CHAPTER 1
The Laughter Club
THE PHYSICAL NATURE OF EMOTION
It is estimated that one in fifteen American adults, about 21 million, is living with major depression.1 Most of us feel down in the dumps from time to time, but depression is a never-ending feeling of sadness that affects how you think, how you feel, and how you behave. For people living with a major depressive disorder, everything is gray and life seems bleak, not worth living.
Despite recent headway made in understanding the inner workings of the brain, there is still no treatment for depression that works for everyone. Psychotherapy and drugs like Prozac have helped millions of people stave off depression, but these modalities havenât worked for millions more. The sad fact is that some individualsâ depression is resistant to treatment.
Yet consider for a moment that almost all available treatments for depression (whether therapy or medication) target whatâs going on inside the head. What if there were a way to alleviate depression that went beyond the cortex and altered the body? It might seem odd to focus on the body as an antidote for a disorder seemingly rooted in the mind, but striking new scientific evidence suggests that our body has a powerful influence on our psychological state.
Take the case of Laura, an intelligent, driven twenty-two-year-old. Laura had just graduated from a prestigious Ivy League university and taken her first job at a top public relations firm in Manhattan when her fiancé, Brian, was involved in a car accident and died. Laura was devastated.
Brian and Laura had been high school sweethearts. He was her third kiss and her first love. Even though they had gone off to college on different sides of the country, the two had managed to stay connected as a couple. Brian was her family, the âone,â but suddenly, in the midst of planning their late summer wedding and only three short weeks after they had moved into their first apartment together, Brian was gone.
In the several months after Brianâs unexpected death, Laura tried to put her life back together. She rented a new apartment in order to get a change of scenery and even went out on a few blind dates her concerned friends had set up for her. But her heart just wasnât in it. While her friends were busy planning their lives, Laura spent her days contemplating the bleakness of life. She constantly broke down in tears and often had trouble getting out of bed, especially on weekends and holidays when she wasnât expected to be anywhere in particular. Her physical energy and her ability to concentrate all but disappeared, and she became increasingly isolated from friends and family. She was noticeably different. As Elizabeth Wurtzel wrote about her own depression in Prozac Nation, thatâs how depression hits: gradually, then suddenly. Laura woke up one morning afraid of what might happen that day, scared to live her life. Everything seemed dark, and she could not think of anything that would make her happy. At some point her mother suggested that she see a psychiatrist, who, not surprisingly, diagnosed Laura with a major depressive disorder.
Laura initially began taking Prozac and going to weekly psychotherapy sessions. At first the drugâs effects were almost miraculously positive. Laura couldnât believe how much better she felt. She was more energetic and motivated at work, started seeing her friends, and became interested in life again. Over time, however, she had to take higher and higher doses of Prozac to beat her depression, until the drug seemed to stop working completely. Lauraâs doctor started her on another medication, but again Lauraâs depression failed to lift. After a few years she gave up on both drugs and therapy. She was stuck. Then she heard that Botox had been found to help ease depression.
Depressed individuals can often be recognized by their facial expression: a frown with a furrowed brow and downturned mouth. Kurt Cavanaugh, a cosmetic surgeon, immediately picks up on this when patients like Laura walk into his office. On a cool fall day, almost two years to the day after her fiancé had been killed, Laura went to Cavanaugh for Botox treatments.
The active ingredient in Botox is a neurotoxin that paralyzes the muscles into which itâs injected. When people get Botox for their frown lines, not only do the frown lines disappear, but their ability to produce unhappy or sour expressions goes away too. Physicians believe that preventing the outward expression of negative emotions helps alter the inner experience of negativity. In other words, certain body movements (or lack thereof) help to change the mindâs experience of emotions. On several instances Cavanaugh had casually noted that the moods of his Botox patients after treatments seemed less negative than those of his patients who didnât use Botox. Of course, such differences could easily be due to increased feelings of attractiveness after treatment.
In Hollywood the immense pressure to stay youthful drives actors to use Botox repeatedly. But too much Botox can immobilize your face and your internal feelings. This is bad news for an actor, who needs to convey emotion, but maybe not for someone like Laura with major depression. The media has reported that Nicole Kidman, for example, has had a Botox-induced frozen face; this appeared to be in evidence when she accepted an Academy Award for her performance in The Hours. She was clearly crying, yet nothing on her face seemed to be moving. Actorsâ emotional expressions make their performances more believable to their audience and also help them internally experience their characterâs feelings. The eighteenth-century German philosopher Gotthold Lessing wrote, âI believe that when the actor properly imitates all the external signs and indicators and all the bodily alterations which experience taught him are expressions of a particular [inner] state, the resulting sense impressions will automatically induce a state in his soul that properly accords with his own movements, posture, and vocal tone.â2 Botox can be bad for actorsâ ability to emote convincingly, yet it can help depressed individuals to quell their internal feelings of sadness by blocking its physical expression.
It may seem odd to think that the expressions we produce outwardly can affect our internal state. After all, we tend to assume that itâs the mind that controls the body, not the other way around. But there are direct connections running from the body to the mind. For example, when people are asked to hold a golf tee between their eyebrows in such a way that they have to furrow their brow, they report being in a bad mood.3 People also judge stories, pictures, and cartoons to be less funny when they are asked to hold a pencil between pursed lips so that their face makes a frown. The opposite is also true: when you hold a pencil in your teeth so that you are smiling, you feel happier. And itâs not just facial expressions that send feedback to our brain about our feelings and emotions. When you sit in a slumped position (as opposed to straight, with shoulders back), you donât feel as good about your accomplishments, such as how you just performed on a test or in a presentation. Simply assuming a happy or sad bodily posture, a confident or anxious mien, conveys to our brain what emotional state we are in.
Our facial expressions also affect how we react to stress. Smiling while submerging your hand in ice water for several minutes lessens stress and leads to a quicker recovery from the painful incident than if you donât smile.4 There really is something to the old adage âGrin and bear it.â Of course, there is also a catch: this smile technique works best if you donât know you are doing itâif you form an unconscious smile rather than smile intentionally. In the latter case, the brain seems to catch on and doesnât interpret the bodily expression as happiness. But even faking a smile is better than nothing, because our neural circuitry doesnât always make a clear distinction between what is fake and what is real. Even if you âsmile while your heart is breaking,â as the ballad suggests, at some level your brain canât help but interpret your smiling as a sign that everything is okay.
A relatively new type of yoga known as Laughter Yoga, or Hasyayoga (hasya means âlaughterâ in Sanskrit), combines laughter with rhythmic breathing. Laughter clubs, where people can engage in this playful activity, have formed from India to Chicago. What starts as forced laughter at some point turns spontaneous and contagious. Laughter not only provides physiological benefits (an abdominal muscle workout and increased lung capacity) but psychological benefits too. Laughter lifts our spirits precisely because our body has a direct line to our mind, telling us how to feel.
In the movie Mary Poppins, Uncle Albert (played by Ed Wynn) floats up to the ceiling of his study because he is filled with uncontrollable laughter, singing a song entitled âI Love to Laugh.â Uncle Albertâs levitation obviously involved some movie fakery, but there is something real in the power of laughter to lighten our moods. A laughing body is an inhospitable host to negativity and stress. There is now even a World Laughter Dayâthe first Sunday in May, in case you are interested in taking part.
What if your body canât take part in these emotional experiences? This actually happens to the unlucky people born with a rare neurological disorder known as Moebius syndrome. Moebius syndrome prevents people from moving their facial muscles; they canât smile, frown, grimace, or even blink their eyes. Itâs like âliving a life of the mind,â one patient said. âI . . . think happy or I think sad, not . . . actually feeling happy or feeling sad.â5 Folks with Moebius syndrome, unable to shape their face into a particular expression, have trouble expressing themselves to others and difficulty experiencing emotions themselves.
To treat Lauraâs depression, Cavanaugh reasoned that using Botox to prevent frowning might serve as an artificial Moebius syndrome and at least impede negative emotions. The Botox injections he settled on would work on her glabellar frown lines, the wrinkles that occur above the nose and between the eyes and express emotions such as sadness, anger, and distress. Before giving her the injections, however, Cavanaugh asked Laura to complete a common psychological test for evaluating depression, the Beck Depression Inventory,6 which gauges the severity of symptoms of depression, such as hopelessness and irritability. People taking the test are asked to pick the statements that most closely resemble how they have felt during the previous two weeks. There are twenty-one questions; here is a sample:7
UNHAPPINESS
0 I do not feel unhappy.
1 I feel unhappy.
2 I am unhappy.
3 I am so unhappy that I canât stand it.
CHANGES IN ACTIVITY LEVEL
0 I have not experienced any change in activity level.
1 I am somewhat less active than usual.
2 I am a lot less active than usual.
3 I am not active most of the day.
A score of 13 or less signifies that the person is experiencing normal ups and downs (picking mostly 0âs and 1âs). A score of 29 or more indicates a severe depressive state. Laura scored 42.
In the procedure that followed, which took only a few minutes, Cavanaugh injected Botox into several sites between Lauraâs eyes and on her forehead. All you have to do is scrunch up your forehead to furrow your brow to see which areas he targeted.
Two months after her Botox treatment, Lauraâs depression had lifted completely. Given that there was no major change in her life, Cavanaughâs best guess was that her improvement in mood was due to the Botox.
Botox works by blocking the movement of acetylcholine, a neurotransmitter, from the nerves to the muscles. Acetylcholine helps carry signals from the brain to the muscles, letting the muscles know when to tense up. When the flow of acetylcholine is blocked, or at least significantly reduced, the muscle is no longer being told to contract, and so it relaxes. Thatâs why the wrinkled areas into which Botox is injected smooth out and soften: theyâre not getting the message to tighten. After a while the acetylcholine does get back through. (A normal course of Botox typically lasts between four and six months.) The muscles once again begin to contract and the wrinkles reappear. Thatâs the bad news. The good news is that the wrinkles usually become less prominent after Botox because the muscles have been âtrainedâ to be in a more relaxed state. Perhaps this explains why, when Laura returned to Cavanaugh for a second treatment, her frown lines werenât as pronounced (nor her depressive symptoms as extreme) as on her initial visit. Because Botox can permanently retrain the muscles, the need for further treatment is gradually reduced.
Botox is also approved by the Food and Drug Administration to treat chronic migraines; injections every twelve weeks or so into the head or neck help dull future headaches.8 Even excessive underarm sweating can be fought with Botox injections to the armpits.9 Both migraines and sweating have physical as well as emotional triggers. Lauraâs story suggests that Botox can alleviate depression and improve mental health too, though itâs important to point out that Laura knew why she was getting Botox and anticipated that it would help her, just as the Prozac helped initially. But the Botox has kept her depression from returning, so it is unlikely that Lauraâs changes in mood were simply due to her hopes and expectations about the treatment.
Lauraâs experience wasnât a fluke. A few years ago a group of psychologists in the United Kingdom tracked down people who had recently had cosmetic treatments. They were particularly interested in comparing the moods of people who had had Botox injections for frown lines (at the same facial sites where Laura had received treatment) with the moods of those who had received other treatments, such as Botox for crowâs feet around the eyes, chemical peels, or lip fillers like Restylane. The researchers reasoned that, if not being able to frown makes people happier, then folks who got injections for frown lines should have elevated moods compared to those who got other cosmetic treatments. That is exactly what they found. Limiting negative facial expressions seems to affect mood for the better.10
Yet another example of the effectiveness of Botox to change the mind comes from the psychologist David Havas, who specializes in the effects of emotions on how we think and feel. Havas and his colleagues Art Glenberg and Richard Davidson offered first-time Botox users receiving treatment for frown lines a $50 credit toward their treatment if they took part in an experiment before and after the procedure. At both points, the volunteer patients simply had to read a series of sentences depicting positive and negative scenarios:
âYou spring up the stairs to your loverâs apartment.â (happy)
âYou open your email in-box on your birthday to find no new emails.â (sad)
âReeling from the fight with that stubborn bigot, you slam the car door.â (angry)
Unbeknownst to the volunteers, the researchers measured how long it took them to read the different sentences. Generally it takes longer to read about unfamiliar events than familiar ones, and it also takes longer to read things you donât understand. Reading time thus ends up reflecting how well the information resonates with your own experienceâhow well you are able to, say, empathize with the emotions you are reading about.
The researchers found that it took the patients roughly the same amount of time to read the happy sentences before and after the Botox treatment. However, they were much slower at reading the sad or angry sentences after the treatment as compared to before. Botox didnât alter comprehension across the board, but it increased the time it took to read and comprehend negative information. According to Havas and his colleagues, t...