Sense of humor in patients with schizophrenia

A Comprehensive Review on the Effects of Humor in Patients With Depression

Depression is a leading cause of disability worldwide and a major contributor to the overall global burden of disease. Although there are known, effective treatments for depression, people in low- and middle-income areas experience multiple barriers which limit their ability to receive adequate treatment. Some known barriers to effective care include a lack of resources, lack of trained healthcare providers, and social stigma associated with mental disorders and this creates gaps in mental health care and the need for more treatment modalities and adjuvant therapies to address these gaps. This review article was conducted using the scale for the assessment of non-systematic review articles (SANRA). We searched three databases; EMBASE, PubMed (MEDLINE), and Google Scholar using specified search terms. We had a total of nine articles with sample sizes ranging from 37 to 1551, and the age of participants ranged from 23 to 93 years. Articles were diverse in race and geographical locations. The articles were derived from cross-sectional studies, randomized studies, and experimental studies, and they focused on the relationship between humor and depression, and the reduced risk of depression in the study population. The articles identified different aspects of the relationship between humor and depression. The willingness of patients with depression to recognize or participate in humor could be defective resulting in abnormal social interactions such as withdrawal. However, there was some significant influence of humor or its styles on patients with depression either mitigating depressive symptoms or having no impact at all.

Use of Laughter for the Detection of Parkinson's Disease: Feasibility Study for Clinical Decision Support Systems, Based on Speech Recognition and Automatic Classification Techniques

Parkinson's disease (PD) is an incurable neurodegenerative disorder which affects over 10 million people worldwide. Early detection and correct evaluation of the disease is critical for appropriate medication and to slow the advance of the symptoms. In this scenario, it is critical to develop clinical decision support systems contributing to an early, efficient, and reliable diagnosis of this illness. In this paper we present a feasibility study for a clinical decision support system for the diagnosis of PD based on the acoustic characteristics of laughter. Our decision support system is based on laugh analysis with speech recognition methods and automatic classification techniques. We evaluated different cepstral coefficients to identify laugh characteristics of healthy and ill subjects combined with machine learning classification models. The decision support system reached 83% accuracy rate with an AUC value of 0.86 for PD-healthy laughs classification in a database of 20,000 samples randomly generated from a pool of 120 laughs from healthy and PD subjects. Laughter could be employed for the efficient and reliable detection of PD; such a detection system can be achieved using speech recognition and automatic classification techniques; a clinical decision support system can be built using the above techniques. Significance: PD clinical decision support systems for the early detection of the disease will help to improve the efficiency of available and upcoming therapeutic treatments which, in turn, would improve life conditions of the affected people and would decrease costs and efforts in public and private healthcare systems.

Humor in Psychiatry: Lessons From Neuroscience, Psychopathology, and Treatment Research

Humor is a ubiquitous human characteristic that is socially motivated at its core and has a broad range of significant positive effects on emotional well-being and interpersonal relationships. Simultaneously, however, impairments in humor abilities have often been described in close association with the occurrence and course of neuropsychiatric disorders, such as schizophrenia, social anxiety, or depression. In the past decade, research in the neuroimaging and psychiatric domain has substantially progressed to (i) characterize impaired humor as an element of psychopathology, and (ii) shed light on the neurobiological mechanisms underlying the role of humor in neuropsychiatric diseases. However, (iii) targeted interventions using concepts of positive psychology have revealed first evidence that a systematic training and/or a potential reactivation of humor-related skills can improve rehabilitative outcome in neuropsychiatric patient groups. Here, we sought to integrate evidence from neuroscience, as well as from psychopathology and treatment research to shed more light on the role of humor in psychiatry. Based on these considerations, we provide directions for future research and application in mental health services, focusing on the question of how our scientific understanding of humor can provide the basis for psychological interventions that foster positive attitudes and well-being.

Plausibility of a Neural Network Classifier-Based Neuroprosthesis for Depression Detection via Laughter Records

The present work explores the diagnostic performance for depression of neural network classifiers analyzing the sound structures of laughter as registered from clinical patients and healthy controls. The main methodological novelty of this work is that simple sound variables of laughter are used as inputs, instead of electrophysiological signals or local field potentials (LFPs) or spoken language utterances, which are the usual protocols up-to-date. In the present study, involving 934 laughs from 30 patients and 20 controls, four different neural networks models were tested for sensitivity analysis, and were additionally trained for depression detection. Some elementary sound variables were extracted from the records: timing, fundamental frequency mean, first three formants, average power, and the Shannon-Wiener entropy. In the results obtained, two of the neural networks show a diagnostic discrimination capability of 93.02 and 91.15% respectively, while the third and fourth ones have an 87.96 and 82.40% percentage of success. Remarkably, entropy turns out to be a fundamental variable to distinguish between patients and controls, and this is a significant factor which becomes essential to understand the deep neurocognitive relationships between laughter and depression. In biomedical terms, our neural network classifier-based neuroprosthesis opens up the possibility of applying the same methodology to other mental-health and neuropsychiatric pathologies. Indeed, exploring the application of laughter in the early detection and prognosis of Alzheimer and Parkinson would represent an enticing possibility, both from the biomedical and the computational points of view.

Frontal hypoactivation and alterations in the reward-system during humor processing in patients with schizophrenia spectrum disorders

Humor is a ubiquitous human ability with important implications for both social and emotional functioning. Patients with neuropsychiatric disorders, such as schizophrenia, experience difficulties in the comprehension and appreciation of humor. However, the specific neural mechanisms underlying these deficits are unknown. In the current study, we sought to elucidate the neural correlates of humor processing in patients with schizophrenia spectrum disorders (SSD). Functional Magnetic Resonance Imaging (fMRI) was used in thirty-one patients with SSD and a control group, performing a humor processing paradigm. Both regional brain activation and parametric modulation of brain responses via subjective funniness ratings were collected during the scanning procedure. On a neural level, large overlaps in fronto-temporal brain activation was found in both groups. However, patients compared to healthy control subjects showed attenuated responses in frontal brain regions, including the anterior cingulate cortex, medial prefrontal cortex (mPFC), superior frontal gyrus and middle frontal gyrus, as well as in the striatum (i.e. caudate nucleus, putamen). Furthermore, parametric modulation of subjective funniness ratings resulted in attenuated responses in the mPFC, bilateral insula, and left hippocampus. Analysis of functional connectivity revealed alterations in mPFC-caudate nucleus coupling in patients with SSD, which might reflect impairments in reward-related processing. Notably, alterations in mPFC-caudate nucleus coupling in patients were significantly associated to subjective funniness ratings. Our results extend previous findings demonstrating the relevance of frontal hypoactivation for humor processing impairments in patients with SSD and first point towards alterations in humor appreciation processes.

Assessing the Temperamental Basis of the Sense of Humor: Adaptation of the English Language Version of the State-Trait Cheerfulness Inventory Long and Standard Form

The State-Trait Model of Cheerfulness assesses the temperamental basis of the sense of humor with the traits and respective states of cheerfulness, seriousness, and bad mood. Cheerfulness is a dominant factor in current measures of the sense of humor and explains both, the disposition to engaging in smiling and laughter, as well as humor behaviors, and trait seriousness and bad mood are antagonistic to the elicitation of amusement (albeit for different reasons). Several studies have shown the validity and reliability of the STCI questionnaire in German and other language versions (i.e., Spanish). In this study, the English language version with 106 items (STCI-T <106>) was translated, checked for its item and scale characteristics, and tested with a confirmatory factor analysis approach (N = 1101) to investigate the factorial validity of the STCI-T <106> scale. Results show good psychometric characteristics, good internal consistencies, and a fit to the postulated underlying structure of the STCI-T. Then, the standard form with 60 items (STCI-T <60>) was developed and the psychometric characteristics initially tested. In an independent sample (N = 169), the characteristics of the standard form were compared to the parent form and German equivalent. It showed good psychometric characteristics, internal consistencies, as well as a good self- and peer-report congruence. To conclude, the STCI-T <106> is the measure of choice for the assessment of the temperamental basis of the sense of humor and the separate facets of the traits, while the standard form (60 items) allows of an economic assessment of cheerfulness, seriousness, and bad mood, free of context-saturated items and humor preferences.

Neural circuit of verbal humor comprehension in schizophrenia - an fMRI study

Individuals with schizophrenia exhibit problems with understanding the figurative meaning of language. This study evaluates neural correlates of diminished humor comprehension observed in schizophrenia. The study included chronic schizophrenia (SCH) outpatients (n = 20), and sex, age and education level matched healthy controls (n = 20). The fMRI punchline based humor comprehension task consisted of 60 stories of which 20 had funny, 20 nonsensical and 20 neutral (not funny) punchlines. After the punchlines were presented, the participants were asked to indicate whether the story was comprehensible and how funny it was. Three contrasts were analyzed in both groups reflecting stages of humor processing: abstract vs neutral stories - incongruity detection; funny vs abstract - incongruity resolution and elaboration; and funny vs neutral - complete humor processing. Additionally, parametric modulation analysis was performed using both subjective ratings separately. Between-group comparisons revealed that the SCH subjects had attenuated activation in the right posterior superior temporal gyrus (BA 41) in case of irresolvable incongruity processing of nonsensical puns; in the left dorsomedial middle and superior frontal gyri (BA 8/9) in case of incongruity resolution and elaboration processing of funny puns; and in the interhemispheric dorsal anterior cingulate cortex (BA 24) in case of complete processing of funny puns. Additionally, during comprehensibility ratings the SCH group showed a suppressed activity in the left dorsomedial middle and superior frontal gyri (BA 8/9) and revealed weaker activation during funniness ratings in the left dorsal anterior cingulate cortex (BA 24). Interestingly, these differences in the SCH group were accompanied behaviorally by a protraction of time in both types of rating responses and by indicating funny punchlines less comprehensible. Summarizing, our results indicate neural substrates of humor comprehension processing impairments in schizophrenia, which is accompanied by fronto-temporal hypoactivation.

Effects of a Humor Therapy Program on Stress Levels in Pediatric Inpatients

OBJECTIVE

Disease and hospitalization generate stress, which can affect the response to treatment. Humor has been used in many hospitals to decrease stress. The aim of this study was to evaluate the impact of a humor therapy program on stress levels in pediatric inpatients.

METHODS

In the first phase, an intervention and a control group were studied over 2 consecutive 3-month periods; the interventions were performed by a team of artists trained in humor therapy. Salivary cortisol levels were measured by enzyme-linked immunosorbent assay, and the Weisz test, a pictorial chart that determines subjective stress perception, and the Parker test, which assesses objective stress, were applied. In the second phase, salivary cortisol levels were measured and the Weisz test was administered before and after the interventions.

RESULTS

A total of 306 patients were recruited into this study: 198 in the first phase (94 in the intervention group and 104 in the nonintervention group) and 108 in the second phase. There were no differences between groups regarding age, sex, or medical diagnosis. The children in the intervention group presented lower cortisol levels, lower scores on the Parker test, and higher scores on the Weisz test than children in the nonintervention group. In the second phase, the children showed lower salivary cortisol levels and higher scores on the Weisz test after the intervention.

CONCLUSIONS

Humor therapy has beneficial effects on stress and cortisol levels in pediatric inpatients. This supports the implementation and reinforcement of these therapies in pediatric hospitals.

Do better communication skills promote sheltered employment in schizophrenia?

Alongside various psychopathological symptoms and neurocognitive dysfunctions, communication skill impairments may be considered core feature of schizophrenia. Although many studies examined the relation between employment status and neurocognition in schizophrenia, we still know very little about the role of communication skills in vocational status among people with schizophrenia. The purpose of this study is to identify the most characteristic communication, neurocognitive and social cognition differences which separate the employed schizophrenia outpatients from those who do not work. The study included three groups: 33 schizophrenia outpatients employed in social firms, 29 unemployed schizophrenia outpatients participating in occupational therapy and sex & age matched 31 healthy controls. We assessed communication skills, global cognitive functioning, executive functions, memory, social cognition as well as severity of psychopathology. Our results indicate that the most characteristic differences between employed and unemployed schizophrenia outpatients are associated with selective language and communication skills, i.e. paralinguistic aspects of communication, understanding of discrete meaning of linguistic context and figurative meaning of language. We find no significant differences between both clinical groups with regard to neurocognition and social cognition. Moreover, unemployed group had more severe psychopathology than the employed group, so we re-analyzed results controlling for symptom severity. The only differences that endured were related to general communication skills and explanation of pictured metaphors, but only when controlling solely for positive or negative syndrome. In conclusion, the present study indicates that employment in schizophrenia is associated with better symptomatic remission and communication skills, but not with better neurocognition and social cognition.

Investigating vision in schizophrenia through responses to humorous stimuli

The visual environment of humans contains abundant ambiguity and fragmentary information. Therefore, an early step of vision must disambiguate the incessant stream of information. Humorous stimuli produce a situation that is strikingly analogous to this process: Funniness is associated with the incongruity contained in a joke, pun, or cartoon. Like in vision in general, appreciating a visual pun as funny necessitates disambiguation of incongruous information. Therefore, perceived funniness of visual puns was implemented to study visual perception in a sample of 36 schizophrenia patients and 56 healthy control participants. We found that both visual incongruity and Theory of Mind (ToM) content of the puns were associated with increased experienced funniness. This was significantly less so in participants with schizophrenia, consistent with the gestalt hypothesis of schizophrenia, which would predict compromised perceptual organization in patients. The association of incongruity with funniness was not mediated by known predictors of humor appreciation, such as affective state, depression, or extraversion. Patients with higher excitement symptoms and, at a trend level, reduced cognitive symptoms, reported lower funniness experiences. An open question remained whether patients showed this deficiency of visual incongruity detection independent of their ToM deficiency. Humorous stimuli may be viewed as a convenient method to study perceptual processes, but also fundamental questions of higher-level cognition.

Irony and proverb comprehension in schizophrenia: do female patients "dislike" ironic remarks?

Difficulties in understanding irony and sarcasm are part of the social cognition deficits in patients with schizophrenia. A number of studies have reported higher error rates during comprehension in patients with schizophrenia. However, the relationships of these impairments to schizotypal personality traits and other language deficits, such as the comprehension of proverbs, are unclear. We investigated irony and proverb comprehension in an all-female sample of 20 schizophrenia patients and 27 matched controls. Subjects indicated if a statement was intended to be ironic, literal, or meaningless and furthermore rated the meanness and funniness of the stimuli and certainty of their decision. Patients made significantly more errors than controls did. Globally, there were no overall differences in the ratings. However, patients rated the subgroup of stimuli with answers given incorrectly as having significantly less meanness and in case of an error indicated a significantly higher certainty than controls. Across all of the study participants, performances in irony (r = -0.51) and proverb (r = 0.56) comprehension were significantly correlated with schizotypal personality traits, suggesting a continuum of nonliteral language understanding. Because irony is so frequent in everyday conversations, this makes irony an especially promising candidate for social cognition training in schizophrenia.

The use of humor in serious mental illness: a review

There is now a relatively good understanding of the broad range of direct and indirect effects of humor and laughter on perceptions, attitudes, judgments and emotions, which can potentially benefit the physical and psychological state. This article presents a review and discussion of the use of humor and laughter in treating people with serious mental illness, distinguishing between clinical papers on individual and group psychotherapy, and empirical research reports describing humor and laughter interventions. In spite of the exponential growth of the field over the last 30 years, I conclude that empirical studies are still lacking, the studies that do exist have major methodological shortcomings, and the field is in dire need of further investigation.

Relationships between humor, subversion, and genuine connection among persons with severe mental illness

Although humor has been linked to resilience among many populations, little is known regarding the role of humor in the coping of individuals with severe mental illness (SMI). In this study, a series of interviews focused on humor was completed by 15 individuals with SMI, with narratives analyzed using grounded theory methods.The marginalized and stigmatized social position occupied by persons with SMI was found to affect both the use and meanings of humor. Humor was described as being the subject of clinical scrutiny. Humor was also emphasized as a means of subverting power differentials revolving around the identity of SMI with, for many, the primary goal being the development of "real" and genuine connections with service providers.

Trait cheerfulness modulates BOLD response in lateral cortical but not limbic brain areas--a pilot fMRI study

Having a good "sense of humor" is an important personality characteristic that significantly influences social communication and may represent an important coping strategy. To take things "with humor" does not only represent a state characteristic but also a personality trait that can reliably be assessed with questionnaires like the "state-trait-cheerfulness-inventory" (STCI) by Ruch [Ruch et al., Assessing the "humorous temperament": construction of the facet and standard trait forms of the state-trait-cheerfulness-inventory-STCI, Humor 9 (1996) 303-339]. Substantial inter-individual differences among study subjects are a key feature of almost all functional magnetic resonance imaging studies on higher cognitive functions. Usually, they are considered as "statistical noise" and are not recommended for the data analysis, although they can have a high intra-individual stability. However, a number of recent fMRI studies found robust correlations between inter-individual differences in BOLD response and personality traits such as extraversion. The aim of this pilot exploratory study was to localise regions where the BOLD response was predicted by "humor personality" scores. 10 healthy male subjects viewed funny or non-funny versions of Gary Larson cartoons while BOLD response was measured with functional magnetic resonance imaging (fMRI). Data were collected from the whole brain (28 slices, slice thickness 4 mm, 1 mm gap, TR = 3s). SPM 99 software was used. A simple regression analysis with the sub-score cheerfulness from the STCI was applied. Higher cheerfulness in the STCI predicted brain activation in the right inferior parietal lobule (Tal X, Y, Z: 45, -77, 29), but not in limbic and prefrontal brain areas. We conclude that neural correlates of cheerfulness are correlated with BOLD response in lateral cortical rather than limbic brain areas. Likely the activated region is important for a readiness or tendency to be amused, whereas the regions previously shown to be activated in humor appreciation studies are related to the understanding of the joke and the emotional reaction.