JUST WHAT THE DOCTOR ORDERED MORE ALCOHOL AND SEX

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

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 1708)(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 theeminent
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)(12,13)

But what of the presence of pleasure? We can define the different
emotional, cognitive, and behavioural components of happiness(14); 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.

Anthony J Cleare Senior clinical research fellow email:
a.cleare@iop.bpmf.ac.uk Simon C Wessely Professor of epidemiological and
liaison psychiatry email: sphascw@iop.bpmf.ac.uk Department of
Psychological Medicine, Kings College School of Medicine and Dentistry and
the Institute of Psychiatry, London SE5 8AF

References

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3 Bygren L O, Konlaan B B, Johansson S E. Attendance at cultural events,
reading books or periodicals, and making music or singing in a choir as
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4 Crayford T, Hoopr R, Evans S. Death rates of characters in soap operas on
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