Psychoneuroendocrinology (2009) 34, 163171

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / p s y n e u e n

Salivary cortisol as a biomarker in stress research

Dirk H. Hellhammer a,*, Stefan Wust a,b, Brigitte M. Kudielka a,c

a
Psychology, Department of Clinical and Physiological Psychology, University of Trier, Johanniterufer 15, 54290 Trier, Germany
b
Department of Genetic Epidemiology in Psychiatry, Central Institute of Mental Health, J5, 68159 Mannheim, Germany
c
Jacobs Center on Lifelong Learning and Institutional Development, Jacobs University Bremen,
Campus Ring 1, 28759 Bremen, Germany

Received 15 July 2008; received in revised form 30 October 2008; accepted 31 October 2008

KEYWORDS Summary Salivary cortisol is frequently used as a biomarker of psychological stress. However,
Stress response; psychobiological mechanisms, which trigger the hypothalamuspituitaryadrenal axis (HPAA)
Cortisol; can only indirectly be assessed by salivary cortisol measures. The different instances that control
CRF; HPAA reactivity (hippocampus, hypothalamus, pituitary, adrenals) and their respective
AVP; modulators, receptors, or binding proteins, may all affect salivary cortisol measures. Thus, a
ACTH linear relationship with measures of plasma ACTH and cortisol in blood or urine does not
necessarily exist. This is particularly true under response conditions. The present paper addresses
several psychological and biological variables, which may account for such dissociations, and aims
to help researchers to rate the validity and psychobiological significance of salivary cortisol as an
HPAA biomarker of stress in their experiments.
# 2008 Elsevier Ltd. All rights reserved.

1. Introduction observed. This paper describes such dissociations and puta-

Today, salivary cortisol is routinely used as a biomarker of
psychological stress and related mental or physical diseases.
Most studies consider salivary cortisol levels a reliable mea-
sure of hypothalamuspituitaryadrenal axis (HPAA) adapta-
tion to stress. However, the stress response of the HPAA is
rather complex and modulated by numerous factors. Cortisol
levels in saliva are partly dissociated from levels of para-
ventricular corticotrophin releasing factor (CRF), arginine
vasopressin (AVP), adrenocorticotropic hormone (ACTH), and
cortisol in blood or urine. Under several circumstances a
partial but significant dissociation between salivary cortisol
levels and other HPAA related endocrine signals can be
* Corresponding author. Tel.: +49 651 2012928;
fax: +49 651 2012934.
E-mail address: albertz@uni-trier.de (D.H. Hellhammer).
tive mechanisms. We aim to illustrate the physiological
significance of salivary cortisol as a biomarker of HPAA
responsivity by addressing several sources of variance con-
tributing to such dissociations.
2. Dissociations with CRF/AVP
The process between the initiation of an HPAA response in the
central nervous system and salivary cortisol variations as an
outcome measure is modulated by numerous psychological
and biological events. Psychological events initiate an HPAA
response by predominantly activating CRF/AVP neurons in
the paraventricular nucleus (PVN) of the hypothalamus (see
Chrousos and Kino, 2007 for a review). The degree of activa-
tion will vary, depending on the psychological components
of the situation, such as unpredictability, uncontrollability,
novelty, anticipation, ego-involvement, habituation, etc.

0306-4530/$ see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.psyneuen.2008.10.026
164
(Mason, 1968; Kudielka et al., 2007). Furthermore, classically
conditioned stimuli may also elicit CRF mediated HPAA
responses (Kreutz et al., 1992). In addition, whenever the
brain needs energy to fulfill its function it needs to initiate
HPAA activity in order to allocate glucose to the brain. This is
particularly true under stressful conditions (Peters et al.,
2004). The interplay of these factors already accounts for
some variability.
Interestingly, it is generally assumed that endocrine and
psychological stress responses represent indicators of the
same construct and thus a high psycho-endocrine covariance
should be expected. On a neuroanatomical level this hypoth-
esis is corroborated by close links between the HPAA and
cortical and limbic structures, which are important media-
tors of subjective-psychological stress responses (Feldman
et al., 1995; Lopez et al., 1999; Buijs and Van Eden, 2000;
Heckmann et al., 2005; Herman et al., 2005; Wang et al.,
2005). However, the analyses of psycho-endocrine covariance
in studies using a variety of stressors and subjects have
yielded inconsistent and largely negative results (alAbsi
et al., 1997; Buchanan et al., 1999; Cohen et al., 2000;
Oswald et al., 2004). Considering the time lag between
psychological and endocrine stress responses probably
enlarges the detectable covariance (Smyth et al., 1998;
Schlotz et al., 2008), but the proportion of explained var-
iance is nevertheless small (Hellhammer and Hellhammer,
2008). Although beyond the scope of this manuscript, it
should be noted that not only neuroendocrine factors
account for the limited association between cortisol and
subjective-psychological stress responses, but also factors
related to the assessment of perceived stress by self-report
methods. Amongst others, stress questionnaires differ sub-
stantially in underlying theoretical stress concepts and foci,
and several personality traits (e.g. neuroticism, locus of
control, general affectivity) as well as gender are known
to impact on self-reported stress levels.
Hypothetically, it should be expected that a stress-
induced activation of CRF/AVP neurons in the PVN results
in a subsequent linear release of ACTH from the pituitary and
of cortisol from the adrenals, as finally represented by
salivary cortisol levels. However, research investigating the
linearity between CRF and ACTH release suggests that only
part of the variance of ACTH and glucocorticoid release can
be explained by CRF release under stimulated (Carlson et al.,
2007) and unstimulated conditions (Watts, 2005). The role of
AVP remains to be fully elucidated. In animals, both peptides
seem to act synergistically, with CRF playing a permissive,
and AVP a dynamic role (Plotsky, 1991). Again, it is not yet
fully clear, how acute or chronic psychological stress differ-
entially affects these peptides, and which role each of them
plays in ACTH release under stress conditions in humans.
However, the multiplicity of central factors regulating the
HPAA response may well account for response differences
among individuals and occasions. For instance, women in the
follicular phase of the menstrual cycle show smaller ACTH
and salivary cortisol responses to the TSST than men, while
women (irrespective of cycle phase) show higher salivary
cortisol levels 4560 min after awakening (Kirschbaum et al.,
1996, 1999; Wust et al., 2000a). In animal studies, chronic
stress results in a shift towards an increased AVP/CRF ratio in
parvocellular neurons (for review see Dinan and Scott, 2005).
Findings in humans are currently not consistent but a certain
D.H. Hellhammer et al.
HPAA hyporeactivity in chronically stressed individuals seems
to be likely. For instance, aspects of chronic work stress were
associated with a dampening of the HPAA response to the
TSST (Bellingrath and Kudielka, 2008), while perceived
chronic stress was related to an elevation of salivary cortisol
after awakening (Schulz et al., 1998; Wust et al., 2000b;
Pruessner et al., 2003; Watts, 2005). In a study by Bellingrath
et al. (2008) enhanced cortisol suppression to a low dose of
dexamethasone in a much larger study sample was also
observed. Dexamethasone mainly affects glucocorticoid
receptors in the pituitary. However, both parvocellular CRF
and AVP are also under inhibitory control of glucocorticoids
(Erkut et al., 1998) and the glucocorticoid receptor may thus
primarily modulate the dynamic response to acute and
chronic psychological stress.
Under stress conditions, the interplay between the PVN
and the noradrenergic neurons arising from the locus coer-
uleus (LC) is most crucial (Chrousos and Kino, 2007). Liu et al.
(1994) provided evidence that CRF/AVP neurons are acti-
vated by noradrenergic or neuropeptide Y neurons, resulting
in an increased AVP/CRH ratio, and their data suggest a major
involvement of this interplay in depression and stress related
disorders. Under these circumstances, paraventricular CRF/
AVP neurons activate sympathetic preganglionic neurons in
the spinal cord, which control cortisol release from the
adrenals and may mainly drive the circadian rhythm (Enge-
land and Arnhold, 2005). In turn, ACTH does not only stimu-
late the release of cortisol from the adrenals, but, in
addition, regulates gene expression of Norepinephrine (NE)
biosynthetic enzymes in the superior cervical ganglia and
locus coeruleus (LC) by an adrenal independent mechanism
(Serova et al., 2008). In sum, the interplay between CRF/AVP
neurons, ACTH and other peptides, as well as noradrenergic
and sympathetic activation contributes to the missing covar-
iance between psychological measures of stress and salivary
cortisol levels.
Sex steroids are another important modulator of HPAA
measures. The influence of sex steroids on central HPAA
activity is rather complex, only partially understood and
has predominantly been studied in rodents. For instance,
the affinity of hippocampal mineralocorticoid receptors (MR)
for glucocorticoids is significantly higher in male than in
female rats (Turner, 1997). Progesterone seems to decrease
the affinity of hippocampal MRs while estrogens decrease MR
binding capacity (Carey et al., 1995). Testosterone was
shown to enhance glucocorticoid receptor (GR) binding in
the preoptic area of the hypothalamus (Viau and Meaney,
1996) and the progesterone receptor binds to hormone
responsive elements on the DNA with the same affinity as
the GR and the MR (von der Ahe et al., 1985). Estrogens and
dihydrotestosterone inhibit GR and MR expression in several
tissues (Patchev and Almeida, 1996). Progesterone was found
to modulate the inhibitory estrogen effect on the GR and
enhances MR mRNA transcription (Castren et al., 1995;
Patchev and Almeida, 1996). Recent studies provided further
convincing evidence for a significant impact of gonadal ster-
oids on HPAA regulation. Male rats that were prenatally and
at an early postnatal stage treated with either an antiandro-
gen or a drug, which inhibits aromatization of testosterone to
estradiol, showed a feminized HPAA including enhanced
corticosterone levels (basal and in response to challenge)
as well as elevated CRF mRNA levels in the PVN and proo-
Salivary cortisol as a biomarker in stress research
piomelanocortin mRNA levels in the adenohypophysis (Seale
et al., 2005b). An analogous HPAA masculinization was
observed in female rats that were exposed to a testosterone
propionate (TP) injection early after birth. Remarkably, in
adult TP rats these effects on HPAA regulation could be
reversed by estradiol treatment (Seale et al., 2005a). How-
ever, it is important to note that sex steroid effects on
processes related to HPAA regulation often depend on the
experimental design, the scrutinized brain region and the sex
of the studied animal. In a recent review Federman (2006)
concludes that due to the pronounced specificity of present
receptors, coactivators, corepressors and enzymes, each
target tissue can have its own androgenic or estrogenic
identity. Moreover, it has been shown that cortisol binding
globuline (CBG) levels are influenced by circulating gonadal
steroids (Kajantie and Phillips, 2006) and that CBG synthesis
is regulated by glucocorticoids (Cole et al., 1999). In humans
the use of ethinyl-estradiol containing oral contraceptives
(OC) stimulates CBG synthesis (Wiegratz et al., 2003) result-
ing in higher total cortisol levels. The observation of a
blunted salivary cortisol response following psychosocial
and pharmacological stimulation was related to the CBG
enhancing effect of ethinyl-estradiol (Kirschbaum et al.,
1999). This assumption was recently confirmed by the obser-
vation that CBG levels were negatively associated with ACTH
and salivary cortisol responses to the TSST but positively with
total cortisol levels (Kumsta et al., 2007a). Diminished ACTH
responses might be explained by changes in pituitary CRF
receptors. In the course of OC intake and the concomitant
and unphysiological increase of CBG, a larger fraction of free
cortisol will be bound, resulting in a permanently enhanced
activation of CRF neurons in the PVN to maintain comparable
free basal cortisol levels. An increased CRF drive could
eventually result in a down-regulation of CRF receptors on
pituitary corticotrophs. This assumption is consistent with
the observed blunted ACTH responses to CRF administration
in OC users compared to non-users (Jacobs et al., 1989).
Remarkably, an impact of CBG as a regulatory element of
HPAA responses is not limited to women with exogenously up-
regulated CBG levels. In men, positive associations were
observed between CBG and ACTH as well as total cortisol
levels following the TSST (Kumsta et al., 2007a).
3. Dissociations with ACTH
In a recent review, Bornstein et al. (2008) summarized dis-
sociations of ACTH and glucocorticoids in critical illness,
inflammation, and mental disorders. They name numerous
factors, such as neuropeptides, neurotransmitters, opioids,
growth factors, cytokines, adipokines, and bacterial ligands,
which modulate adrenal glucocorticoid release indepen-
dently of pituitary ACTH. Thus, it should be noted that the
salivary cortisol response to stress can be confounded by a
broad array of intervening variables.
In this review, Bornstein et al. (2008) showed that the
adrenal release of cortisol during the circadian slope and the
stress response are under dual control of both ACTH and
preganglionic sympathetic neurons. Other studies suggest
that reward can dampen adrenal glucocorticoid release
independent of ACTH release and that several factors mod-
ulate ACTH sensitivity of the adrenals. Among those factors
are chronic stress, long-term exercise, and gonadal steroids.
165
Interestingly, physical challenge and psychological stress
seem to exert different effects: physically demanding,
life-threatening stressors result in an augmented adrenal
response, whereas psychological, anxiety-producing stres-
sors result in a diminished response. These findings suggest
that an extra-ACTH mechanism shapes the adrenal response
in exercising animals, providing elevated corticosteroids
when needed to withstand physical insults, but reduced
corticosteroid when exercise alone is sufficient to offset
psychological challenges (Bornstein et al., 2008).
Studies assessing changes of the circadian slope as a
measure of stress load may consider that light induces the
expression of clock genes in the adrenal gland independent of
ACTH release. In this context also the cortisol awakening
response (CAR) should be mentioned. Pruessner et al. (1997)
were the first who proposed that the repeated assessment of
this cortisol increase after awakening in saliva might repre-
sent a useful and easy to measure index of cortisol regulation.
Later the term CAR was coined (Federenko et al., 2004) and
in most studies the CAR was observed to be an increase in
salivary cortisol levels of about 5075% within 3045 min
after awakening. The CAR is increasingly used in psychoneur-
oendocrinology as an indicator of HPAA activity and a com-
prehensive overview of findings related to the CAR is well
beyond the scope of the present report (for current reviews
see Clow et al., 2004; Chida and Steptoe, in press; Fries
et al., in press). Interestingly, a certain dissociation between
ACTH and cortisol seems to become detectable at the end of
the sleep phase. We could recently show that within a 30 min
interval after awakening plasma ACTH and serum cortisol
levels rose steeper than in the last hours before morning
awakening (Wilhelm et al., 2007). Our data indicate conclu-
sively that the increased secretory activity of the HPA axis
after morning awakening is at least in part caused by the
process of awakening itself, i.e., represents a genuine
response to awakening. However, we also found that in
the last hour before awakening ACTH levels showed a trend
towards a steeper rise as compared to cortisol levels. This
finding might be suggestive of a partly dissociated regulation
before awakening and it is in line with a study by Born et al.
(1999) who reported a significant ACTH but not cortisol
increase in the last hour of sleep in subjects being woken
rather early. All this information is important in order to
understand that ACTH responses to stress explain only part of
the variance of salivary cortisol response measures. In 212
young healthy males and females (all using oral contracep-
tives; Kumsta et al., 2007b) the correlation between ACTH
and salivary cortisol responses to the TSST was r = .54 for the
area under the curve (AUC) and r = .66 for the response peak.
After premedication with 0.25 mg dexamethasone early
morning ACTH levels showed a correlation of r = .35 (AUC)
and r = .28 (peak) to the salivary cortisol awakening
response. All these correlations were statistically significant
but when the proportion of explained variance is taken into
account (between 8 and 44%) it becomes obvious that ACTH
and salivary cortisol are not interchangeable measures.
4. Dissociations with blood cortisol levels
There is a high correlation between salivary cortisol levels
and unbound free cortisol levels in plasma and serum, which
remains high during the circadian cycle and under different
166 D.H. Hellhammer et al.

dynamic tests, such as dexamethasone suppression and ACTH

stimulation (Vining et al., 1983b; Umeda et al., 1981; Wede-
kind et al., 2000; Levine et al., 2007). Since free cortisol
represents the biologically active hormone fraction, salivary
cortisol measures have early been considered to be a better
measure of adrenocortical function than serum cortisol (Vin-
ing et al., 1983a). Recently, the free hormone hypothesis has
been challenged, and it has been suggested that CBG-bound
cortisol may also have physiological effects on target tissues,
as recently reviewed by Levine et al. (2007).
The proportion of salivary cortisol to total cortisol is about
12% in the lower range, but about 89% in the upper range.
Thus, salivary cortisol levels have to be treated with caution,
since they will not behave linear to serum levels in response
to a challenge or under conditions which affect CBG levels,
such as oral contraceptives, menstrual cycle or pregnancy.
The salivary cortisol assay used by Vining and co-workers
showed such aberrations already for cortisol levels above
10 nmol/l. This is an important issue, which is often
neglected in psychobiological research.
However, the relation between total and free cortisol
levels in blood changes once CBG is saturated (Vining
et al., 1983a). Fig. 1 shows simultaneous measures for sali-
vary and serum cortisol in men, women, and women taking
oral contraceptives. In men (Fig. 1a), CBG seems to be
saturated when serum cortisol levels range between 450
and 500 nmol/l. Sex steroids enhance CBG levels (see above),
which may result in a broader variability of cortisol levels in
women (Fig. 1b), and in a far higher proportion of serum
cortisol to salivary cortisol levels in women taking oral con-
traceptives (Fig. 1c).
This situation has practical implications, which can be
illustrated by the following example: if an HPAA response is
assessed by cortisol in saliva, the magnitude of this response
will differ with respect to CBG saturation. For instance, an
increase of salivary cortisol of only 5 nmol/l would be
detected if total cortisol levels increased from 200 to
400 nmol/l in response to a challenge. But the same total
cortisol increase of 200 nmol/l from 500 to 700 nmol/l would
result in a threefold higher increase of about 15 nmol/l. In
the salivary cortisol assay we are employing in Trier, this
problem of non-linearity affects probably only relatively high
salivary cortisol levels (Fig. 1a and b); for example, mean
TSST responses or mean daytime cortisol peak levels are
usually below the mean CBG saturation range. Surely, salivary
cortisol levels have to be interpreted with caution (a) under
conditions affecting CBG levels, such as oral contraceptives,
menstrual cycle or pregnancy and (b) in response to pharma-
cological or strong psychological challenges.
Salivary cortisol levels do not just reflect a linear adre-
nocortical response to ACTH or adrenergic stimulation, but
vary with different determinants, which have been shown to
be relevant in psychobiological research. For example, pre-
and early postnatal adversity have been reported to affect Figure 1 Simultaneous measures for salivary and serum corti-
cortisol availability by two different mechanisms. First, the sol in (a) men (744 measures), (b) women (100 measures), and (c)
adrenal capacity to mount a cortisol response may be women taking oral contraceptives (920 measures).
impaired, and secondly, the degree of cortisol metabolism
in the liver and visceral fat may be affected (Buffington, et al., 2006). In sum, total cortisol levels cannot be consid-
2004; Yehuda et al., 2006; Klingmann and Hellhammer, 2008; ered a passive bridge between the ACTH and salivary
Klingmann et al., in press). In addition, the hair follicle is able cortisol response to stress, but rather a considerable source
to synthesize CRF, ACTH, and cortisol, and it is not yet known, of variance, particularly under hyper- and hypocortisolemic
how much this source contributes to total cortisol levels (Paus conditions (Fries, 2008; Putz, 2008).
Salivary cortisol as a biomarker in stress research
Despite the conditions mentioned above, salivary cortisol
levels can be expected to correlate reasonably well with
total cortisol levels in the upper or lower range, as defined by
CBG binding. For instance, in the above mentioned cohort of
212 healthy males and females the correlation between
serum cortisol and salivary cortisol responses to the TSST
was r = .47 (AUC) and r = .58 (peak), respectively. However,
both ranges need to be treated separately.
5. Dissociations with free cortisol levels in
blood
Although most studies report a high correlation between free
cortisol levels in blood and saliva, some studies call for
caution. Levine et al. (2007) summarize such studies, report-
ing dissociation between both measures during the circadian
circle, under challenge conditions, and with respect to the
magnitude of free cortisol levels. Referring to data which
suggest that about 14% of salivary cortisol is bound to CBG in
saliva, they assume that this may be one important reason
behind such dissociations. In addition, about 30% of free
cortisol is enzymatically converted to cortisone in saliva,
thus resulting in relatively lower levels of free cortisol in
saliva as compared to plasma.
However, given the numerous advantages in the stress-
free collection and processing of salivary cortisol and the
reasonable overall correlation between free cortisol in saliva
and blood, we feel that salivary measures are the method of
choice in stress research, at least for the assessment of free
cortisol levels.
6. Dissociations with urinary cortisol levels
Free cortisol is metabolized in the liver and about 70% of these
biologically inactive metabolites are excreted in urine, about
20% (via bile) in stool, and about 8% in the skin. In urine, only
about 1% of free blood cortisol is excreted (Hatz, 1998). In the
early stress literature, cortisol conjugates and metabolites
(17-hydroxycorticosteroids and 17-ketosteroids) were com-
monly used as HPAA measures, before new assays were avail-
able allowing precise assessment of cortisol in blood and
saliva. Overnight or 24 h urine measures have the advantage
to provide integrative HPAA measures over larger time periods,
although the compliance is poor, particularly for 24 h mea-
sures. Furthermore, renal conditions may specifically affect
urinary cortisol levels. Thus, creatinine clearance is usually
assessed for the adjustment of urinary cortisol levels. More
than 95% of cortisol is metabolized before excretion. Free
cortisol can thus not only be considered a consequence of
cortisol production, but, in addition, of cortisol clearance in
the liver. In patients with chronic fatigue, for example, low
salivary cortisol levels have been discussed to be associated
with a faster clearance of cortisol (Jerjes et al., 2006).
However, it should be noted that (if the subjects com-
pliance is ensured) urine analyses can be a useful and valid
approach to assess glucocorticoid secretion if not only urinary
cortisol but also cortisol metabolites are assessed, ideally
with a modern gas chromatography/mass spectrometry
method (Heckmann et al., 2005; Remer et al., 2008). It
was shown that the seven major urinary cortisol metabolites
5alpha-tetrahydrocortisol (5a-THF), 5beta-tetrahydrocorti-
167
sol (THF), 5beta-tetrahydrocortisone (THE), alpha-cortol,
beta-cortol, alpha-cortolone, and beta-cortolone, encom-
pass almost 80% of the cortisol secreted by the adrenal gland
(Stewart and Krozowski, 1999).
7. Dissociations with effects on target
tissues
The measurement and interpretation of (salivary) cortisol
levels in stress research is often based on the implicit
assumption that, firstly, a given cortisol level reflects a
certain effect across different GC target tissues within one
subject and that, secondly, a given level of cortisol elicits
comparable target tissue effects in different subjects. Both
aspects of this assumption are not necessarily correct. It is
well documented that within the normal population, a con-
siderable variability in the sensitivity to glucocorticoids
across individuals exists (Baxter and Rousseau, 1979; Hui-
zenga et al., 1998). Furthermore, it has been shown that GC
sensitivity of one target tissue does often not reflect GC
sensitivity of other organs in both patients receiving GC
treatment (Corrigan et al., 1991, 1996; Sher et al., 1994;
Caldji et al., 1998) and in healthy individuals (Ebrecht et al.,
2000; Vasiliadi et al., 2002). It is well beyond the scope of this
manuscript to summarize all putative molecular sources of
this variability. However, one important determinant of
magnitude and efficacy of GC action are characteristics of
the GR. Rare clinical abnormalities in GC sensitivity, such as
the generalized inherited GC resistance syndrome, have been
linked to mutations of the GR (Charmandari et al., 2004).
More common polymorphisms of the GR gene have been
associated with variability in sensitivity to exogenous GCs
in the general population (Koper et al., 1997; Huizenga et al.,
1998; Panarelli et al., 1998; DeRijk et al., 2001; van Rossum
et al., 2002, 2003; Fleury et al., 2003; Wust et al., 2004).
Moreover, GR gene variants (and probably also polymorph-
isms in other genes) cannot only partly explain differences
between two individuals, they can also mediate GC effect
differences between different target tissues within one indi-
vidual. For instance, we have recently observed an associa-
tion between a certain GR genotype (BclI GG) and measures
of GC sensitivity of the pituitary and subdermal blood vessels,
but we did not detect an association with the GC sensitivity of
peripheral leukocytes (Kumsta et al., 2008). The molecular
basis for the observed variability in GC responsiveness can be
partially attributed to existence of isoforms of the GR result-
ing from alternative splicing, alternative translation initia-
tion and posttranslational modifications (Lu and Cidlowski,
2006). Different cellular environments are likely to result in
differential expression of GR isoforms, all possessing unique
transcriptional regulatory profiles. Tissue specific GR isoform
compositions could determine the cell specific response to
glucocorticoids thus accounting for the diverse and specific
effects of GCs (Lu and Cidlowski, 2006). The molecular
mechanisms underlying GR isoform generation have been
identified (Lu and Cidlowski, 2005). However, how tissues
direct this expression to achieve their unique cell specific
isoform composition is largely unknown. It has been demon-
strated that presence of GR gene variants can impact on the
regulation of isoform expression and thus alter the cellular
composition and proportion of these isoforms.
168
Another presumably very important mechanism contribut-
ing to target tissue specificity of glucocorticoid action is the
presence or absence of the enzyme 11b-hydroxysteroid dehy-
drogenase type 1 (11b-HSD1) (Seckl and Walker, 2001). This
enzyme can be found in peripheral tissues (liver, lung, adi-
pose tissue, vasculature, ovary) but it is also expressed in
several brain regions including hippocampus, hypothalamus
and pituitary. 11b-HSD1 catalyzes the conversion from inert
11-keto forms (cortisone, 11-dehydrocorticosterone), which
are sufficiently present in the blood stream, into active
glucocorticoids (cortisol, corticosterone). This results in a
local and specific amplification of glucocorticoid action in
11b-HSD1 expressing tissues.
Since alterations in GC sensitivity are implicated in the
onset and course of stress related diseases and due to the
inaccessibility of brain tissue, reliable peripheral markers
reflecting changes in GC signaling are needed. Given the
highly tissue specific effects, it is a clear limitation that
markers of GC sensitivity in peripheral tissue do not neces-
sarily reflect functional changes in central GC signaling.
However, at least in depressed patients, there are consistent
findings of non-suppression in the dexamethasone suppres-
sion test and a reduced in vitro inhibition of lymphocyte
proliferation in response to dexamethasone in the same
patients (Pariante, 2004). Recently, Carvalho et al. (2008)
have shown that patients resistant to antidepressant treat-
ment in vivo were also resistant to the antidepressant clo-
mipramine in vitro.
Taken together, different GR gene variants can probably
have tissue specific effects on GC sensitivity, and polymorph-
ism of the GR gene might constitute a vulnerability or
protection factor for stress related disorders and altered
GC sensitivity. Thus, variability of effects on target tissues
may affect relationships among salivary cortisol, related
organ function and vulnerability of diseases.
8. Conclusions
Salivary cortisol is a useful biomarker in stress research, as long
as the researcher is aware of possible sources of variance,
which may affect this measure. Whether these modulating
factors are considered as confounders or as important part of
the information certainly depends on the research question. As
described here, a missing or poor covariance of perceived
stress and salivary cortisol is not surprising, given the complex
interplay of neurobiological events that link perceived stress
to HPAA activation (not to mention methodological difficulties
related to the assessment of perceived stress by self-report
instruments). Even ACTH measures cannot be expected to
explain much variance of perceived stress, although these
measures are closely affected by HPAA regulation of the
central nervous system. Several additional variables, such
as adrenal sensitivity, capacity, cortisol binding, etc. affect
total and free cortisol levels in blood, and, finally, salivary
cortisol levels. Thus, perceived stress can only be expected to
be moderately associated with salivary cortisol.
ACTH, total cortisol in blood and salivary cortisol mea-
surements carry partially different information and for many
study questions determining all three analytes would there-
fore be the best solution. This is, however, in many cases not
feasible and sometimes collecting blood is even undesirable.
D.H. Hellhammer et al.
The assessment of salivary cortisol offers the opportunity to
collect the samples stress-free, without medical personnel,
and in many different environments. These advantages are of
particular relevance for ambulatory assessments, studies in
large cohorts and for studies in children (Jessop and Turner-
Cobb, 2008).
However, researchers who decide to assess salivary corti-
sol have to consider that variables such as estrogens (gender,
menstrual cycle, oral contraceptives) or medical conditions
could affect cortisol binding and HPAA responsivity. In addi-
tion, the expected range of cortisol measures should be
considered as levels are elevated once CBG binding is satu-
rated.
If the research focus is on free cortisol effects on target
tissue, salivary cortisol could be the measure of choice.
However, as described above, a linear doseresponse rela-
tion in terms of target cell effects should not be expected,
but salivary cortisol will be the most valid parameter of HPAA
activation in such studies.
In sum, the complexity of factors accounting for varia-
bility of stress induced HPAA activation and effects demands
a careful a priori analysis to select the right HPAA parameters
and to control for the most relevant intervening variables.
Such an approach will help to design adequate experimental
designs and to create a data set, which allows for ideal
testing of the research hypotheses.
Conflict of interest
None declared.
References
alAbsi, M., Bongard, S., Buchanan, T., Pincomb, G.A., Licinio, J.,
Lovallo, W.R., 1997. Cardiovascular and neuroendocrine adjust-
ment to public speaking and mental arithmetic stressors. Psy-
chophysiology 34, 266275.
Baxter, J.D., Rousseau, G.G., 1979. Glucocorticoid hormone action:
an overview. Monogr. Endocrinol. 12, 124.
Bellingrath, S., Kudielka, B.M., 2008. Effort-reward-imbalance and
overcommitment are associated with hypothalamus-pituitary-
adrenal (HPA) axis responses to acute psychosocial stress in
healthy working school teachers. Psychoneuroendocrinology
33, 13351343.
Bellingrath, S., Weigl, T., Kudielka, B.M., 2008. Cortisol dysregula-
tion in school teachers in relation to burnout, vital exhaustion,
and effort-reward-imbalance. Biol. Psychol. 78, 104113.
Born, J., Hansen, K., Marshall, L., Molle, M., Fehm, H.L., 1999.
Timing the end of nocturnal sleep. Nature 397, 2930.
Bornstein, S.R., Engeland, W.C., Ehrhart-Bornstein, M., Herman,
J.P., 2008. Dissociation of ACTH and glucocorticoids. Trends
Endocrinol. Metab. 19, 175180.
Buchanan, T.W., alAbsi, M., Lovallo, W.R., 1999. Cortisol fluctuates
with increases and decreases in negative affect. Psychoneuroen-
docrinology 24, 227241.
Buffington, C.A., 2004. Comorbidity of interstitial cystitis with other
unexplained clinical conditions. J. Urol. 172, 12421248.
Buijs, R.M., Van Eden, C.G., 2000. The integration of stress by the
hypothalamus, amygdala and prefrontal cortex: balance between
the autonomic nervous system and the neuroendocrine system.
Prog. Brain Res. 126, 117132.
Caldji, C., Tannenbaum, B., Sharma, S., Francis, D., Plotsky, P.M.,
Meaney, M.J., 1998. Maternal care during infancy regulates the
development of neural systems mediating the expression of
Salivary cortisol as a biomarker in stress research
fearfulness in the rat. Proc. Natl. Acad. Sci. U.S.A. 95, 5335
5340.
Carey, M.P., Deterd, C.H., de Koning, J., Helmerhorst, F., de Kloet,
E.R., 1995. The influence of ovarian steroids on hypothalamic
pituitaryadrenal regulation in the female rat. J. Endocrinol.
144, 311321.
Carlson, D.E., Chiu, W.C., Fiedler, S.M., Hoffman, G.E., 2007. Central
neural distribution of immunoreactive Fos and CRH in relation to
plasma ACTH and corticosterone during sepsis in the rat. Exp.
Neurol. 205, 485500.
Carvalho, L.A., Juruena, M.F., Papadopoulos, A.S., Poon, L., Kerwin,
R., Cleare, A.J., Pariante, C.M., 2008. Clomipramine in vitro
reduces glucocorticoid receptor function in healthy subjects
but not in patients with major depression. Neuropsychopharma-
cology, doi:10.1038/npp.2008.44.
Castren, M., Patchev, V.K., Almeida, O.F., Holsboer, F., Trapp, T.,
Castren, E., 1995. Regulation of rat mineralocorticoid receptor
expression in neurons by progesterone. Endocrinology 136, 3800
3806.
Charmandari, E., Kino, T., Chrousos, G.P., 2004. Familial/sporadic
glucocorticoid resistance: clinical phenotype and molecular
mechanisms. Ann. N. Y. Acad. Sci. 1024, 168181.
Chida, Y., Steptoe, A., in press. Cortisol awakening response and
psychosocial factors: a systematic review and meta-analysis. Biol
Psychol., doi:10.1016/j.biopsycho.2008.10.004.
Chrousos, G.P., Kino, T., 2007. Glucocorticoid action networks and
complex psychiatric and/or somatic disorders. Stress 10, 213219.
Clow, A., Thorn, L., Evans, P., Hucklebridge, F., 2004. The awakening
cortisol response: methodological issues and significance. Stress
7, 2937.
Cohen, S., Hamrick, N., Rodriguez, M.S., Feldman, P.J., Rabin, B.S.,
Manuck, S.B., 2000. The stability of and intercorrelations among
cardiovascular, immune, endocrine, and psychological reactivity.
Ann. Behav. Med. 22, 171179.
Cole, T.J., Harris, H.J., Hoong, I., Solomon, N., Smith, R., Krozowski,
Z., Fullerton, M.J., 1999. The glucocorticoid receptor is essential
for maintaining basal and dexamethasone-induced repression of
the murine corticosteroid-binding globulin gene. Mol. Cell. Endo-
crinol. 154, 2936.
Corrigan, C.J., Brown, P.H., Barnes, N.C., Tsai, J.J., Frew, A.J., Kay,
A.B., 1991. Glucocorticoid resistance in chronic asthma. Periph-
eral blood T lymphocyte activation and comparison of the T
lymphocyte inhibitory effects of glucocorticoids and cyclosporin
A. Am. Rev. Respir. Dis. 144, 10261032.
Corrigan, C.J., Bungre, J.K., Assoufi, B., Cooper, A.E., Seddon, H.,
Kay, A.B., 1996. Glucocorticoid resistant asthma: T-lymphocyte
steroid metabolism and sensitivity to glucocorticoids and immu-
nosuppressive agents. Eur. Respir. J. 9, 20772086.
DeRijk, R.H., Schaaf, M.J., Turner, G., Datson, N.A., Vreugdenhil, E.,
Cidlowski, J., de Kloet, E.R., Emery, P., Sternberg, E.M., Detera-
Wadleigh, S.D., 2001. A human glucocorticoid receptor gene
variant that increases the stability of the glucocorticoid receptor
beta-isoform mRNA is associated with rheumatoid arthritis. J.
Rheumatol. 28, 23832388.
Dinan, T.G., Scott, L.V., 2005. Anatomy of melancholia: focus on
hypothalamicpituitaryadrenal axis overactivity and the role of
vasopressin. J. Anat. 207, 259264.
Ebrecht, M., Buske-Kirschbaum, A., Hellhammer, D., Kern, S., Roh-
leder, N., Walker, B., Kirschbaum, C., 2000. Tissue specificity of
glucocorticoid sensitivity in healthy adults. J. Clin. Endocrinol.
Metab. 85, 37333739.
Engeland, W.C., Arnhold, M.M., 2005. Neural circuitry in the regula-
tion of adrenal corticosterone rhythmicity. Endocrine 28, 325
332.
Erkut, Z.A., Pool, C., Swaab, D.F., 1998. Glucocorticoids suppress
corticotropin-releasing hormone and vasopressin expression in
human hypothalamic neurons. J. Clin. Endocrinol. Metab. 83,
20662073.
169
Federenko, I., Wust, S., Hellhammer, D.H., Dechoux, R., Kumsta, R.,
Kirschbaum, C., 2004. Free cortisol awakening responses are
influenced by awakening time. Psychoneuroendocrinology 29,
174184.
Federman, D.D., 2006. The biology of human sex differences. N.
Engl. J. Med. 354, 15071514.
Feldman, S., Conforti, N., Weidenfeld, J., 1995. Limbic pathways
and hypothalamic neurotransmitters mediating adrenocortical
responses to neural stimuli. Neurosci. Biobehav. Rev. 19, 235
240.
Fleury, I., Beaulieu, P., Primeau, M., Labuda, D., Sinnett, D., Kra-
jinovic, M., 2003. Characterization of the BclI polymorphism in
the glucocorticoid receptor gene. Clin. Chem. 49, 15281531.
Fries, E., 2008. Hypocortisolemic disorders. In: Hellhammer, J.,
Hellhammer, D.H. (Eds.), Stress: The MindBody Connection,
vol. 174. Karger, Basel, pp. 6077.
Fries, E., Dettenborn, L., Kirschbaum, C., in press. The cortisol
awakening response (CAR): facts and future directions. Int. J.
Psychophysiol., doi:10.1016/j.ijpsycho.2008.03.014.
Hatz, H.J., 1998. Glucocorticoide. Immunologische Grundlagen,
Pharmakologie und Therapierichtlinien. Wissenschaftliche Ver-
lagsgesellschaft, Stuttgart.
Heckmann, M., Hartmann, M.F., Kampschulte, B., Gack, H., Bodeker,
R.H., Gortner, L., Wudy, S.A., 2005. Assessing cortisol production
in preterm infants: do not dispose of the nappies. Pediatr. Res. 57,
412418.
Hellhammer, D.H., Hellhammer, J., 2008. Neurobehavioral medicine
and stress-related disorders. In: Hellhammer, J., Hellhammer,
D.H. (Eds.), Stress: The MindBody Connection, vol. 174. Karger,
Basel, pp. 110.
Herman, J.P., Ostrander, M.M., Mueller, N.K., Figueiredo, H., 2005.
Limbic system mechanisms of stress regulation: hypothalamo-
pituitary-adrenocortical axis. Prog. Neuropsychopharmacol. Biol.
Psychiatry 29, 12011213.
Huizenga, N.A., Koper, J.W., De Lange, P., Pols, H.A., Stolk, R.P.,
Burger, H., Grobbee, D.E., Brinkmann, A.O., De Jong, F.H.,
Lamberts, S.W., 1998. A polymorphism in the glucocorticoid
receptor gene may be associated with and increased sensitivity
to glucocorticoids in vivo. J. Clin. Endocrinol. Metab. 83, 144
151.
Jacobs, A.J., Odom, M.J., Word, R.A., Carr, B.R., 1989. Effect of oral
contraceptives on adrenocorticotropin and growth hormone
secretion following CRH and GHRH administration. Contraception
40, 691699.
Jerjes, W.K., Taylor, N.F., Peters, T.J., Wessely, S., Cleare, A.J.,
2006. Urinary cortisol and cortisol metabolite excretion in chronic
fatigue syndrome. Psychosom. Med. 68, 578582.
Jessop, D.S., Turner-Cobb, J.M., 2008. Measurement and meaning of
salivary cortisol: a focus on health and disease in children. Stress
11, 114.
Kajantie, E., Phillips, D.I., 2006. The effects of sex and hormonal
status on the physiological response to acute psychosocial stress.
Psychoneuroendocrinology 31, 151178.
Kirschbaum, C., Platte, P., Pirke, K.M., Hellhammer, D.H., 1996.
Adrenocortical activation following stressful exercise: further
evidence for attenuated free cortisol responses in women using
oral contraceptives. Stress Med. 12, 137143.
Kirschbaum, C., Kudielka, B.M., Gaab, J., Schommer, N.C., Hellham-
mer, D.H., 1999. The Impact of gender, menstrual cycle phase,
and oral contraceptives on the activity of the hypothalamus
pituitaryadrenal axis. Psychosom. Med. 61, 154162.
Klingmann, P., Hellhammer, D., 2008. Noradrenergic and sympathetic
disorders. In: Hellhammer, D.H., Hellhammer, J. (Eds.), Stress:
The BrainBody Connection. Karger, Basel.
Klingmann, P.O., Kugler, I., Steffke, T.S., Bellingrath, S., Kudielka,
B.M., Hellhammer, D.H., in press. Prenatal programming and FMS:
sex-specific prenatal programming: a risk for fibromyalgia? Ann.
N. Y. Acad. Sci. 1148, ISBN: 1-57331-692-X.
170
Koper, J.W., Stolk, R.P., de Lange, P., Huizenga, N.A., Molijn, G.J.,
Pols, H.A., Grobbee, D.E., Karl, M., de Jong, F.H., Brinkmann,
A.O., Lamberts, S.W., 1997. Lack of association between five
polymorphisms in the human glucocorticoid receptor gene and
glucocorticoid resistance. Hum. Genet. 99, 663668.
Kreutz, M., Hellhammer, D., Murison, R., Vetter, H., Krause, U.,
Lehnert, H., 1992. Pavlovian conditioning of corticotropin-releas-
ing factor-induced increase of blood pressure and corticosterone
secretion in the rat. Acta Physiol. Scand. 145, 5963.
Kudielka, B.M., Hellhammer, D.H., Kirschbaum, C., 2007. Ten years
of research with the trier social stress test revisited. In: Harmon-
Jones, E., Winkielman, P. (Eds.), Social Neuroscience: Integrating
Biological and Psychological Explanations of Social Behavior.
Guilford Press, New York, (Chapter 4), pp. 5683.
Kumsta, R., Entringer, S., Hellhammer, D.H., Wust, S., 2007a. Corti-
sol and ACTH responses to psychosocial stress are modulated by
corticosteroid binding globulin levels. Psychoneuroendocrinology
32, 11531157.
Kumsta, R., Entringer, S., Koper, J.W., van Rossum, E.F., Hellhammer,
D.H., Wust, S., 2007b. Sex specific associations between common
glucocorticoid receptor gene variants and hypothalamuspitui-
taryadrenal axis responses to psychosocial stress. Biol. Psychia-
try 62, 863869.
Kumsta, R., Entringer, S., Koper, J.W., van Rossum, E.F., Hellhammer,
D.H., Wust, S., 2008. Glucocorticoid receptor gene polymorph-
isms and glucocorticoid sensitivity of subdermal blood vessels and
leukocytes. Biol. Psychol. 79, 179184.
Levine, A., Zagoory-Sharon, O., Feldman, R., Lewis, J.G., Weller, A.,
2007. Measuring cortisol in human psychobiological studies. Phy-
siol. Behav. 90, 4353.
Liu, J.P., Clarke, I.J., Funder, J.W., Engler, D., 1994. Studies of the
secretion of corticotropin-releasing factor and arginine vasopres-
sin into the hypophysial-portal circulation of the conscious sheep.
II. The central noradrenergic and neuropeptide Y pathways cause
immediate and prolonged hypothalamicpituitaryadrenal acti-
vation. Potential involvement in the pseudo-Cushings syndrome
of endogenous depression and anorexia nervosa. J. Clin. Invest.
93, 14391450.
Lopez, J.F., Akil, H., Watson, S.J., 1999. Neural circuits mediating
stress. Biol. Psychiatry 46, 14611471.
Lu, N.Z., Cidlowski, J.A., 2005. Translational regulatory mechanisms
generate N-terminal glucocorticoid receptor isoforms with
unique transcriptional target genes. Mol. Cell 18, 331342.
Lu, N.Z., Cidlowski, J.A., 2006. Glucocorticoid receptor isoforms
generate transcription specificity. Trends Cell. Biol. 16, 301307.
Mason, J.W., 1968. A review of psychoendocrine research on the
pituitaryadrenal cortical system. Psychosom. Med. 30, 576
607.
Oswald, L.M., Mathena, J.R., Wand, G.S., 2004. Comparison of HPA
axis hormonal responses to naloxone vs. psychologically induced
stress. Psychoneuroendocrinology 29, 371388.
Panarelli, M., Holloway, C.D., Fraser, R., Connell, J.M., Ingram, M.C.,
Anderson, N.H., Kenyon, C.J., 1998. Glucocorticoid receptor
polymorphism, skin vasoconstriction, and other metabolic inter-
mediate phenotypes in normal human subjects. J. Clin. Endocri-
nol. Metab. 83, 18461852.
Pariante, C.M., 2004. Glucocorticoid receptor function in vitro in
patients with major depression. Stress 7, 209219.
Patchev, V.K., Almeida, O.F., 1996. Gonadal steroids exert facilitat-
ing and buffering effects on glucocorticoid-mediated tran-
scriptional regulation of corticotropin-releasing hormone and
corticosteroid receptor genes in rat brain. J. Neurosci. 16,
70777084.
Paus, R., Theoharides, T.C., Arck, P.C., 2006. Neuroimmunoendo-
crine circuitry of the brainskin connection. Trends Immunol. van Rossum, E.F.C., Koper, J.W., Van Den Beld, A.W., Uitterlinden,
27, 3239.
Peters, A., Schweiger, U., Pellerin, L., Hubold, C., Oltmanns, K.M.,
Conrad, M., Schultes, B., Born, J., Fehm, H.L., 2004. The selfish
D.H. Hellhammer et al.
brain: competition for energy resources. Neurosci. Biobehav. Rev.
28, 143180.
Plotsky, P.M., 1991. Pathways to the secretion of adrenocorticotro-
pin: a view from the portal. J. Neuroendocrinol. 3, 19.
Pruessner, J.C., Wolf, O.T., Hellhammer, D.H., Buske-Kirschbaum, A.,
von Auer, K., Jobst, S., Kaspers, F., Kirschbaum, C., 1997. Free
cortisol levels after awakening: a reliable biological marker for the
assessment of adrenocortical activity. Life Sci. 61, 25392549.
Pruessner, M., Hellhammer, D.H., Pruessner, J.C., Lupien, S.J., 2003.
Self-reported depressive symptoms and stress levels in healthy
young men: associations with the cortisol response to awakening.
Psychosom. Med. 65, 9299.
Putz, P., 2008. Hypercortisolemic disorders. In: Hellhammer, J.,
Hellhammer, D.H. (Eds.), Stress: The MindBody Connection,
vol. 174. Karger, Basel, pp. 3959.
Remer, T., Maser-Gluth, C., Wudy, S.A., 2008. Glucocorticoid mea-
surements in health and diseasemetabolic implications and the
potential of 24-h urine analyses. Mini Rev. Med. Chem. 8, 153
170.
Schlotz, W., Kumsta, R., Layes, I., Entringer, S., Jones, A., Hellham-
mer, D.H., Wust, S., 2008. Cross-correlation functions demon-
strate offset effects in the covariance of endocrine and
subjective-psychological responses to a pharmacological chal-
lenge test and a psychosocial laboratory stressor. Psychosom.
Med. 70, 787796.
Schulz, P., Kirschbaum, C., Pruessner, J., Hellhammer, D.H., 1998.
Increased free cortisol secretion after awakening in chronically
stressed individuals due to work overload. Stress Med. 14, 9197.
Seale, J.V., Wood, S.A., Atkinson, H.C., Harbuz, M.S., Lightman,
S.L., 2005a. Postnatal masculinization alters the HPA axis phe-
notype in the adult female rat. J. Physiol. 563, 265274.
Seale, J.V., Wood, S.A., Atkinson, H.C., Lightman, S.L., Harbuz,
M.S., 2005b. Organizational role for testosterone and estrogen
on adult hypothalamicpituitaryadrenal axis activity in the
male rat. Endocrinology 146, 19731982.
Seckl, J.R., Walker, B.R., 2001. Minireview: 11beta-hydroxysteroid
dehydrogenase type 1a tissue-specific amplifier of glucocorti-
coid action. Endocrinology 142, 13711376.
Serova, L.I., Gueorguiev, V., Cheng, S.Y., Sabban, E.L., 2008. Adre-
nocorticotropic hormone elevates gene expression for catecho-
lamine biosynthesis in rat superior cervical ganglia and locus
coeruleus by an adrenal independent mechanism. Neuroscience
153, 13801389.
Sher, E.R., Leung, D.Y., Surs, W., Kam, J.C., Zieg, G., Kamada, A.K.,
Szefler, S.J., 1994. Steroid-resistant asthma. Cellular mechan-
isms contributing to inadequate response to glucocorticoid ther-
apy. J. Clin. Invest. 93, 3339.
Smyth, J., Ockenfels, M.C., Porter, L., Kirschbaum, C., Hellhammer,
D.H., Stone, A.A., 1998. Stressors and mood measured on a
momentary basis are associated with salivary cortisol secretion.
Psychoneuroendocrinology 23, 353370.
Stewart, P.M., Krozowski, Z.S., 1999. 11 Beta-hydroxysteroid dehy-
drogenase. Vitam. Horm. 57, 249324.
Turner, B.B., 1997. Influence of gonadal steroids on brain corticos-
teroid receptors: a minireview. Neurochem. Res. 22, 13751385.
Umeda, T., Hiramatsu, R., Iwaoka, T., Shimada, T., Miura, F., Sato, T.,
1981. Use of saliva for monitoring unbound free cortisol levels in
serum. Clin. Chim. Acta 110, 245253.
van Rossum, E.F.C., Koper, J.W., Huizenga, N.A., Uitterlinden, A.G.,
Janssen, J.A., Brinkmann, A.O., Grobbee, D.E., de Jong, F.H., van
Duyn, C.M., Pols, H.A., Lamberts, S.W., 2002. A polymorphism in
the glucocorticoid receptor gene, which decreases sensitivity to
glucocorticoids in vivo, is associated with low insulin and cho-
lesterol levels. Diabetes 51, 31283134.
A.G., Arp, P., Ester, W., Janssen, J.A., Brinkmann, A.O., De Jong,
F.H., Grobbee, D.E., Pols, H.A., Lamberts, S.W., 2003. Identifica-
tion of the BclI polymorphism in the glucocorticoid receptor gene:
Salivary cortisol as a biomarker in stress research
association with sensitivity to glucocorticoids in vivo and body
mass index. Clin. Endocrinol. (Oxf.) 59, 585592.
Vasiliadi, D., Gratsias, Y., Tsagarakis, S., Botoula, E., Trivizas, P.,
Thalassinos, N., Moutsatsou, P., 2002. Glucocortidoid sensitivity
assessed in peripheral blood cells do not correlate with the
feedback sensitivity of the hypothalamo-pituitary adrenal AXIS.
Hormones (Athens, Greece) 1, 233238.
Viau, V., Meaney, M.J., 1996. The inhibitory effect of testosterone on
hypothalamicpituitaryadrenal responses to stress is mediated
by the medial preoptic area. J. Neurosci. 16, 18661876.
Vining, R.F., McGinley, R.A., Maksvytis, J.J., Ho, K.Y., 1983a. Salivary
cortisol: a better measure of adrenal cortical function than serum
cortisol. Ann. Clin. Biochem. 20 (Pt 6), 329335.
Vining, R.F., McGinley, R.A., Symons, R.G., 1983b. Hormones in
saliva: mode of entry and consequent implications for clinical
interpretation. Clin. Chem. 29, 17521756.
von der Ahe, D., Janich, S., Scheidereit, C., Renkawitz, R., Schutz,
G., Beato, M., 1985. Glucocorticoid and progesterone receptors
bind to the same sites in two hormonally regulated promoters.
Nature 313, 706709.
Wang, J., Rao, H., Wetmore, G.S., Furlan, P.M., Korczykowski, M.,
Dinges, D.F., Detre, J.A., 2005. Perfusion functional MRI reveals
cerebral blood flow pattern under psychological stress. Proc.
Natl. Acad. Sci. U.S.A. 102, 1780417809.
Watts, A.G., 2005. Glucocorticoid regulation of peptide genes in
neuroendocrine CRH neurons: a complexity beyond negative
feedback. Front. Neuroendocrinol. 26, 109130.
171
Wedekind, D., Bandelow, B., Broocks, A., Hajak, G., Ruther, E., 2000.
Salivary, total plasma and plasma free cortisol in panic disorder. J.
Neural Transm. 107, 831837.
Wiegratz, I., Kutschera, E., Lee, J.H., Moore, C., Mellinger, U.,
Winkler, U.H., Kuhl, H., 2003. Effect of four different oral contra-
ceptives on various sex hormones and serum-binding globulins.
Contraception 67, 2532.
Wilhelm, I., Born, J., Kudielka, B.M., Schlotz, W., Wust, S., 2007. Is
the cortisol awakening rise a response to awakening? Psycho-
neuroendocrinology 32, 358366.
Wust, S., Federenko, I., Hellhammer, D.H., Kirschbaum, C., 2000a.
Genetic factors, perceived chronic stress, and the free cortisol
response to awakening. Psychoneuroendocrinology 25, 707
720.
Wust, S., Wolf, J., Hellhammer, D.H., Federenko, I., Schommer, N.,
Kirschbaum, C., 2000b. The cortisol awakening responsenormal
values and confounds. Noise Health 2, 7988.
Wust, S., Federenko, I.S., van Rossum, E.F., Koper, J.W., Kumsta,
R., Entringer, S., Hellhammer, D.H., 2004. A psychobiological
perspective on genetic determinants of hypothalamuspitui-
taryadrenal axis activity. Ann. N. Y. Acad. Sci. 1032, 52
62.
Yehuda, R., Labinsky, E., Tischler, L., Brand, S.R., Lavin, Y., Blair, W.,
Bierer, L.M., Goodman, R.Z., Grossman, R.A., 2006. Are adult
offspring reliable informants about parental PTSD? A validation
study. Ann. N. Y. Acad. Sci. 1071, 484487.