Standard Review Article

Psychother Psychosom 2021;90:11–27 Received: July 17, 2020

Accepted: August 6, 2020
DOI: 10.1159/000510696 Published online: August 14, 2020

Allostatic Load and Its Impact on Health:

A Systematic Review
Jenny Guidi a Marcella Lucente a Nicoletta Sonino b, c Giovanni A. Fava c
a Department
of Psychology, University of Bologna, Bologna, Italy; b Department of Statistical Sciences, University of
Padova, Padova, Italy; c Department of Psychiatry, State University of New York at Buffalo, Buffalo, NY, USA

Keywords ies, as well as clinical studies on consequences of allostatic

Allostatic load · Allostatic overload · Biomarkers · load/overload on both physical and mental health across a
Clinimetrics · Diagnostic Criteria for Psychosomatic variety of settings. Conclusions: The findings indicate that
Research · Stress allostatic load and overload are associated with poorer
health outcomes. Assessment of allostatic load provides
support to the understanding of psychosocial determinants
Abstract of health and lifestyle medicine. An integrated approach
Introduction: Allostatic load refers to the cumulative burden that includes both biological markers and clinimetric criteria
of chronic stress and life events. It involves the interaction of is recommended. © 2020 S. Karger AG, Basel
different physiological systems at varying degrees of activi-
ty. When environmental challenges exceed the individual
ability to cope, then allostatic overload ensues. Allostatic
load is identified by the use of biomarkers and clinical crite- Introduction
ria. Objective: To summarize the current knowledge on al-
lostatic load and overload and its clinical implications based The concept of allostatic load was introduced by Mc­
on a systematic review of the literature. Methods: PubMed, Ewen and Stellar in 1993 [1] and refers to the cost of
PsycINFO, Web of Science, and the Cochrane Library were chronic exposure to fluctuating or heightened neural and
searched from inception to December 2019. A manual search neuroendocrine responses resulting from repeated or
of the literature was also performed, and reference lists of chronic environmental challenges that an individual re­
the retrieved articles were examined. We considered only acts to as being particularly stressful. It derives from the
studies in which allostatic load or overload were adequately definition of allostasis as the ability of the organism to
described and assessed in either clinical or non-clinical adult achieve stability through change [2], and the view that
populations. Results: A total of 267 original investigations healthy functioning requires continual adjustments of the
were included. They encompassed general population stud- internal physiological milieu [3].

karger@[Link] © 2020 S. Karger AG, Basel Jenny Guidi

[Link]/pps Department of Psychology, University of Bologna
Viale Berti Pichat 5
IT–40127 Bologna (Italy)
jenny.guidi2 @ [Link]
Table 1. Clinical criteria for allostatic overload (A through B are required)

Criterion A The presence of a current identifiable source of distress in the form of recent life events and/or chronic stress; the
stressor is judged to tax or exceed the individual coping skills when its full nature and full circumstances are evaluated
Criterion B The stressor is associated with one or more of the following features, which have occurred within 6 months after the
onset of the stressor:
1. At least two of the following symptoms: difficulty falling asleep, restless sleep, early morning awakening, lack of
energy, dizziness, generalized anxiety, irritability, sadness, demoralization
2. Significant impairment in social or occupational functioning
3. Significant impairment in environmental mastery (feeling overwhelmed by the demands of everyday life)

The definition of allostatic load [1, 4, 5] reflects the cu­ end of the spectrum of associated symptomatology, sub­
mulative effect of experiences in daily life that involve or­ sumed under the rubric of allostatic overload.
dinary events (subtle and long-standing life situations) as Several studies have focused on identifying allostatic
well as major challenges (life events), and also includes load through biological markers [5, 7, 14, 16–25]. Seeman
the physiological consequences of the resulting health- et al. [16, 17] identified 10 biological parameters: cortisol,
damaging behaviors, such as poor sleep and circadian dis­ dehydroepiandrosterone (DHEA), epinephrine, norepi­
ruption, lack of exercise, smoking, alcohol consumption nephrine, cholesterol, glycosylated hemoglobin, resting
and unhealthy diet. When environmental challenges ex­ systolic and diastolic blood pressure, body mass index,
ceed the individual ability to cope, then allostatic over­ and waist-hip ratio. The first four parameters have been
load ensues [3, 6] as a transition to an extreme state where considered as primary mediators of allostatic load be­
stress response systems are repeatedly activated and buff­ cause of their immediate correlation with adrenal func­
ering factors are not adequate [7]. tion, whereas the remaining parameters were defined as
Situations that may lead to the development of allo­ secondary mediators [16, 17]. Biological markers of dis­
static load/overload are: (a) exposure to frequent stressors eases resulting from a condition of allostatic load were
that may determine a status of chronic stress and repeat­ defined as tertiary mediators [26]. Additional biomarkers
ed physiological arousal; (b) lack of adaptation to repeat­ (glucose levels, lipid profiles, interleukin-6, heart rate
ed stressors; (c) inability to shut off the stress response variability) have subsequently been recognized as having
after a stressor is terminated; (d) allostatic response not a role in the allostatic load response and were then in­
sufficient to deal with the stressor [8, 9]. cluded in a cumulative index of allostatic load, common­
In response to environmental demands, different ly known as the “allostatic load battery” [14, 17, 27]. This
physiological systems interact at varying degrees of activ­ index of allostatic load was found to be a better predictor
ity [1]. The neuroendocrine and immune systems re­ of mortality and decline in physical functioning than in­
spond to internal or external challenges and promote dividual biomarkers alone [28–31], yet a number of limi­
adaptation to threats or adversities [5, 8]. The hypotha­ tations emerged due to the complexity and dynamic na­
lamic-pituitary-adrenal axis plays a key role in the patho­ ture of this multisystem network [22].
physiology of allostatic load [5, 10]. Brain architecture While the biological perspective does not allow for a
and neurochemical functions are affected by both ge­ comprehensive understanding of allostatic load and over­
nomic and nongenomic mechanisms [11, 12]. Adjust­ load and related clinical phenomena, a substantial contri­
ments in the immune system (e.g., leukocytes, cytokines, bution has come from clinimetrics, the science of clinical
inflammation) do occur, with immunosuppressive effects measurements [32, 33]. Clinimetric criteria for the deter­
in the long run [13]. Alterations in body functions involv­ mination of allostatic overload and the underlying expe­
ing cardiovascular and gastrointestinal systems, endo­ riential factors (Table 1), as well as a semi-structured in­
crine-metabolic balances and sleep may ensue [5, 10, 14, terview, have been developed [6, 34] and included in the
15]. Diagnostic Criteria for Psychosomatic Research (DCPR)
Characterization of allostatic load has been carried out [35]. The interview can be supplemented by the Psycho­
by two distinct approaches. One is concerned with the use Social Index (PSI) [36, 37], a simple self-rated question­
of biomarkers that reflect physiological derangements; naire, tailored to a busy clinical setting, for a comprehen­
the other is a clinical approach targeted to the more severe sive assessment of stress, psychological distress, abnor­

12 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava

DOI: 10.1159/000510696
mal illness behavior and well-being. The PSI may provide Results
a quantitative measurement of the degree of allostatic
load, with opportunity to monitor its course over time. The initial search strategy provided 3,633 published
Use of cut-off points for identifying allostatic overload is articles that were screened for potential inclusion in the
also possible [36, 37]. The interview and the PSI may con­ review (online suppl. Fig. S1; for all online suppl. mate­
tribute to formulating a global clinical judgment of indi­ rial, see [Link]/doi/10.1159/000510696). A to­
vidual assets and coping skills in dealing with current life tal of 524 full-text articles were assessed for eligibility, 267
situations. The clinimetric evaluation of allostatic over­ of which were included in the systematic review.
load may help identify a state that, by exceeding individ­
ual resources, could constitute a danger to health. Unlike General Population Studies
in the DSM-5 diagnosis of adjustment disorder [38], the Sociodemographic Correlates
presence of a psychiatric disorder is not a source of exclu­ Several studies focused on the association between so­
sion from the criteria. ciodemographic variables and allostatic load [18, 19, 22,
With this systematic review we try to summarize the 23, 42–58].
current knowledge on allostatic load/overload and its Low socioeconomic status was associated with high
clinical implications. Previous systematic reviews [29, 30, levels of allostatic load [59–68]. The findings were con­
39, 40] were concerned with specific aspects such as firmed by other investigations where high socioeconom­
health disparities, workforce, socioeconomic position ic position appeared to be related to low allostatic load
and psychosocial resources. [45, 53, 69–72]. Similarly, income level was negatively re­
lated to allostatic load in different populations [65, 73–
76]. Perceived neighborhood quality may have an impact
Methods on allostatic load [77, 78], and high levels of allostatic load
Search Strategy
were reported by individuals living in impoverished [79–
The methods used fulfilled the PRISMA guidelines [41]. Pub­ 85] or segregated neighborhoods [86]. Nonetheless,
lished articles concerning allostatic load/overload were identified adults who grew up in low socioeconomic status house­
by searching in PubMed, PsycINFO, Web of Science, and the Co­ holds showed lower levels of allostatic load when adapt­
chrane Library from inception to December 2019. Search terms ing to life stressors maintaining a focus on the future [87].
included “allostatic load” or “allostatic overload.” Only published
articles in the English language and involving human subjects were
Factors such as renting one’s home, having low income,
considered for inclusion. A manual search of the literature was also and smoking were found to mediate the association be­
performed, and reference lists of the retrieved articles were exam­ tween socioeconomic position and allostatic load [88]
ined for further studies not yet identified. and explain socioeconomic disparities in allostatic load
[88]. Parental socioeconomic position was found to be
Study Selection
We considered only those studies in which allostatic load or
inversely associated with midlife allostatic load, and part
overload were adequately described and assessed in either clinical of this association was mediated by education [89]. In a
or non-clinical adult populations. Biological evaluation of allostat­ longitudinal community-based study on a multi-ethnic
ic load should be based on at least 3 biological markers. Allostatic cohort of midlife women, high racial discrimination and
overload was determined according to clinimetric criteria. Studies hostility, low income, and low education significantly
involving pediatric or adolescent populations were excluded.
predicted high allostatic load levels [65].
Data Extraction In some studies, allostatic load was negatively associ­
The first two authors (J.G. and M.L.) independently performed ated with years of education [61, 73, 79, 90–92]. However,
the search, screened titles and abstracts, assessed the full text of two investigations [93, 94], examining the mediating role
articles appearing potentially relevant, and selected studies meet­ of ethnicity in the relationship between allostatic load and
ing the eligibility criteria. In case of disagreement, a consensus was
reached through discussion with the senior authors (N.S. and educational attainment, found the highest levels of allo­
G.A.F). static load among minorities with a college degree or
more.
Data Synthesis Ethnicity was associated with allostatic load, with
All selected original investigations were reported in the system­ Black Americans displaying higher levels of allostatic load
atic review. Other studies (e.g., articles not primarily focused on
allostatic load and studies not involving adults) were not included. compared to Whites [95–99]. Among immigrants, a pos­
The most relevant reviews were cited in the introduction and dis­ itive association between allostatic load and duration of
cussion. residence was found [100–102], whereas studies on age at

Allostatic Load and Health Psychother Psychosom 2021;90:11–27 13

DOI: 10.1159/000510696
immigration yielded mixed results [101, 102]. The rela­ adults with canine companionship displayed lower levels
tionship between perceived racial discrimination and al­ of allostatic load compared to those without [144].
lostatic load was found to be mitigated by the effect of Data from a large community-based study on partici­
educational attainment among African American women pants aged 60 years and over showed a significant asso­
[103]. Differential associations between everyday versus ciation between increased allostatic load levels and wors­
institution-specific racial discrimination and allostatic ening of visual acuity, after adjustment for confounders
load were found among black women [104]. Further­ [145]. Further, worse visual acuity increased mortality
more, higher allostatic load was shown by individuals re­ risk, with a potential mediating effect of allostatic load
porting greater perceived racial [105] or social inequali­ [145].
ties [63, 106], or adversities over the life course [107, 108].
In addition to perceived racial discrimination [65, 109– Work and Environment
114], also acculturation stress [115] and weight discrimi­ Several studies showed that high levels of allostatic
nation [116, 117] were found to be associated with high load were correlated with work-related stress [108, 114,
levels of allostatic load. 146–151], poor quality job [152] and burnout syndrome
There was an association between allostatic load and [153, 154], but no significant associations were found in
gender-related characteristics (e.g., androgynous and un­ other studies [155–158]. A negative association between
differentiated individuals, masculinity levels), as well as allostatic load and heart rate variability in males em­
sexual orientation (i.e., lesbian, gay, and bisexual indi­ ployed full-time was reported [159]. Allostatic load was
viduals) [118–122]. related to insufficient recovery from work stress in wom­
A negative association between allostatic load bio­ en [160], job demand and reorganization at workplace
markers and religious attendance has been reported [150, 161, 162], self-employment [163] and effort-reward
[123]. Weekly religious service attendance was associated imbalance that is regarded as the core dimension of the
with lower allostatic load in older adults [124–126]. A sig­ burnout syndrome [146, 164]. In a study on civil service
nificant inverse association between church attendance workers [165], a non-linear, stable association between
and all-cause mortality risk, partially explained by allo­ negative emotional response to major life events and al­
static load, was also found [127]. lostatic load was observed.
In two cross-sectional studies, greater vegetated land
Aging cover near residence was associated with low allostatic
Several studies have shown an association between al­ load levels [166, 167]. Conversely, living in an unhealthy
lostatic load and frailty, a multidimensional loss of indi­ environment may have deleterious effects on health. Lead
vidual resources with aging [128–130]. Evaluation of exposure [168, 169], perception of pollution [170], dan­
data from two prospective population-based cohort gerous traffic [125], household crowding [171], and envi­
studies [131] have suggested that several allostatic load ronmental riskscapes [172] may contribute to allostatic
parameters could be considered as a preclinical marker load increased levels. Furthermore, poor indoor environ­
of frailty. mental quality could raise allostatic load [173], whereas
Allostatic load was associated with a decline in cogni­ better housing conditions and satisfaction with own
tive and physical functioning in older adults [16, 17, 130, house appeared to reduce allostatic load [125].
132–135], changes in brain structure with aging [136],
brain-predicted age difference [137], and inversely relat­ Early Life Events
ed to white-matter and brain volume [138]. A potential Adverse childhood experiences, including child abuse
link between an immune risk phenotype and allostatic and maltreatment, were found to be associated with high
load in very old adults was identified [139]. Allostatic load levels of allostatic load in adulthood [174–180]; only in
was also found to increase delirium in hospitalized elder­ one study [181] childhood socioeconomic status and
ly patients [140] and the risk of mortality [141, 142]. Data stress exposure in adulthood were found to predict allo­
from a representative longitudinal study on older adults static load, while adverse childhood experiences were not.
[143] showed that high allostatic load levels were associ­ Perceived social support across the life span partially
ated with several personality characteristics (neuroticism, mediated the association between child maltreatment
lower extroversion, lower conscientiousness) at baseline, and allostatic load in adulthood [182]. As to family envi­
and with declines in extroversion, conscientiousness, ronment, some studies reported the association between
agreeableness and openness at a 4-year follow-up. Older either harsh parenting in adolescence [183], lower family

14 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava

DOI: 10.1159/000510696
support [184], or negative family interactions [185, 186] Consequences on Physical Health
and allostatic load in adulthood. Conversely, emotional A number of studies addressed the relationship be­
and instrumental support in childhood [187], warmth tween allostatic load and health status and outcomes
within the family [174], and parental academic involve­ [204–208], including chronic conditions [209], disabili­
ment [188] appeared to be associated with lower allostat­ ties [210], pain [211, 212], and mortality [17, 24, 56, 213–
ic load in adulthood. Allostatic load in adulthood seems 218].
to be related also to avoidant attachment patterns [189] Poor self-rated health, a measure of actual health status
and predicted by adult anxious attachment style [190]. as perceived by an individual, was associated with mark­
ers of allostatic load, such as increased cytokine levels
Well-Being and Coping Strategies [219], higher body mass index and worse lipid profiles
Cross-sectional data derived from a multidisciplinary [220]. A negative association between self-rated health
prospective population-based cohort study showed an in­ and allostatic load has been documented by other studies
verse association between allostatic load and positive af­ [206, 221–223], and ethnicity seemed to play a mediating
fects, after adjusting for confounders, with a stronger as­ role [223].
sociation in women than men [191]. Allostatic load was found to be related to leukocyte
As to well-being dimensions, data from the Midlife in telomere length [224]. Levels of vitamin D [225] and se­
the United States (MIDUS) survey showed that greater rum carotenoid concentrations [226] appeared to be in­
purpose in life predicted lower levels of allostatic load at versely associated with allostatic load.
a 10-year follow-up [192], while studies on positive rela­
tionships and social support yielded mixed results [50, Lifestyle Habits
193–196]. In a longitudinal study on middle-aged healthy Physical activity was found to be associated with lower
women, allostatic load at baseline was found to be a neg­ allostatic load [227–229], whereas poor sleep quality
ative predictor of sense of coherence at a 6-year follow-up [230–233], unhealthy diet and overweight [52, 218, 228,
[197]. 234–239], alcohol consumption [52, 92, 228, 229, 240]
In a cross-sectional analysis of data from a large com­ and smoking habits [241] were associated with high allo­
munity-based study on African American adults [198], static load levels.
women, but not men, using disengagement coping styles
displayed significantly higher allostatic load scores. Cardiovascular Diseases
Among self-employed individuals, problem-focused cop­ Allostatic load was linked to increased risk for cardio­
ing strategies were negatively associated with allostatic vascular diseases, particularly coronary heart disease
load [163]. Cognitive reappraisal was indirectly associat­ [242], ischemic heart disease [243] and peripheral arte­
ed with lower allostatic load, whereas the tendency to use rial disease [244].
emotion suppression was indirectly associated with great­ A clinimetric evaluation of allostatic overload by spe­
er allostatic load [199]. Further, a significant inverse as­ cific criteria [6, 34, 35] was performed in a number of
sociation was found between intrinsic capacity (i.e., phys­ studies in cardiac settings. In outpatients with essential
ical and mental skills acquired and modified throughout hypertension and coronary heart disease [245], the pres­
life) and allostatic load among older adults [200]. ence of allostatic overload was characterized by a higher
disease-related emotional burden, poor psychosocial
Caregiving functioning and high rates of psychopathology. Similarly,
Caring for an ill and/or disabled person (i.e., caregiving) in patients with atrial fibrillation [246], allostatic over­
represents a risk factor for developing allostatic load, load was associated with increased psychological distress
which, in turn, may affect individual health status [151]. (e.g., depressive and anxiety disorders). In a study on pa­
The number of negative life events among caregivers of tients undergoing implantable cardioverter defibrillator
patients with Alzheimer disease was found to be related to implantation [247], 16.2% reported moderate allostatic
allostatic load [201]. Caregivers of patients with Alzheimer overload, while 4.3% reported severe allostatic overload.
disease showed higher levels of allostatic load compared to The presence of allostatic overload before implantation
controls, and this association was mitigated by personal was the only significant predictor of subsequent negative
sense of mastery [202]. Parents of children with develop­ cardiac outcomes, including complications and death af­
mental disorders had lower allostatic load when reporting ter implantation. In patients with congestive heart failure,
higher positive affects in a controlled study [203]. prevalence of allostatic overload was as high as 32.9%

Allostatic Load and Health Psychother Psychosom 2021;90:11–27 15

DOI: 10.1159/000510696
[248], with a significant association with hyperglycemia stress [267]. In a sample of individuals with a first unpro­
among cardiac risk factors. In essential hypertension, voked seizure or newly diagnosed epilepsy, allostatic load
32.5% of patients reported allostatic overload and dis­ was associated with a higher risk of seizures [268].
played significantly higher levels of psychological distress In a recent study [269], allostatic overload based on
and a greater prevalence of psychosomatic syndromes clinimetric criteria was one of the most frequent psycho­
[249]. The presence of allostatic overload among hyper­ somatic diagnoses among patients with either episodic or
tensive patients was associated with lower levels of well- chronic migraine.
being and quality of life [249], unlike in a previous study
that used different criteria [250]. Cancer
Women with breast and ovarian cancer displayed el­
Diabetes evated basal cortisol levels and decreased acute cortisol
Patients with type 2 diabetes experienced higher allo­ reactivity compared to healthy controls [270]. Among pa­
static load and greater depressive and hostile symptoms tients with breast cancer, black women reported higher
compared to controls [251]. They were found to display levels of allostatic load compared to both white patients
a disruption of multisystem responses to stress, as indi­ and control subjects [271], after adjusting for confound­
cated by systolic and diastolic blood pressure, heart rate, ers. Allostatic overload was more common among cancer
total cholesterol, salivary cortisol, and plasma IL-6 levels. survivors (52%) than healthy controls (33%) [272].
Similarly, among patients with type 2 diabetes, allostatic A randomized controlled trial reported the clinical
load was associated with high systolic and diastolic blood utility of a mentor-based supportive-expressive program
pressure, and glycated hemoglobin [252]. designed to help women with metastatic breast cancer,
that obtained significant improvements in allostatic load
Gynecology and Obstetrics parameters as well as in affective symptoms and quality
There was an association between early age at men­ of life [273].
arche, retrospectively ascertained, and allostatic load
[253]. Periodontal Diseases
Allostatic load in early pregnancy was significantly Data from a large community-based investigation
higher in a sample of women with preeclampsia com­ [243] and a subsequent study [274] provided support for
pared to controls, suggesting a possible role of chronic the association between allostatic load and periodontal
stress in the development of this condition [254]. Al­ diseases. Further, children of mothers with increased al­
though some studies reported that allostatic load among lostatic load were significantly more likely to have dental
pregnant women may contribute to adverse pregnancy caries, suggesting the role of maternal stress in child oral
and birth outcomes [255–257], research findings appear health [275].
to be rather controversial [81, 258, 259].
Consequences on Mental Health
Musculoskeletal Disorders A clinimetric assessment in the general population
In a cross-sectional study, greater allostatic load levels [276] revealed that subjects with allostatic overload had
were associated with lower spine bone mineral density significantly higher levels of self-rated stress, psychologi­
and lower femoral neck strength values [260]. cal distress and abnormal illness behavior than those
Symptom frequency and intensity were associated with without. The clinimetric criteria for allostatic overload
higher levels of allostatic load among chronic fatigue syn­ were able to discriminate the presence of psychological
drome patients compared to controls [261–263]. In this distress in another sample of the general population as
condition, polymorphisms in angiotensin-1-converting well [277]. In a primary care setting [278], allostatic over­
enzyme linked to allostatic load were reported [264]. load was the most frequently reported psychosomatic
A recent preliminary study on female outpatients with syndrome according to the DCPR [35]; it was associated
fibromyalgia found a prevalence allostatic overload, based with significantly greater psychological distress, lower
on clinimetric criteria, as high as 25% of the sample [265]. well-being and impaired quality of life.

Neurological Disorders Mood and Anxiety Disorders

Depressive symptoms after traumatic brain injury ap­ Several studies showed a significant association be­
peared to be related to chronic stress [266] and perceived tween depressive and anxiety symptoms and allostatic

16 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava

DOI: 10.1159/000510696
load [279–283], not confirmed by others [233, 284–286]. static load appeared to be inversely related to psychoso­
In the association between childhood physical abuse and cial [299] and cognitive functioning [301] in psychotic
depression in adulthood, allostatic load appeared to have patients.
a mediating role [287]. In a prospective study [288], reac­
tion time in adolescence was found to be predictive of Alcohol Dependence
depressive symptoms in adulthood, with a mediating ef­ The combined contribution of hypothalamic-pitu­
fect of cumulative allostatic load. Data from a large com­ itary-adrenal reactivity and environmental stressors to
munity-based study showed that high allostatic load was relapse severity in alcohol-dependent men following
more strongly associated with depression among white treatment was investigated [302]. Greater levels of ongo­
women and black men than among their respective coun­ ing life stress strengthened the relationship between ad­
terparts, with differences across gendered race groups renocortical sensitivity and post-treatment drinking. En­
[282]. In emergency patients primarily diagnosed with vironmental stressors increased relapse intensity [302].
mood or anxiety disorders [283], higher levels of allostat­
ic load were found than in those diagnosed with personal­
ity disorders. Discussion
In a study on older adults, higher levels of allostatic
load were associated with both affective and somatic de­ Most research on allostatic load relies on biomarkers
pressive symptoms [280] and were prospectively associ­ that express a state of body systems, but do not provide in­
ated with depressive symptoms at a 3-year follow-up in formation on the underlying individual causes. Moreover,
another [279]. Among older euthymic bipolar disorder substantial heterogeneity exists across studies as to the type
patients [289], allostatic load was found to be associated and number of parameters to be considered. It seems that
with delayed memory performance. use of clinimetric tools can increase the number of people
screened, set the use of biomarkers in a clinical context,
Post-Traumatic Stress Disorder and broaden dissemination of measures to prevent or de­
Allostatic load helped to understand the association crease the negative impact of toxic stress on health.
between maternal post-traumatic stress disorder (PTSD) The findings indicate that higher allostatic load and
and birth outcomes (i.e., pregnancy complications, pre­ overload are associated with poorer health outcomes in
term birth) [290]. Mothers of pediatric cancer survivors both general and clinical populations. The results provide
were found to display significantly higher levels of allo­ support to the clinical utility of the trans-diagnostic iden­
static load compared to control mothers of healthy chil­ tification of allostatic load and overload in a variety of
dren, and those meeting criteria for PTSD reported the settings, with a number of potential applications.
highest allostatic load levels [291, 292]. In adults with ear­ Consideration of allostatic load may increase the pre­
ly life traumas, neuroendocrine biomarkers of allostatic dictive power of the assessment procedure and may con­
load were significantly related to early life stress and sub­ tribute to the understanding of many symptoms that are
sequent PTSD development [293]. In a study on women commonly encountered in clinical practice, but that, in a
veterans reporting multiple sexual assaults during child­ predominantly disease focused model, fail to receive ade­
hood and civilian and military life, higher allostatic load quate attention and care [303, 304]. Clinical assessment of
levels were detected compared to women reporting sexu­ allostatic overload may help to demarcate important dif­
al assault in only one life circumstance [294]. ferences in patients who otherwise seem deceptively simi­
lar because they share the same medical diagnosis, as it was
Psychotic Disorders found to be the case in cardiovascular diseases [242–244],
Allostatic load was associated with cortical thickness particularly congestive heart failure [248], atrial fibrillation
[295] and fornix microstructure [296] in schizophrenic [246] and hypertension [249]. Allostatic load acknowledg­
patients. It seemed to have a role early in the course of es the burden of different phases of medical disorders. Ex­
schizophrenia and in greater severity of positive psychot­ amples are provided by the post-hospital syndrome, a pe­
ic symptoms in its early stages [297], as well as in the riod of enhanced vulnerability to disease and to adverse
chronic course of the disease [298]. Accordingly, higher events [305]; difficulties related to the process of recovery
levels of allostatic load were found in patients at their first or rehabilitation [306]; and the cumulative long-standing
psychotic episode [299, 300] and at acute relapse of chronic disease impairment [307]. In general, psychologi­
schizophrenia [301] compared to control subjects. Allo­ cal distress was reported in subjects displaying allostatic

Allostatic Load and Health Psychother Psychosom 2021;90:11–27 17

DOI: 10.1159/000510696
overload [276–278], which could also be linked to the onset situations [304, 318–320] may also be of value. The clinical
and course of psychiatric disorders [297, 308, 309]. diagnosis of allostatic overload may be helpful in a com­
General population studies indicate that allostatic load prehensive approach that seeks to understand how the in­
is increased by low socioeconomic status, living in impov­ teractions among genetics, mind, body, behavior and the
erished neighborhoods, low educational attainment, eth­ environment affect both the risk of disease and the re­
nicity and racial discrimination [39, 93]. Further, most of sponse to treatment [321]. However, we still lack studies
the studies indicate a relationship between high levels of that employ both clinimetric criteria and biological mark­
allostatic load and work-related stress (including caregiv­ ers. Such investigations would shed some light on the cor­
ing) with the ensuing risk of burnout syndrome [151, 153, respondence between clinical and biological parameters,
154]. In this regard, allostatic overload has been used as a and provide a determination of the state of allostatic over­
conceptual framework for understanding the physical and load better than either criteria used alone. In this context,
psychological state of medical health workers facing the consideration of components that may buffer the impact
COVID-19 pandemic [310, 311]. In older adults, allostatic of stress may be important [313]. In clinimetric terms, this
load was found to be associated with a decline in cognitive translates into consideration of psychological well-being
and physical functioning, and with frailty, as a multidi­ and euthymia [317, 322]. McEwen [314] has emphasized
mensional loss of individual resources [128–132]. Adverse how coping with daily life challenges is continuously shap­
experiences in childhood, including child abuse and mal­ ing both brain circuitry and systemic physiology, which, in
treatment, were found to predict high levels of allostatic turn, determine lifestyle choices in terms of protective or
load later in life [15, 312]. Altogether, individual psycho­ damaging health behaviors. Such adaptive changes may
logical well-being and coping styles may modulate the as­ trigger epigenetic mechanisms [314, 323] that modulate
sociation between socio-demographic factors and allostat­ physiological and psychological sensitivity and are rele­
ic load [87], and higher psychosocial resources were linked vant for regenerative processes [313]. Consideration of the
to lower allostatic load [40, 194]. Environmental factors, impact of allostatic load on health also calls for a multidis­
such as work and living conditions, play an important role ciplinary organization of health care to overcome the arti­
in determining allostatic load [125, 149, 162], but their ficial boundaries among medical specialties, based mostly
modification is often not taken into account. Work condi­ on organ systems (e.g., cardiology, endocrinology) that ap­
tions are modifiable factors to be targeted by specific inter­ pear more and more inadequate in dealing with symptoms
ventions [313]. Work reorganization and stress manage­ and problems which cut across organ system subdivisions
ment in employees may reverse allostatic overload and [303, 324, 325].
stimulate physiological regeneration processes and recu­
peration [313]. Inclusion of allostatic load in the clinical
assessment allows to view illness within the interaction be­ Acknowledgments
tween the individual and the surrounding environment.
We are grateful to Emanuela Offidani, PhD, for helpful sugges­
Allostatic load was associated with health-damaging
tions.
lifestyle habits, such as lack of physical activity, unhealthy
diet and poor sleep, in several investigations [52, 228, 229,
233, 239]. The metabolic syndrome, which may be fre­ Conflict of Interest Statement
quently associated with allostatic load [17], is an important
example of the devastating effects of harmful lifestyles and The authors have no conflicts of interest to declare.
of the need to prevent its occurrence as early as possible in
life [314]. Individuals may try to counteract manifestations
of allostatic overload by the use of medications (e.g., sleep­ Funding Sources
ing pills). However, the adverse iatrogenic effects [315]
may cause a state of “pharmacological allostatic load” [27] None.
and medications do not entail solution to problems they
are used for. Promoting lifestyle modifications and pursuit
of psychological well-being, whose importance is increas­ Author Contributions
ingly recognized in clinical medicine [316] and psychiatry All authors conceived the project. J. Guidi and M. Lucente per­
[317], may provide more enduring effects. Psychothera­ formed the searches and collected the data. All authors analyzed
peutic strategies aimed at improving coping with stressful the data, drafted and revised the paper.

18 Psychother Psychosom 2021;90:11–27 Guidi/Lucente/Sonino/Fava

DOI: 10.1159/000510696
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