Navigating the New Normal: How to Cope with Re-Entry Anxiety

Dr. Turck:
The so-called quarantine blues may be coming to an end for many people as the country begins to slowly open back up. But let us not forget about those who may have found comfort in social distancing and mask-wearing mandates. In fact, as restrictions lift, many people are experiencing feelings of anxiety and stress when returning to public places. Which is why today, we're going to talk about how we can help our patients navigate this change.

Coming to you from the ReachMD studios, this is COVID-19: On the Frontlines. I'm Dr. Charles Turck. And joining me is Dr. Gail Saltz, a psychiatrist and author of a book titled, The Power of Different: The Link Between Disorder and Genius. She's also the host of the podcast, “How Can I Help.” Dr. Saltz, welcome to the program.

Dr. Saltz:
Well, thanks for having me. 

Dr. Turck:
To start us off Dr. Saltz, would you explain what the quarantine blues are?

Dr. Saltz:
It's not a diagnostic term as in the DSM-5, but it's really sort of shorthand for what I think clinicians like myself and the general public are using to describe the difficulty that this year has posed on mental health for many, many people. I think another phrase that actually coined by the American Psychoanalytic Association has been pandemic trauma and stress experience. So not PTSD. But PTSE. Basically, the idea that this has been a traumatic year for many people, whether it's related to fear of illness, someone they know or love or themselves becoming ill, economic strain, rising awareness of systemic racism. So many stressors that it has, in a chronic stress way, impacted many people's mental health. And it can go from the level of what I would call blues, meaning not a clinical depression, but still feelings of sadness or loneliness, a lot of stress, feeling worried a lot of the time, or blues can be experienced as kind of numbness feeling of Adam Grant described, you know, languishing, the feeling that nothing's that important, ‘I feel incredibly blah all the time, I have low energy, I am not excited or looking forward to things.’ And this being a distinct difference from the way, for example, that you may have felt pre-pandemic.

We do know that the CDC released numbers and a couple of months ago that rates of clinical depression and anxiety disorders was up 41% this year, which is really extraordinary. But even beyond clinical depression, anxiety, many more people are feeling blueness of some sort, a difference from the way they felt before that affects their emotional well-being.

Dr. Turck:
Well, now that the country is slowly opening back up, do you think we'll see any lasting effects of the quarantine blues or pandemic trauma and stress experience on our patients?

Dr. Saltz:
Absolutely. And I think it will not only be on our patients, but it will be on ourselves. Healthcare workers have been struggling with mental health issues much more than one would expect because, of course, healthcare workers have really been on the front lines. And the pandemic, as it were of mental health issues, is a delayed curve from the pandemic itself. So it started later because it was in reaction to the stressors brought on by the pandemic. And I think it will end later because people are just now having those effects. And it takes some time for people to either do self-care, or find treatment and go through treatment.

I will also tell you that there really aren't enough therapists to go around. That's just a reality, whether we're talking about psychiatrists or psychologists or social workers, we just don't have enough people to actually  meet the need. Many, many of my colleagues have incredibly long wait lists. And I'm in New York City where we have more mental health professionals per square foot than most places. So there are a lot of places that there's a real dearth in terms of fulfilling the need.

I do think this will continue to be an issue because some of the things will also lag behind in terms of the pandemic. Yes, many people have become vaccinated, things can open up, but two things strike me. One is that this will not instantly economically change things for a lot of people. It will not instantly  repair a lot of the divide that has gone on this year. It will not instantly resolve a lot of the social isolation that a lot of people have felt. In addition, there is a need to increase awareness, decrease stigma so that people can seek the help, because stigma is still an issue. So I think that we will continue to see some of this continue to be a problem.

Dr. Turck:
So what can physicians and other healthcare professionals do to help change their patients’ mindsets or improve how they're feeling mentally?

Dr. Saltz:
Well I think helping patients to know that it's almost normal to be having some struggle right now, that many, many people are and that the best way to handle that is not to stay strong and carry on but to at least initiate self-care. Which I would say hopefully doctors can be explaining there are things you can do that help your mental health at home, aerobic exercise for 30 minutes three, four times a week, paced, deep breathing, which you can learn literally watching a YouTube video and allows you to decrease the activity of your sympathetic nervous system to calm your body to decrease anxiety can be done in 5 or 10 minutes once a day. The same goes for something like progressive muscle relaxation, talking to others in your life who you trust and feel can be supportive to us that you can share your feelings, and be with other people.

Another thing I didn't mention in terms of will there be continued problems; as we open up and people have worked so hard all year to distance themselves and not go to the places that they normally went and have that instigated by being protective, and a certain amount of fear of contagion, and so on motivating that, it can be hard to come back and go into situations where you're sort of now after a year and a half, you know, ‘Ooh, I'm not wearing a mask, ooh, do I hug you hello, do I do I kiss someone,’ you know. Children might be nervous about returning to school. And what I could say is it's not going to be surprising that we might have an increase in social phobia, in school phobia because of this very unusual event. And I would say that self-care in this instance, would be about doing those things anyway, little by little, and tolerating a certain amount of anxiety as you do, and using those self-care methods to calm yourself. Because if you say to children, ‘Oh, you're nervous? Okay, it's okay not to go to school, or it's okay to not go to work.’ Let's say the CDC has deemed it to be a safe situation, then you're feeding the anxiety and you're likely to shrink your world. That's what happens when I treat someone with a phobia, right, we want to expose them to that fear at the same time we give them tools to help them stay less anxious so that we don't grow the phobia  and shrink their world. And so I think that's really important.

But for some people, if despite doing those things, they find that they are increasingly having their emotional state impact their functionality at work, they can't concentrate or really stay in there at work. If it's affecting their relationships, maybe because they feel withdrawn, they feel difficulty being intimate, they feel difficulty trusting someone, or they're highly irritable, and they're having a lot of angry outbursts that are affecting relationships as a result of their mental health, I would certainly, if it's affecting their sleep significantly, or their appetite significantly, and they're not able to take pleasure in things that they previously did take pleasure in. And of course, the psychiatric emergency, if you have thoughts of suicide, for life really isn't worth living anymore, then I really highly urge people to seek out a professional evaluation and treatment.

Dr. Turck:
For those just tuning in, you're listening to COVID-19: On the Frontlines on ReachMD. I'm Dr. Charles Turck. And I'm speaking with psychiatrist Dr. Gail Saltz about actionable tips to help our patients navigate the process of reemerging into public places amidst the pandemic.

Now Dr. Saltz, recently the mask mandate has been lifted in many areas, and this can leave some patients, especially those who are immunocompromised, with feelings of stress and anxiety. So what tips could we share with those patients to help them cope with the change?

Dr. Saltz:
Well I think there, of course, are a subset of patients, and there may be medical guidance on what they should be doing. And I think, of course, they should be following that medical guidance. If there's reason to believe that the vaccine has not covered you, so to speak, and your doctor is advising you to continue masking, well then by all means, continue masking. But continue masking and going out and having social connection.

One real crisis for many people this year is the amount of social distancing that really ramped up loneliness, which was already a public health issue. And we know that long-term loneliness does cause depression and anxiety and does take a toll on both mental health but also physical health. So it is important to re-engage in in-person contacts as long as that is done in a healthy way. So if that means masking, then that means masking. And people will understand if you have a situation where that's required that you are required to do that.

But I also think that it's easy to feel uncertain. And I could only advise people to follow the science. I'm a big believer in follow the science. And if something is not really supported by the science, and you feel very, very afraid of it, then you have to question whether this is a rational or irrational worry. That can be hard to do when you're in the midst of terrible anxiety. Anxiety disorders are defined by irrational worry. And  the answer to an irrational worry is, to some degree, to not pay a lot of attention to it. The more that we attend to an irrational worry, as though it were a rational worry, the more it gains strength, the more it stays present in our mind, the more it changes our behavior, and not in a healthier, positive way. So if you are truly immunocompromised, and your doctor is saying wear a mask, wear a mask. If you are wondering about this and you have spoken with your doctor who says, ‘No, there's really no data to support that concern,’ then you would hopefully not feel that you have to operate that way. Because you keep having, as I would say, these non-science backed or irrational worries because then really what you're doing is simply growing an anxiety disorder.

Dr. Turck:
Is there anything specific or different you'd like to add for patients who have anxiety about returning to their workplaces?

Dr. Saltz:
Well, I think twofold. One is that it's expectable. This is the largest behavioral change made in our nation, across the board, probably in pretty much everybody's lifetime, right? I mean, we told people, ‘Hey, smoking can cause cancer,’ and that didn't cause everyone to stop smoking. So it's a marvel, really, when you think about it that in a reasonably short period of time, we told everybody to socially distance, to not go into work, to close their business, toto wash their hands, and disinfect their food, and wear masks. And all these different behaviors that were hard for people to do, really hard, and they did them. And that I'm sure that we will be studying that for years to come, but  it seems highly likely to me at least that fear was a huge driver of all this behavioral change.

And so when you make behavioral change based on fear in the brain, you basically are doing your own positive reinforcement. You made the change, and then your brain said, ‘Ah, I feel relieved of my fear and my worry,’ and that reinforces the behavior. Now we're saying, ‘Oh, you've been doing that for a year and a half.’ And, you know, it takes some effort to undo that behavioral reinforcement. And that's why I'm saying I think most people will have some anxiety even as they may, at the same moment have joy about being back out and being with people. But they may experience it as feeling weird, or worried, or anxious, or just uncertain. And I would expect that. But it's really a matter of how tenacious is that feeling. Does it stay with you? Does over a few exposures, does that sort of dissipate? Okay, fine. Or over exposures, does it grow? Are you avoiding things because of it? And that would be the red flag or hallmark that you may have developed an anxiety problem. And that would be something you'd want to address.

Dr. Turck:
Now we're almost out of time for today, Dr. Saltz, but before we close, I'm going to open up the floor to you. We've experienced so many changes since the start of the pandemic, so are there any final thoughts you'd like to leave with our audience today?

Dr. Saltz:
I think it's been a marvel, really as a psychiatrist, when I look at this year. It's been a marvel that  I think even though a lot of people have struggled that there has been a tremendous amount of resilience. And resilience doesn't mean I'm fine after terrible things happen. Resilience means you weathered something incredibly difficult. You develop some coping tools to manage in that time, even as it was so hard. And you came out the other end. And it doesn't mean you have to come out the other end like blooming flowers. It means you came out the other end. And the thing about resilience is now you've developed these coping tools, and they'll always be with you so that when difficult things come up in the future, you can look back and say, ‘Wow, well, in that really difficult time, I did this, and this, and this, and it helped me, and I weathered the situation.’ And so that's what builds resilience.

Dr. Turck:
Well, especially because the COVID-19 pandemic continues to wage a considerable toll on our patients’ mental health, I want to thank my guest, Dr. Gail Saltz, for joining me today to share how we can help our patients navigate reemerging into public places in the midst of the pandemic. Dr. Saltz, it was great having you on the program.

Dr. Saltz:
Well thank you so much for having me.

Dr. Turck:
I’m Dr. Charles Turck. To access this and other episodes in our series, visit reachmd.com/COVID-19, where you can Be Part of the Knowledge. Thanks for listening.