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Perceived stress and salivary cortisol in daily life

Article  in  Annals of Behavioral Medicine · January 1994

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 PERCEIVED STRESS AND SALIVARY CORTISOL IN DAII.,Y LIFE 1,z
Maneen M. van Eck, M.S.c and Nancy A. Nicolson, Ph.D.
University of Limburg
ABSTRACT
Clarifying the nature of endocrine responses to chronic or
intermittent stress in daily life requires repeated measurements
oJstress, hormone levels, and emotional states. In this study, 42
High Stress(HS)and 46 Low Stress(LS)subjects were selected
on the basis ofPerceived Stress Scale scoresfrom a largersample
of male white-collar workers. Subjects completed self-reports
[Experience Sampling Method(ESM)J and collected saliva sam-
plesjor cortisol determination ten times a day overfive consec-
utivedays, incl:~ding three work and two non-work days. We test
the hypothesis that high perceived stress is associated with ele-
vated cortisol.
The HS group scored higher than the LS group on measures
of trail anziet}~, depression, anger, and psychosomatic com-
plaints, as wel! as on ESM measures oJpositive and negative
affect and stressful daily events. Although negative a}ject was
higher and stressful events morefrequent on workdays than week-
ends (especially for HS subjects), no dijjerence in workday vs.
weekend cortiso! levels was found in the subsample ofsubjects
á rather than enhance biological defense mechanisms. They are
with sujjrcienl data. On workdays, HS subjects had higher mean
cortisol levels than LS subjects at each ofthe ten sampling times
between 8 a.m. and 10 p.m. (repeated measures ANOVA, p <
.02). Mean workday conisol wcu correlated with higher trait
anxiety, depression, and the low arousal ~fimension ofESM neg-
ative a,~ect. _
(Ann Behav Med 199A, 163):221-227)
INTRODUCT7[ON
Over the last 20 years, a wide range of studies bas estab-
lished an association between psychcsocial stress and a variety
of psychological and physical disorders. The strengths of these
associations aze usually small and inconsistent, but stressful life
events, for instance, have been linked to depression, neurotic
impairment, and other psychological symptomatology (1-3).
Suess has also been linked empirically with increased suscep-
tibility to infectious disease (4), with other immune-related dis-
orders like recurrences of herpes infections (5) and asthmatic
exacerbations (6), with coronary heart disease (7), and with di-
'We thank Dr. J. Sulon, University of Liege, for performing RIA ana]-
yses of salivary cortisol, and C. Dijlanan for assistance in all aspecu of
the study.
'..Funding was provided by the Netherlands Organization for Scientific
Research(NWO)and the University of Limburg.
Reprint Address: M. M.van Eck, Social Psychiatry Section, Department
of Psychiatry and Neuropsychology, University of Limburg, P.O. Box
616, 6200 MD Maastricht, the Netherlands.
'~;"; m .1994 by The Society of Behavioral Medicine.
abetes mellitus(8). The diversity ofstress concepts and research
methodologies used in these studies makes it difficult to integraté
all of the findings.
Since the beginning of this century, the endocrine system
has received much attention in stress research (9,10) with an
emphasis on the hypothalamicpituitary—adrenal (HPA) axis.
This system forms a theoretically promising pathway for me-
diating the relationships between psychosocio] stress and sub-
sequent disorder (1 1). Cortisol secretion appears to play an im-
portant role in the regulation of physiological and behavioral
responses under stressful situations (12,13j. Cortisol increases
after strenuous physical exercise(14)and mental task load, spe-
ci5cally in response to distress as opposed to effort or general
arousal (15,16). Cortisol is also the most important glucocor-
ticoid, with the potential of exerting its effects on practically all
cells and tissues. Some of the most important effects of cortisol
are stimulation ofgluconeogenesis,inhibition ofglucose uptake,
suppression ofinflammation,and suppression of numerous ini-
mune functions. Glucocorticoids almost invariably suppress
thought to protect against the normal defense reactions that are
activated by stress by preventing these defense reactions from
overshooting and by preserving the specificity of immune
reactions (17).
Indeeà, moss of the physiological reactions to stress are
thougt-~t to b:, adaptive, i.e. they counter the effects of physical
7 stress (trauma, bleeding), or are seen as a preparation íor fight
or flight responses to acute danger (18). The question now is,
why and when could this adaptive mechanism be a pathway to
disease? There are indications that the same suppressive effects
of glucocorticoids on several functions of the immune system
may leave a subject more susceptible to infections or even tu-
mors(19). Other studies indicate that increased levels ofcortisol
may be involved in the etiology ofcoronary heart diseases (20).
The general idea is that stress causes an overproduction ofanti-
inflammatory and immune suppressive actions, leading to ad-
verse consequences (e.g. breakdown of the immune system)
(21,22). There is also evidence from animal studies for a gradual
loss ofadaptation within the pituitary-corticoadrenal response.
Ifstress is prolonged, hypophyseal receptors appear to lose their
sensitivity to cortisol,and as a consequence, prolonged increases
in cortisol tend to further slow the recovery of wrtisol after
stress because of the ineffectiveness of the negative feedback
loop (23,24). Recent theoretical overviews by Henry and Ste-
phens (25) and Siegrist (26) are more or less in line with this
concept of loss of adaptation.
It is reasonable to assume that stress reactions will only
lead todisease when they are prolonged or occur. very often.
t The effects of chronic or .internuttent stress on the HPA-axis,
however, have received far less attention in the literature than
the effects of acute suessors, and studies on naturally occurring
stressors and their effects are even more rare. Data on cortisol
levels during chronic psychosocial stress are inconsistent, wíth
222 ANNALS OF BEHAVIORAL MEDICINE
enhanced as well as decreased concentrations repoRed,and large
variability among individuals. Elevated levels of cortisol were
found in subjects living near the damaged nuclear power plant
at Three Mile Island (27). Higher levels of urinary coRisol cor-
related significantly with urinary catecholamines, self-reports of
physical and mental symptoms, and decrements in task perfor-
mance. Astudy following parents ofleukemic children into the
period of bereavement for as long as three years after the death
ofthe child showed that l 7-hydroxycoRicosteroid excretion rates
were related to the effectiveness of subjects' psychological de-
fenses (28,29). Elevated levels of plasma and salivary cortisol
were found in Iran hostages after release from captivity, reflect-
ing distress, anxiety, and elation. Salivary cortisol was the only
physiological measurement that demonstrated a significant cor-
relation with psychiatrists' ratings ofthe hostages' psychological
disturbance (30).
The above studies have examined stress under rather ex-
treme or unusual situations. With respect to more normal set-
tings, studies of air traffic controllers suggest that occupational
stress is associated with increased cortisol production (31,32).
Caplan et al. (33) studied white-collar workers in a relatively
everyday organizational setting. While there was no main effect
of work load or personality traits on mean cortisol, high per-
ceived work load was associated with lower morning coRisol
values.
The results presented here are part of a larger study con-
cerningemotional and hormonal responses[o naturally occuring
stress in daily life. Stress is cuirentiy conceptualized as a dy-
namic process, whi~•h changes over time and in relation to the
environment. It is therefore necessary to include repeated mea-
surements of stress, hormone levels, and emotional states to
investigate the stress—hormone relationship. This relationship
should ideally be studied in naturalistic settings and over time,
so that we can begin to understand how adaptation occurs in
response to intermittent daily hassles in individuals who are
observed in their normal social networks,settings,and activities
(34). For these reasons, we chose to use two relatively new
techniques, Experience Sampling Method (ESM)(35,36) and
monitoring of salivary cortisol (37), to assess the relationship
between an indiviáual's affective state and neuroendocrine
changes over time. Subjects were selected on the basis of Per-
ceivedStress Scale scores(3H)from a large sample of male white-
collar workers and were then monitored during their daily ac-
tivities. Subjects completed self-repoRs (ESM) and collected
saliva samples for cortisol determination at semi-random in-
tervals ten times a day over five consecutive days, including
three work and two non-work days.
We test the hypothesis that high perceived stress is asso-
ciated with elevated cortisol, either in general, or during certain
phases of the circadian cycle or certain days of the week (e.g.
work versus non-work days). With respect to diurnal patterns,
no specific hypothesis was formulated. The few studies in which
conisol has been measured at more than one time of day in
healthy subjects report significant relationships between cortisol
and psychological trait measures at some time points and not
at others. For example, in a large German survey study in which
salivary cortisol was measured three times on a single day, only
8 a.m. levels showed clear associations with psychological and
demographic variables(39).In a similar fashion, perceived work
load had an effect on cortisol levels in white-collar workers that
was dependent on the time of day when blood was sampled
(33), and hostility was associated with high cortisol in daytime,
van Eck and Nicolson
but not in evening or overnight urine samples (40). Depressive
symptoms could also be related to increased coRisol secretion
at specific times ofthe day. Concerning day-of-the-week effects,
we hypothesized that cortisol would be elevated on workdays
compared to the weekend,possibly in interaction with perceived
stress. Although- subject groups were selected according to a
global measure of stress and not on the basis of work-related
stress, we reasoned that work might be a major source of stress.
Studies by Frankenhaeuser and colleagues (41) have demon-
stratedthat cardiovascular and neurcendocrine activity are higher
at work than at home, and that slow recovery of responses, or
"unwinding," after work might represent along-term health
risk.
Finally, we examined the extent to which psychological
variables (trait amciety, depression, anger, and psychosomatic
complaints; ESM measures of mood and stressful events) might
contribute to individual differences in workday cortisol level.
SUBJECTS
Local industries and government agencies were approached
via their personnel departments to participate in the study. A
decision as to which categories of employees fell under the def-
iiution:of "white-collar" was made by each personnel depart-
ment on the basis of standard job function descriptions. Ques-
tionnaireswere distributed among these employees,accompanied
by a letter explaining the goals of the study. Participation was
voluntary, and care was taken to insure anonymity. Three hun-
3red sixteen male employees from six different industries or
agencies completed the screening questionnaire. The mean score
on !hc Perceived Stress Scale(PSS)for this sample was 12.7 (sd
= 6.i1), similar to U.S. norms(mean 13.02, sd = 6.45)(38).
Ninety-two subjects with scores in the upper or lower ter-
tiles of the screening sample distribution (PSS-10 score <_ 10 or
>_ 1 b) were recruited to participate in the study, excluding any
individuals with a history of endocrine disorder, medications
known to affect cortisol levels, psychopathology(major affective
disorder, psychoses), or currently in treatment for mental health
problems. High- and low-stress subjects were matched for age
group, marital status, and household composition. Because it
was not possible to match all subjects, numbers of subjects in
the final two groups differ slightly.
Four subjects failed to meet Experience Sampling compli-
ance criteria (see Daily Experience section, below) and were
therefore excluded from further analysis. Of the 88 remaining
subjects, 42 subjects comprised the High-Stress(HS)group and
46 subjects the Low-Stress(LS)group. Mean age was 42.1 years
(range 27 to 57 years), with no significant difference between
the two groups. Eighty-nine percent were marred,and 81%had
children living at home.
ME.~SURES
Questionnaires
In addition to the PSS, questionnaires concerning psycho-
social stress, coping style, and psychological and physical symp-
toms were completed. Self-report instruments were chosen on
the basis of their theoretical relevance to the stress process and
psychometric reliability and validity. The following measures
are used in the current analysis:
Perceived Stress: The 10-item version ofthe PSS was trans-
lated into Dutch by the first author and then back-translated as
a check into English by the second author. The items were rated
r

VOLUME 16, NUMBER 3, 1994 223

Stress and Cortisol

missing and invalid responses on weekends could be attributed

~n a five-point frequency scale, ranging from 0 = "never," to 4
="very often" in the last month. A total perceived stress score to the factthatsubjects veere still asleep.
The ESM form contained open-ended questions concerning
avas obtained by reversing the scoring on the positive items and
thought content, the physical and social context, and what the
Then summing across the ten items. All subjects completed the
individual was doing when signalled. The forms also included
PSS twice, during the initial screening and again immediately
preceding Experience Sampling. The two PSS scores were highly seven-point Likert scales (from 1 = "not at all;" to 7 = "very
much"), for rating aspects of thoughts, mood, physical well-
.correlated (rho = .73, p c .001); the mean score will be used
being, individually defined (psycho)somatic complaints, and
in the analysis.
present activity. Subjects were asked to describe any stressful
Psychosomatic Symptoms: The SUNYA Psychosomatic events or situations which may have taken place in the interval
Symptom Checklist(PSC)includes 17 common psychosomatic since the last ESM report and to rate these events on a number
complaints (e.g. headaches, backaches, and nausea). The scale of dimensions. Information about smoking (49), food (50), cof-
was originally developed by Cox, Freundlich, and Meyer (42) fee (51), and alcohol intake, medications, and physical exertion
and revised by Attanasio et al.(43). Subjects rate each complaint (52) since the last beep was also obtained, to help control for
on 5-point scales for frequency (0 = "never or rarely occurs;" possible confounding influences on cortisol secretion.
to 4 = "occurs daily") and intensity(0 = "not bothersome;" to
4="extremely bothersome"). A Total Score,reflecting the over- Salivary Cortisol
all level of psychosomatic distress, is obtained by summing the Salivary cortisol is a reliable and valid indicator of the free
cross-products of each item's frequency by intensity. cortisol in plasma, which is considered to be the biologically
Depression: Depressive symptomatology was assessed with active hormone. Cortisol concentrations aze independent ofthe
the Dutch translarion (44) of the Zung Self-Rating Depression flow rate of saliva (53). Salivary cortisol increases within min-
Scale (45). utes in response to acute stressons (54) and has ahalf-life of
approximately one hour(55). We found no difference in cortisol
Anxiety: Trait anxiety was measured with the Dutch ver-
levels in saliva samples either frozen immediately or kept at
sion (46) of the State-Trait Anxiety Inventory (STAD.
room temperature for two days(56); others report no change in
Anger: Trait anger was measured with the Dutch version unfrozen samples up to 30 days (57).
(47)ofthe Spielberger Trait Anger Scale. Although two subscales At the same time ESM forms were being completed, sub-
exist("anger-temperament" and "anger-reaction"), only the to- jects collected saliva by holding a cotton dental roll in the mouth
tal score is used here. for approximately one minute. The saturated roll was placed in
Daily Experience a capped plastic vial (Salivette; Sarstedt), which was stored in
a specially designed wallet. At the end of each day, subjects
The Experience Sampling Method (35,36,48) was used to
placed the vials in their home freezers. At the end of the sam-
collect data from subjects at selected moments during their nor-
plingperiod, uncentrifuged samples were stored at -20 C. Com-
mal daily activities. Subjects received auditory signals, after
pliance with the saliva sampling procedure »vas good in both
which they filled in a questionnaire and collected asaliva sám-
high and low. stress.groups, with the same mean response rate
ple. Although additional reports were completed at the end. of
(83%) as for the ESM reports.
each day, for the purpose of this analysis we will refer only to
Salivary cortisol levels were determined in duplicate by
the "beep level" data.
direct radioimmunoassay (58), using123I-cortisol (Panmos diag-
After a briefing session, in which all procedures were ex-
nostica, Finland) and antiserum madeagainst the 3-CMO-BSA
plained in detail and informed consent was obtained, subjects
conjugate by Dr. J. Sulon, University of Liege, Belgium. The
- were sampled for a period of five consecutive days, begnning
In lower detection limit of the assay was 12 ng/dl, with a mean
early on a Thursday morning and ending late on Mónday.
non-w orkdays. A Seiko wrist- intra-assay coefficient of variation of 4.8% (range: 2.2%-7.5%
this sample, the weekends were
at for fow assays). Each subjects samples were analyzed in .the
watch was programmed to emit beeps ten rimes each day, '
tely 90 minutes between same assay to reduce sources of variability.
.t semi-random intervals of approxima
~;, ._ the hours of8 a.m. and 10 p.m. Beeps were clustered around statistical Analysis
11:15
the midpoint ofeach time block (e.g. 8:15 a.m.,9:45 a.m.,
on); the exact time sequence of beeps was varied The 16 ESM mood items were reduced to three mood mea-
a.m. and so
session, sures, based on the results of a principal component analysis
éach day to decrease predictability. In afinal debriefing
for legibility, and subjects were asked with varimax rotation, which accounted for 78% of the total
_ESM forms were checked
variance when subject mean scores were used. Ratings on Zhe
- - to clarify reasons for missing data.
items cheerful, satisfied, relaxed,-energetic, self-assured., con-
Compliance with the procedures was generally -good. The
reports centrated, and enthusiastic were summed to form a Posirive
criteria we set for inclusion in the analysis (>_20 ESM
after being signalled and no miss- AfFect(PA)scale (Cronbaoh'salpha = :95). Two separate com-
completed within 20 minutes
entire days) were met by all but four subjecu (two ponents of negative affect (NA) were identified: "NA-]ow
ing data for
88 subjecu completed an av- arousal," including the items depressed,anxious, worried,lonely,
from each group). The remaining
of all possible responses within the time limit, for tired, and miserable(alpha =.87),and"NA-high arousal," with
erage of 83°ró
HS and IS groups did the items restless, irritated, hurried, and nervous(alpha = .93).
àn average of ~41 responses per subject.
per sub- The sums of the scale items were divided -by •the number of
not differ in compliance rates(40.1 vs. 42.3 responses
Complian ce was lowest items in the scale, so that all mood measures have ranges from
jest, Mann-Whitney U-test, p > .OS). 1 to 7.
approxima tely 8:15 a.m:), with an average
for the first beep (at
for first beeps Because the distribution of cortisol values was positively
of73%valid reports. On Saturdays,response rate
59°rb. Seventy-f our percent of all skewed, isansformation to natural logarithms of cortisol con-
~:. was 61%, and on Sundays,
224 ANNALS OF BEHAVIORAL MEDICINE van Eck and Nicolson

T~+~BLE 1 -~- hlgh alrni

Differences in Psychological Measures behveen Low and -.- ww eras
High Sáess Groups

Low PSS High PSS

Mean Mean p-value
(st. dev.) (st. dev.) (2-tailed)

Trait measures
Perceived Stress
(p$S) 7.2(2.2) 18.1 (3.4) <.000I
Trait amciety 28.3(4.4) 39.8 (7.6) <.0001
Trait anger 18.8 (4.6) 23.0(5.2) <.0001
Zung Depression 36.5 (5.5) 48.4(7.7) <.00O l
Psychosomatic
Symptoms(PSC) 6.1 (5.6) 27.5 (23.2) <.0001 ~~r~

ESM measures'
pp 5.7 (0.6) 5.3(03) <.00 I
NA-low arousal 1.2 (0.1) l.4 (0.4) <.0001 Q L
<.0001 a.~s 9.45 11.15 12.45 14.15 15.45 17.15 78.45 20.75 21.45
NA-high azousal l.3 (0.3) 1.& (0.6)
TIME OF DAY
Frequency of
stressful events 12.3%(11.91 22.0%(20.0) <.01 FIGURE 1: Mean cortisol (ng/dl; ±s.e.) during workdays
for the High Stress group(N = 34) and the Low Stress group
'Subject means, aggregated From beep-level data.
(N = 39).

centrations was performed prior to statistical analysis. Non-

parametric tests were ~~sed for univariate group(Mann-Whiney
U-testj and within-sub;ect{Wilcoxon watched-pau-s signed-rank
:est)comp~zsons. Unless noted otherwise, significance tests are
two-tailed. Analysis of variance (SPSS procedure MANOVA)
was used to test differences (and interactions) between HS and
LS groups, workdays and weekends, and the ten times of day
sampled. Analyses were performed with SPSS-Macintosh
version.
RESULTS
Given the general nature of the PSS, which was used to
define high and low stress groups in this study, it is useful to
contrast the two groups on more specific measures of distress.
In addition to trait measures, we compared groups on a number
of aggregated state measures derived from the ESM data. Mean
scores on each of the three ESM mood scales were computed
across a(1 valid beeps for each subject. Frequency of stressful
daily events was calculated as the percentage of total beeps for
a subject on which a stressful event was reported, regardless of
rated severity.
As shown in Table 1, subjects with a high level ofperceived
stress were significantly more trait aiixious and depressed than
subjects with a relatively lower level of perceived stress. They
also scored higher on trait anger and repoRed more psychoso-
matic symptoms. HS subjects had significantly lower ESM pos-
itive affect, higher negative affect-low arousal, and higher neg-
ative affect-high arousal scores. They were almost twice as likely
to report stressful daily events as LS subjects. In absolute terms,
the mean number ofstressful events reported over the five days
of ESM was 9.0 for the HS group and 5.3 for the LS group.
We next examined whether high perceived stress was as-
sociated with elevated salivary cortisol. Mean cortisol levels
were first computed for each subject at each of the ten time
blocks for workdays and again for weekend days. To test for
main effects on cortisol levels as well as interactions, analysis
ofvariance was performed with the between-subject factor group
(HS, I.S) and within-subject factors time ofday(ten beeps) and
day type(workday, weekend). Thirty-nine ofthe 88 subject cases
were rejected because of missing data for any ofthe 20(10 time
blocks x Z day types) measures. The remaining 49 subjects
included 28 LS and 21 HS subjects.
Cortisol concentrations showed the well-defined circadian
rhythm with peak salivary concentrations in the early morning
samples, declining values in the afternoon, and lowest concen-
trations at the end of the day. The main effect tór time of day
was highly significant (F(9,423) = 182.04, p < .001), with no
significant interactions with either group or day type. Contrary
to our hypothesis, no significant main effect for group was found.
Further, there was no workday-weekend difference in cortisol
levels, either as a main effect or in interaction with group.
As noted earlier (see Daily Experience, above) the per-
centage of missing responses was higher on weekends than on
workdays, especially for early morning samples. Inclusion of
weekend data ín the model is thus largely responsible for the
considerable data attrition. We therefore chose to examine
workdays and weekends again separately. While this does not
address the issue of workday vs. weekend differences, it allows
us to test for group differences in cortisol in a larger sample.
For workdays, I S subjects were forced out of the analysis
due to missing data, leaving 39 LS and 34 HS subjects. Time
ofday again showed the lazgest effect on cortisol levels(F(9,639)
= 262.98,. p < .001), but here the difference between HS and
LS groups was also significant (F(1,71) = 6.02, p < .02). The
interaction effect was not significant (F(9,639) _ .67, p > .OS).
Cortisol concentrations for HS and LS groups on workdays are
shown in Figure 1.
In the analysis ofdifferences in cortisol levels on weekends,
only 56 subjects (32. LS and 24 HS) had sufficient data for
inclusion. For this subsample, the usual time of day effect was
found (F(9,486)= 85.80, p < .001), but there was no consistent
difference between the two stress groups (F(1,54) _ .79, p >
.OS). The group by time of day interaction approached signifi-
cance (F(9,486) = 1.83, p = .06), with a tendency for the high
suess group to have higher cortisol levels in the morning through
eaziy afternoon (beeps 2, 3, 4, and 5, between 9:30 a.m. and
2:30 p.m.)and in the late evening(beeps 9 and !0, after 8 p.m.)
Stress and Cortisol
only. Again, it is important to note that this (non-significant)
pattern is based on a relatively small subset ofthe entire sample.
To summarize, cortisol levels showed the expected strong
diurnal pattern in all analyses we performed. More interestingly,
high stress subjects had elevated cor[isol throughout the day on
workdays, confirming our hypothesis, at least for these days. It
would seem logical to assume that such a pattern would be
mediated by group differences in stress exposure or, more spe-
cifically, in emotional response to daily stress. Questions con-
cerning reactivity of mood and cortisol to stressful events are
beyond the scope ofthis paper. However, measures of workday
stress and distress could provide additional insights into the
perceived stress--cortisol relationship.
Within subjects, workdays in comparison to weekends were
associated with a higher rate of stressful events (Wilcoxon
matched-pairs test, p c .0001) and greater NA-high arousal (p
< .0001), with no differences in either NA-low arousal or PA.
The coded descriptions of reported stressors suggested that the
work environment was a major arena for such daily hassles,
with stressons more often occurring in work than in household,
leisure, or social network contexts. Forty-three percent ofevents
in LS subjects and 47% of events in HS subjects were work-
related. While this general pattern ofworkday distress was found
in both groups, within-subject differences in workday vs. week-
end NA-high arousal were greater in HS than in LS subjects
(Mann-Whitney, p < .001); that is, HS subjects were dispro-
portionately more negatively aroused on workdays. Workday/
weekend differentials in NA-low (.OS c p < .10) and stressful
events (.OS < p c .10) did not distinguish the two groups,
although results were in the expected direction of relatively
greater work-related stress/distress in HS subjects.
Since HS subjects scored higher than LS subjects on trait
anxiety, depression, anger, and psychosomatic complaints, as
well as. on ESM measures of positive anti negative affect, we
expected positive relationships between these variables and cor-
tisol levels, at least on workdays. Mean levels of cortisol over
the three workdays were determined by first calculating the mean
at each of the ten time blocks for every subject and then av-
eraging the ten values for each subject. This aggregated measurer,..'
of mean cortisol was slightly higher in the HS (116 ng/dl, sd
37.5)compared to the LS group(101 ng/dl, sd 28.2)(one-tailed
Mann-Whitney test, p c .OS).
Spearman rank order correlations between mean workday
conisol and both psychological measures and ESM mood scales
are shown in Table 2. Small but significant (one-tailed tests)
positive correlations were found between cortisol and trait anx-
iety, depressive symptomatology, and NA-low arousal.
Although these results indirectly support the conclusion
that daily soesa and distress lead to increases in cortisol, the
role of possible confounding factors should be explored. If, for
example, HS subjects smoked more than IS subjects, this might
explain the observed differences in cortisol secretion. HS and
LS groups were therefore compared on the percentage of work-
àay beeps with reported smoking, strenuous physical exertion
(rated 7 on the 7-point scale), coffee, food,and alcohol intake—
all activities that could theoretically result in elevated cortisol
secretion (see Daily Experience, above). No significant differ-
ences were found, with mean rates for HS and LS groups as
follows(HS/IS): smoking 17~k/16%,exertion 0.7%/1.3%,cofïee
46%/41%,food 42%/39%,and alcoho18.0°x/7.8%. Although we
cannot conclude that these behaviors had no influence on cor-
tisol secretion, effects seem equally likely to have occurred in
either group.
VOLUME 16, NUMBER 3, 1994 225
TABLE 2
Correlations between Psychological Variables and Mean Salivary
Cortisol during Workdays
r N
Trait anxiety .18" 88
Trait anger .08 88
Zung Depression .18' $7
Psychosomatic Symptoms
(PSC) .14 88
PA —.10 87
NA —low arousal .20• 87
NA —high arousal .08 87
p < .OS (Spearman; one-tailed tesu).
DISCUSSION
In this study, two groups of male white-collar workers dif-
fering in levels of perceived soesa were compared on subjective,
self-report measures ofdistress and on levels ofsalivary cortisol,
as measured repeatedly over five days. The High Stress group
scored higher than the Low Stress group on measures of trait
anxiety, depression, anger, and psychosomatic complaints, as
well as on ESM measures of positive and negative affect and
stressful daily events. Cortisol showed a clear diurnal secretory
pattern in both groups, with values in the normal range for
healthy men (37). On workdays, cortisol was elevated through-
out the day in the High Stress relative to the Low Stress group.
Several measures of distress, including both trait (anxiety, de-
pression) and concurrent state(NA-low arousal) measures, cor-
related significantly with mean workday cortisol.
The observed pattern of higher workday cortisol levels in
the High Stress group is consistent with our initial hypothesis;
a straightforward interpretation would be that mild chronic or
intermittent stress in situations like those subjects reported dur-
ing the ESM sampling period was sufficient to increase secretion
ofthe hormone. Since the half-life ofcortisol in saliva is shorter
than the intervals between beeps, consistently elevated cortisol
from morning through late evening indicates continued secre-
tion. More detailed temporal analyses are needed, however, to
understand cortisol dynamics in response to daily svess.
Of the few studies of stress and cortisol in everyday envi-
ronments to date, results have been inconsistent. Caplan et al.
(33)tested the effect ofperceived work load(a summary measure
of quantity, deadlines, and calls and office visits) on plasma
cortisol and found that high work load was associated with low
morning cortisol levels. The authors suggested that this finding
might reflect a shift in the circadian rhythm ofcortisol as a result
ofjob soesa. A major disadvantage of this study is the cross-
sectional design, in which blood samples were drawn at various
times of day, with only one cortisol determination per subject.
In other words, comparisons between morning, midday, and
afrernoon cortisol concentrations were comparisons between
subjects and not within subjects. Although perceived stress may
differ in important ways from perceived work load, our results
clearly contradict those of Caplan and colleagues; we found
higher early morning cortisol in high stress subjects and no
evidence at all for a circadian shift. Brandtst~dter et al. (39),
who measured salivary cortisol concentration in 767 adults three
times over the course ofone day,found higher morning cortisol
concentrations in men with high lífe satisfaction, high psycho-
logical well-being, and high level ofemployment. Cortisol levels
226 ANNAIS OF BEHAVIORAI. MEDICINE
in the afternoon or early evening were not predicted by psy-
chological variables. Again,these results are difficult to reconcile
with our findings.
Trait negarive affectivity(NA)is conceptualized as the ten-
dency to experience a wide range of negative emotions (59). In
studies of stress-illness relationships, trait NA has been held
responsible for inflated correlations between stressons and self-
reported health symptoms (60,61). In general, NA has not been
found to predict objective health problems or physiological stress
responses and has therefore been considered a nuisance in the
analysis of stress data (62). The High Stress group in our study
was defined on the basis of scores on a very clearly subjective
self-report measure, the Perceived Stress Scale, and the fact that
HS subjects scored higher on state and trait measures ofdistress
as well as self-reported stress exposure suggests the pervasive
influence oftrait NA.In this light, our findings ofan association
between subjective stress, trait and state NA measures, and
salivary cortisol levels is particularly noteworthy.
As is usually the case in ps~c:hophysiological studies, the
psychological variables we measured accounted for only a small
percentage ofthe variability in cortisol. Moreover, the observed
elevations in workday cortisol secretion in HS subjects were
slight, relative to pathophysiological levels seen in Cushing's
disease or some cases of major depression. Since cortisol levels
are not routinely measured in prospective eoidemiolugical stud-
ies of healthy individuals, we have no guidelines at present for
assessing the clinical relevance or health implications o:these
findings.
Analysés in this study were done on aggregated data, which
has the advantage of increasing the reliability of measurement
when only the chronic level of variables is of interest. On the
other hand, aggregated measures may be based (63), and they
obfuscate the important interplay between experiential and
physiological states and processes which momentary measures
are intended to clarify. To gain more insight into the relationship
between perceived stress and cortisol, we need to move to beep-
level analyses. We can then investigate fluctuations over time
in stressful events, mood, and psychosomatic complainu and
determine how these Ructuations relate to endocrine activity
(concurrent and lagged relationships). One promising method
for the analyses oftemporal data is hierarchical linear modeling
or multi-level analysis (64). This approach can account for the
dependency of data within a subject, can deal with the problem
of missing data, and allows for individual differences in inter-
cepts, slopes, and error structures. We are currently undertaking
multi-level analyses, in the belief that these new methods will
help realize the enormous research pot~tial afforded by mo-
mentary measures.
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