Stress & Why I Don’t Do Salivary Cortisol Tests Anymore

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Kelly Brogan, MD,

Stress: Is it real or imagined?

Stress. It has become our constant companion. We know when we feel it and when we don’t feel it, we actually may even go looking for it. Have you ever had a moment of peace and quiet, only to watch your mind pounce into action in a desperate effort to figure out what you “should” be doing?

America is a culture predicated on an endless marathon toward the promised land of ease. We goad our populace along with fear of illness and death, fear of pain, fear of suffering, fear of failure. Ten minutes of television is enough to convince you that deadly enemies are lurking around every corner. We are ever layering quick fix upon quick fix, self-medicating, and digging ourselves deeper and deeper into dark holes. Then we wonder why we feel the need to scream, freak out, and wave the white flag.

This is why stress is such an important topic—it is biological, psychological, and spiritual. But ultimately, it is a reflection of misalignment with our highest expression. We are now learning that stress can travel from your mind to your brain to your gut1 AND from your gut to your brain to your mind!2 The language that it uses to communicate this message appears to be inflammation. We hear this communication as a feeling of tension, agitation, exasperation. A sense that we are being pulled beyond our capacity.

Modern science, and specifically the science of psychoneuroimmunology , has taken us on a tour of what stress looks like in the body. And while stress is no longer just in your mind, it can, in fact, be controlled by your mind, giving us a powerful way to affect our immune systems through our perception.3

Stress: If you believe in it, it’s real

We have been told there is good stress and bad stress. That good stress, or eustress, helps us grow, and that bad stress makes us sick. I would say that the perception of stress is the determining factor between whether we are sending our body a signal of danger or safety.

In a recent review by Ray et al,4 the authors refer to this definition:

More modern concepts view stress as a consciously or unconsciously sensed threat to homeostasis, in which the response has a degree of specificity, depending among other things, on the particular challenge to homeostasis, the organism’s perception of the stressor and the perceived ability to cope with it.

I often illustrate the role of perception to my patients by describing the following scenario:

Let’s say you are walking down a dark alley way at night, alone. You hear footsteps rapidly approaching from behind. What’s going to happen? Your mouth will go dry, your heart will start pounding, your breath will quicken, and you may have intrusive images of catastrophic possibilities.

If, then, you hear your friend’s voice coming from those footsteps, that entire cascade is going to reverse and you may even start laughing to release all of that tension.

The only thing that changed, of course, was your perception that there was danger. Your mind commandeered your body.

Can stress perception make you sick?

McEwen5 has written about the principle role of perception in the stress response that leads to bodily expression of illness. He refers to the burden on your bodymind as allostatic load, with perception of stress playing a major part in the development of physiologic response and illness.

Relatedly, Cohen et al report that the response to this simple question was the most meaningful determinant of clinical experience of the common cold: “In general, how would you rate your health?” After being inoculated with cold viruses, participants in Cohen’s study demonstrated that negative health perception led to the experience of common cold symptoms regardless of whether the immune system was reacting. In other words, if someone had a positive health perception, got exposed, and had antibody confirmation of immune response, they did not manifest clinical symptoms of the cold (i.e., get sick). Now, it’s possible that positive and negative perceptions result from a sensed experience of an inflammatory state that would lead to more frequent infections, but this relationship between thoughts, emotions, and the immune system is tridirectional. Each arm as significant as the other.

Do we need to measure stress?

When I first started out in functional medicine, I had transferred my mechanistic appreciation of the body to a greener approach. I still worked, as a clinician, from the perspective that biochemistry was reducible to cycles and pathways, except that now I was interested in the vitamins, amino acids, and minerals that made them “work.” Over time, and my own evolution, I began to appreciate that this quantification-focused healing was distracting both me and my patients from the larger shifts in consciousness that needed to happen. And from the personalization of the journey.

I began to understand the role of a test for stress response—the salivary cortisol test—in the ritual of healing and the potential placebo effect of seeing your own stress mapped out on paper, inspiring you to commit to bettering that line.

A deeper skepticism around the true meaning of measured salivary cortisol arose when I learned more about epigenomics and the role of receptor function in genetic expression. When we measure a hormone in blood, saliva, or urine, we can certainly get a bird’s eye view of whether there is something dramatically amiss, but we cannot be sure about how that compares to your optimal range, and what that hormone is doing on a cellular level, and in its interactions with the greater systems within your body.

A paper entitled “Mind-body Therapies and Control of Inflammatory Biology: A Descriptive Review”6 speaks to this complexity.

Bower et al reviewed 26 randomized controlled trials of “mind-body therapies” including Tai Chi, yoga, and meditation. What they found, in a nutshell, is that despite reports of improvement in stress levels, subjectively, study subjects showed mixed effects of inflammatory markers including CRP and IL-6 that have been correlated with stress and depression. They did find, however, that genomic markers revealed a more nuanced effect with a decrease in expression of inflammation-related genes and reduced signaling through the pro-inflammatory transcription factor NF-kB.

They suspect that these modalities exert their effect through a top-down self-regulatory process involving the autonomic nervous system, the endocrine system, and behavioral conditioning. It could also be, of course, that these ancient technologies serve to simultaneously use the body as its own healing instrument and connect consciousness to a place of expanded receptivity.

This is why I found it amusing that the paper ultimately speaks to identifying the “active ingredient” of these practices, seeking to reduce these complex tools into pharmacologic-like interventions.

Healing your stress response

While I believe in the symphony of lifestyle changes including detox, nutrition, and targeted supplementation, I believe a daily commitment to meditation to be the most powerful tool in the stress response arsenal. An intense type A, I destressed my human experience when I began meditating, pre-dawn in a dark moment of desperation after my mentor’s sudden death. I haven’t missed a day since because my perception of adversity, challenges, and conflict changed within two months of starting. I don’t need genomic testing to confirm what I already know—that I have greater access to my life force energy, every day, thanks to meditation.

This is why I champion the do-it-yourself approach to medicine—spend one month working with lifestyle interventions before you run to a consultation with a fancy doctor.

Try it and you’ll see, no tests necessary. Here’s one to get you started: it’s called Meditation for Negative Mind and it has the capacity to flip the switch on your inner alarm system dissolving all of the walls that were keeping you captive.

Copyright © Kelly Brogan. This work, originally appeared here, is reproduced and distributed with the permission of Kelly Brogan, MD. For more articles, sign up for her newsletter at



Kelly Brogan is boarded in Psychiatry/Psychosomatic Medicine/Reproductive Psychiatry and Integrative Holistic Medicine and practices Functional Medicine, a root-cause approach to illness as a manifestation of multiple-interrelated systems. After studying Cognitive Neuroscience at MIT and receiving her MD from Cornell University, she completed her residency and fellowship at Bellevue/NYU. She is one of the nation’s only physicians with perinatal psychiatric training who takes a holistic evidence-based approach in the care of patients with a focus on environmental medicine and nutrition. She is also a mom of two and an active supporter of women’s birth experience. She is the Medical Director for Fearless Parent and an advisory board member for Visit her website.

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