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Cortisol awakening response and psychosocial factors: A systematic review and meta-analysis
Abstract
The magnitude of the cortisol awakening response, a relatively new indicator of hypothalamic-pituitary-adrenocortical (HPA) axis activation, has been related to a number of psychosocial factors. But findings have been inconsistent across studies. We systematically reviewed previous studies investigating the association between the cortisol awakening response and psychosocial factors. 147 eligible studies from 62 articles were identified. Separate analyses were carried out on the increase in cortisol following waking (CARi), and the integrated volume of cortisol released over the waking period (CARauc). We found that the CARi was positively associated with job stress and general life stress. It was negatively associated with fatigue, burnout, or exhaustion. There were less reliable negative associations between the CARi and positive affects. The CARauc was positively related to general life stress and negatively related to posttraumatic stress syndrome. This review concludes that different psychosocial factors are associated with an enhanced or reduced cortisol awakening response.
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In the citing paper
“According to a meta-analysis, higher CARs are associated with increased appraisals of general life and job stress (Chida & Steptoe, 2009).”
From It's not what you think, it's how you relate to it: Dispositional mindfulness moderates the relationship between psychological distress and the cortisol awakening response (2014) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“However, negative affect, anxiety, and rumination are not reliably associated with the CAR (Chida & Steptoe, 2009; Zoccola &Dickerson, 2012).”
From It's not what you think, it's how you relate to it: Dispositional mindfulness moderates the relationship between psychological distress and the cortisol awakening response (2014) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“Specifically, CAR may be a unique component of the HPA-axis, representing its response to awakening, and is less likely to be influenced by stressors throughout the day.32,33”
From DIURNAL CORTISOL INTERACTS WITH STRESSFUL EVENTS TO PROSPECTIVELY PREDICT DEPRESSIVE SYMPTOMS IN ADOLESCENT GIRLS (2017) · cites this paper as [32]
In the citing paper
“Furthermore, it has been concluded in a systematic review that a lower post-awakening increase in cortisol was associated with higher symptoms of fatigue, burnout or exhaustion [60].”
From Preliminary Results: The Impact of Smartphone Use and Short-Wavelength Light during the Evening on Circadian Rhythm, Sleep and Alertness (2021) · cites this paper as [60]
In the citing paper
“A meta-analysis of 62 studies revealed considerable heterogeneity in findings linking psychosocial functioning to the CAR (Chida & Steptoe, 2009).”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“AUCw was positively related to general life stress but negatively related to posttraumatic stress (Chida & Steptoe, 2009).”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“Chida and Steptoe (2009) described seven different types of psychosocial predictors: job stress, general life stress (non-work-related), depression, anxiety (including neuroticism and negative affect), fatigue/burnout/exhaustion, posttraumatic stress, and positive psychosocial traits.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“CARi was positively correlated with job stress and general life stress but negatively correlated with fatigue, burnout, or exhaustion and not reliably associated with positive affect.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“In studies in which both CARi and AUCw were measured, their relationships to measures of psychosocial functioning were not the same (e.g., Bhattacharyya et al., 2008; Chida & Steptoe, 2009; Ellenbogen et al., 2006; Mommersteeg et al., 2006; Sonnenschein et al., 2007; Whitehead et al., 2007)”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“AUCw was positively related to general life stress but negatively related to posttraumatic stress (Chida & Steptoe, 2009).”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“CARi was positively correlated with job stress and general life stress but negatively correlated with fatigue, burnout, or exhaustion and not reliably associated with positive affect.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“CARi was positively correlated with job stress and general life stress but negatively correlated with fatigue, burnout, or exhaustion and not reliably associated with positive affect.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“Heterogeneity in the literature linking psychosocial functioning to the CAR is the rule rather than the exception”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“in four of seven types of psychosocial predictors, studies showing both positive and negative associations exist (Chida & Steptoe, 2009)”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“CARi was positively correlated with job stress and general life stress but negatively correlated with fatigue, burnout, or exhaustion and not reliably associated with positive affect.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“Chida and Steptoe (2009) described seven categories of psychosocial predictors that have been associated with the CAR: job stress, general life stress, depression, anxiety, fatigue/burnout/exhaustion, posttraumatic stress, and positive psychosocial traits.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida and Steptoe (2009)
In the citing paper
“This heterogeneity is partially the result of methodological and operationalization inconsistencies across studies and potential measure-dependent and/or predictor-specific associations (Chida & Steptoe, 2009; Stadler et al., 2016).”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida & Steptoe, 2009
In the citing paper
“These small effects were similar to those reported by Chida and Steptoe (2009), with r's ranging from -.065 to .069 depending on the specific predictor.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida and Steptoe (2009)
In the citing paper
“This corroborates meta-analytic results from Chida and Steptoe (2009).”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida and Steptoe, 2009
In the citing paper
“Of the seven categories previously defined by Chida and Steptoe (2009), it was found that only fatigue/burnout/exhaustion was negatively correlated with CARi.”
From Psychosocial functioning and the cortisol awakening response: meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies (2017) · cites this paper as Chida and Steptoe, 2009
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“These mixed findings also occur with other psychopathologies like major depression whereby the CAR is indistinguishable, hyperactive (Pruessner et al., 2003; Chida and Steptoe, 2009; Vreeburg et al., 2009), or hypoactive (Stetler and Miller, 2005; Kuehner et al.”
Cortisol awakening response is linked to disease course and progression in multiple sclerosis
Kern, S., Krause, I., Horntrich, A., Thomas, K., Aderhold, J., & Ziemssen, T. (2013) · PLoS ONE · doi:10.1371/journal.pone.0060647 · Cited by 50
“The cortisol awakening response (CAR) is a well described phenomenon which is characterized by a pronounced increase of cortisol within 20 to 30 minutes after awakening [1,2].”
BackgroundEpigenetic Modulation of Mood Disorders
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“First, cortisol awakening rise, reflecting the natural response to waking-up, with 50-75% increases in cortisol within 30 min, is modulated by sleep patterns, seasonal variation, daily activities, health indicators, and stressors/trauma [112,113].”
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Backgroundde Bloom, J., Kinnunen, U. M., & Korpela, K. (2014) · BMC Public Health · doi:10.1186/1471-2458-14-488 · Cited by 67
“Cortisol represents a valid measure for hypothalamic-pituitary-adrenal (HPA) axis activity [98,99].”
BackgroundOptimism moderates psychophysiological responses to stress in older people with Type 2 diabetes
Puig‐Pérez, S., Hackett, R. A., Salvador, A., & Steptoe, A. (2016) · Psychophysiology · doi:10.1111/psyp.12806 · Cited by 50
“…levels in the first 30 min after waking (Stalder et al., 2016), which has been related to multiple psychosocial factors: for example, the CAR has been positively related to job stress and general life stress, and negatively associated with fatigue, burnout, or exhaustion (Chida & Steptoe, 2009).”
BackgroundSelf-citationvan den Heuvel, M. I., van Assen, M. A. L. M., Glover, V. A. S., Claes, S. J., & den Bergh, B. R. H. V. (2018) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2018.06.005 · Cited by 51
“In the non-pregnant population, lower morning cortisol has been associated with burnout, fatigue, exhaustion, and sleep problems (Backhaus et al., 2004; Chida and Steptoe, 2009).”
BackgroundChild care and cortisol across early childhood: Context matters.
Berry, D., Family Life Project Key Investigators, Blair, C., Ursache, A., Willoughby, M., Garrett-Peters, P., Vernon-Feagans, L., Bratsch-Hines, M., Mills-Koonce, W. R., & Granger, D. A. (2014) · Developmental Psychology · doi:10.1037/a0033379 · Cited by 50
Aging, health behaviors, and the diurnal rhythm and awakening response of salivary cortisol
Heaney, J. L. J., Phillips, A. C., & Carroll, D. (2012) · Experimental Aging Research · doi:10.1080/0361073x.2012.672134 · Cited by 50
“Different psychosocial factors, such as job stress, general life stress, and posttraumatic stress, are associated with enhanced or reduced CAR (Chida & Steptoe, 2009 ).”
BackgroundKeeshin, B. R., Strawn, J. R., Out, D., Granger, D. A., & Putnam, F. W. (2013) · Depression and Anxiety · doi:10.1002/da.22154 · Cited by 49
“An increase in cortisol just after wakening is a well-known and replicated phenomenon that occurs is a variety of healthy populations, and alterations in the normal awakening response have been investigated in a number of psychiatric and psychosocial conditions,[38] including but not limited to depression[39] first ep…”
BackgroundLongitudinal effects of the SSRI paroxetine on salivary cortisol in Major Depressive Disorder
Ruhé, H. G., Khoenkhoen, S. J., Ottenhof, K., Koeter, M. W. J., Mocking, R. J. T., & Schene, A. H. (2014) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2014.10.024 · Cited by 54
Izawa, S., Saito, K., Shirotsuki, K., Sugaya, N., & Nomura, S. (2011) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2011.10.001 · Cited by 49
“A meta-analysis by Chida and Steptoe (2009) showed that work-related stress and other types of life stress (e.g., financial strain, loneliness, and poor marital quality) were associated with an increased cortisol awakening response.”
BackgroundMethodInfluentialHigh cortisol awakening response and cortisol levels moderate exposure-based psychotherapy success
Meuret, A. E., Trueba, A. F., Abelson, J. L., Liberzon, I., Auchus, R. J., Bhaskara, L., Ritz, T., & Rosenfield, D. (2014) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2014.10.008 · Cited by 50
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Cortisol Awakening Response and Acute Stress Reactivity in First Nations People
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“Furthermore, in a recent metaanalysis, Chida and Steptoe (2009) reported a positive association between the rise in cortisol after waking (now known as the cortisol awakening rise, CAR) and job stress, but a negative association between the CAR and burnout.”
BackgroundMethodMichels, N., Sioen, I., Huybrechts, I., Bammann, K., Vanaelst, B., De Vriendt, T., Iacoviello, L., Konstabel, K., Ahrens, W., & De Henauw, S. (2012) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2012.02.004 · Cited by 48
“A recent meta-analysis found a global 407 positive relation of the CAR with life stress, but not with negative emotions and only a limited 408 with positive emotions (Chida and Steptoe, 2009).”
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Cognitive behavioral therapy, mindfulness, and cortisol habituation: A randomized controlled trial
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“Importantly, the severity of psychiatric symptoms for ill-defined syndromes like burnout is essential, since at times results appear to be positively associated with awakening and morning cortisol among patient populations (15), and yet blunted cortisol concentrations are equally reported in sub-clinical and clinical…”
InfluentialOng, A. D., Fuller‐Rowell, T. E., Bonanno, G. A., & Almeida, D. M. (2011) · Health Psychology · doi:10.1037/a0022262 · Cited by 47
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“This finding is consistent with meta-analysis of 147 studies that found robust associations between fatigue, burnout, and a reduced CAR (56).”
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“It is unclear what the CAR represents, as some reviews have suggested that both a large CAR and a small CAR can be associated with adverse correlates (Chida & Steptoe, 2009).”
BackgroundCircadian cortisol, depressive symptoms and neurological impairment in early multiple sclerosis
Kern, S., Schultheiß, T., Schneider, H., Schrempf, W., Reichmann, H., & Ziemssen, T. (2011) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2011.04.004 · Cited by 47
“A low magnitude in CAR has also been described in states of burnout or exhaustion (Chida and Steptoe, 2009).”
BackgroundSocial isolation and diurnal cortisol patterns in an ageing cohort
Stafford, M., Gardner, M. P., Meena Kumari, B., Kuh, D. J., & Ben‐Shlomo, Y. (2013) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2013.07.002 · Cited by 49
“Objective social isolation may be linked to cortisol patterns through multiple pathways including reduced opportunity to confide and more limited access to financial and practical resources, both of which may increase the risk of psychological distress, poor health behaviours and cortisol (Prince et al., 1997; Chida a…”
Effects of Mindfulness Training on Levels of Cortisol in Cancer Patients
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“Although there are many studies only comparing cortisol and other physiologic parameters between two days or two work situations (Axelsson et al., 2006; Lowden et al., 2009), we recommend that future studies collect saliva samples on more days.”
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“The CAR magnitude has been shown to be affected by chronic psychologic stress [13,50].”
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“Moreover, the same psychosocial variables are also known to affect stress biomarkers (Chida & Steptoe, 2009; Childs & de Wit, 2014; Lai et al., 2012).”
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“One common method of investigating HPA-axis function is through the measurement of the cortisol awakening response (CAR).”
InfluentialKempke, S., Luyten, P., Coninck, S. D., van Houdenhove, B., Mayes, L., & Claes, S. (2015) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2014.10.027 · Cited by 44
Affective processes as mediators of links between close relationships and physical health
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“For example, cosleeping with an infant is associated with lower testosterone (Gettler, McKenna, McDade, Agustin, & Kuzawa, 2012), and sleep disturbance may influence the cortisol awakening response (Chida & Steptoe, 2009).”
BackgroundGex‐Fabry, M., Jermann, F., Kosel, M., Rossier, M. F., der Linden, M. V., Bertschy, G., Bondolfi, G., & Aubry, J. (2011) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2011.09.011 · Cited by 44
“, 2010), and job and general life stress (Chida and Steptoe, 2009).”
BackgroundMadsen, K. S., Jernigan, T. L., Iversen, P., Frøkjær, V. G., Mortensen, E. L., Knudsen, G. M., & Baaré, W. F. C. (2012) · Psychiatry Research Neuroimaging · doi:10.1016/j.pscychresns.2011.07.015 · Cited by 44
“, 2010) and major depression (Chida and Steptoe, 2009; Vreeburg et al., 2009).”
BackgroundInfluentialHoyt, L. T., Ehrlich, K. B., Cham, H., & Adam, E. K. (2016) · Stress · doi:10.1080/10253890.2016.1206884 · Cited by 46
“However, the CAR is sensitive to chronic stress (Chida & Steptoe, 2009; KunzEbrecht et al., 2004; Schlotz et al., 2004) and a higher CAR prospectively predicts the development of major depressive disorder (Adam et al., 2010; Vrshek-Schallhorn et al., 2013) and first onsets of anxiety disorder (Adam…”
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“Objective health markers comprise, for example, cortisol awakening response (see Chida & Steptoe, 2009, for a meta-analysis), hair cortisol (see Russell, Koren, Rieder, & van Uum, 2012, for an evaluation of this method), or exercise electrocardiography.”
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“We recognise that this single measure design cannot address the cortisol awakening response (Clow et al., 2004; Chida and Steptoe, 2009).”
BackgroundFerguson, E., & Bibby, P. A. (2012) · British Journal of Health Psychology · doi:10.1111/j.2044-8287.2011.02055.x · Cited by 53
Political influence associates with cortisol and health among egalitarian forager-farmers
Rueden, C. R. V., Trumble, B. C., Thompson, M. E., Stieglitz, J., Hooper, P. L., Blackwell, A. D., Kaplan, H. S., & Gurven, M. (2014) · Evolution Medicine and Public Health · doi:10.1093/emph/eou021 · Cited by 44
“Chronic psychosocial stress can not only produce relatively high levels of cortisol but in severe cases is associated with ‘burnout’ of the hypothalamic– pituitary–adrenal axis and low levels of cortisol, or reduced circadian variation in cortisol [28].”
Assessing a hyperarousal hypothesis of insomnia in adults with autism spectrum disorder
Baker, E. K., Richdale, A. L., Hazi, A., & Prendergast, L. A. (2019) · Autism Research · doi:10.1002/aur.2094 · Cited by 42
Bitsika, V., Sharpley, C. F., Andronicos, N. M., & Agnew, L. L. (2014) · Physiology & Behavior · doi:10.1016/j.physbeh.2014.11.010 · Cited by 41
“In their meta-analysis of 147 studies of psychosocial factors that influence the CAR Chida and Steptoe [50] reported that the CAR was enhanced by job stress and general life stress but negatively influenced by fatigue, burnout and exhaustion, although methodological factors were also associated with many conflicting r…”
BackgroundResultRudolph, K. E., Wand Gary, S., Stuart, E. A., Glass, T. A., Marques, A. H., Dunčko, R., & Merikangas, K. R. (2013) · Health & Place · doi:10.1016/j.healthplace.2013.11.001 · Cited by 41
“Cortisol peaks in the morning during the cortisol awakening response (CAR) and then declines over the rest of the day (Chida and Steptoe, 2009).”
BackgroundChronotype and diurnal cortisol profile in working women: Differences between work and leisure days
Dockray, S., & Steptoe, A. (2010) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2010.09.008 · Cited by 41
“…differences in cortisol profile are noted in disease states and mood disorders and diurnal profiles are also influenced by sleep, light exposure, sex and age; there may be additional influences of stress, happiness, gender and waking time (Chida and Steptoe, 2009; Hellhammer et al., 2009).”
Self-citationLopresti, A. L., Smith, S. J., & Drummond, P. D. (2021) · Sleep Medicine · doi:10.1016/j.sleep.2021.08.001 · Cited by 41
Ghiciuc, C. M., Cozma-Dima, C. L., Pasquali, V., Renzi, P., Simeoni, S., Lupușoru, C. E., & Patacchioli, F. R. (2011) · PubMed · Cited by 41
The circadian system modulates the cortisol awakening response in humans
Bowles, N. P., Thosar, S. S., Butler, M. P., Clemons, N. A., Robinson, L. D., Ordaz-Johnson, O., Herzig, M. X., McHill, A. W., Rice, S. P. M., Emens, J. S., et al. (2022) · Frontiers in Neuroscience · doi:10.3389/fnins.2022.995452 · Cited by 46
“As noted above, the CAR has been extensively studied as a potential biomarker for physical and psychological health outcomes such as chronic stress, depression, and hypertension (Chida and Steptoe, 2009; O’Connor et al., 2009; Juster et al., 2011; Lovell et al., 2011; Saban et al., 2012; Duan et al., 2013).”
BackgroundGostisha, A. J., Vitacco, M. J., Dismukes, A. R., Brieman, C. L., Merz, J., & Shirtcliff, E. A. (2014) · Hormones and Behavior · doi:10.1016/j.yhbeh.2014.03.016 · Cited by 47
“…forms of stress exposure are associated with a blunted CAR (e.g., burnout, fatigue), but other stressors are associated with a heightened CAR especially if the stressor is engaging or active (Chida and Steptoe, 2009; Fries et al., 2009; Gonzalez et al., 2009; Thorn et al., 2009; Wust et al., 2000).”
Hall, D. L., Lattie, E. G., Antoni, M. H., FLETCHER, M. A., Czaja, S. J., Perdomo, D. M., & Klimas, N. G. (2014) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2014.06.021 · Cited by 40
“A commonly used parameter for modeling total cortisol secretion, CARg is less subject to measurement error associated with variability in the awakening measurement than other CAR measures (i.e., CARi), and has been positively related to chronic stress (Chida and Steptoe, 2009).”
BackgroundMethodInfluentialSimon, C. D., Adam, E. K., Holl, J. L., Wolfe, K., Grobman, W. A., & Borders, A. E. B. (2016) · Maternal and Child Health Journal · doi:10.1007/s10995-016-2060-7 · Cited by 41
“In one meta-analysis, general life and job stress was associated with a larger CAR, while exhaustion and presence of posttraumatic stress syndrome was associated with a smaller CAR [8].”
BackgroundTiming matters: Endogenous cortisol mediates benefits from early-day psychotherapy
Meuret, A. E., Rosenfield, D., Bhaskara, L., Auchus, R. J., Liberzon, I., Ritz, T., & Abelson, J. L. (2016) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2016.09.008 · Cited by 42
Plieger, T., Felten, A., Splittgerber, H., Duke, É., & Reuter, M. (2017) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2017.10.020 · Cited by 40
Lopes‐Júnior, L. C., Pereira-da-Silva, G., da Silveira, D. S. C., Veronez, L. C., dos Santos, J. C., Alonso, J. B., & de Lima, R. A. G. (2018) · Integrative Cancer Therapies · doi:10.1177/1534735418781725 · Cited by 41
Wild, J., El-Salahi, S., Tyson, G., Lorenz, H., Pariante, C. M., Danese, A., Tsiachristas, A., Watkins, E. R., Middleton, B., Blaber, A., et al. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-022292 · Cited by 46
“A meta-analysis of 62 studies concluded that increases in the CAR were associated with job stress and life stress and linked to greater fatigue, burnout and exhaustion and risk for later health states, such as coronary heart disease.(21) A recent study found that higher CAR predicted future episodes of MD within a 2.”
BackgroundBasson, R. J., O’Loughlin, J. I., Weinberg, J., Young, A. H., Bodnar, T. S., & Brotto, L. A. (2019) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2019.03.001 · Cited by 40
“This finding is consistent with meta-analyses showing that individuals with a history of PTSD and sexual abuse have a lower CAR (Chida and Steptoe, 2009).”
ResultBurnout as an important factor in the psychophysiological responses to a work day in Teachers
Moya‐Albiol, L., Serrano, M. Á., & Salvador, A. (2010) · Stress and Health · doi:10.1002/smi.1309 · Cited by 45
Savla, J. T., Roberto, K. A., Blieszner, R., Cox, M., & Gwazdauskas, F. (2011) · The Journals of Gerontology Series B · doi:10.1093/geronb/gbr041 · Cited by 44
“Even though the exact interpretation of the cortisol slope is subject to debate, scholars are coalescing on its meaning (Adam & Kumari, 2009; Chida & Steptoe, 2009; Saxbe, 2008).”
BackgroundCortisol profiles differ by race/ethnicity among young sexual minority men
Cook, S., Juster, R., Calebs, B. J., Heinze, J. E., & Miller, A. L. (2016) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2016.10.006 · Cited by 39
Johnson, M. M., Caron, K. M., Mikolajewski, A. J., Shirtcliff, E. A., Eckel, L. A., & Taylor, J. E. (2014) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-014-9412-7 · Cited by 43
“Individuals within putatively stressful life states, such as burnout or chronic role overload, may display a blunted CAR (Chida and Steptoe 2009; Sonnenschein et al. 2007) as these individuals are overwhelmed by chronic stress and not able to become prepared for the oppressive challenges of the day ahead.”
BackgroundMajor depression in young girls is related to altered cortisol awakening response
Schmidt, U., Reinhold, L., & Dirk, H. (2013) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-012-0371-9 · Cited by 38
“awakening response as has been shown in a meta-analysis [4].”
MethodDonoho, C. J., Weigensberg, M. J., Emken, B. A., Hsu, J., & Spruijt‐Metz, D. (2010) · Obesity · doi:10.1038/oby.2010.287 · Cited by 38
“The CAR is associated with chronic stress (13) and central adiposity (14,15), and has shown a moderate degree of heritability (40–60%) (16,17).”
BackgroundEffort-reward imbalance, overcommitment, and cellular immune measures among white-collar employees
Nakata, A., Takahashi, M., & Irie, M. (2011) · Biological Psychology · doi:10.1016/j.biopsycho.2011.08.012 · Cited by 38
Liao, J., Brunner, E. J., & Meena Kumari, B. (2013) · PLoS ONE · doi:10.1371/journal.pone.0081020 · Cited by 41
“Evidence to date has been synthesized in two recent reviews [25,26].”
BackgroundFekedulegn, D. B., Burchfiel, C. M., Violanti, J. M., Hartley, T. A., Charles, L. E., Andrew, M. E., & Miller, D. B. (2012) · Industrial Health · doi:10.2486/indhealth.2012-0043 · Cited by 39
“A number of previous studies that examined associations of perceived stress, job strain, and fatigue/burnout with awakening cortisol response indirectly support the current results 34, 39, 40, 41–43 ) .”
Black, D. S., Peng, C., Sleight, A. G., Nguyen, N. T., Lenz, H., & Figueiredo, J. C. (2017) · Cancer · doi:10.1002/cncr.30698 · Cited by 38
Racial/ethnic disparities in cortisol diurnal patterns and affect in adolescence
Deer, L. K., Shields, G. S., Ivory, S. L., Hostinar, C. E., & Telzer, E. H. (2018) · Development and Psychopathology · doi:10.1017/s0954579418001098 · Cited by 42
“…stress and depression have been associated with an elevated cortisol awakening response, whereas posttraumatic stress, fatigue, burnout, and exhaustion have been linked to an atypically low cortisol awakening response (Boggero, Hostinar, Haak, Murphy, & Segerstrom, 2017; Chida & Steptoe, 2009).”
BackgroundGerber, M., Imboden, C., Beck, J., Brand, S., Colledge, F., Eckert, A., Holsboer‐Trachsler, E., Pühse, U., & Hatzinger, M. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9051419 · Cited by 43
“In line with this notion, previous studies have shown that chronically high stress levels are associated with a dysregulated diurnal HPA axis activity [14], an increased cortisol awakening response [15], and an increased reactivity in response to experimentally induced stress [16,17].”
ResultSelf-esteem change and diurnal cortisol secretion in older adulthood
Liu, S. Y., Wrosch, C., Miller, G. E., & Pruessner, J. C. (2013) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2013.12.010 · Cited by 39
“The 30-min samples were excluded from the calculation of AUCG because the awakening response has been shown to be relatively independent from other aspects of the diurnal cortisol rhythm (Pruessner et al., 2003; Chida and Steptoe, 2009).”
Very Long (> 48 hours) Shifts and Cardiovascular Strain in Firefighters: a Theoretical Framework
Choi, B., Schnall, P. L., Dobson, M., Garcia-Rivas, J., Kim, H., Zaldivar, F., Israel, L., & Baker, D. (2014) · Annals of Occupational and Environmental Medicine · doi:10.1186/2052-4374-26-5 · Cited by 37
THE IMPACT OF PTSD TREATMENT ON THE CORTISOL AWAKENING RESPONSE
Pacella‐LaBarbara, M. L., Feeny, N. C., Zoellner, L. A., & Delahanty, D. L. (2014) · Depression and Anxiety · doi:10.1002/da.22298 · Cited by 37
“[24] Though no significant relationships emerged between posttraumatic stress and CAR increase (defined by the AUCi, and the mean cortisol increase),[24] analysis of the highest quality studies (n = 2) revealed a negative relationship.”
BackgroundMethodResultInfluentialJob Satisfaction and Cortisol Awakening Response in Teachers Scoring high and low on Burnout
Moya‐Albiol, L., Serrano, M. Á., & Salvador, A. (2010) · The Spanish Journal of Psychology · doi:10.1017/s1138741600002304 · Cited by 35
“The direction of the association might be due to the characteristics of the sample studied (Chida & Steptoe, 2009; Kudielka, Bellingrath, & Hellhammer, 2006) and to the point in time and procedure with which the HPA axis is assessed, as when using the dexamethasone suppression test (Mommersteeg,…”
MethodIs There a Testosterone Awakening Response in Humans?
Kuzawa, C. W., Georgiev, A. V., McDade, T. W., Bechayda, S. A., & Gettler, L. T. (2015) · Adaptive Human Behavior and Physiology · doi:10.1007/s40750-015-0038-0 · Cited by 39
“Although CORT levels rise during sleep, most individuals experience a marked surge in cortisol production, over and above the circadian pattern, immediately after waking (the cortisol awakening response, or CAR), which precedes the gradual, sustained decline in hormone levels across the day (Chida and Steptoe 2009; Cl…”
BackgroundCortisol awakening response among women exposed to intimate partner violence
Pinto, R. J., Correia‐Santos, P., Costa-Leite, J., Levendosky, A. A., & Jongenelen, I. (2016) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2016.08.024 · Cited by 42
Petrowski, K., Schmalbach, B., Niedling, M., & Stalder, T. (2019) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2019.05.016 · Cited by 41
Buselli, R., Veltri, A., Baldanzi, S., Marino, R., Bonotti, A., Chiumiento, M., Girardi, M., Pellegrini, L., Guglielmi, G., Dell’Osso, L., et al. (2019) · Brain and Behavior · doi:10.1002/brb3.1298 · Cited by 41
Bathman, L. M., Almond, J., Hazi, A., & Wright, B. J. (2013) · Brain Behavior and Immunity · doi:10.1016/j.bbi.2013.05.010 · Cited by 37
Impact of Stress and Strain on Current LGBT Health Disparities
Juster, R., Vencill, J. A., & Johnson, P. J. (2017) · Springer eBooks · doi:10.1007/978-3-319-54509-7_4 · Cited by 36
Effects of limiting digital screen use on well-being, mood, and biomarkers of stress in adults
Pedersen, J., Rasmussen, M. G. B., Sørensen, S. O., Mortensen, S. R., Olesen, L. G., Brage, S., Kristensen, P. L., Puterman, E. M., & Grøntved, A. (2022) · npj Mental Health Research · doi:10.1038/s44184-022-00015-6 · Cited by 39
Circadian Biomarkers in Humans: Methodological Insights into the Detection of Melatonin and Cortisol
Skubic, C., Zevnik, U., Nahtigal, K., Dolenc‐Grošelj, L., & Rozman, D. (2025) · Biomolecules · doi:10.3390/biom15071006 · Cited by 38
“Evidence suggests that CAR intensity may be influenced by psychosocial factors, such as stress and burnout, although the exact relationships remain unclear [49].”
Determinants of cortisol awakening responses to naps and nighttime sleep
Devine, J. K., & Wolf, J. M. (2015) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2015.09.016 · Cited by 36
Work stress models and diurnal cortisol variations: The SALVEO study.
Marchand, A., Juster, R., Durand, P., & LUPIEN, S. J. (2015) · Journal of Occupational Health Psychology · doi:10.1037/a0039674 · Cited by 37
Hidalgo, V., Almela, M., Pulopulos, M. M., & Salvador, A. (2016) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2016.05.019 · Cited by 37
Johnson, M. M., Deardorff, J., Davis, E. L., Martinez, W., Eskenazi, B., & Alkon, A. (2017) · International Journal of Psychophysiology · doi:10.1016/j.ijpsycho.2017.02.010 · Cited by 38
Katz, D. A., Harris, A. R., Abenavoli, R. M., Greenberg, M. T., & Jennings, P. A. (2017) · Stress and Health · doi:10.1002/smi.2782 · Cited by 37
Family Dynamics in Sleep Health and Hypertension
Gunn, H. E., & Eberhardt, K. R. (2019) · Current Hypertension Reports · doi:10.1007/s11906-019-0944-9 · Cited by 38
Gifford, R. M., O’Leary, T. J., Double, R. L., Wardle, S. L., Wilson, K. S., Boyle, L. D., Homer, N. Z. M., Kirschbaum, C., Greeves, J. P., Woods, D. R., et al. (2019) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2019.104432 · Cited by 36
Xiong, B., Chen, C., Tian, Y., Zhang, S., Liu, C., Evans, T. M., Fernández, G., Wu, J., & Qin, S. (2021) · Progress in Neurobiology · doi:10.1016/j.pneurobio.2021.102127 · Cited by 38
“, 2010a, b), while atypical CAR including either a blunted or elevated pattern is often linked to stress-related psychopathology such as anxiety, depression and higher-order cognitive impairments (Chida and Steptoe, 2009; Clow et al., 2004; Fries et al., 2009; Kudielka and Wust, 2010).”
Koudela-Hamila, S., Smyth, J. M., Santangelo, P., & Ebner‐Priemer, U. (2020) · Journal of American College Health · doi:10.1080/07448481.2020.1784906 · Cited by 35
Metadata
- Authors
- Chida, Y., & Steptoe, A.
- Affiliations
- University College London (GB)
- Corresponding author
- Chida, Yoichi
- ORCID
- Steptoe, Andrew
- Venue
- Biological Psychology
- Publisher
- Elsevier BV
- Published
- 2009-03
- Volume
- 80
- Issue
- 3
- Pages
- 265-278
- ISSN
- 0301-0511 (ISSN-L)
- OpenAlex
- W1987445189
- Cited by
- 1,032
- References
- 106
- Citations by year
- 2026: 35 · 2025: 36 · 2024: 32 · 2023: 43 · 2022: 69 · 2021: 58 · 2020: 68 · 2019: 68 · 2018: 59 · 2017: 80 · 2016: 74 · 2015: 75 · 2014: 72 · 2013: 70 · 2012: 63
- FWCI
- 3.25
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Biological Psychology (publishedVersion)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Funders
- British Heart Foundation
- Topics
- Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Keywords
- cortisol awakening response, hypothalamic-pituitary-adrenal axis, occupational stress, life events, burnout, fatigue, exhaustion, positive affect, post-traumatic stress disorder, psychosocial factors, cortisol
- MeSH terms
- Animals, Humans, Hydrocortisone, Psychology, Wakefulness, Meta-Analysis as Topic, Databases, Bibliographic
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