Assessment of the cortisol awakening response: Expert consensus guidelines
Abstract
The cortisol awakening response (CAR), the marked increase in cortisol secretion over the first 30-45 min after morning awakening, has been related to a wide range of psychosocial, physical and mental health parameters, making it a key variable for psychoneuroendocrinological research. The CAR is typically assessed from self-collection of saliva samples within the domestic setting. While this confers ecological validity, it lacks direct researcher oversight which can be problematic as the validity of CAR measurement critically relies on participants closely following a timed sampling schedule, beginning with the moment of awakening. Researchers assessing the CAR thus need to take important steps to maximize and monitor saliva sampling accuracy as well as consider a range of other relevant methodological factors. To promote best practice of future research in this field, the International Society of Psychoneuroendocrinology initiated an expert panel charged with (i) summarizing relevant evidence and collective experience on methodological factors affecting CAR assessment and (ii) formulating clear consensus guidelines for future research. The present report summarizes the results of this undertaking. Consensus guidelines are presented on central aspects of CAR assessment, including objective control of sampling accuracy/adherence, participant instructions, covariate accounting, sampling protocols, quantification strategies as well as reporting and interpreting of CAR data. Meeting these methodological standards in future research will create more powerful research designs, thus yielding more reliable and reproducible results and helping to further advance understanding in this evolving field of research.
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State covariates such as time of day, psychotropic medication, oral contraceptives and somatic disease greatly influence cortisol measurement.
“especially considering these factors greatly influence cortisol measurement (Stalder et al., 2016).”
From Effectiveness of stress management interventions to change cortisol levels: a systematic review and meta-analysis. (2024) · cites this paper as Stalder et al., 2016
A 40 min resting period was implemented prior to starting the TSST to standardize stress markers to baseline levels.
“Because of this, a 40 min resting period was implemented prior to starting the TSST in an attempt to standardize stress markers to baseline levels.”
From Box breathing and prolonged exhalation reduces markers of physiological stress reactivity in response to a virtual trier social stress test (2026) · cites this paper as [28]
Time of day has been shown to impact heart rate, salivary alpha-amylase, secretory immunoglobulin A, and cortisol concentrations in different ways.
“It should be noted that time of day has been shown to impact heart rate, salivary α-amylase (sAA), secretory immunoglobulin A (SIgA), and cortisol concentrations (in different ways) [28,29].”
From Box breathing and prolonged exhalation reduces markers of physiological stress reactivity in response to a virtual trier social stress test (2026) · cites this paper as [28]
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- Authors
- Stalder, T., Kirschbaum, C., Kudielka, B. M., Adam, E. K., Pruessner, J. C., Wüst, S., Dockray, S., Smyth, N., Evans, P., Hellhammer, D. H., Miller, R., Wetherell, M. A., Lupien, S. J., & Clow, A.
- Affiliations
- Technische Universität Dresden (DE)
- University of Regensburg (DE)
- Northwestern University (US)
- McGill University (CA)
- University College Cork (IE)
- University of Westminster (GB)
- Universität Trier (DE)
- Northumbria University (GB)
- Université de Montréal (CA)
- ORCID
- Venue
- Psychoneuroendocrinology
- Publisher
- Elsevier BV
- Published
- 2016-01
- Volume
- 63
- Pages
- 414-432
- ISSN
- 0306-4530 (ISSN-L)
- OpenAlex
- W1754058279
- Cited by
- 967
- References
- 24
- Citations by year
- 2026: 65 · 2025: 74 · 2024: 82 · 2023: 82 · 2022: 98 · 2021: 102 · 2020: 119 · 2019: 99 · 2018: 98 · 2017: 85 · 2016: 59 · 2015: 2
- FWCI
- 42.29
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychoneuroendocrinology (publishedVersion)
- PubMed (publishedVersion)
- Northumbria Research Link (Northumbria University) (acceptedVersion)
- WestminsterResearch (University of Westminster) (acceptedVersion)
- KOPS (University of Konstanz) (submittedVersion)
- Swinburne figshare (Swinburne University of Technology) (submittedVersion)
- 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, salivary cortisol, sampling accuracy, participant instructions, sampling protocols, methodological recommendations, circadian rhythm
- MeSH terms
- Circadian Rhythm, Diagnostic Techniques, Endocrine, Expert Testimony, Humans, Hydrocortisone, Predictive Value of Tests, Saliva, Specimen Handling, Wakefulness, Reproducibility of Results, Practice Guidelines as Topic, Consensus
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