Cortisol awakening response

Shortly after awakening, a sharp 38–75% (average 50%) increase occurs in the blood level of cortisol in about 77% of healthy people of all ages.{{cite journal | last1=Fries | first1=Eva | last2=Dettenborn | first2=Lucia | last3=Kirschbaum | first3=Clemens | title=The cortisol awakening response (CAR): Facts and future directions | journal=International Journal of Psychophysiology| volume=72 | issue=1 | date=April 2009 | issn=0167-8760 | doi=10.1016/j.ijpsycho.2008.03.014| pmid = 18854200 | pages=67–73}} The average level of salivary cortisol upon waking is roughly 15 nmol/L; 30 minutes later it may be 23 nmol/L, though there are wide variations.{{cite journal | url=http://www.noiseandhealth.org/article.asp?issn=1463-1741;year=2000;volume=2;issue=7;spage=79;epage=88;aulast=Wust | pmid=12689474 | volume=2 | issue=7 | title=The cortisol awakening response - normal values and confounds | year=2000

| last1 = Wust | first1 = Stefan

| last2 = Wolf | first2 = Jutta

| last3 = Hellhammer | first3 = Dirk H

| last4 = Federenko | first4 = Ilona

| last5 = Schommer | first5 = Nicole

| last6 = Kirschbaum | first6 = Clemens

| journal=Noise Health | pages=79–88 | access-date=2009-08-22 | archive-url=https://web.archive.org/web/20171201032811/http://www.noiseandhealth.org/article.asp?issn=1463-1741;year=2000;volume=2;issue=7;spage=79;epage=88;aulast=Wust | archive-date=2017-12-01 | url-status=live}} The cortisol awakening response reaches a maximum approximately 30 minutes after awakening though it may still be heightened by 34% an hour after waking. The pattern of this response to waking is relatively stable for any individual.{{cite journal | vauthors = Hucklebridge F, Hussain T, Evans P, Clow A | year = 2005 | title = The diurnal patterns of the adrenal steroids cortisol and dehydroepiandrosterone (DHEA) in relation to awakening | journal = Psychoneuroendocrinology | volume = 30 | issue = 1| pages = 51–7 | pmid = 15358442 | doi = 10.1016/j.psyneuen.2004.04.007 | s2cid = 24499836 }} Twin studies show its pattern is largely genetically determined since there is a heritability of 0.40 for the mean cortisol increase after awakening and 0.48 for the area under the cortisol rise curve.{{cite journal | vauthors = Wüst S, Federenko I, Hellhammer DH, Kirschbaum C | year = 2000 | title = Genetic factors, perceived chronic stress, and the free cortisol response to awakening | journal = Psychoneuroendocrinology | volume = 25 | issue = 7| pages = 707–20 | pmid = 10938450 | doi = 10.1016/s0306-4530(00)00021-4 | s2cid = 12858990 }}

Normally, the highest cortisol secretion happens in the second half of the night with peak cortisol production occurring in the early morning. Following this, cortisol levels decline throughout the day with lowest levels during the first half of the night.{{cite journal | vauthors = Tsigos C, Chrousos GP | year = 2002 | title = Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress | url = https://zenodo.org/record/1259653| journal = J Psychosom Res | volume = 53 | issue = 4| pages = 865–71 | doi = 10.1016/S0022-3999(02)00429-4 | pmid = 12377295 }} Cortisol awakening response is independent of this circadian variation in HPA axis activity; it is superimposed upon the daily rhythm of HPA axis activity, and it seems to be linked specifically to the event of awakening.{{cite journal | vauthors = Wilhelm I, Born J, Kudielka BM, Schlotz W, Wüst S | year = 2007 | title = Is the cortisol awakening rise a response to awakening? | journal = Psychoneuroendocrinology | volume = 32 | issue = 4| pages = 358–66 | pmid = 17408865 | doi = 10.1016/j.psyneuen.2007.01.008 | s2cid = 25044761 }}{{Cite journal |last1=Powell |first1=Daniel J. |last2=Schlotz |first2=Wolff |date=2012-12-20 |title=Daily Life Stress and the Cortisol Awakening Response: Testing the Anticipation Hypothesis |journal=PLOS ONE |volume=7 |issue=12 |pages=e52067 |doi=10.1371/journal.pone.0052067 |doi-access=free |issn=1932-6203 |pmc=3527370 |pmid=23284871 |bibcode=2012PLoSO...752067P }}

Cortisol awakening response provides an easy measure of the reactivity capacity of the HPA axis.{{cite journal | vauthors = Schmidt-Reinwald A, Pruessner JC, Hellhammer DH, Federenko I, Rohleder N, Schürmeyer TH, Kirschbaum C | year = 1999 | title = The cortisol response to awakening in relation to different challenge tests and a 12-hour cortisol rhythm | journal = Life Sci | volume = 64 | issue = 18| pages = 1653–60 | pmid = 10328525 | doi = 10.1016/s0024-3205(99)00103-4 }}

• Waking up earlier in the morning increases the response.{{cite journal | vauthors = Kudielka BM, Kirschbaum C | year = 2003 | title = Awakening cortisol responses are influenced by health status and awakening time but not by menstrual cycle phase | journal = Psychoneuroendocrinology | volume = 28 | issue = 1| pages = 35–47 | pmid = 12445835 | doi = 10.1016/s0306-4530(02)00008-2 | s2cid = 23846041 }}
• Shift work: nurses working on morning shifts with very early awakening (between 4:00–5:30 a.m.) had a greater and prolonged cortisol awakening response than those on the late day shift (between 6:00–9:00 a.m.) or the night shift (between 11:00 a.m.–2:00 p.m.).{{cite journal | vauthors = Federenko I, Wüst S, Hellhammer DH, Dechoux R, Kumsta R, Kirschbaum C | year = 2004 | title = Free cortisol awakening responses are influenced by awakening time | journal = Psychoneuroendocrinology | volume = 29 | issue = 2| pages = 174–84 | pmid = 14604599 | doi = 10.1016/s0306-4530(03)00021-0 | s2cid = 29227742 }} However another study found that this greater response could be attributed to increased stress and impaired sleep quality before an early work shift ("when these factors were taken into account, the difference in CAR related to experimental condition was no longer significant").{{cite journal | vauthors = Williams E, Magid K, Steptoe A | year = 2005 | title = The impact of time of waking and concurrent subjective stress on the cortisol response to awakening | journal = Psychoneuroendocrinology | volume = 30 | issue = 2| pages = 139–48 | pmid = 15471612 | doi = 10.1016/j.psyneuen.2004.06.006 | s2cid = 108257 }}
• Naps: students taking a nap of one to two hours in the early evening hours (between 6:45–8:30 p.m.) had no cortisol awakening response, suggesting cortisol awakening response only occurs after night sleep.
• Waking up in the light: cortisol awakening response is larger when people wake up in light rather than darkness.{{cite journal | vauthors = Scheer FA, Buijs RM | year = 1999 | title = Light affects morning salivary cortisol in humans | journal = J Clin Endocrinol Metab | volume = 84 | issue = 9| pages = 3395–8 | pmid = 10487717 | doi = 10.1210/jcem.84.9.6102 | doi-access = free }}{{cite journal | vauthors = Thorn L, Hucklebridge F, Esgate A, Evans P, Clow A | year = 2004 | title = The effect of dawn simulation on the cortisol response to awakening in healthy participants | journal = Psychoneuroendocrinology | volume = 29 | issue = 7| pages = 925–30 | pmid = 15177708 | doi = 10.1016/j.psyneuen.2003.08.005 | s2cid = 14394805 }}
• Noise: there is no cortisol rise after nights with traffic-like low-frequency noise.{{cite journal | vauthors = Waye KP, Clow A, Edwards S, Hucklebridge F, Rylander R | year = 2003 | title = Effects of nighttime low frequency noise on the cortisol response to awakening and subjective sleep quality | journal = Life Sci | volume = 72 | issue = 8| pages = 863–75 | pmid = 12493567 | doi = 10.1016/s0024-3205(02)02336-6 }}
• Alarm clock vs. spontaneous waking: there is no difference on days when people woke up spontaneously or used the alarm clock.
• Aspirin has been found to reduce the response probably through an action upon ACTH.{{cite journal | vauthors = Watson S, Horton K, Bulmer S, Carlile J, Corcoran C, Gallagher P, Ferrier IN | year = 2009 | title = Effect of aspirin on hypothalamic-pituitary-adrenal function and on neuropsychological performance in healthy adults: a pilot study | journal = Psychopharmacology | volume = 205 | issue = 1| pages = 151–5 | pmid = 19404617 | doi = 10.1007/s00213-009-1525-4 | s2cid = 7312121 }}

• Morning types show a larger cortisol awakening response than evening types.{{cite journal |vauthors = Kudielka BM, Federenko IS, Hellhammer DH, Wüst S | year = 2006 | title = Morningness and eveningness: the free cortisol rise after awakening in "early birds" and "night owls" | journal = Biol Psychol | volume = 72 | issue = 2| pages = 141–6 | pmid = 16236420 | doi = 10.1016/j.biopsycho.2005.08.003 | s2cid = 35202187 }}
• Those with fatigue show a low rise and flat plateau.{{cite journal | pmid = 19497676 | doi=10.1016/j.psyneuen.2009.05.001 | volume=34 | issue=10 | title=Cortisol secretion and fatigue: associations in a community based cohort | date=November 2009 | vauthors=Kumari M, Badrick E, Chandola T | display-authors = etal | journal=Psychoneuroendocrinology | pages=1476–85 | s2cid=35741736 }}
• Those in pain: the response is reduced the more people are in pain.{{cite journal | vauthors = Fabian LA, McGuire L, Page GG, Goodin BR, Edwards RR, Haythornthwaite J | year = 2009 | title = The association of the cortisol awakening response with experimental pain ratings | journal = Psychoneuroendocrinology | volume = 34 | issue = 8| pages = 1247–51 | pmid = 19375866 | doi = 10.1016/j.psyneuen.2009.03.008 | pmc = 2740898 }}
• The lower a person's socioeconomic status, the higher their response.{{cite journal | vauthors = Wright CE, Steptoe A | year = 2005 | title = Subjective socioeconomic position, gender and cortisol responses to waking in an elderly population | journal = Psychoneuroendocrinology | volume = 30 | issue = 6| pages = 582–90 | pmid = 15808928 | doi = 10.1016/j.psyneuen.2005.01.007 | s2cid = 36466495 }} This might link to the material hardship that occurs with low socioeconomic status.{{cite journal | vauthors = Ranjit N, Young EA, Kaplan GA | year = 2005 | title = Material hardship alters the diurnal rhythm of salivary cortisol | journal = Int J Epidemiol | volume = 34 | issue = 5| pages = 1138–43 | pmid = 15951357 | doi = 10.1093/ije/dyi120 | doi-access = free | hdl = 2027.42/51499 | hdl-access = free }}

Cortisol awakening response is larger for those:

• Waking up to a working day compared to work-free weekend day.{{cite journal | vauthors = Thorn L, Hucklebridge F, Evans P, Clow A | year = 2006 | title = Suspected non-adherence and weekend versus week day differences in the awakening cortisol response | journal = Psychoneuroendocrinology | volume = 31 | issue = 8| pages = 1009–18 | pmid = 16876958 | doi = 10.1016/j.psyneuen.2006.05.012 | s2cid = 42619910 }}{{cite journal | vauthors = Schlotz W, Hellhammer J, Schulz P, Stone AA | year = 2004 | title = Perceived work overload and chronic worrying predict weekend-weekday differences in the cortisol awakening response | url = http://www.psychosomaticmedicine.org/cgi/reprint/66/2/207 | journal = Psychosom. Med. | volume = 66 | issue = 2| pages = 207–14 | pmid = 15039505 | doi = 10.1097/01.psy.0000116715.78238.56 | s2cid = 21210648 }}
• Experiencing chronic stress and worry.
• Overloaded with work.{{cite journal | vauthors = Steptoe A, Cropley M, Griffith J, Kirschbaum C | year = 2000 | title = Job strain and anger expression predict early morning elevations in salivary cortisol | url = http://www.psychosomaticmedicine.org/cgi/reprint/62/2/286 | journal = Psychosom. Med. | volume = 62 | issue = 2| pages = 286–92 | pmid = 10772410 | doi = 10.1097/00006842-200003000-00022 | s2cid = 1182409 }}
• In acute stress. People taking part in a competitive ballroom dance tournament had an increased cortisol awakening response on the morning of their competition day but not their non-competition one.{{cite journal | vauthors = Rohleder N, Beulen SE, Chen E, Wolf JM, Kirschbaum C | year = 2007 | title = Stress on the dance floor: the cortisol stress response to social-evaluative threat in competitive ballroom dancers | journal = Pers Soc Psychol Bull | volume = 33 | issue = 1| pages = 69–84 | pmid = 17178931 | doi = 10.1177/0146167206293986 | s2cid = 1430950 }}
• Worn down by burnout: some studies find an increased response,{{cite journal | vauthors = Grossi G, Perski A, Ekstedt M, Johansson T, Lindström M, Holm K | year = 2005 | title = The morning salivary cortisol response in burnout | journal = J Psychosom Res | volume = 59 | issue = 2| pages = 103–11 | pmid = 16186006 | doi = 10.1016/j.jpsychores.2005.02.009 }}{{cite journal | url = http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1765727&blobtype=pdf | pmid = 12782748 | volume=60 | title=Physiological differences between burnout patients and healthy controls: blood pressure, heart rate, and cortisol responses | pmc=1765727 | date=June 2003 | vauthors=De Vente W, Olff M, Van Amsterdam JG, Kamphuis JH, Emmelkamp PM | journal=Occup Environ Med | issue = Suppl 1 | pages=i54–61 | doi = 10.1136/oem.60.suppl_1.i54 }} though other researchers find a decreased{{cite journal | url = http://www.psychosomaticmedicine.org/cgi/reprint/61/2/197 | pmid = 10204973 | volume=61 | issue=2 | title=Burnout, perceived stress, and cortisol responses to awakening | year=1999 | vauthors=Pruessner JC, Hellhammer DH, Kirschbaum C | journal=Psychosom Med | pages=197–204 | doi=10.1097/00006842-199903000-00012 }} or normal response.{{cite journal | vauthors = Mommersteeg PM, Heijnen CJ, Verbraak MJ, van Doornen LJ | year = 2006 | title = Clinical burnout is not reflected in the cortisol awakening response, the day-curve or the response to a low-dose dexamethasone suppression test | journal = Psychoneuroendocrinology | volume = 31 | issue = 2| pages = 216–25 | pmid = 16150550 | doi = 10.1016/j.psyneuen.2005.07.003 | s2cid = 8444094 }}

Cortisol is released from the adrenal glands following activation by ACTH release from the pituitary. The ACTH release creating the cortisol awakening response is strongly inhibited after intake of a low-dose dexamethasone.{{cite journal | vauthors = Ehrhart-Bornstein M, Bornstein SR, Scherbaum WA | year = 1996 | title = Sympathoadrenal system and immune system in the regulation of adrenocortical function | journal = Eur J Endocrinol | volume = 135 | issue = 1| pages = 19–26 | pmid = 8765968 | doi = 10.1530/eje.0.1350019 }} This is a synthetic glucocorticoid and this inhibition allows the detection of the presence of negative feedback from circulating cortisol that controls to ACTH-secreting cells of the pituitary.

In the hypothalamic-pituitary-adrenal axis the pituitary release of ACTH is regulated by the hypothalamus. This occurs through the hypothalamus's production of the hypophysiotropic hormone corticotropin-releasing hormone, the production of which is subject to circadian influence and the day/night cycle.{{Cite book|title=Vander's Human Physiology: The Mechanisms of Body Function|last1=Widmarier|first1=Eric P.|last2=Raff|first2=Hershel|last3=Strang|first3=Kevin T.|publisher=McGraw Hill|year=2016|edition=14th|location=New York, NY|pages=335}} In the cortisol awakening response, the hypothalamic-pituitary-adrenal axis is controlled by the hippocampus. For example, cortisol awakening response is absent in those with bilateral and unilateral hippocampus damage{{cite journal | vauthors = Buchanan TW, Kern S, Allen JS, Tranel D, Kirschbaum C | year = 2004 | title = Circadian regulation of cortisol after hippocampal damage in humans | journal = Biol Psychiatry | volume = 56 | issue = 9| pages = 651–6 | pmid = 15522248 | doi = 10.1016/j.biopsych.2004.08.014 | s2cid = 7401473 }} and hippocampal atrophy.{{cite journal | vauthors = Bruehl H, Wolf OT, Convit A | year = 2009 | title = A blunted cortisol awakening response and hippocampal atrophy in type 2 diabetes mellitus | journal = Psychoneuroendocrinology | volume = 34 | issue = 6| pages = 815–21 | pmid = 19167831 | doi = 10.1016/j.psyneuen.2008.12.010 | pmc = 2774914 }} Those with severe amnesia, and thus with presumed damage to the temporal lobe, also do not have it.{{cite journal | vauthors = Wolf OT, Fujiwara E, Luwinski G, Kirschbaum C, Markowitsch HJ | year = 2005 | title = No morning cortisol response in patients with severe global amnesia | journal = Psychoneuroendocrinology | volume = 30 | issue = 1| pages = 101–5 | pmid = 15358447 | doi = 10.1016/j.psyneuen.2004.05.001 | s2cid = 19739260 }} Those with a larger hippocampus have a greater response.{{cite journal | vauthors = Pruessner M, Pruessner JC, Hellhammer DH, Bruce Pike G, Lupien SJ | year = 2007 | title = The associations among hippocampal volume, cortisol reactivity, and memory performance in healthy young men | journal = Psychiatry Res | volume = 155 | issue = 1| pages = 1–10 | pmid = 17395434 | doi = 10.1016/j.pscychresns.2006.12.007 | s2cid = 31707798 }}

It's plausible also that the suprachiasmatic nucleus, the light-sensitive biological clock, plays a role in cortisol awakening response regulation.

The function of cortisol awakening response is unknown but it has been suggested to link with a stress-related preparation in regard to the upcoming day by the hippocampus.{{cite journal|last1=Law|first1=Robin|last2=Evans|first2=Phil|last3=Thorn|first3=Lisa|last4=Clow|first4=Angela|last5=Hucklebridge|first5=Frank|title=The cortisol awakening response predicts same morning executive function: results from a 50-day case study|journal=Stress|date=2015|volume=18|issue=6|pages=616–621|doi=10.3109/10253890.2015.1076789|pmid=26382884|s2cid=22921488|language=en|issn=1025-3890|url=https://westminsterresearch.westminster.ac.uk/download/8b1d6ff2fd0e0657f63204406d0bba0193db5f74aa045b7ba0ecca8a26341c12/123021/CAR%20and%20EF%20Revised-1.pdf}} One hypothesis is: "that the cortisol rise after awakening may accompany an activation of prospective memory representations at awakening enabling individual's orientation about the self in time and space as well as anticipation of demands of the upcoming day... it is tempting to speculate that for the CAR, anticipation of these upcoming demands may be essential in regulating the CAR magnitude for the particular day. The hippocampus is, besides its established role in long-term memory consolidation, involved in the formation of a cohesive construct and representation of the outside world within the central nervous system processing information about space, time and relationships of environmental cues. This puts the hippocampus in a pivotal position for the regulation of the CAR."

• Dawn phenomenon
• Hypothalamic-pituitary-adrenal axis
• Sleep

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Category:Neuroendocrinology

Category:Sleep physiology

Category:Unsolved problems in neuroscience

Category:Stress (biology)