Cortisol and Anxiety: Understanding the Connection

An estimated 75-90% of human diseases have been linked to activation of the stress response. The stress hormone cortisol is, in part, responsible for causing anxiety, which is a mental health disorder that affects over 40 million American adults. 

The relationship between cortisol and anxiety is complex and bidirectional. Chronic elevation of cortisol levels can contribute to heightened anxiety symptoms, affecting mood, cognition, and behavior. Conversely, anxiety and stress can stimulate cortisol secretion, perpetuating a cycle of dysregulation that impacts both mental and physical health. Understanding this intricate relationship is essential for developing effective strategies to manage anxiety and cortisol levels.

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Understanding Cortisol

Cortisol is a hormone that helps regulate metabolism, immune responses, blood sugar levels, and inflammation. Its secretion follows a circadian rhythm, peaking in the early morning to help wake the body and gradually declining throughout the day, promoting sleep at night. (28) 

The body's hypothalamus-pituitary-adrenal (HPA) axis is activated in response to stress. The hypothalamus releases corticotropin-releasing hormone (CRH), stimulating the pituitary gland to produce adrenocorticotropic hormone (ACTH). ACTH then signals the adrenal glands to release cortisol. This cortisol surge helps the body cope with stress by increasing energy production and suppressing non-essential functions like digestion and reproduction. Once the stress subsides, cortisol levels return to baseline, allowing the body to resume normal functioning. However, chronic stress can lead to dysregulation of the HPA axis, contributing to various health issues like anxiety, depression, and metabolic disorders. (28) 

The Link Between Cortisol and Anxiety

The relationship between cortisol and anxiety is a topic of significant interest and research. Understanding the link between the two provides valuable insight into the development, progression, and holistic management of anxiety disorders.

Cortisol's Impact on Mental Health

Elevated cortisol levels have been closely associated with heightened anxiety symptoms, including restlessness, insomnia, racing heart, and sweating (3, 14).  

Cortisol interacts with receptors in the amygdala, hippocampus, and prefrontal cortex, affecting emotional processing, memory, and decision-making. Chronic exposure to elevated cortisol levels can lead to structural changes in the brain, contributing to cognitive and emotional deficits.

Research findings demonstrate a correlation between chronic stress, high cortisol levels, and the exacerbation or onset of mood disorders, including anxiety.

Anxiety Disorders and Cortisol Response

Individuals with anxiety disorders often exhibit abnormal cortisol responses to stress, characterized by either hyperactivity or hypoactivity of the adrenal axis. Some individuals may have exaggerated cortisol responses, leading to increased anxiety sensitivity and risk of developing anxiety disorders. Conversely, others may display blunted cortisol responses, indicating dysregulation of the stress response system. 

The cortisol awakening response (CAR) refers to the natural increase in cortisol levels within the first hour after waking up in the morning. It's a measure of the body's physiological response to the transition from sleep to wakefulness. It is influenced by the body's internal circadian rhythm and external factors like stress.

The CAR provides insights into the functioning of the HPA axis. A robust CAR indicates a healthy HPA axis and an efficient stress response system. Abnormalities in the CAR, such as blunted or exaggerated responses, can indicate dysregulation of the HPA axis. (15) According to a 2014 six-year prospective study, a higher CAR was a significant predictor of the first onset of anxiety disorders.

Identifying and Managing High Cortisol Levels

Early recognition of the signs of high cortisol prevents long-term health consequences of chronic stress, including the following chronic diseases:

• Cardiometabolic disease
• Infertility
• Immune dysregulation
• Psychiatric disorders
• Osteoporosis
• Neurocognitive decline (46) 

Signs of Elevated Cortisol

During the "fight or flight" response, triggered during stressful situations, cortisol mobilizes energy reserves, increasing blood sugar levels and enhancing the metabolism of carbohydrates, proteins, and fats. This provides the body with immediate energy to cope with the perceived threat. (44) 

Elevated cortisol levels during the stress response can lead to various signs and symptoms, including: 

• Increased heart rate
• Elevated blood pressure and blood sugar
• Sweating
• Rapid breathing
• Anxiety
• Insomnia (31, 52) 

Cushing's syndrome is a hormonal disorder caused by prolonged exposure to high levels of cortisol, either produced by the body in excess or introduced externally through medications like corticosteroids. Hallmark signs and symptoms of Cushing's syndrome include:

• Weight gain around the abdomen and face ("moon facies") 
• Fat pads on the upper back ("buffalo hump")
• Thin, fragile skin that bruises easily
• Purple stretch marks on the skin
• Slow wound healing
• Muscle weakness and wasting
• High blood pressure

Cortisol Testing

Cortisol levels can be measured through blood, saliva, or urine tests. 

Blood Tests

Blood tests, typically done at 8 am, provide a snapshot of cortisol levels at the time of the blood draw. They can be ordered as first-line testing when endocrine disorders, such as Cushing's or Addison's disease, are suspected. (50) 

Serum Cortisol Testing Options:  

• Cortisol by Access Med Labs
• Cortisol by BostonHeart Diagnostics

Salivary Tests

Salivary testing involves collecting multiple samples throughout the day, providing a more comprehensive picture of cortisol secretion patterns, including the CAR. Salivary testing is less invasive and can be done at home. (8)

Salivary Cortisol Testing Options: 

• Diurnal Cortisol by ZRT Laboratory
• ASP with CAR by Genova Diagnostics

Urine Tests

Urine tests can measure cortisol levels through single or multiple sample collections. In single-sample urine testing, a urine sample is collected at a specific time, typically in the morning. This method is helpful for measuring cortisol and its metabolites to aid in assessing HPA axis activity. (7) 

24-hour urine testing involves collecting all urine produced over a whole day to measure total cortisol output. This aids in diagnosing conditions like Cushing's syndrome or adrenal insufficiency. (7) 

Urinary Cortisol Testing Options: 

• Adrenal Corticoids Profile by Doctor's Data
• NeuroAdrenal Profile - Random by Doctor's Data

5 Natural Strategies for Reducing Cortisol and Anxiety

Certain foods and lifestyle habits can help develop resiliency to stress, reestablish a healthy stress response, and alleviate the symptoms of high cortisol.

Regular Physical Activity

Physical activity is an effective strategy for lowering cortisol levels and reducing symptoms of anxiety. 

Individuals with anxiety who exercise before being subjected to stress have a lower cortisol response than those who do not. Exercise also reduces inflammation and oxidative stress, both of which have also been implicated in anxiety's pathophysiology. (40) 

Practice Mindfulness

Mindfulness involves maintaining awareness of the present moment without making judgments. Practicing mindfulness and other mind-body practices balances the nervous system, enhancing one's ability to cope with stress and reduce cortisol levels. 

According to a 2018 analysis that included more than 12,000 participants, treating anxiety and depression with mindfulness-based approaches is just as effective as first-line treatment therapies, such as cognitive behavioral therapy (CBT) and antidepressant medications.

Adequate Sleep

Sleep deprivation is connected to increased cortisol levels, stress, and anxiety.

Deep sleep inhibits the HPA axis, so making sure you can fall asleep and stay asleep soundly is essential for regulating the body's stress response. Here are basic tips for improving sleep hygiene:

• Go to bed and wake up at the same time every day, even on weekends
• Create a relaxing bedtime routine
• Make sure your bedroom is dark, quiet, and cool
• Limit exposure to screens at least an hour before bedtime
• Avoid large meals, caffeine, and alcohol before bedtime

Balanced Diet

Diets high in added sugars, refined grains, and saturated fats have been linked to higher cortisol levels compared to diets high in whole grains, fruits, vegetables, and polyunsaturated fats. Nutrient-dense foods, such as those eaten on a Mediterranean diet, counteract the effects of stress-induced inflammation and potentially reduce the risk of mental health disorders. 

Fermented foods have also gained attention for their potential benefits in supporting mental health through the gut-brain axis. This axis refers to the bidirectional communication between the gut microbiota and the brain that regulates mood, cognition, and behavior.

The Role of Professional Help

From comprehensive evaluations to personalized treatment plans, mental health professionals provide support and guidance for individuals navigating challenges related to high cortisol and anxiety. 

When to Seek Medical Advice

Patients should be encouraged to seek medical advice if they are experiencing persistent symptoms of high cortisol and anxiety, such as chronic stress, sleep disturbances, and mood changes, despite self-care efforts. 

A comprehensive evaluation by a healthcare provider can identify underlying health issues contributing to cortisol dysregulation and anxiety disorders. Mental health professionals, including psychologists and psychiatrists, can offer specialized support and treatment options tailored to the individual's needs, ranging from psychotherapy to medication management.

Treatment Options for Anxiety and Cortisol Dysregulation

Managing anxiety and cortisol dysregulation involves a multidisciplinary approach. CBT is a well-established psychotherapeutic approach that helps individuals identify and modify maladaptive thought patterns and behaviors contributing to anxiety symptoms. 

When needed, medications such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may be prescribed to alleviate anxiety symptoms and regulate cortisol levels.

In addition to therapy and medication, stress management techniques can be instrumental in managing cortisol dysregulation and anxiety. These may include mindfulness meditation, deep breathing exercises, progressive muscle relaxation, regular physical activity, and adaptogenic and stress-relieving supplements. 

Developing personalized treatment plans in collaboration with healthcare professionals ensures that interventions are tailored to the individual's specific needs, preferences, and health status, optimizing outcomes and promoting overall well-being.

Frequently Asked Questions

Here are answers to frequently asked questions about cortisol. 

What Type of Hormone Is Cortisol?

Cortisol is a stress hormone belonging to the glucocorticoid class of steroid hormones. The body makes steroid hormones from cholesterol. (23) 

Where Is Cortisol Produced? 

Cortisol is produced by the adrenal glands, located on top of the kidneys. Specifically, the zona fasciculata of the adrenal cortex is responsible for synthesizing cortisol. (13)

What Causes Cortisol to Increase? 

High cortisol levels can be caused by tumors, excessive use of steroid medications, prolonged stress, and chronic inflammation (12).  

How Can You Lower Cortisol?

Strategies like stress management techniques (meditation, deep breathing, CBT), regular exercise, adequate sleep, and a balanced diet with mindful consumption of caffeine and alcohol can help lower cortisol (12). 

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Key Takeaways

• Cortisol plays a significant role in anxiety and stress, influencing both mental and physical health. Therefore, diagnosing and managing high cortisol levels is one aspect of a comprehensive care plan to manage and promote resilience to stress.
• Stress management techniques, such as regular exercise, good sleep, mindfulness, and a balanced diet, are evidence-based therapies that can normalize cortisol levels and reduce anxiety symptoms.
• Healthcare professionals can provide support and personalized treatment options for individuals struggling with symptoms of stress and anxiety despite adhering to self-care practices.