Assessing Stress

// Corey Schuler, MS, DC, LN, CNS


The hypothalamic-pituitary-adrenal (HPA) axis is a highly adaptive system and measuring it can be difficult. A biochemical and a clinical tool combined may be more useful than just one or the other. The cortisol-awakening response (CAR) is a marker of circadian rhythm as well as HPA axis function. It is suspected that a sudden rise in cortisol helps to mobilize energy in the transition from sleep to wakefulness.1 Upon wakening, cortisol production and measurement in saliva peaks within the first 30-45 minutes.2 In 15-25% of individuals, a rise in cortisol is not observed.3 However, it should be noted that one study suggested that absence of CAR may be due to sampling error as instructions are prone to non-compliance for collection of saliva in the early morning.4 However, that is not a complete explanation for the lack of morning cortisol peaks.5 6 7Being a “morning person” rather than a “night owl” may contribute to variances in CAR.8 9 So too can situational factors add variance and serial values may be helpful in ruling out these variables.10 11 One may conceive that smoking, drinking coffee, menstrual cycle phase, oral contraceptive use, and sleep length may be major contributing factors to CAR, but they are of minor relative consequence.12 13 14 15 Yet, sudden changes in sleep-wake schedules do influence the timing of the cortisol rise.16 Sleep restriction as seen by the use of alarms can reduce cortisol secretion at awakening. CAR occurs in dark or light and whether the patient awakes and remains lying down or immediately rises. However, CAR is larger if patients are exposed to bright light. Exposure of 800 Lux is sufficient, which is approximately the same exposure as a partly cloudy day or a bright kitchen. An overly robust cortisol-awakening response may be indicative of a condition that requires further evaluation.17 18 19 20 21 22

The cortisol-awakening response (CAR) is a marker of circadian rhythm as well as HPA axis function.

Limiting the assessment of stress to cortisol may only weakly guide interventions. Understanding other lifestyle factors further contributes to understanding patients’ responses. While not suitable for most clinical environments, a validated testing procedure provides helpful information about what does and does not activate the HPA and to what magnitude. This procedure is the Trier Social Stress Test (TSST).23 TSST includes a mock job interview and performing mental arithmetic in front of an audience who has been trained to not provide positive nor negative feedback. This provocative test is not a test of maximal stress response, but rather of sub-maximal novel stressors. While not predictive of any particular condition, TSST provides valuable information about determinants of HPA activity and reactivity.

Despite being incomplete of the representative literature on the subject, the following factors affect the HPA according to TSST research.

  • Smoking 24
  • Caffeine 25
  • Alcohol 26
  • Excess Food 27 28
  • High glucose load 29
  • Socially dominant men are affected more so than subordinate men 30

Factors that attenuate the HPA response include

  • Social support with the greatest effect in men via oxytocin31
  • Caffeine 25
  • Brief group-based cognitive-behavioral management 32 33
  • Relaxing music34
  • Progressive muscle relaxation35

Of significant interest is that larger HPA responses have been reported in men independent of age differences. The hypothesis stands that female sex hormones may attenuate the HPA axis response and some hormone-related changes in women may be due to varying HPA axis responses. Women in the luteal phase of their menstrual cycle reported similar responses to men while those using oral contraceptives or in the follicular phase did not.

The complexity of the hypothalamic-pituitary-adrenal axis with considerable environmental, behavioral, physiological, and psychological is an important system for the integrative practitioner to master clinically. It is however, an art, with no overly simple assessments providing complete answers. Assessment and support of the HPA axis requires recognition of each of these important factors.

HPA Axis Optimization Program

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