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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 increased response is determined by the degree of stress (Chida and Steptoe 2009).”
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“Cortisol tends to be at its highest volume in the morning and then decreases throughout the day, and higher morning cortisol volumes have been associated with general life stress and adverse family functioning (Chida & Steptoe, 2009; Cutuli, Wiik, Herbers, Gunnar, & Masten, 2010).”
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“[2,4]) indicate that various forms of stress are associated with the CAR.”
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“A flattened or blunted CAR may be indicative of dysregulation of the HPA axis (Chida and Steptoe, 2009; Clow et al., 2010; Stalder et al., 2017).”
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“…(NA, PAF, DASS-S, VAS), the area under the curve with respect to increase (AUCi) was calculated, a widely used approach in stress research (e.g., 62 ) that provides a summarizing indicator of changes over time while preserving information from repeated measurements; thus, the AUCi quantifies…”
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“Although studies that examined the effect of perceived stress on CAR found mixed results, the evidence for an association between an increased CAR and chronic stress is growing and becoming more robust [22,50].”
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“Overall, it appears that CAR is sensitive to hypothalamic‐pituitary‐adrenal axis activity, which can be measured reliably through the sampling of salivary cortisol concentration (Chida and Steptoe 2009).”
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“First, the pandemic was experienced by many as a chronic stressor, which has the potential to result in a blunted CAR (Chida and Steptoe 2009); this may have contributed to a lower response to awakening in the context of the COVID-19 pandemic.”
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“Extant studies [25,26] indicate that measures of stress are associated with the CAR, which is defined as the change in cortisol concentration that occurs during the first hour after waking from sleep.”
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“In addition, the stress hormone cortisol (surveyed via saliva samples) could also provide important information about psychological stress and recovery processes [66].”
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“Different deviations from the typical CAR result were reported for depression (Chida and Steptoe 2009; Dedovic and Ngiam 2015).”
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“The 30-minute measure was excluded from this calculation as the early morning increase of cortisol is relatively independent from overall cortisol volume (Chida and Steptoe, 2003).”
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Kurien, J., & Aubuchon-Endsley, N. L. (2025) · Obesities · doi:10.3390/obesities5020038 · Cited by 1
The cortisol awakening response: predicting self-reported daily stress reactivity
Shi, X., Lu, W. D., Nie, X., Liu, S., & Hu, K. (2025) · Anxiety Stress & Coping · doi:10.1080/10615806.2025.2518113 · Cited by 1
“AINC was computed as the difference between the peak cortisol value at 15, 30, or 45 min after awakening and the cortisol value at awakening (Chida & Steptoe, 2009).”
Sung, S. M., Lee, H., & Kim, J. Y. (2025) · Military Psychology · doi:10.1080/08995605.2025.2527453 · Cited by 1
“Existing research recommends checking the cortisol level within one hour of waking up in the morning (Chida & Steptoe, 2009).”
The relationship between childhood autistic traits and diurnal cortisol activity in adolescence
Roberts, E., Francesconi, M., & Flouri, E. (2025) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2025.107672 · Cited by 1
The Endocrinology of Loneliness and Social Isolation
Knauft, K. M., Israil, L. Z., & Zilioli, S. (2025) · Springer eBooks · doi:10.1007/978-3-032-02959-1_15 · Cited by 1
Cardillo, G. (2026) · Frontiers in Endocrinology · doi:10.3389/fendo.2026.1785454 · Cited by 1
Stress and resilience: cortisol hypo-response to acute stress in non-resilient individuals
Riske, N. D., Schenk, C., Ahrens, K. F., Kollmann, B., Weichert, D., Steinbach, N., Burlage, J. F., Freudenberg, F., Lieb, K., Kalisch, R., et al. (2026) · Journal of Neural Transmission · doi:10.1007/s00702-026-03218-9 · Cited by 1
“This is noteworthy, given that many studies on PTSD patients report differences in the cortisol awakening response (CAR), which is a common indicator for HPA function (Chida and Steptoe 2009).”
Physiological Response as Biomarkers of Adverse Effects of the Psychosocial Work Environment
Marie, S., Høgh, A., & Mikkelsen, E. G. (2012) · InTech eBooks · doi:10.5772/38544 · Cited by 1
“Salivary cortisol has increasingly been used in the study of the responsiveness of the hypothalamic pituitary adrenal (HPA) axis in occupational stress studies and employed in both field studies and experimental studies (for review see (Chida & Steptoe, 2009)).”
MethodStoretvedt, K., & Garde, A. H. (2014) · Rehabilitation Research and Practice · doi:10.1155/2014/793641 · Cited by 1
“Chida and Steptoe [10] found that CAR is negatively related to fatigue, burnout or exhaustion.”
BackgroundNeyer, S., Witthöft, M., Cropley, M., Pawelzik, M. R., Sütterlin, S., & Lugo, R. G. (2022) · Frontiers in Neuroscience · doi:10.3389/fnins.2022.952903 · Cited by 2
“Sleeping disorders may lead to a disruption in cortisol production which then itself might result in altered cortisol levels after awakening (Dockray et al., 2008; Chida and Steptoe, 2009).”
BackgroundInfluentialSuryasree, K., & Kadhiravan, S. (2022) · Cognitie, Creier, Comportament · doi:10.24193/cbb.2022.26.13 · Cited by 1
Stańczykiewicz, B., Bogudzińska, B., Kowalski, K., & Misiak, B. (2023) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2023.106924 · Cited by 1
“Moreover, it has been revealed that the direction of the association between the CAR and depression might be related to specific psychosocial factors and the severity of symptoms (Chida and Steptoe, 2009; Wardenaar et al., 2011).”
BackgroundMeasurements Used in Studying Mindfulness-Based Programs
Lo, H. H. M. (2024) · Mindfulness in behavioral health · doi:10.1007/978-3-031-51943-7_3 · Cited by 1
Krukowski, K. (2013) · Loyola eCommons (Loyola University of Chicago) · Cited by 1
Regression When There Are Two Covariates: Some Practical Reasons for Considering Quantile Grids
Wilcox, R. R. (2020) · Journal of Modern Applied Statistical Methods · doi:10.22237/jmasm/1556670120 · Cited by 1
“Past studies (e.g., Bhattacharyya et al., 2008; Chida & Steptoe, 2009) indicate that measures of stress are associated with the CAR.”
BackgroundOmura, M., Suetake, N., Itao, K., Yamaguchi, T., Hu, A., & Kobayashi, H. (2020) · Health · doi:10.4236/health.2020.127059 · Cited by 1
“The cortisol level is normally high in the morning and low from daytime to night-time due to a phenomenon known as the cortisol awakening response (CAR) [23] [24], in which the amount of cortisol secretion increases rapidly upon waking up in the morning, and it has been reported that those who are exposed to chronic o…”
BackgroundQing, Y., van Zuiden, M., Eriksson, C. B., Cardozo, B. L., Simon, W., Ager, A., Snider, L., Sabin, M. L., Scholte, W. F., Kaiser, R., et al. (2020) · European Journal of Psychotraumatology · doi:10.1080/20008198.2020.1816649 · Cited by 1
“Perceived social support was previously found not to be associated with the CAR in a small number of cross-sectional studies among healthy populations (Chida & Steptoe, 2009; Heaney, Phillips, & Carroll, 2010).”
BackgroundAre attenuated positive symptoms and cortisol levels associated?
Nordholm, D., Hjorthøj, C. R., Mondelli, V., Krakauer, K., Randers, L., Dazzan, P., & Nordentoft, M. (2020) · Schizophrenia Research · doi:10.1016/j.schres.2020.11.024 · Cited by 1
Cortisol awakening response in the airborne rescue service
Braun, D., Frank, M., Theiler, L. G., & Petrowski, K. (2022) · Occupational Medicine · doi:10.1093/occmed/kqac052 · Cited by 1
Anees Fathima Thabassum, Z. (2022) · Chettinad Health City Medical Journal · doi:10.24321/2278.2044.202210 · Cited by 1
Estressores ocupacionais, concentração do cortisol e saúde de motoristas de caminhão
Ulhôa, M. A. (2011) · Digital Library of Theses and Dissertations (Universidade de São Paulo) · doi:10.11606/t.6.2011.tde-16062011-152720 · Cited by 1
Massage Therapy Effects on Pain and Distress/Anxiety in Breast Cancer Patients
Buchrieser, T. B. (2015) · ScholarWorks (Walden University) · Cited by 1
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Hackett, R. A. (2016) · UCL Discovery (University College London) · Cited by 1
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Tuning trophoblast invasion in a gelatin hydrogel via soluble cues from the maternal-fetal interfacePreprint
Zambuto, S. G., Clancy, K. B. H., & Harley, B. A. C. (2020) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2020.04.16.045484 · Cited by 1
Vieira, J. C. F. (2020) · Digital Library of Theses and Dissertations (Universidade de São Paulo) · doi:10.11606/t.17.2020.tde-11022020-153242 · Cited by 1
Chang, W., & Jen, H. (2020) · doi:10.21203/rs.2.20101/v1 · Cited by 1
“A metaanalysis conducted by Chida and Steptoe revealed that CAR is positively correlated with work stress and life stress and negatively correlated with fatigue or burnout [36].”
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Loneliness and Health: Physiological and Cognitive Mechanisms in Adulthood and Childhood
Nowland, R. A. (2014) · CLOK (University of Central Lancashire)
Measuring a sleep/stress switch point
Elder, G. J. (2014) · Northumbria Research Link (Northumbria University)
Alterações cardiometabólicas e de sono em motoristas de caminhão
Marqueze, E. C. (2012) · Digital Library of Theses and Dissertations (Universidade de São Paulo) · doi:10.11606/t.6.2012.tde-25022013-174057
Karhula, K. (2015) · Työväentutkimus Vuosikirja
Psychosocial and stress-related aspects on Ischemic Heart Disease
Bengtsson, I. (2011) · Gothenburg University Publications Electronic Archive (Gothenburg University)
Cortisol Awakening Response and Youth Depression: The Impact of Anxiety, Age, and Sex
Duemling, K. (2014) · Deep Blue (University of Michigan)
唾液中Cortisol，sIgA，α-amylase濃度の睡眠時変化特性
雅子, 大., 一路, 須., & 収作, 野. (2011) · Seitai ikougaku/Seitai ikogaku · doi:10.11239/jsmbe.49.798
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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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