Intended for healthcare professionals

Editorials

Just what the doctor ordered—more alcohol and sex

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7123.1637 (Published 20 December 1997) Cite this as: BMJ 1997;315:1637

Anything I want to do is illegal, fattening, or causes cancer in mice

  1. Anthony J Cleare (a.cleare{at}iop.bpmf.ac.uk), Senior clinical research fellowa,
  2. Simon C Wessely (sphascw{at}iop.bpmf.ac.uk), Professor of epidemiological and liaison psychiatryb
  1. a
  2. b Department of Psychological Medicine, Kings College School of Medicine and Dentistry and the Institute of Psychiatry, London SE5 8AF

So the hedonists were right. At this time of year it is traditional, even in such an open minded journal as the BMJ, to warn with varying degrees of humour or pomposity about the dangers of overindulgence, from the hazards of obesity to the cure for hangovers. Eat, drink, and be merry, for tomorrow we die, has always carried with it the assumption that all three activities directly contribute to the undesired outcome. However, this issue of the BMJ contains intriguing suggestions that eating, drinking, and being merry (in this case a euphemism for sexual activity) defer mortality, presumably allowing added years of more of the same.

We read that alcohol makes you live longer (p 1664)1 and, much more tentatively, so does sex (p 1641).2 Last year we learnt that attending musical events or making music acted similarly.3 The doctor who, in reply to the question, “Will I live longer if I give up drinking and sex?” replied, “No, but it will seem like it” may have been right all along. The only dissonant voice comes from the world of soap operas, which often seem to be dominated by sex and drinking and which seriously damage the health of their characters (p 1649).4 So should we now be advising a sex, drugs, and rock ‘n’ roll lifestyle for the health benefits it brings?

Hedonism has always been a difficult subject. Auden's Oxford don who didn't feel quite happy about pleasure expressed the English sense of unease with the finer things in life. Likewise, the medical profession has taken an ambivalent stance towards hedonism. The concept of pleasure is so unfamiliar for many psychiatrists that Freud wrote possibly his least humorous article on the psychoanalysis of jokes,5 while a contemporary professor of psychology has pointed out, with, we assume, his tongue firmly in his cheek, that happiness ought to be considered a psychiatric disorder.6 Medical affective disorder, pleasant type, has yet to appear in the International Classification of Diseases, but it is statistically abnormal, consists of a reproducible cluster of symptoms, and is linked to abnormalities of cognitive brain function and cerebral brain flow.6 The lunchtime habits of French doctors remind us of the origins of the term Rabelaisian (p 1711)7 and are certain to attract the disapproval of their English colleagues and the total incomprehension of any American readers.

Medical interest in the study of pleasure began, strangely, with the absence of pleasure, or anhedonia. This term was first used by the eminent French psychologist Ribot to describe the case of a young girl who suffered from a loss of pleasure sense in the course of an apparent disorder of the liver.8 However, medicine seemed unhappy with this simple concept. In his seminal paper “Anhedonia” Myerson reformulated it as “organic anaesthesia” together with “a disorganised spread of excitement.” He acknowledged that anhedonia affected the desire for and satisfaction from food, drink, sex, and sleep. However, loss of energy was a central symptom in anhedonia: “The feeling of energy is low so that effort is painful, fatigue following rapidly upon exertion and having a peculiar painful component not present in ordinary fatigue.” He concluded that “it is probable that what we call sadness is to a large extent the disappearance of the energy feeling.” In fact, pleasure, or the lack of it, was “merely … neurasthenia in a different way.”8

Loss of pleasure was thus another consequence of neurasthenia, which, ironically, was itself clearly seen as the result of overindulgence in life's many pleasures and generally blamed on modern civilisation.9 The first half of this century saw the replacement of neurasthenia, the illness of excess, with depression, the illness of loss. Anhedonia become its cardinal feature.10 However, it is becoming clearer that the shift from neurasthenia to depression, and hence from loss of energy to loss of pleasure, is merely replacing one overstretched concept with another. Anhedonia is almost certainly not a single phenomenon.11 We are now beginning to appreciate the phenomenological and neurobiological separation of the concepts of loss of pleasure, depression, and loss of energy.10 1213

But what of the presence of pleasure? We can define the different emotional, cognitive, and behavioural components of happiness14; we can even hazard a guess at the neurobiological substrates of mood states,15 but people seem rarely actually to be happy.6 The concept of “hedonic tone” has been introduced to measure the capacity to feel pleasure, and scales exist to quantify it.16 It has been possible to quantify how enjoyable people find different activities—which of course varies widely. Nevertheless, the amount of pleasure people report on average from activities is very similar. Thus, the concept of the “pleasure quota” has been introduced, suggesting that people chose their pleasures carefully to achieve the required dose of “hedons.”17

Although this might sound lighthearted, there are serious ramifications. Public health campaigns have often ignored people's requirement for pleasure. On drug abuse, unhealthy diets, sexual activities, and alcohol, the message has been clear: they are bad. Just say no. Except, as the hero in the cult 1990's film Trainspotting says about heroin, “People think it's about misery and deprivation and death and all that shite, which is not to be ignored, but what they forget [image of needle entering vein] is the pleasure of it all. Otherwise we wouldn't do it … Take your best orgasm, multiply by a thousand, and you're still nowhere near.”18 Among college students, about 90% report pleasure as a reason for drug use, compared with under 30% who cite stress or habit.19 Ignoring this must surely serve to alienate the intended audience.

So, finally, what do we tell our patients now? We are left with a paradox, which the late and much missed Geoffrey Rose would certainly have appreciated.20 What we thought was bad for you may actually be good for you, but it may not be good to tell you in case you do it too much, and it is certainly not good to tell you it is good for you if you do too much of it already—assuming we could agree what was too much in the first place.

References

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