frederickson
• People experiencing positive • Kids do better academically
emotions have a wider if before a math test, they
awareness and can see the think of a pleasant, positive
big picture. memory.
• Positive emotions help us to • Positive emotions make us
see more possibilities. more socially connected,
people are more trusting,
• People experiencing positive
emotions are more likely to be and come to better win-win
solutions.
resilient.

Interview with Barbara Frederickson, PhD: 6/21/2011, [Link]

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 39

Fredrickson BL, Cohn MA, Coffey KA, Pek J, Finkel SM. Open hearts build lives: positive emotions, induced through loving-kindness meditation, build consequential personal
resources. Journal of personality and social psychology. 2008;95(5):1045.

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 How do we get more positivity?
• 1) Be open
• 2) Be appreciative
• 3) Be curious
• 4) Be kind
• 5) Be real
• 6) Be sincere
Barbara Frederickson, PhD

Interview with Barbara Frederickson, PhD: 6/21/2011, [Link]

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Positive Psychology = Happiness?

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 Beyond Happiness
• Positive Emotion
• Engagement
• Relationships
• Meaning
• Accomplishment

Seligman ME. Flourish: A visionary new understanding of happiness and well-being. Simon and Schuster; 2012.

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Founder and Father of
Positive Psychology
• “Positive Psychology is the
scientific study of the strengths
and virtues that enable individuals
and communities to thrive. The
field is founded on the belief that
people want to lead meaningful
and fulfilling lives, to cultivate
what is best within themselves,
and to enhance their experiences
of love, work, and play.”
Martin Seligman, PhD
University of Pennsylvania

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 Martin Seligman
• Seligman + Csikszentmihalyi
• Positive Psychology: An
Introduction. American
Psychologist 2000: 55(1); 5-14
• 2004 Ted Talk on Positive
Psychology
• 2012 Course Syllabus at
UPenn[Link]
edu/[Link]
Seligman ME, Csikszentmihalyi M. Positive psychology: An introduction. In: Flow and the foundations of positive psychology. Springer; 2014:279-298.

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Virtues
• 1) Wisdom and knowledge • Only online scientifically validated
survey of character strengths.
• 2) Courage
• VIA Character Strengths
• 3) Love and humanity
Assessment (free)
• 4) Justice
• [Link]
• 5) Temperance /
• 6) Spirituality and
transcendence

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 46

Strengths
• Wisdom and Knowledge
• Curiosity/Interest in the World
• Love of Learning
• Judgement/Critical Thinking/Open-Mindedness
• Ingenuity/Originality/Practical Intelligence/Street Smarts
• Social Intelligence/Personal Intelligence/Emotional Intelligence
• Perspective
• Courage
• Valor and Bravery
• Perseverance/Industry/Diligence
• Integrity/Genuineness/Honesty
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Strengths continued
• Humanity and Love
• Kindness and Generosity
• Loving and Allowing Oneself to be Loved Justice
• Citizenship/Duty/Teamwork/Loyalty
• Fairness and Equity
• Leadership
• Temperance
• Self-Control
• Prudence/Discretion/Caution
• Humility and Modesty

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Strengths continued
• Transcendence
• Appreciation of Beauty and Excellence
• Gratitude
Hope/Optimism/Future-Mindedness
• Spirituality/Sense of Purpose/Faith/Religiousness
• Forgiveness and Mercy
• Playfulness and Humor
• Zest/Passion/Enthusiasm
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 Homeless in America-Guidelines from the
American Psychological Association (APA)

“Provide strength-based clinical and assessment services to

populations who are homeless or at risk of homelessness, including
families involved with child welfare agencies, children in foster care
placements, unaccompanied youth, persons experiencing alcohol
or illegal substance dependence, and persons of all ages identified
with pervasive and/or chronic mental illness.”

American Psychological Association. Helping people without homes: The role of psychologists and recommendations to advance re search, training, practice, and policy. Report of the APA
Presidential Task Force on Psychology’s Contribution to End Homelessness. 2009.

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 GRATITUDE

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Gratitude Quote
• “Gratitude bestows reverence,
allowing us to encounter everyday
epiphanies, those transcendent
moments of awe that change
forever how we experience life and
the world.”

John Milton 1607- 1674 English Poet

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Gratitude in Action
• Thanksgiving
• Gratia = grace, graciousness,
gratefulness
• Gratitude = “Thankful appreciation
for what an individual receives,
whether tangible or intangible.”
• At this moment-what are you most
grateful for?

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Gratitude and Positive Psychology
• In positive psychology, there is • It helps people deal with
much research on gratitude adversity.
• Gratitude is associated with • It helps people build strong
increased happiness. connections/relationships
• It increases positive emotions. • It helps people improve their
health.

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RESEARCH SPOTLIGHT

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 Gratitude and Seligman
• 411 subjects
• Compared the effects of 5 weekly assignments
• Placebo control exercise:
• early memories
• Gratitude visit:
• write and hand deliver a letter of gratitude
• 3 good things in life:
• Write 3 things that went well each day and their causes
• You at your best:
• Write about a time when you were at your best and consider
strengths
• Using signature strengths in a new way
• Use 1 of top 5 strengths in a new and different way for one week.

Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. American psychologist. 2005;60(5):410.

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 Gratitude Research Results
• Using signature strengths in a new way

• Three good things

• Increased happiness and decreased depressive symptoms

for six months

• Self-report- Center for Epidemiological Studies-Depression

Scale and Steen Happiness Index
Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. American psychologist. 2005;60(5):410.

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 Gratitude and Seligman
• Writing and personally delivering a
letter of gratitude to someone who
had never been properly thanked
revealed an immediate increase in
happiness score
• Benefits lasted one month

Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of interventions. American psychologist. 2005;60(5):410.

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Positive Psychology
• Positive psychology is “the scientific study of the strengths and
virtues that enable individuals and communities to thrive.”
• Martin Seligman
• Includes-Inner strengths, savoring pleasure, flow, finding meaning
in life, and GRATITUDE

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Robert Emmons, PhD
• Gratitude Power
• UC Davis
• Thanks: How the New Science of
Gratitude Can Make You Happier
• Chosen attitude
• Cultivating an attitude of gratitude
• Research

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Gratitude Scale
• 1. I have so much in life to be thankful for. 1 = strongly disagree
• 2. If I had to list everything that I felt grateful
for, it would be a very long list. 2 = disagree
• 3. When I look at the world, I don’t see much 3 = slightly disagree
to be grateful for.* 4 = neutral
• 4. I am grateful to a wide variety of people. 5 = slightly agree
• 5. As I get older I find myself more able to
appreciate the people, events, and situations 6 = agree
that have been part of my life history. 7 = strongly agree
• 6. Long amounts of time can go by before I
feel grateful to something or someone.

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RESEARCH SPOTLIGHT

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 Benefits of Gratitude
• According to Dr. Emmons and
colleagues:
• Improves subjective emotional
well-being

Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. Journal of personality and
social psychology. 2003;84(2):377.

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 A Research Study
• 2 month period
• Students were subjects
• One group listed blessings vs hassles or neutral life events on a
weekly basis
• People who kept gratitude lists were more likely to
• Have made progress in personal goals
• Academic, interpersonal, or health based

Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. Journal of personality and
social psychology. 2003;84(2):377.

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 More Results of Gratitude Study
• Those who kept a weekly gratitude journal
• 1)Exercised more regularly
• 2)Reported fewer physical symptoms
• 3)Felt better about their lives as a whole
• 4)Were more optimistic about upcoming week

Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. Journal of personality and
social psychology. 2003;84(2):377.

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 A Second Study
• Three conditions- undergraduate • Daily gratitude group showed
students over a two week period more gratitude
• One daily gratitude intervention • Higher levels of positive states of
(self-guided exercises) alertness, enthusiasm,
determination, attentiveness and
• One with a focus on things that energy compared to other groups
annoyed them=hassles
• Also they were more likely to have
• One with a focus on social offered emotional support to
comparison-looking down on others and to have helped
others someone with a problem.
Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. Journal of personality and
social psychology. 2003;84(2):377.

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 Third Study Reported in the Paper
• 65 adults with neuromuscular disease were subjects
• Intervention compared to control group
• 21 day gratitude intervention listing blessings

Resulted in:
Greater amounts of high energy positive moods, a
greater sense of feeling connected to others, more
optimistic ratings of one’s life, and better sleep
duration + quality
Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. Journal of personality and
social psychology. 2003;84(2):377.

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 Gratitude, Depression,
Anxiety and Sleep
• Amount of gratitude shown in daily lives compared to sleep quality,
symptoms of anxiety and depression.
• Higher levels of gratitude were associated with less depression and
higher quality of sleep.
• After controlling for sleep quantity, gratitude had no effect on
anxiety.
• Gratitude increased sleep, decreased depression and due to
increased sleep decreased anxiety.

Ng M-Y, Wong W-S. The differential effects of gratitude and sleep on psychological distress in patients with chronic pain. Journal of health psychology. 2013;18(2):263-271.

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 Where in the brain is gratitude?
• Examined blood flow in various regions
of the brain
• Subjects with more gratitude had
higher levels of activity in the
hypothalamus—control center for vital
functions-sleep, eat, drink, stress,
metabolism

Zahn R, Moll J, Paiva M, et al. The neural basis of human social values: evidence from functional MRI. Cerebral cortex. 2009;19(2):276-283.

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 Ways to Cultivate Gratitude
• Keep a gratitude journal • Talk to yourself in a creative,
optimistic, and appreciative
• Learn prayers of gratitude
manner.
• Use visual reminders • Dr. Quick
• Create a list of benefits in • Reframe a situation by looking
your life and ask, “To what at it with a different, more
extent do I take these for positive attitude.
Granted?” • Dr. Quick
• Dr. Emmons

Heubeck E. Boost Your Health With a Dose of Gratitude. WebMD. Published [Link] Accessed July 17, 2020.

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RESEARCH SPOTLIGHT

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 Scoring High on Gratitude (6-7)
• Higher positive emotions, life satisfaction, vitality, optimism
• Lower depression and stress
• Enhances good feelings better than it decreases unpleasant
emotions.
• Grateful people do not deny or ignore negative emotions, feelings
or events.

McCullough ME, Emmons RA, Tsang J-A. The grateful disposition: A conceptual and empirical topography. Journal of personality and social psychology. 2002;82(1):112.

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 Scoring High on Gratitude (6-7)
• Increased capacity to be empathic and to take the perspective of
others
• Rated as more generous and more helpful by people in their
social networks.

McCullough ME, Emmons RA, Tsang J-A. The grateful disposition: A conceptual and empirical topography. Journal of personality and social psychology. 2002;82(1):112.

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 Scoring High on Gratitude (6-7)
• More likely to acknowledge a belief in the interconnectedness of
all life and a commitment to and responsibility to others.
• People who regularly attend religious services and engage in
religious activities including prayer and reading religious material
are more likely to be grateful.

McCullough ME, Emmons RA, Tsang J-A. The grateful disposition: A conceptual and empirical topography. Journal of personality and social psychology. 2002;82(1):112.

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 Scoring High on Gratitude (6-7)
• People who score high on gratitude place less emphasis on
material items.
• They are less likely to judge their own success and the success of
others based on material possessions.
• They are less envious of wealthy people.
• They are more likely to share their own material possessions with
others.

McCullough ME, Emmons RA, Tsang J-A. The grateful disposition: A conceptual and empirical topography. Journal of personality and social psychology. 2002;82(1):112.

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 Feeling grateful is not feeling indebted
•Compared to those that write about gratitude, those who
write about being indebted to others report
• Higher levels of anger
• Lower levels of appreciation
• Lower levels of happiness
• Lower levels of love

Gray S, Emmons R, Morrison A. Distinguishing gratitude from indebtedness in affect and action tendencies. Paper presented at: Poster presented at the 109th Annual Convention
of the American Psychological Association, San Francisco, CA2001.

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Gratitude Journals
• Every night list 3 things for which
you are grateful.
• Therapeutic intervention for
depression.
• Consider writing a thank you note
to someone this week.

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 LIVE AND
LIVE AND LEARN LEARN

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 HAPPINESS

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 Tal Ben-Shahar, PhD

Ben-Shahar T. Happier: Learn the secrets to daily joy and lasting fulfillment. McGraw-Hill Companies; 2007.

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 Quote
“By pursuing work, education, and relationships that yield both
meaning and pleasure, we become progressively happier---
experiencing not just an ephemeral high that withers with the
leaves but lasting happiness with deep and stable roots.”

• Happier page 139

Ben-Shahar T. Happier: Learn the secrets to daily joy and lasting fulfillment. McGraw-Hill Companies; 2007.

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 Meaningful Life
• “The meaningful life: using your • Happiness has three dimensions that
signature strengths and virtues in the can be cultivated-
service of something much larger
than you are.” (p. 263) • Pleasant life
• Savor, appreciate
• Reconcile two views of human
happiness- • Good life
• Individualistic approach • Discover unique virtues and
strengths and use them
• Take care of ourselves and nurture
our strengths • Meaningful life
• Altruistic approach • Deep sense of fulfillment by using
our strengths for a purpose greater
• Sacrificing for a greater purpose than ourselves
Seligman ME. Authentic happiness: Using the new positive psychology to realize your potential for lasting fulfillment. Simon and Schuster; 2004.

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 Viktor Frankl, MD, PhD

Frankl VE. Man's search for meaning. Simon and Schuster; 1985.

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 Man’s Search for Meaning
• Viktor Frankl, MD, PhD •D = S - M
• Austrian psychiatrist, • Despair = Suffering without
neurologist, & Meaning
philosopher
• Holocaust survivor • Turning tragedy into triumph:
concentration camp prisoners
• 1905-1997 whose minds were fixated on an all-
consuming reason to live—reuniting
with loved ones, completing
unfinished work, alerting the world
to atrocities—were most apt to
Frankl VE. Man's search for meaning. Simon and Schuster; 1985. survive.
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 Interventions to increase meaning in
life for students in schools
• Ask what life expects from • Belong to and serve something
you? larger than yourself (religion,
education).
• Not what do you expect from
life. • Working towards a vision.
• How can we leverage our • What is sacred in your life?
signature strengths to • Who do you turn to in times of
promote goodness in the
trouble?
world?
• What do you feel grateful for?
• Align one’s behaviors with
one’s values.
Yeo S-E. Resilience, Character Strengths and Flourishing: A Positive Education Workshop for Singapore Teachers. 2011.

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What is your purpose?
• Consider writing your own
obituary.
• Consider writing a mission
statement.
• Stephen Covey
• Consider crafting a vision of
yourself in 10 years.

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Farming for Resilience—
What are the seeds?
• Finding purpose
• Using a growth mindset
• Cultivating optimism
• Having powerful, healthy
connections
• Attitude of gratitude
• Identifying a charismatic adult

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 How to Overcome
Obstacles in Your Life: Resilience
• 1) Stay flexible • 6) Have a sense of purpose
• 2) Learn lessons • 7) Learn healthy habits
• 3) Take action • 8) Believe in yourself
• 4) Stay connected • 9) Keep laughing
• 5) Release tension • 10) Be optimistic

Uscher J. How to overcome obstacles in your life: resilience. How to overcome obstacles in your life: resilience. Published 2014. Accessed June 3, 2020.

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Charismatic Adult
• A person from whom a child gathers strength.
• Children are not the only ones who need
strength.
• Adults need charismatic adults too.
• Lifestyle medicine practitioners and coaches
are often charismatic adults in people’s lives.
• ---Dr. Julius Segal

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Happiness
• “The things that make us feel • Why do we have kids?
good in the moment aren’t
necessarily the things that • Dr. Seligman’s answer is that
make life feel worth living.” by parents are looking for more
Jason Marsh of Greater Good: than happy feelings.
The Science of a Meaningful • “If we just wanted positive
Life emotions, our species would
• In the moment--$, alcohol, have died out a long time ago.
drugs, winning a metal, buying We have children to pursue
other elements of well-being. We
a second home, buying a new
shirt want meaning in life. We want
relationships.”

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Who said this about
happiness and success?
• "Again and again I therefore admonish my students in Europe and America:
Don't aim at success - the more you aim at it and make it a target, the more
you are going to miss it. For success, like happiness, cannot be pursued; it
must ensue, and it only does so as the unintended side effect of one's
personal dedication to a cause greater than oneself or as the by-product of
one's surrender to a person other than oneself. Happiness must happen,
and the same holds for success: you have to let it happen by not caring
about it. I want you to listen to what your conscience commands you to do
and go on to carry it out to the best of your knowledge. Then you will live to
see that in the long-run - in the long-run, I say! - success will follow you
precisely because you had forgotten to think about it."

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 Happiness and Subjective Well Being
Psychologist Ed Diener describes what psychologists call
“subjective well-being” as a combination of life satisfaction and
having more positive emotions than negative emotions.

Diener E, Biswas-Diener R. Happiness: Unlocking the mysteries of psychological wealth. John Wiley & Sons; 2011.

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Dr. Happiness
• Professor Ed Diener
• Father of Happiness Research
• 25 years of Happiness
research in Illinois
• Happiness: Unlocking the
Mysteries of Psychological
Wealth, by Ed Diener and
Robert Biswas-Diener

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THE HAPPINESS-HEALTH CONNECTION

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RESEARCH SPOTLIGHT

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 Positive Emotion Increases Life
Satisfaction and Creates Happy State
• Affective profiles • Sweden
• Self-fulfilling • Used to discern differences in
• High positive, low negative profiles regarding happiness,
depression, and also life
• High affective
satisfaction.
• High positive, high negative
• This study used these profiles in
• Low affective the US
• Low positive, low negative
• Also investigated the use of
• Self-destructive happiness-increasing strategies.
• Low positive, high negative
Schütz E, Sailer U, Al Nima A, et al. The affective profiles in the USA: happiness, depression, life satisfaction, and happiness-increasing strategies. PeerJ. 2013;1:e156.

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 Methods
• 1,900 subjects- Study 1
• Positive Affect Negative Affect
Schedule PANAS
• Happiness-Depression Scale
• 500 subjects-Study 2
• PANAS, Satisfaction with Life
Scale, and Happiness-Increasing
Strategies Scale
Schütz E, Sailer U, Al Nima A, et al. The affective profiles in the USA: happiness, depression, life satisfaction, and happiness-increasing strategies. PeerJ. 2013;1:e156.

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 8 Strategies Used to
Increase Happiness
• Social affiliation • Passive Leisure
• Support and encourage friends • Surf the internet
• Partying and clubbing • Active Leisure
• Drink alcohol • Exercise
• Mental control • Religion
• Try not to think about being • Seek support from faith
unhappy
• Direct Attempts
• Instrumental Goal Pursuit • Act happy/smile
• Study

Schütz E, Sailer U, Al Nima A, et al. The affective profiles in the USA: happiness, depression, life satisfaction, and happiness-increasing strategies. PeerJ. 2013;1:e156.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 99

 Results
• Individuals classified as • Self-destructive individuals (low
self-fulfilling (high positive positive affect, high negative
affect, low negative affect) affect) were more depressed,
showed lower levels of unhappier, and less satisfied
depression, tended to be than all other profiles.
happier, and were more
satisfied with their lives.

Schütz E, Sailer U, Al Nima A, et al. The affective profiles in the USA: happiness, depression, life satisfaction, and happiness-increasing strategies. PeerJ. 2013;1:e156.

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 Results continued
• Self-fulfilling individuals • Self-fulfilling individuals were
tended to use strategies more prone to directly attempt to
related to agency smile, get themselves in a happy
(instrumental goal pursuit), mood, improve their social skills,
community (social and work on their self-control.
affiliation), and spirituality • They scored lower than high
(religion) when pursuing affectives and self-destructives in
happiness. the strategy of mental control.
• They also drank less alcohol

Schütz E, Sailer U, Al Nima A, et al. The affective profiles in the USA: happiness, depression, life satisfaction, and happiness-increasing strategies. PeerJ. 2013;1:e156.

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RESEARCH SPOTLIGHT

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 Positive psychological condition and
cardiovascular disease
• “Perceived level of life • Subjects = 88,175 Japanese men
enjoyment is considered a and women (40-69 years old) free
positive psychological of CVD
condition that reflects the • Follow up 12.0 years
ability to engage
pleasurably with the • Self-administered questionnaires
environment.” • “Are you enjoying your life?”
• (0= low, 1= medium, 2=high)

Shirai K, Iso H, Ohira T, et al. CLINICAL PERSPECTIVE. Circulation. 2009;120(11):956-963.

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 Results
• Japanese men with low • Limitations
perceived level of life enjoyment
• One question at one time point
showed increased risk for
stroke and coronary heart • Women’s and men’s risks
disease, incidence and increase at different times
mortality. • For men 55
• For women 65
• For women, perceived level of
life enjoyment was not
associated with risks of
cardiovascular disease
incidence or mortality.
Shirai K, Iso H, Ohira T, et al. CLINICAL PERSPECTIVE. Circulation. 2009;120(11):956-963.

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 Conclusions:
• The findings with the Japanese
men suggests a protective role of
positive psychological conditions
on cardiovascular disease.

Shirai K, Iso H, Ohira T, et al. CLINICAL PERSPECTIVE. Circulation. 2009;120(11):956-963.

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Negative psychological conditions and
heart disease
• Large numbers of studies • Depressive symptoms
reveal the association
• Anger
between negative
psychological conditions and • Hostility
higher risks of • Anxiety
cardiovascular disease
incidence and mortality. • Hopelessness

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RESEARCH SPOTLIGHT

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 Heart Disease and Life Satisfaction
Is there a correlation?
• Heart health when life is
satisfying: evidence from the
Whitehall II cohort study.

Boehm JK, Peterson C, Kivimaki M, Kubzansky LD. Heart health when life is satisfying: evidence from the Whitehall II cohort study. European heart journal. 2011;32(21):2672-2677.

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 The Study
• 7,956 healthy subjects • Satisfaction with seven life
• Outcomes= angina, non-fatal domains
MI, or death • Marital or love relationship
• 5 year follow up • Leisure time activities
• Survey- (1-7 Likert Scale) • Standard of living
• All things considered how satisfied
or dissatisfied are you with the • Job
following areas of your life?
• Feelings about yourself as a
person
• Family life
• Sex life
Boehm JK, Peterson C, Kivimaki M, Kubzansky LD. Heart health when life is satisfying: evidence from the Whitehall II cohort study. European heart journal. 2011;32(21):2672-2677.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 109
 Results
• Subjects that scored higher • Associations with lower CHD were
than average in all categories evident for increased satisfaction
had up to in four life domains:
• 13% less risk of heart • Job
disease, heart attacks, and • Family
angina.
• Sex life
• Feelings about yourself as a
person

Boehm JK, Peterson C, Kivimaki M, Kubzansky LD. Heart health when life is satisfying: evidence from the Whitehall II cohort study. European heart journal. 2011;32(21):2672-2677.

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 LAUGHTER

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 111
Laughter
•“A merry heart doeth good
like a medicine, but a
broken spirit drieth the
bone.”
• Proverbs 17:22

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Norman Cousins-Father of Laughter
Therapy
• Painful ankylosing spondylitis
• Left the hospital as therapies were not
helping
• Went to a motel
• Took high doses of Vitamin C
• Watched Marx Brother and Candid Camera
• Reported that 10 minutes of humor resulting
in “belly laughing” resulted in 2 hours of pain
relief and possibly 2 hours of sleep.

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 Writings
• New England Journal of Medicine
December 23, 1976
• Anatomy of an Illness (As
Perceived by the Patient)

Cousins N. Anatomy of an illness (as perceived by the patient). New England Journal of Medicine. 1976;295(26):1458-1463.

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 After being diagnosed with cancer
• “The other reactions; anger, depression, suppression, denial, took
a little piece of me with them. Each made me feel just a little less
human. Yet laughter made me more open to ideas, more inviting
to others, and even a little stronger inside. It proved to me that,
even as my body was devastated and my spirit challenged, I was
still a vital human.”

Strean WB. Laughter prescription. Canadian Family Physician. 2009;55(10):965-967.

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RESEARCH SPOTLIGHT

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 Definitions
• Humor = • Laughter =
• The stimulus such as a joke, • Physical reaction characterized
which evokes a response. by a distinct repetitive vocal
sound, certain facial
expressions, and contraction of
various muscle groups

Louie D, Brook K, Frates E. The laughter prescription: a tool for lifestyle medicine. American journal of lifestyle medicine. 2016;10(4):262-267.

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 Types of Laughter
• Spontaneous • Physical act of laughing is
• Genuine from something enough to create the
funny, humor, joke, sit com physiological effects
• Simulated • Motion Creates Emotion
• Forced, laughter yoga Theory (MCET)

Louie D, Brook K, Frates E. The laughter prescription: a tool for lifestyle medicine. American journal of lifestyle medicine. 2016;10(4):262-267.

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 Laughter Theories
• 100 different theories
• Dominated by 3
• Release theory
• Physical manifestation of repressed
desires
• Superiority theory
• Means of increasing one’s self esteem at
the expense of others
• Incongruity theory
• Created by a sense of disparity between
two or more objects or ideas within a joke
Louie D, Brook K, Frates E. The laughter prescription: a tool for lifestyle medicine. American journal of lifestyle medicine. 2016;10(4):262-267.

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 Health Benefits of Spontaneous
Laughter
PSYCHOLOGICAL EFFECTS

•Improving affect
•Improving depression
•Improving anxiety
•Decreasing stress
•Decreasing agitation (in
dementia patients)
Louie D, Brook K, Frates E. The laughter prescription: a tool for lifestyle medicine. American journal of lifestyle medicine. 2016;10(4):262-267.

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 Health Benefits of Spontaneous
Laughter
PHYSIOLOGICAL EFFECTS

•Increase epinephrine and •Endorphin release

norepinephrin
•Increase pain tolerance
•Decreased cortisol levels •Natural Killer cell activity
•Increase systolic BP like increases
exercise
•Decreasing total peripheral
•Increase stroke volume resistance
•Increase cardiac output •Vasodilation
Louie D, Brook K, Frates E. The laughter prescription: a tool for lifestyle medicine. American journal of lifestyle medicine. 2016;10(4):262-267.

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RESEARCH SPOTLIGHT

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 Your Arteries Know What you Watch
on Television
• 20 non-smoking, healthy men and
women, average age of 33.
• View a 15-30 minutes segment of
a movie
• One designed to induce mental
stress and one laughter.
• Randomly assigned
• Measured brachial artery flow
mediated vasodilation
Miller M, Mangano C, Park Y, Goel R, Plotnick G, Vogel R. Impact of cinematic viewing on endothelial function. Heart. 2006;92(2):261-262.

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 Did you Watch a Comedy or a Tragedy?
Check your brachial flow mediated vasodilation
• Brachial artery flow mediated
dilation was reduced in 14/20 of
the subjects after watching the
mental stress clips
• Brachial artery flow mediated
dilation was increased in 19/20
subjects after watching the
laughter clip.

Miller M, Mangano C, Park Y, Goel R, Plotnick G, Vogel R. Impact of cinematic viewing on endothelial function. Heart. 2006;92(2):261-262.

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 Discussion
• Brachial artery flow • Improvement in flow mediated
mediated vasodilation was vasodilation after watching a
impaired while watching a funny movie
mentally stressful movie • Similar to the improvements after
• Similar to the conditions aerobic exercise.
of anger recall and mental
• Mechanism for these findings is
arithmetic.
not fully understood.

Miller M, Mangano C, Park Y, Goel R, Plotnick G, Vogel R. Impact of cinematic viewing on endothelial function. Heart. 2006;92(2):261-262.

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 The Reward of a Good Joke:
neural correlates of viewing dynamic displays of stand-up comedy
• 20 participants (10 men
and 10 women)
• 18-35 yrs old paid $20
• Comedy clips rated high
and low humor
Right nucleus accumbens, caudate, and putamen • Viewed comedy clips while
bilaterally measured by fMRI
Left inferior frontal gyrus and left temporoparietal
junction and the right supplementary motor cortex

Franklin RG, Adams RB. The reward of a good joke: neural correlates of viewing dynamic displays of stand-up comedy. Cognitive, Affective, & Behavioral Neuroscience. 2011;11(4):508-515.

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 Laughter Yoga vs Group Exercise vs
Control: RCT
• 60 geriatric depressed women in Tehran, Iran
• Laughter yoga (10 sessions), group exercise
(10 sessions jogging and stretching) or control
• Exercise and Laughter yoga had decrease in
Depression scores
• Laughter yoga group had increase in
• Life satisfaction compared to control
• No significant difference between laughter
yoga and exercise groups

Shahidi M, Mojtahed A, Modabbernia A, et al. Laughter yoga versus group exercise program in elderly depressed women: a randomized controlled trial. International journal of
geriatric psychiatry. 2011;26(3):322-327.

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 Laughter Yoga with
IT Professionals in India
• 115 Information Technology
Professionals in India (laughter
yoga vs control-no intervention)
• 7 sessions of laughter yoga
• Greater drop in blood pressure vs
control
• Significant drop in cortisol levels
vs control
Nagendra H, Chaya M, Nagarathna R, Kataria M, Manjunath M, Raghavendra R. The efficacy of Laughter Yoga on IT professionals to overcome professional stress. Laughter
Yoga International: Mumbai, India. 2007.

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 Laughter Yoga and
Nursing Students 2014
• 38 male nursing students
• Study group 8 one hour laughter
yoga classes
• Twice a week
• Control group had no intervention
• Intervention had a positive effect
on general health, sleep disorders,
lowered anxiety and depression,
and improved social function
Yazdani M, Esmaeilzadeh M, Pahlavanzadeh S, Khaledi F. The effect of laughter Yoga on general health among nursing students. Iranian journal of nursing and midwifery research. 2014;19(1):36.

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 Limitations of research
• Need more randomized controlled trials
• Need more power-more subjects
• Need long term follow up.
• Need clarification between types of laughter.
• Need frequency and length of laughter interventions

Yazdani M, Esmaeilzadeh M, Pahlavanzadeh S, Khaledi F. The effect of laughter Yoga on general health among nursing students. Iranian journal of nursing and midwifery research. 2014;19(1):36.

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Weighing risks and benefits
• Risks
• Wetting pants
• Too much fun

March 12, 2012---Marie Osmond and brother

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 132
Is Laughter Appropriate in the Medical
Setting?
•The ICU vs a lifestyle
medicine visit
•Different types of humor
• Cynical, derogatory humor is
off limits
• Dark and negative humor is
off limits

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Appropriate Humor and Laughter
• Shared between provider and patient
• Requires a certain measure of trust,
understanding and lightheartedness
• Possibly can improve communication
by creating positive emotions in
provider and patient.
• Following lead of patient is best
strategy

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 134
The Laughter in the Doctor’s Office
• Ask/Assess-
• What has made you laugh
recently?
• One minute conversation about
laughter.
• Checking in to see if patient knows
latest literature.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 135
The Importance of a Sense of Humor
• Paul McGhee, PhD
• Founder of the Laughter
Remedy Humor Training
Programs
• “Your sense of humor is one
of the most powerful tools you
have to make certain that
your daily mood and
emotional state support good
health.”
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FITT PRESCRIPTION FOR LAUGHTER
• F – daily or weekly
• I – spontaneous, tickling, belly laughing
• T– duration of laughter episode
• T – laughter. yoga, comedy club, favorite sitcom etc

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The Laughter Prescription
• Frequency
• One a week
• Intensity
• Belly laughing
• Time
• 30 minutes
• Type
• Laughter yoga class

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References
American Psychological Association. Helping people without homes: The role of psychologists and
recommendations to advance research, training, practice, and policy. Report of the APA Presidential
Task Force on Psychology’s Contribution to End Homelessness. 2009.
Ben-Shahar T. Happier: Learn the secrets to daily joy and lasting fulfillment. McGraw-Hill Companies;
2007.
Boehm JK, Peterson C, Kivimaki M, Kubzansky LD. Heart health when life is satisfying: evidence from
the Whitehall II cohort study. European heart journal. 2011;32(21):2672-2677.
Brown NJ, Sokal AD, Friedman HL. The complex dynamics of wishful thinking: The critical positivity ratio.
2013.
Busemeyer JR. Book Review: Multidimensional Models of Perception and Cognition: Edited by F.
Gregory Ashby Hillsdale NJ: Erlbaum, 1992, 523 pp., $125.00. Applied Psychological Measurement.
1994;18(4):383-384.
Cousins N. Anatomy of an illness (as perceived by the patient). New England Journal of Medicine.
1976;295(26):1458-1463.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 139
References
Diener E, Biswas-Diener R. Happiness: Unlocking the mysteries of psychological wealth. John
Wiley & Sons; 2011.
Dweck CS. Mindset: The new psychology of success. Random House Digital, Inc.; 2008.
Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of
gratitude and subjective well-being in daily life. Journal of personality and social psychology.
2003;84(2):377.
Frankl VE. Man's search for meaning. Simon and Schuster; 1985.
Franklin RG, Adams RB. The reward of a good joke: neural correlates of viewing dynamic displays of
stand-up comedy. Cognitive, Affective, & Behavioral Neuroscience. 2011;11(4):508-515.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 140
References
Frates B, Bonnet JP, Joseph R, Peterson JA. Positively Positive. In: Frates B, ed. Lifestyle
Medicine Handbook: An Introduction to the Power of Healthy Habits. Monterey, CA: Healthy
Learning; 2021:371-396.
Fredrickson B. Positivity. Harmony; 2009.
Fredrickson BL, Cohn MA, Coffey KA, Pek J, Finkel SM. Open hearts build lives: positive emotions,
induced through loving-kindness meditation, build consequential personal resources. Journal of
personality and social psychology. 2008;95(5):1045.
Goodin BR, Bulls HW. Optimism and the experience of pain: benefits of seeing the glass as half
full. Current pain and headache reports. 2013;17(5):329.
Gray S, Emmons R, Morrison A. Distinguishing gratitude from indebtedness in affect and action
tendencies. Paper presented at: Poster presented at the 109th Annual Convention of the
American Psychological Association, San Francisco, CA2001.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 141
References
Heubeck E. Boost Your Health With a Dose of Gratitude. WebMD. Published
[Link] Accessed July 17, 2020.
Louie D, Brook K, Frates E. The laughter prescription: a tool for lifestyle medicine. American journal
of lifestyle medicine. 2016;10(4):262-267.
McCullough ME, Emmons RA, Tsang J-A. The grateful disposition: A conceptual and empirical
topography. Journal of personality and social psychology. 2002;82(1):112.
Miller M, Mangano C, Park Y, Goel R, Plotnick G, Vogel R. Impact of cinematic viewing on
endothelial function. Heart. 2006;92(2):261-262.
Moser JS, Schroder HS, Heeter C, Moran TP, Lee Y-H. Mind your errors: Evidence for a neural
mechanism linking growth mind-set to adaptive posterror adjustments. Psychological Science.
2011;22(12):1484-1489.
Nadler RT, Rabi R, Minda JP. Better mood and better performance: Learning rule-described
categories is enhanced by positive mood. Psychological Science. 2010;21(12):1770-1776.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 142
References
Nagendra H, Chaya M, Nagarathna R, Kataria M, Manjunath M, Raghavendra R. The efficacy of
Laughter Yoga on IT professionals to overcome professional stress. Laughter Yoga International:
Mumbai, India. 2007.
Ng M-Y, Wong W-S. The differential effects of gratitude and sleep on psychological distress in
patients with chronic pain. Journal of health psychology. 2013;18(2):263-271.
Power AE. Slow-wave sleep, acetylcholine, and memory consolidation. Proceedings of the National
Academy of Sciences. 2004;101(7):1795-1796.
Schütz E, Sailer U, Al Nima A, et al. The affective profiles in the USA: happiness, depression, life
satisfaction, and happiness-increasing strategies. PeerJ. 2013;1:e156.
Seligman ME, Csikszentmihalyi M. Positive psychology: An introduction. In: Flow and the
foundations of positive psychology. Springer; 2014:279-298.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 143
References
Seligman ME, Steen TA, Park N, Peterson C. Positive psychology progress: empirical validation of
interventions. American psychologist. 2005;60(5):410.
Seligman ME. Authentic happiness: Using the new positive psychology to realize your potential for
lasting fulfillment. Simon and Schuster; 2004.
Seligman ME. Flourish: A visionary new understanding of happiness and well-being. Simon and
Schuster; 2012.
Shahidi M, Mojtahed A, Modabbernia A, et al. Laughter yoga versus group exercise program in
elderly depressed women: a randomized controlled trial. International journal of geriatric
psychiatry. 2011;26(3):322-327.
Shirai K, Iso H, Ohira T, et al. CLINICAL PERSPECTIVE. Circulation. 2009;120(11):956-963.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 144
References
Stephens JP, Heaphy ED, Carmeli A, Spreitzer GM, Dutton JE. Relationship quality and
virtuousness: Emotional carrying capacity as a source of individual and team resilience. The
Journal of Applied Behavioral Science. 2013;49(1):13-41.
Strean WB. Laughter prescription. Canadian Family Physician. 2009;55(10):965-967.
Sugawara SK, Tanaka S, Okazaki S, Watanabe K, Sadato N. Social rewards enhance offline
improvements in motor skill. PLoS One. 2012;7(11):e48174.
The Effect of Positive Emotions on Our Health. Fractal Enlightenment.
[Link]
Accessed July 17, 2020.
Uscher J. How to overcome obstacles in your life: resilience. How to overcome obstacles in your
life: resilience. Published 2014. Accessed June 3, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 145
References
Yazdani M, Esmaeilzadeh M, Pahlavanzadeh S, Khaledi F. The effect of laughter Yoga on general
health among nursing students. Iranian journal of nursing and midwifery research. 2014;19(1):36.
Yeo S-E. Resilience, Character Strengths and Flourishing: A Positive Education Workshop for
Singapore Teachers. 2011.
Zahn R, Moll J, Paiva M, et al. The neural basis of human social values: evidence from functional
MRI. Cerebral cortex. 2009;19(2):276-283.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 146