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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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Progression in intima media thickness—the significance of hormonal biomarkers of chronic stress
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Encyclopedia of Stress (2nd ed)
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Schulz (1998) · doi:10.1002/(sici)1099-1700(199804)14:2
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Salivary cortisol as a biomarker in stress research
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“The CAR has been linked with stress and a range of health outcomes, though, the pattern of results has been mixed (e.g., Adam et al., 2010; Chida & Steptoe, 2009; Clow et al., 2010; Gartland et al., 2014; Steptoe & Serwinski, 2016; O’Connor et al., 2013).”
BackgroundResultAssessing salivary cortisol in large-scale, epidemiological research
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“The exact interpretation of each of the elements of diurnal HPA axis functioning is still subject to debate, but recent reviews are beginning to close in on the meaning and relevance of the different aspects of the rhythm (Saxbe, 2008; Chida and Steptoe, 2009).”
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“For the purposes of this review, any measure that provides an indication of the magnitude of the difference between morning and evening cortisol values is considered a measure of the DCS. Common types of slopes include: 1) wake-to-bed slopes, which examine the absolute change or rate of change in cortisol from immedia…”
BackgroundResultInfluentialAssessment of the cortisol awakening response: Expert consensus guidelines
Stalder, T., Kirschbaum, C., Kudielka, B. M., Adam, E. K., Pruessner, J. C., Wüst, S., Dockray, S., Smyth, N., Evans, P., Hellhammer, D. H., et al. (2016) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2015.10.010 · Cited by 967
“For in-depth discussions of CAR covariates interested readers are referred to the respective review articles (state factors: Law et al., 2013; trait factors: Fries et al., 2009; Chida & Steptoe, 2009; sleep-related: Elder et al., 2014).”
Influential
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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