Feelings of Pleasure & Well-being as predictors of Health Status 21 Years Later
Thomas R. Blakeslee, and Ronald Grossarth-Maticek
There is a growing recognition today that mental states can significantly affect physical health by inhibiting the immune system and/or causing damaging cardiovascular reactions.1,2 Primitive emotional responses can alter virtually all of the bodys homeostatic regulating systems in ways that significantly affect physical health. Though the exact nature of these interactions is only poorly understood, their effect is clearly demonstrated by the cause and effect relationship between psychosocial stress and many illnesses. Natural killer cell activity is one of many important immune functions that has been experimentally linked to psychological stress.3 In 1991 Cohen et al. tested 394 subjects for psychological stress and then gave them nose drops containing a cold virus. They found a nearly linear relationship between development of cold symptoms and previous stress scores.4
Virtually all studies of neuroendocrine interactions with health to date have focused on the negative effects of stress. Most of these studies have demonstrated a relatively weak relationship between emotions and health because they ignore the positive side of mind-body interactions. Stress is only one end of the continuum of emotional states which range from deep despair and helplessness all the way to euphoria. Feelings of pleasure and well-being are the polar opposite of stress and produce opposite physiological responses. The stress response that suppresses immune reactions is really one side of a bipolar reaction called the elation-dejection response.5 This response is mediated by the hippocampus via the hypothalmus, pituitary and adrenal cortex. It results in increased cortisol production and weakened immunity during feelings of helpless stress. Elevated risk of cancer promotion and infectious diseases can be the result. The reaction at the other end of the emotional scale has received little attention. The one-sided view of this response is demonstrated by the fact that it is more often called "the conservation-withdrawal response" or "negative arousal."
Another neuroendocrine interaction that has been studied extensively from the negative side is the "fight or flight" response responsible for much cardiovascular disease. This response is mediated by the amygdala-adrenal-medulla axis and results in catecholamine production to prepare for vigorous action. Since it is also a bipolar response, it is perhaps more accurately called the coping-relaxation response. Reactions of this system during feelings of pleasure and well-being have received very little study.
Studies of the health consequences of emotions almost always focus on negative aspects such as stress or depression. Research on health effects of the individuals capacity for pleasure are rare. One exception is a 1952 retrospective study by Bacon et al. which found that only 5 out of 40 breast cancer patients interviewed were freely capable of orgasm. Twenty five had never experienced orgasm and considered sex a distasteful wifely duty five were still virgins and five had orgasms only rarely. Other studies have found tht about ninety percent of women in the normal population are capable of orgasm.7 The present prospective study was undertaken in 1973 in an effort to determine the long-term health effects of habitual patterns of positive emotional response.
The Pleasure and Well Being Inventory (PWI) was administered in 1973 by paid student interviewers who visited citizens of Heidelberg, Germany in their homes. They asked to speak to the oldest member of the household and first established an atmosphere of rapport and trust before they went through the questions, clarifying meanings where necessary. Subjects were asked to ignore their feelings today and answer the questions based on normal patterns over the previous year. A letter from the Mayor of Heidelberg urged people to cooperate in the study. Subjects answered voluntarily and were not paid for their participation. A total of 3,440 were offered the test but 284 refused to cooperate leaving a total of 3,156. Only people who were 45-65 years of age and without existing major chronic illnesses were included in the study. Cancer, cardiac disease, multiple sclerosis, and other life-threatening diseases were grounds for exclusion but gastritis, ulcers, and similar less serious illnesses were allowed. The average age of the final included group of 3055 was 58. Contact phone numbers of four relatives, friends, or neighbors were collected to make later follow-up easier in case of relocation or death. Over 200 other questions were also asked to determine physical risk factors such as smoking and drinking, the Grossarth personality types, and Self-Regulation Index (SRI).
The Pleasure and Well-being Inventory (PWI) questionnaire consists of 15 questions. The first seven items are concerned with feelings of pleasure and then the same pattern of questions is repeated about well-being. The questions are answered on a scale of 1 to 7 and cover the following points: 1. How intensely you feel pleasure. 2. How long the feelings last. 3. How often you have them, 4 Do you sacrifice short-term pleasure when necessary to avoid bad long-term consequences, 5. Fear of feelings of pleasure, especially love, 6. Certainty that you will experience pleasure in the future. and 7. Expectation that past peaks of pleasure will be equaled or surpassed in the future. The second half of the test repeats the same pattern for feelings of well-being. The 15th question asks how often you feel guilt or other bad feelings of regret after experiencing pleasure. The results are summed and divided by fifteen to provide a final score that varies from one to seven. The resulting scale covers a wide range of habitual emotional reactions from depression and anhedonia at the low end to virtual euphoria at the high end.
The actual questionnaire was in German, so the word for pleasure was actually "Lust" and well-being was "Wohlbefinden." Using a sample of 815 subjects, internal consistency (Cronbachs alpha) was found to be .78, while test-retest reliability was .75.
Twenty-one years after the original interviews, in 1994, public health records and death certificates were checked. The subjects homes were again visited and family members neighbors and friends were asked about the health status of the subjects.. Letters were sent to contacts to track down people who had moved. Since the original survey was done house-to-house, and probands were asked to name five contacts, much cross checking was possible. A total of 101 people couldnt be traced in 1994 and had to be eliminated from the study leaving a total of 1441 men and 1614 women.
Feelings of pleasure and well being proved to be highly predictive of future good health. As figure 1 shows, the relationship between PWI score and percentage alive and without chronic disease was nearly linear, varying from 2.5% for the lowest scores to 75% for the top scoring group. Only 5 of the 201 people who scored 2 or less on the PWI were alive and well in 1994. Clearly, blocked feelings of pleasure and well-being are predictive of later increased illness and premature death.
Fig 1. Observed Percent Alive and Alive Without Chronic Illness in 1994 verses Score on Pleasure and Well-being Index in 1973. (N=3055)
As table 1 shows, age was not a confounding factor. In fact, the lowest scoring groups were slightly younger than the highest. The distribution of PWI scores was also quite even, with a broad peak centered around a mean score of 4.3. The percent still alive after 21 years also varied quite linearly over a ratio of 16:1 and cancer deaths showed a 11:1 variation. The Self-Regulation Index (SRI) scores were highly correlated with PWI scores. Both halves of the PWI questionnaire appear to be necessary because 9.7% of those tested had a high score on one half and a low score on the other.
Table 1: Number & % Alive and Well vs. Pleasure & Well-being Index
The surprisingly linear variation of health over such a wide range of PWI shows why experiments that focus only on depression are bound to produce weak results. Depression only represents the lowest scores on the graph but physical health continues to improve all the way to the very top end of the PWI scale. Good health appears to vary over a very wide range of primitive emotions from depression to euphoria.
Feelings of pleasure and well being originate in the limbic system which is also deeply involved in many homeostatic feedback loops which significantly affect health. Immune system activity and stress-related cardiovascular reactions are two examples which have been studied extensively. Feelings of pleasure and well-being are a kind of feedback from these ancient parts of the brain indicating that basic needs are being met and all is well. When these needs are met, the organism thrives. But evolution has added a whole new and incompatible kind of cognition to mans brain based on words and logic. This new system is capable of seizing control from more primitive conditioned and instinctive behavior, for example, to stifle a belch, or conceal anger. We call this "self-control."
Each person develops a unique kind of partnership between their conditioned behavior and self-control that may be healthy or unhealthy. This relationship is based on a self-concept learned in childhood. Some people develop a habitual pattern of always ignoring feelings and curbing their natural behavior. Their life is driven entirely by obligations and duties that take priority over their natural feelings. People with low PWI scores habitually ignore the important emotional feedback from the limbic system. With this crucial feedback blocked, behavior tends to drift into increasingly unhealthy and destructive patterns.
In an earlier prospective study, 1353 subjects were given a test on Rationality/Antiemotionality (R/A). When mortality was checked ten years later, 158 of the 166 cancer deaths and 115 of the 164 coronary disease deaths were people who had scored 10 or 11 on the 11 question test. All of the questions involved different ways of ignoring personal feelings and doing the non-assertive, logical thing in your interactions with others. Since Rational/Antiemotional behavior is based on ignoring your own feelings, it naturally leads to a low PWI score.
Another measure strongly correlated with the PWI is called self-regulation. People with high self-regulation are continually monitoring the results of their behavior and adjusting it to produce results that will better satisfy their needs. A large prospective study on 5716 subjects yielded in an almost-linear relationship between the score on a 105-item Self-Regulation Index and mortality from cancer, coronary disease, and other causes. Since good self-regulation naturally leads one towards more pleasure and well-being in life, the high correlation with the PWI is probably a case of simple cause and effect.
Good self-regulation indicates a healthy self-concept just as rationality/antiemotionality represents an unhealthy one. Both are based on learned cognitive assumptions that can be changed by brief cognitive therapy. Most people with a high rationality/antiemotionality score are proud of their good behavior and not aware that it may be extremely bad for their health. They manage their life with a victim/servant model of reality as opposed to the experimenter/mastery model used by people with high self-regulation. One of the benefits of prospective studies such as the present one is that they provide a sound basis for primary prevention of disease through training programs that teach provably healthy cognitive models.
Several intervention studies have already been done which prove the effectiveness of this approach. In one such study 5-7 hours of individual training in self-regulation (one hour sessions every two months) was given to 600 high-risk but healthy elderly subjects. Thirteen years later, 409 of the 600 in the treated group were still alive compared with only 97 in the equal-sized matched control group.16,17 A similar therapy has been used successfully to double the survival time of cancer patients. Since the focus of the therapy in both experiments was on improving pleasure and well-being by making behavioral changes, these intervention studies confirm the strong health effects of these primitive emotions.
There has been increasing evidence in recent years that moderate drinking is actually beneficial to health and longevity. Since alcohol weakens the hold of self control and liberates feelings of pleasure and well-being for most people, the positive health effects may well be through these emotions. Evidence for this explanation was provided by another prospective study by Grossarth-Maticek. Over 2000 probands from the 1972 study were selected because they steadily drank over 20g. of alcohol daily. Another questionairre determined whether they drank for pleasure or to drown sorrows. Twenty years later, when health records were checked, it was found that drinking for pleasure was significantly healthier than non-drinking but negative drinkers had the worst survival rate of all. The positive emotions produced in most people by drinking may be the real cause of its health benefits.
Your ability to feel pleasure and well-being is strongly influenced by the mental habits and attitudes which you have learned in childhood and continue to develop throughout your life. Enjoying life is a habit which can be developed but can also be lost through disuse. A recent study by Bygren of 12,982 Swedish residents found that people who regularly attended concerts, theater, art and other cultural events were 2.38 times more likely to be alive nine years later than those who rarely attended such events. People attend cultural events for pleasure, so this is typical of the kind of habit that is associated with a high score on the pleasure & well-being test.
One well-accepted phenomenon that demonstrates the power of positive mind-body interactions is the placebo effect. Placebo reactions are so powerful that they can make worthless medical treatments seem very effective. One of the foundations of modern medicine is a recognition of the power of placebo effects and the resulting requirement for double-blind testing to prove the efficacy of new treatments. It is a curious paradox that some medical experts still reject the idea of strong interactions between mind and body, yet fully accept the need for placebo testing. If these interactions did not exist, we could save vast sums of research money by simply eliminating placebo testing entirely. If mental attitudes did not strongly affect cancer outcome, for example new cancer treatments could be tested without placebo controls.
Though placebos are generally accepted to be about 35% effective for pain and for curing virtually any ailment, this estimate is based on studies where the placebo is routinely administered.. When treatments are enthusiastically presented by a believing doctor, the success rate can be significantly higher. In a 1993 study, Alan Roberts reviewed medical journal reports of apparently successful new treatments that were later proven worthless under double blind testing. He found that the average placebo effectiveness with enthusiastic presentation averaged 70%. His review of outcome studies involving some 6931 patients found an average of 40% excellent, 30% good, and 30% poor results reported for treatments that were later proven to be no more effective than placebos.
The placebo effect proves conclusively that mental states do directly affect health, but our understanding of the exact mechanisms is still at an early state of development. One important clue is the experimental finding that the opioid antagonist Naloxone can block the pain-reviewing power of placebos. Apparently the mere expectation of relief can internally produce opioids to relieve pain. Animal experiments have demonstrated that Pavlovian conditioning can produce immune system suppression in rats from the taste of saccharin if it has been previously paired repeatedly with an immune suppressing drug injection.
Beta-endorphins are opioids produced by the hypothalamic-pituitary-adrenocortical (HPA) axis which reward instinctive behavior such as sexual satisfaction by producing feelings of euphoria. It is the basis of the "runners high" and also of good feelings after meditation. Bungee jumpers were found to have a 200% increase in beta-endorphin after a jump and this increase was significantly correlated with their feelings of euphoria. Beta-endorphins have been found to increase natural killer cell (NK) activity in humans by 30% (E:T=50:1) and increase maximal effector cell recycling capacity by 170%. Naloxone inhibits this increase. Since NK cells are an important defense against cancer, viruses and bacteria, this could be one of the important links between good health and feelings of pleasure and well-being. Other studies have shown a decrease in NK activity related to psychological stress. It thus appears that the effectiveness of our immune defenses may vary widely as our primitive emotional responses range between despair and ecstasy.
The amazingly strong correlation between positive emotions and health demonstrated by this study in no way conflicts with our current understanding of disease. Bacteria, viruses, carcinogens and external stresses are still the actual causes of disease. Mental factors affect health only by altering the effectiveness of the bodys natural defenses against these insults. A healthy body naturally resists infection and destroys cancer cells before they are promoted into actual tumors. With an improved understanding of the mental factors required for good health, we can institute educational programs that will significantly reduce medical costs by stopping disease before it gets a foothold.