This article was downloaded by: [UNAM Ciudad Universitaria]

On: 06 June 2013, At: 22:34

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Behavioral Sleep Medicine

Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/hbsm20

Bi-Directional Associations Between

Psychological Arousal, Cortisol, and
Sleep
a b c a d
Anne Helene Garde , Karen Albertsen , Roger Persson , Åse
a c a c d
Marie Hansen & Reiner Rugulies
a
National Research Centre for the Working Environment,
Copenhagen, Denmark
b
Team Working Life, Valby, Denmark
c
Institute of Public Health, University of Copenhagen, Copenhagen,
Denmark
d
Department of Psychology, University of Copenhagen, Copenhagen,
Denmark
Published online: 17 Jan 2012.

To cite this article: Anne Helene Garde , Karen Albertsen , Roger Persson , Åse Marie Hansen & Reiner
Rugulies (2011): Bi-Directional Associations Between Psychological Arousal, Cortisol, and Sleep,
Behavioral Sleep Medicine, 10:1, 28-40

To link to this article: http://dx.doi.org/10.1080/15402002.2012.636272

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation
that the contents will be complete or accurate or up to date. The accuracy of any
instructions, formulae, and drug doses should be independently verified with primary
sources. The publisher shall not be liable for any loss, actions, claims, proceedings,
demand, or costs or damages whatsoever or howsoever caused arising directly or
indirectly in connection with or arising out of the use of this material.
 Behavioral Sleep Medicine, 10:28–40, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1540-2002 print/1540-2010 online
DOI: 10.1080/15402002.2012.636272

Bi-Directional Associations Between

Psychological Arousal, Cortisol, and Sleep
Anne Helene Garde
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

National Research Centre for the Working Environment, Copenhagen, Denmark

Karen Albertsen
Team Working Life, Valby, Denmark
Institute of Public Health, University of Copenhagen, Copenhagen, Denmark

Roger Persson
National Research Centre for the Working Environment, Copenhagen, Denmark; and
Department of Psychology
University of Copenhagen, Copenhagen, Denmark

Åse Marie Hansen

National Research Centre for the Working Environment, Copenhagen, Denmark; and
Institute of Public Health, University of Copenhagen, Copenhagen, Denmark

Reiner Rugulies
National Research Centre for the Working Environment, Copenhagen, Denmark;
Institute of Public Health, University of Copenhagen, Copenhagen, Denmark; and
Department of Psychology
University of Copenhagen, Copenhagen, Denmark

The aim was to elucidate the possible bi-directional relation between daytime psychological arousal,
cortisol, and self-reported sleep in a group of healthy employees in active employment. Logbook
ratings of sleep (Karolinska Sleep Questionnaire), stress, and energy, as well as positive and
negative experiences in work and private life, were collected together with salivary cortisol over 3
days (n D 265). Higher bedtime ratings of stress and problems during the day were associated with
morning ratings of poor sleep. Poorer morning ratings of sleep were associated with higher ratings
of stress and problems during the day. The results underpin the possibility that arousal and poor
sleep might create a self-reinforcing vicious circle that negatively affects a person’s well-being.

Correspondence should be addressed to Anne Helene Garde, National Research Centre for the Working
Environment, Lersø Parkallé 105, DK-2100, Copenhagen, Denmark. E-mail: ahg@nrcwe.dk

28
 AROUSAL, CORTISOL, AND SLEEP 29

In healthy working populations, the prevalence of self-reported sleep disturbances have been
estimated to be 20% to 30% (Luckhaupt, Tak, & Calvert, 2010; Westerlund et al., 2008). Sleep
disturbances, such as insomnia, are known to be associated with poor daytime functioning and
overall well-being (Kyle, Morgan, & Espie, 2010; Shekleton, Rogers, & Rajaratnam, 2010),
and has been linked to sickness absence in working populations (Westerlund et al., 2008).
The causes for sleep disturbances may vary. One cause may be psychological arousal due to
everyday hassles and negative or positive experiences related to work and private life.
Indeed, stress, worry, and apprehension at bedtime have been associated with poor sleep that
night on a day-to-day basis (Åkerstedt, Kecklund, & Axelsson, 2007; Kecklund & Åkerstedt,
2004; Morin, Rodrigue, & Ivers, 2003). Intense schoolwork and the expectation of a forthcom-
ing examination have also been reported to be associated with shorter sleep (Galambos, Dalton,
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

& Maggs, 2010). However, only a few empirical studies have addressed this issue on a day-
to-day basis, and even fewer have evaluated the reverse association—that is, how sleep affects
daytime functioning. However, studies indicate a possible bi-directionality between day-to-day
reports of sleep and daily experiences: Better sleep has been found to precede positive affect and
decreased negative affect among students (Galambos et al., 2010) and older adults (Mccrae
et al., 2008). When focusing on a healthy, working population, moderately impaired sleep
was associated with higher psychological arousal in terms of moderate increase in amount of
stress and worry at bedtime the following day (Åkerstedt et al., 2007). Furthermore, Totterdell,
Reynolds, Parkinson, and Briner (1994) found that sleep was associated with subsequent well-
being in a group of healthy employees.
The possible bi-directionality between day-to-day self-reports of sleep and daily experiences
is supported by the neuro-anatomical interconnectedness between sleep and arousal systems
(Saper, Cano, & Scammell, 2005). Cortisol is a hormone in the hypothalamus–pituitary–adrenal
(HPA) axis, which has been shown to increase in response to stressful situations in both
field and experimental studies (Biondi & Picardi, 1999; Jönsson et al., 2010; Kirschbaum
et al., 1995; Schlotz, Hellhammer, Schulz, & Stone, 2004). Concentrations of cortisol are high
in the morning, decline over the day, and are low at night. On top of this, diurnal rhythm
concentrations of cortisol increase up to 50% upon awakening (cortisol awakening response
[CAR]). Furthermore, hormones of the HPA axis, such as corticotrophin-releasing hormone
(CRH) and cortisol, play a specific role in sleep regulation and vice versa (Balbo, Leproult,
& van Cauter, 2010; Steiger, 2007). It is well documented that administration of CRH impairs
sleep and enhances vigilance, whereas acute cortisol administration increases slow-wave sleep
(SWS), probably due to feedback inhibition of CRH (Steiger, 2007). Sleep also affects cortisol.
Sleep onset exerts an inhibitory effect on cortisol secretion, whereas awakening and sleep offset
are accompanied by cortisol stimulation (Balbo et al., 2010).
Studies on day-to-day variations in sleep and measures of salivary cortisol in healthy
individuals are scarce, but the few existing studies have shown that longer sleep is positively
associated with better sleep quality and recovery, as well as higher concentrations of cortisol
at awakening (Backhaus, Junghanns, & Hohagen, 2004; Stalder, Hucklebridge, Evan, & Clow,
2009). In contrast, experience of sleep disturbances and nightly micro-arousals have been
reported to be associated with lower morning cortisol concentrations (Backhaus et al., 2004;
Ekstedt, Åkerstedt, & Soderstrom, 2004). Other studies have found that those who slept longer
had a lower CAR (Schlotz et al., 2004; Wüst et al., 2000), which may be related to samples
 30 GARDE ET AL.

being taken later, when sleeping longer (Okun et al., 2010). In view of these studies, it seems
as if long sleep is associated with better perceived sleep quality and higher concentrations of
cortisol at awakening (Backhaus et al., 2004; Stalder et al., 2009) and a lower CAR (Schlotz
et al., 2004; Wüst et al., 2000). In addition, long sleep duration was also associated with low
evening cortisol levels (Hsiao et al., 2010) and a steep diurnal slope in cortisol concentrations,
which may be related to lower evening cortisol (Hsiao et al., 2010; Kumari et al., 2009).
Persons who sleep longer, therefore, appear to have higher morning cortisol, lower CAR, and
a steeper slope over the day, resulting in a lower evening cortisol concentration compared to
persons who sleep less.
It may be speculated that arousal and sleep follow each other in a vicious circle, and that
this is associated with cortisol: Poor sleep is followed by lower concentrations of cortisol
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

in the morning. Furthermore, there is a need for increased effort to comply with the tasks
during the day. The increased effort results in stress and, therefore, increased concentrations of
cortisol in the evening. The metabolic properties of cortisol may make sleep incompatible with
higher concentrations of cortisol, resulting in difficulties falling asleep and sleep impairment.
This sleep impairment is again followed by lower concentrations of morning cortisol, thus
promoting a vicious circle of arousal and poor sleep. Insight into the bi-directionality between
psychological arousal, cortisol, and sleep may, therefore, improve the understanding of how
circumstances at work and at home can lead to tiredness and poor functioning, as well as
poor health.
The overall objective of this study was to examine the bi-directional associations between
psychological arousal and concentrations of cortisol, on the one hand, and self-reported sleep
characteristics, on the other hand. For this purpose, a study was designed where psychological
arousal was determined together with self-reports on sleep and concentrations of cortisol on
three consecutive days in a population of employed knowledge workers (e.g., see Benson &
Brown, 2007). The design served to answer the following research questions:

RQ1: Is psychological arousal prior to bedtime and concentrations of cortisol associated

with sleep quality that night?
RQ2: Is sleep quality assessed in the morning associated with psychological arousal and
concentrations of cortisol that day?

Specifically, we hypothesized the following:

H1a: Psychological arousal in terms of self-reports of more stress and energy at bed-
time and positively and negatively evaluated experiences that had occurred during the
day.
H1b: High concentrations of cortisol in the evening and a less steep slope over the day
would be associated with poor sleep that night.
H2a: Poor sleep would be followed by reports of more stress and negatively evaluated
experiences during the day.
H2b: Poor sleep would be followed by higher concentrations of cortisol in the morning
lower CAR and less steep slope in concentrations of cortisol over the day.
 AROUSAL, CORTISOL, AND SLEEP 31

METHOD

Participants
Participants were recruited in relation to a study on knowledge work, stress, sleep, and psy-
chosocial work environment (Albertsen, Garde, Rugulies, & Persson, 2009; Albertsen, Rugulies,
Garde, & Burr, 2010). A total of 853 knowledge workers from the second National Danish
Psychosocial Work Environment Study (see www.arbejdsmiljoforskning.dk/apss) encompassing
a representative sample of Danish wage earners were invited. Knowledge workers were broadly
defined as people working with signs and symbols (e.g., data management), communication
(e.g., in the media), or development of knowledge (e.g., teaching) as an important part of their
jobs. Participants were employed for example as physicians, dentists, engineers, architects, staff
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

within IT and media, teachers, researchers, managers and leaders, social workers, librarians,
accountants, bank clerks, or salespersons. Two hundred sixty-five (31%) participants returned
either logbooks, saliva samples, or both in September 2006 through February 2007. The study
was approved by the local ethical committee (Reference No. 11510).

Procedure and Study Design

Data were collected over 3 days. The participants were asked to fill in a baseline questionnaire,
a logbook, and to collect three saliva samples. An evening logbook concerning experience of
stress and energy during the past 2 hr before bedtime and emotion-provoking events during
the day was filled in on the evening on Days 1 and 2. On the mornings of Days 2 and 3, a
morning logbook concerning the past night’s sleep was filled in. Participants were requested
to sample saliva at awakening, C30 min after awakening, and at 20:00 on the second day.
The exact sampling time was recorded by the participants. The material was returned to the
laboratory in pre-stamped envelopes.

Measures of Sleep
A modified version of the Karolinska Sleep Questionnaire was used to assess sleep quality
during the past night (Åkerstedt et al., 2002). In total, seven items tapped (a) difficulties
falling asleep, (b) disturbed/restless sleep, (c) repeated awakenings, (d) premature awakenings,
(e) difficulties waking up, (f) non-refreshing sleep, and (g) exhausted at awakening. Number of
awakenings was given scores between 1 (zero awakenings) and 5 (four or more awakenings).
All other items were scored on a 5-point scale, with higher scores representing poorer sleep. A
disturbed sleep index (DSI; range D 1–5) was calculated as the mean score of Items a through d.
High scores represented a more disturbed sleep. The awakening index (AWI; range D 1–5) was
calculated as the mean score of Items e through g. Lower scores represent a more satisfactory
awakening. Cronbach’s alphas were .61 and .81 for DSI and AWI, respectively. Correspond-
ingly, DSI and AWI during the past 3 months were assessed in the baseline questionnaire.

Psychological Arousal
The Stress–Energy Inventory (SEI) was used to assess psychological arousal during the past
2 hr before bedtime. The SEI is a mood adjective checklist that measures feelings of arousal
 32 GARDE ET AL.

in two dimensions, stress and energy, each comprising six items (Kjellberg & Iwanowski,
1989; Kjellberg & Wadman, 2002). It has been used in several occupational field studies
(Persson, Carlsson, Österberg, Ørbæk, & Karlson, 2008; Persson et al., 2010). The overall
question, “How did you feel within the last two hours?,” was responded to by evaluating 12
statements. The stress dimension comprised the negatively valued states of “tense,” “stressed,”
and “pressured”; and the positively valued states of “rested,” “relaxed,” and “calm.” The energy
dimension comprised the positively valued states of “active,” “energetic,” and “focused”; and
the negatively valued states of “dull,” “inefficient,” and “passive.” For each statement, the
participants reported how they felt on a 6-point scale ranging from 0 (not at all) to 5 (extremely).
After reversing the three positively valued items on the stress scale and the three negatively
valued items on the energy scale, stress and energy scores were calculated as the mean score
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

of the six items in each dimension. Thus, higher values indicate higher levels of stress and
energy, respectively. In this study, Cronbach’s alphas were .89 for the stress score and .86 for
the energy score.
The evening logbook also included questions on positively and negatively evaluated expe-
riences during the day. The first question, “Did something happen today which affected you
negatively?,” had five response alternatives: 1 (no), 2 (yes, problems with relations at work), 3
(yes, problems with work tasks), 4 (yes, family-related problems), and 5 (yes, other). Multiple
answers were allowed. Reports of one type of problem were not correlated with reports of
other types of problems. The second question, “Did something happen today which affected
you positively?,” had four response alternatives related to the site of origin: 1 (no), 2 (yes, at
work), 3 (yes, at home), and 4 (other). Multiple answers were allowed. The participants were
also asked, “Have you worked this evening?” The response categories were yes and no.

Measurement of Cortisol in Saliva

The saliva samples were stored at 20ı C and analyzed within 6 months. Approximately 12%
of the samples did not contain enough saliva to be analyzed for cortisol. Cortisol in saliva
was measured with a competitive radioimmunoassay (RIA) from Orion Diagnostica (Espoo,
Finland). Analysis was carried out according to the manufacturer’s specifications. To ensure
high quality, the analytical method was evaluated in our laboratory by analyzing samples with a
known amount of certified reference material in water. The evaluation indicated that the method
was not biased. The limit of detection was 1.6 nmol/l. Between-run coefficients of variation
were 19% at 11.5 nmol/l and 16% at 49.2 nmol/l (Garde, Hansen, & Nikolajsen, 2003). Saliva
samples (5.9 nmol/l and 18.5 nmol/l) were used as control materials and analyzed together
with the samples. The performance of the method has been further validated by participation
in inter-laboratory comparison schemes (Garde et al., 2003; Hansen, Garde, Christensen, Eller,
& Netterstrøm, 2003).
The cortisol curve was described either by using four derived measures of cortisol (RQ1)
or concentrations of cortisol from all saliva samples (cortisol profile) in one statistical model
(RQ2). The four derived measures of cortisol were two static measures: (a) the maximum
morning concentration (the maximum of the 2 morning samples) and (b) the evening cortisol
concentration; and two dynamic measures (c) CAR (nmol/l difference between second morning
sample and the first) and (d) the cortisol decline over the day (slope, nmol/l difference between
the evening sample and the maximum). Due to the diurnal variation, the slope was negative
 AROUSAL, CORTISOL, AND SLEEP 33

in most cases. The cortisol measures were highly correlated, particularly slope to maximum
morning concentration ( D :93) and CAR ( D :62). Maximum morning concentration
was also correlated to CAR ( D :66). Other correlation coefficients between measures of
cortisol were below .37.

Statistics
A single outlier was deleted for concentrations of salivary cortisol based on Grubb’s outlier test
(1969). SAS statistical software (version 9.1; SAS Institute, Inc., Cary, NC, USA) was used
to analyze associations between measures of arousal and sleep quality. The mixed procedure
(proc mixed) was used for continuous outcome variables, and the logistic procedure was used
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

for binary outcome variables. All models were adjusted for gender and age, and it was ensured
that the collection of data had been done in the right sequence and with the correct interval.
Thus, logbook entries with missing dates and missing saliva samples, sets of saliva samples
taken over more than 1 day, and pairs of data in which saliva was not collected the day after
the logbook entry were excluded. Analyses were performed on different sub-datasets, which
differed in number of records according to differences in the properties of the variables and
compliance. Statistical significance was set to ˛ D 0:05, which was reduced to ˛ D 0:004 after
Bonferroni correction, due to multiple comparisons (n D 14 for RQ1 and n D 11 for RQ2).

RQ1. DSI and AWI were used as continuous outcome variables. Associations between
psychological arousal assessed at bedtime on Days 1 and 2 and DSI and AWI assessed in the
morning on Days 2 and 3 were tested in separate, repeated-measures models, with subject as
a random effect (2 days as repeated measures). The dataset for these analyses included 2 days
for all 265 participants (n D 499 records). Associations between derived measures of cortisol
(continuous) on Day 2 and DSI and AWI assessed in the morning on Day 3 were performed
on a reduced dataset (n D 189 participants). In analysis of CAR, another 51 participants, who
reported to sample saliva more than 15 min after awakening, were excluded (Okun et al., 2010).

RQ2. DSI and AWI assessed on Day 2 were used as independent variables in all models
testing associations between DSI and AWI during the night and psychological arousal and
concentrations of cortisol that day (Day 2). Indexes of stress and energy were used as continuous
outcomes in separate models (n D 265). Experience of positive and negative events today
(together with their subcategories) and worked this evening were tested as binary outcome
variables (n D 265). Concentrations of cortisol (cortisol profile) were used as continuous
outcomes in a model, with subject as a random effect (3 saliva samples per participant).
Due to non-normal (skewed) distributions and increasing variances, analyses of concentrations
of cortisol were performed on a logarithmic scale. Accordingly, the mean and confidence
intervals were assessed on a log scale and converted back to get the geometric means and
asymmetric confidence intervals. Time (categorical; 3 levels) was included as a main factor
and in interaction with DSI or AWI in the initial models for cortisol concentrations. Deviations
in time of sampling were handled by including time-of-sampling as a continuous variable. The
initial dataset included n D 753 records (up to 3 saliva samples per participant). The final
dataset included 613 records from 210 participants. To test the effect of overall sleep quality,
DSI and AWI during the past 3 months were included in the final model. The robustness of
 34 GARDE ET AL.

the models was evaluated by excluding all records where the participant had been drinking
alcohol in the evening or taking painkillers and hypnotics.

RESULTS

Demographic characteristics and mean of ratings of DSI, AWI, stress, energy, concentrations of
cortisol, and derived cortisol measures are given in Table 1. Table 1 also includes distributions
for negatively and positively evaluated events and if the participants had worked the night
before.
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

Sleep Following Daytime Arousal

Results from models with DSI or AWI as outcome and psychological arousal or concentrations
of cortisol as independent factors are summarized in Table 2. Psychological arousal in terms of

TABLE 1
Sample Characteristics

Variable N n (%) or M (SD) 95% CI

Female 265 157 (60%)

Age 265 44.8 years (8.7 years)
Body mass index 265 25.2 kg/m2 (4.4 kg/m2 )
DSI during past 3 months 265 2.45 2.36–2.54
AWI during past 3 months 265 2.59 2.50–2.69
Drank alcohol last night 265 44 (17%)
Took pain killers last night 265 2 (1%)
Used hypnotics last night 265 3 (1%)
More than 15 min delay between awakening 189 51 (27%)
and first saliva sample
DSI (average of Day 1 and Day 2) 265 1.91 1.84–1.99
AWI (average of Day 1 and Day 2) 265 2.71 2.62–2.80
Stress (average of Day 1 and Day 2) 265 1.60 1.51–1.69
Energy (average of Day 1 and Day 2) 265 2.91 2.81–3.00
Problems today
Problems with relations at work 265 35 (13%)
Problems with work tasks 265 41 (16%)
Family-related problems 265 32 (12%)
Positive events today
Positive events at work 265 82 (31%)
Positive events at home 265 87 (33%)
Worked last night 265 84 (32%)
Mean cortisol concentration at awakening 189 7.1 nmol/L 6.5–7.8 nmol/L
Mean cortisol concentration at C30 min 189 11.6 nmol/L 10.7–12.6 nmol/L
Mean cortisol concentration in evening 189 1.0 nmol/L 0.9–1.2 nmol/L
Cortisol awakening response 189 4.9 nmol/L 3.8–5.9 nmol/L
Slope over the day in salivary cortisol 189 12.5 nmol/L 11.5– 13.5 nmol/L

Note. CI D confidence interval; DSI D disturbed sleep index; AWI D awakening index; N D number of subjects
in sub-data set.
 AROUSAL, CORTISOL, AND SLEEP 35

TABLE 2
Results From Models Predicting Tonight’s Sleep From Today’s Arousal

DSI AWI

Arousal a N/n ˇ (SD) p ˇ (SD) p

Stress 265/499 0.205 (0.037) < .001 0.354 (0.044) < .001
Energy 265/499 0.052 (0.034) .131 0.079 (0.041) .055
Problems today 265/499 0.147 (0.063) .019 0.401 (0.073) < .001
Problems with relations at work 265/499 0.165 (0.089) .065 0.399 (0.105) < .001
Problems with work tasks 265/499 0.104 (0.084) .216 0.487 (0.098) < .001
Family-related problems 265/499 0.127 (0.100) .206 0.250 (0.118) .035
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

Positive events today 265/499 0.065 (0.062) .295 0.062 (0.074) .402
Positive events at work 265/499 0.021 (0.066) .752 0.027 (0.079) .727
Positive events at home 265/499 0.106 (0.063) .095 0.019 (0.075) .797
Worked last night 265/499 0.016 (0.067) .808 0.118 (0.080) .142
Cortisol awakening response 138/138 0.005 (0.008) .539 0.012 (0.011) .283
Evening concentration 189/189 0.012 (0.019) .540 0.0002 (0.023) .995
Maximum morning concentration 189/189 0.006 (0.007) .415 0.015 (0.008) .062
Slope 189/189 0.008 (0.007) .244 0.019 (0.008) .028

Note. Psychological arousal and derived measures of cortisol were used as independent variables in models with
sleep as an outcome. Psychological arousal was assessed in a logbook at bedtime on Days 1 and 2. Concentrations of
cortisol were assessed in saliva collected at awakening, 30 min after awakening, and at 20:00 on Day 2. Sleep quality
was assessed as disturbed sleep index (DSI) and awakening index (AWI) in the mornings of Days 2 and 3. All models
were adjusted for gender and age. Higher scores for DSI and AWI equal poorer sleep. N D number of participants;
n D number of observations included in the analysis. In cases where data were collected on several days, n is larger
than N .
a Independent variable.

stress ratings at bedtime (Days 1 and 2) was positively associated with the morning ratings on
Days 2 and 3 of DSI (ˇ D 0:205 [SD D 0:037], p < :001) and AWI (ˇ D 0:354 [SD D 0:044],
p < :001). Psychological arousal in terms of bedtime reports of problems today, in general
(Days 1 and 2), was associated with higher ratings of AWI (p < :001), but not DSI, in the
morning on Days 2 and 3 (see Table 2). In detail, experiencing problems with relations at work,
work tasks, or family-related problems were followed by higher AWI, but not DSI, that night.
After a Bonferronni correction, there were no associations between concentrations of cortisol
and sleep quality scores.

Sleep and Arousal That Day

Results from statistical models with psychological arousal assessed at bedtime and concentra-
tions of cortisol on Day 2 as outcome and DSI or AWI assessed in the morning on Day 2
as predictors are summarized in Table 3. Higher morning ratings of DSI and AWI on Day 2
were associated with higher ratings of stress at bedtime on Day 2 (ˇ D 0:307 [SD D 0:071],
p < :001) for DSI and (ˇ D 0:395 [SD D 0:058], p < :001) for AWI, and lower bedtime
ratings of energy on Day 2 for AWI (ˇ D 0:287 [SD D 0:068], p < :001). Ratings of AWI
(p < :005) were positively associated with the reporting of problems at bedtime on Day 2
 Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

36
TABLE 3
Results From Models Predicting Today’s Arousal From the Preceding Night’s Sleep

DSI AWI

Arousal (Outcome) N/na ˇ (SD) p OR (95% CI) p ˇ (SD) p OR (95% CI) p

Stressb 265/265 0.307 (0.071) < .001 0.395 (0.058) < .001
Energyb 265/265 0.179 (0.081) .028 0.287 (0.068) < .001
Problems todayc 265/265 1.44 (1.01–2.07) .045 1.88 (1.35–2.62) < .001
Problems with relations at workc 265/265 1.23 (0.72–2.13) .451 2.40 (1.44–4.02) < .001
Problems with work tasksc 265/265 1.67 (1.06–2.62) .027 1.91 (1.25–2.91) .003
Family-related problemsc 265/265 1.07 (0.56–2.05) .835 2.33 (1.30–4.20) .005
Positive events todayc 265/265 1.16 (0.81–1.66) .412 1.01 (0.79–1.43) .707
Positive events at workc 265/265 0.82 (0.56–1.19) .294 0.76 (0.55–1.04) .081
Positive events at homec 265/265 0.98 (0.68–1.42) .926 1.28 (0.94–1.76) .120
Worked last nightc 265/265 0.78 (0.53–1.14) .200 1.23 (0.83–1.54) .455
Cortisol profiled 210/613 .096 .514

Note. Sleep quality was used as independent variables in models with psychological and physiological arousal as outcomes. Psychological arousal was assessed
in a logbook at bedtime on Day 2. Concentrations of cortisol were assessed in saliva collected at awakening, 30 min after awakening, and at 20:00 on Day 2. Sleep
quality was assessed as disturbed sleep index (DSI) and awakening index (AWI) in the morning of Day 2. Higher scores for DSI and AWI equal poorer sleep. All
models were adjusted for gender and age. OR D odds ratio; CI D confidence interval.
a N D number of participants; n D number of observations. In the case of cortisol, n is larger than N because three samples were collected per person.
b Tested by use of repeated-measures model. c Tested in logistic regression model. d The cortisol profile includes cortisol concentrations in saliva samples collected at

(a) awakening, (b) 30 min after awakening, and (c) at 20:00.

 AROUSAL, CORTISOL, AND SLEEP 37

(see Table 3). There were no statistically significant associations between morning ratings of
DSI and AWI, on the one hand, and bedtime reporting of positive events or evening work that
day, on the other. Likewise, were there no associations between morning DSI and AWI scores
and concentrations of cortisol during the day (see Table 3). Including the sleep quality during
the past 3 months did not change the results for cortisol. A test for robustness in terms of
excluding participants that had been drinking alcohol or taking painkillers or hypnotics only
changed the results to a minor degree.

DISCUSSION
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

The results of this study showed that psychological arousal at bedtime was positively associated
with reports of poor sleep, as indicated by higher morning ratings of DSI and AWI (see Table 2).
This is in accordance with previous studies on working populations, where it was found that
moderately increased bedtime stress/worry and apprehension of the next day were associated
with poor sleep the following night (Åkerstedt et al., 2007; Kecklund & Åkerstedt, 2004).
The design also implied a test of the reverse direction, and we found associations between
poor sleep quality and an increased experience of arousal that day (see Table 3). This corre-
sponds with the results of a study showing that moderately impaired sleep was associated with
higher arousal in terms of a moderate increase in the amount of stress and worry (Åkerstedt
et al., 2007) and negative affect (Galambos et al., 2010) the following day. The results indicate
a possible vicious circle of arousal and disturbed sleep—that is, psychological arousal may
cause sleep impairment, which, in turn, causes increased arousal and need for increased effort
to comply with the tasks the following day, thus promoting a vicious circle of psychological
arousal and disturbed sleep.
Although negative events during the day and stress ratings at bedtime were associated with
poorer sleep quality (high AWI) that night, no associations were found between reports of
positive states and the measures of sleep quality (see Table 2). This suggests that arousal
caused by negative affectivity is more closely related to sleep quality than arousal caused by
positive experiences. That negative emotions have a larger effect on sleep has been observed
in previous studies, although they used other measures of sleep (i.e., variability in duration and
fragmentation of sleep; Mezick et al., 2009). An explanation may be that negative events, in
general, cause more arousal than positively evaluated events.
We could not support the findings by Backhaus et al. (2004) concluding that better sleep
quality and feelings of recovery were associated with higher concentrations of cortisol at
awakening. Thus, the close relationship between sleep and hormones of the HPA axis observed
in previous laboratory studies with strict control of sleep and environment (Balbo et al., 2010;
Steiger, 2007) were not found in this study. The inherent lack of control of many factors in field
studies, such as this one, may introduce variability. This masks the associations observed in
laboratory studies. Thus, we could not support that cortisol is at play in a possible vicious circle
of sleep and arousal in this study. The fact that concentrations of cortisol were not significantly
associated with sleep in this study is in contrast to the finding of a generally higher level of
physiological arousal in patients with insomnia (Bonnet & Arand, 2010; Riemann et al., 2010).
A reason could be that this study was carried out within a healthy working population on a
day-to-day basis, rather than in a group of patients with insomnia.
 38 GARDE ET AL.

Strengths and Limitations

The purpose of this study was to study the bi-directional, short-term fluctuations in psycho-
logical arousal, cortisol, and sleep. Therefore, much effort was put into ensuring that the
collection of data had been done in the right sequence and with the correct intervals. By
use of repeated measures and inclusion of sleep quality during the past 3 months in some of
the models, we controlled for the individual (baseline) levels of sleep and thereby, to some
degree, the possibility of bias due to long-term co-fluctuations between sleep and psychological
arousal. The use of both psychological arousal and concentrations of cortisol, together with the
study of reverse relationships, also strengthened the study. Further, the study population was
relatively large. The participants were in active employment, and the levels of psychological
arousal were in fair agreement with results from other groups of workers obtained by use
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

of a similar methodology (Persson et al., 2008; Persson, Garde, Hansen, Ohlsson, & Ørbæk,
2003). This indicates that the group was not under severe strain, and it is plausible that the
observed association may be stronger in other groups. A test of the robustness of the models
by excluding all records where the participant had been drinking alcohol in the evening, taking
painkillers, or taking hypnotics did not change the conclusions. Overall, the models, therefore,
appear robust.
The fact that cortisol was collected on a single day could be a limit to the study. By
including more days, the intra-individual variation in cortisol would have been reduced and
could be better estimated in the statistical models. Another limitation was that sleep quality was
assessed by self-reports. The study could have been strengthened by technical measurements
such as actigraphy or polysomnography. Being an exploratory study, we included many different
measures, and accordingly performed multiple comparisons, which lead to an increased risk
of finding false positives (type 1 errors). Accordingly, we adjusted the significance level
according to a hypothesis-wise Bonferroni adjustment. However, type 1 errors cannot decrease
without increasing the risk for type 2 errors—that is, the risk of erroneously accepting the
null hypothesis when it should be rejected. Further studies are, therefore, needed to confirm
our findings.
In conclusion, having experienced problems during the day and self-reports of stress at
bedtime were associated with poorer sleep quality that night. Furthermore, poor sleep assessed
in the morning was associated with increased psychological arousal in terms of stress and
energy, as well as experiencing more problems that day. In addition, experiences of negative,
but not positive, events during the day were associated with sleep impairments. The results
underpin the possibility that psychological arousal and poor sleep might create a self-reinforcing
vicious circle that negatively affects a person’s well-being.

ACKNOWLEDGMENTS

Anne Abildtrup, Ulla Tegner, Inge Christiansen, and Dorrit Meincke are thanked for skilful
technical assistance. This study was part of the “Boundaryless Work, Stress, Sleep, and Private
Life” project, financed by Grant No. 20050072489 from The Danish Working Environment
Research Fund.
 AROUSAL, CORTISOL, AND SLEEP 39

REFERENCES

Åkerstedt, T., Kecklund, G., & Axelsson, J. (2007). Impaired sleep after bedtime stress and worries. Biological
Psychology, 76, 170–173.
Åkerstedt, T., Knutsson, A., Westerholm, P., Theorell, T., Alfredsson, L., & Kecklund, G. (2002). Sleep disturbances,
work stress and work hours: A cross-sectional study. Journal of Psychosomatic Research, 53, 741–748.
Albertsen, K., Persson, R., Garde, A. H., & Rugulies, R. (2010). Psychosocial determinants of work-to-family conflict
among knowledge workers with boundaryless work. Applied Psychology, 2, 160–181.
Albertsen, K., Rugulies, R., Garde, A. H., & Burr, H. (2010). The effect of the work environment and performance-
based self-esteem on cognitive stress symptoms among Danish knowledge workers. Scandinavian Journal of Public
Health, 38, 81–89.
Backhaus, J., Junghanns, K., & Hohagen, F. (2004). Sleep disturbances are correlated with decreased morning
awakening salivary cortisol. Psychoneuroendocrinology, 29, 1184–1191.
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

Balbo, M., Leproult, R., & van Cauter, E. (2010). Impact of sleep and its disturbances on hypothalamo–pituitary–
adrenal axis activity. International Journal of Endocrinology, 2010, 1–16.
Benson, J., & Brown, M. (2007). Knowledge workers: What keeps them committed; what turns them away. Work,
Employment and Society, 21, 121–141.
Biondi, M., & Picardi, A. (1999). Psychological stress and neuroendocrine function in humans: The last two decades
of research. Psychotherapy and Psychosomatics, 68, 114–150.
Bonnet, M. H., & Arand, D. L. (2010). Hyperarousal and insomnia: State of the science. Sleep Medicine Reviews, 14,
9–15.
Ekstedt, M., Åkerstedt, T., & Soderstrom, M. (2004). Microarousals during sleep are associated with increased levels
of lipids, cortisol, and blood pressure. Psychosomatic Medicine, 66, 925–931.
Galambos, N. L., Dalton, A. L., & Maggs, J. L. (2010). Losing sleep over it: Daily variation in sleep quantity and
quality in Canadian students’ first semester of university. Journal of Research on Adolescence, 19, 741–761.
Garde, A. H., Hansen, Å. M., & Nikolajsen, T. B. (2003). An inter-laboratory comparison for determination of cortisol
in saliva. Accreditation and Quality Assurance, 8, 16–20.
Hansen, Å. M., Garde, A. H., Christensen, J. M., Eller, N. H., & Netterstrøm, B. (2003). Evaluation of a radio-
immunoassay and establishment of a reference interval for salivary cortisol in healthy subjects in Denmark.
Scandinavian Journal of Clinical and Laboratory Investigation, 63, 303–310.
Hsiao, F. H., Yang, T. T., Ho, R. T., Jow, G. M., Ng, S. M., Chan, C. L., : : : Wang, K. C. (2010). The self-perceived
symptom distress and health-related conditions associated with morning to evening diurnal cortisol patterns in
outpatients with major depressive disorder. Psychoneuroendocrinology, 35, 503–515.
Jönsson, P., Wallergård, M., Österberg, K., Hansen, A. M., Johansson, G., & Karlson, B. (2010). Cardiovascular
and cortisol reactivity and habituation to a virtual reality version of the Trier Social Stress Test: A pilot study.
Psychoneuroendocrinology, 35, 1397–1403.
Kecklund, G., & Åkerstedt, T. (2004). Apprehension of the subsequent working day is associated with a low amount
of slow wave sleep. Biological Psychology, 66, 169–176.
Kirschbaum, C., Prussner, J. C., Stone, A. A., Federenko, I., Gaab, J., Lintz, D., : : : Hellhammer, D. H. (1995).
Persistent high cortisol responses to repeated psychological stress in a subpopulation of healthy men. Psychosomatic
Medicine, 57, 468–474.
Kjellberg, A., & Iwanowski, S. (1989). Stress/Energi-formuläret: Utveckling av en metod för skattning av sinnesstämn-
ing i arbetet [Stress/energy Questionnaire: Development of a method for evaluation of mood at work] (Rep. No.
26). Stockholm, Sweden: National Institute of Occupational Health.
Kjellberg, A., & Wadman, C. (2002). Subjektiv stress och dess samband med psykosociala förhållanden och besvär. En
prövning av Stress–Energi-modellen [Subjective stress and its relation to psychosocial work conditions and health
complaints. A test of the Stress–Energy model] (Rep. No. 12). Stockholm, Sweden: Arbetslivsinstitutet.
Kumari, M., Badrick, E., Ferrie, J., Perski, A., Marmot, M., & Chandola, T. (2009). Self-reported sleep duration and
sleep disturbance are independently associated with cortisol secretion in the Whitehall II study. Journal of Clinical
Endocrinology and Metabolism, 94, 4801–4809.
Kyle, S. D., Morgan, K., & Espie, C. A. (2010). Insomnia and health-related quality of life. Sleep Medicine Reviews,
14, 69–82.
 40 GARDE ET AL.

Luckhaupt, S. E., Tak, S., & Calvert, G. M. (2010). The prevalence of short sleep duration by industry and occupation
in the National Health Interview Survey. Sleep, 33, 149–159.
Mccrae, C. S., Mcnamara, J. P. H., Rowe, M. A., Dzierzewski, J. M., Dirk, J., Marsiske, M., : : : Craggs, J. G. (2008).
Sleep and affect in older adults: Using multilevel modeling to examine daily associations. Journal of Sleep Research,
17, 42–53.
Mezick, E. J., Matthews, K. A., Hall, M., Kamarck, T. W., Buysse, D. J., Owens, J. F., : : : Reis, S. E. (2009). Intra-
individual variability in sleep duration and fragmentation: Associations with stress. Psychoneuroendocrinology, 34,
1346–1354.
Morin, C. M., Rodrigue, S., & Ivers, H. (2003). Role of stress, arousal, and coping skills in primary insomnia.
Psychosomatic Medicine, 65, 259–267.
Okun, M. L., Krafty, R. T., Buysse, D. J., Monk, T. H., Reynolds, C. F., III, Begley, A., : : : Hall, M. (2010).
What constitutes too long of a delay? Determining the cortisol awakening response (CAR) using self-report and
PSG-assessed wake time. Psychoneuroendocrinology, 35, 460–468.
Downloaded by [UNAM Ciudad Universitaria] at 22:34 06 June 2013

Persson, R., Carlsson, E. F., Österberg, K., Ørbæk, P., & Karlson, B. (2008). A two-week monitoring of self-
reported arousal, worry and attribution among persons with annoyance attributed to electrical equipment and smells.
Scandinavian Journal of Psychology, 49, 345–356.
Persson, R., Garde, A. H., Hansen, Å. M., Ohlsson, K., & Ørbæk, P. (2003). The influence of production systems on
self-reported arousal, sleepiness, physical exertion and fatigue—Consequences of increasing mechanization. Stress
and Health, 19, 163–171.
Persson, R., Österberg, K., Garde, A. H., Hansen, Å. M., Ørbæk, P., & Karlson, B. (2010). Seasonal variation in
self-reported arousal and subjective health complaints. Psychology, Health and Medicine, 15, 434–444.
Riemann, D., Spiegelhalder, K., Feige, B., Voderholzer, U., Berger, M., Perlis, M., : : : Nissen, C. (2010). The
hyperarousal model of insomnia: A review of the concept and its evidence. Sleep Medicine Reviews, 14, 19–31.
Saper, C. B., Cano, G., & Scammell, T. E. (2005). Homeostatic, circadian, and emotional regulation of Sleep. Journal
of Comparative Neurology, 493, 92–98.
Schlotz, W., Hellhammer, J., Schulz, P., & Stone, A. A. (2004). Perceived work overload and chronic worrying predict
weekend–weekday differences in the cortisol awakening response. Psychosomatic Medicine, 66, 207–214.
Shekleton, J. A., Rogers, N. L., & Rajaratnam, S. M. (2010). Searching for the daytime impairments of primary
insomnia. Sleep Medicine Reviews, 14, 47–60.
Stalder, T., Hucklebridge, F., Evans, P., & Clow, A. (2009). Use of a single case study design to examine state variation
in the cortisol awakening response: Relationship with time of awakening. Psychoneuroendocrinology, 34, 607–614.
Steiger, A. (2007). Neurochemical regulation of sleep. Journal of Psychiatric Research, 41, 537–552.
Totterdell, P., Reynolds, S., Parkinson, B., & Briner, R. B. (1994). Associations of sleep with everyday mood, minor
symptoms and social interaction experience. Sleep, 17, 466–475.
Westerlund, H., Alexanderson, K., Åkerstedt, T., Magnusson, H. L., Theorell, T., & Kivimäki, M. (2008). Work-related
sleep disturbances and sickness absence in the Swedish working population, 1993–1999. Sleep, 31, 1169–1177.
Wüst, S., Wolf, J., Hellhammer, D. H., Federenko, I., Schommer, N., & Kirschbaum, C. (2000). The cortisol awakening
response—Normal values and confounds. Noise and Health, 7, 79–88.