Managing mask-related anxiety, aggression

UC experts say kids handle guidelines well; adult workers experience stress enforcing compliance

As the delta variant continues to spread, public health guidelines to prevent COVID-19 like mask requirements are becoming more common again. 

Medical experts agree wearing a mask in public is absolutely critical from a public health standpoint to limit the spread of COVID-19, and researchers are continuing to monitor the effects that masking and the pandemic more generally can have on anxiety and stress levels among different groups.

Effects on workers

Doctor smiling

Erica Birkley, PhD, assistant professor of psychiatry and behavioral neuroscience in the University of Cincinnati College of Medicine. Photo/Colleen Kelley/University of Cincinnati

Workers can often feel anxiety and stress when they are put in the position to be enforcers of others’ mask-wearing on top of their regular duties, said Erica Birkley, PhD, assistant professor of psychiatry and behavioral neuroscience in the University of Cincinnati College of Medicine. This, she adds, can occur in retail stores, health care settings and with first responders, adding an additional burden to an already stressful job.

UC research has shown that the more someone feels drained of their resources, “the more difficult it is to execute something that takes a lot of steps or a lot of effort or energy,” said Birkley. “With first responders being masked and the people they’re interacting with being masked as well, as much as they can adhering to social distancing, it can add an increased layer of complexity to their job to maintain safety for their team but also the safety of the public by having to remind people to wear a mask.”

Birkley said the stress health care workers have experienced over more than a year and a half of the pandemic — particularly for those who have been the last human contact for COVID-19 patients before they die — has also led to some cases of post-traumatic stress disorder.

“That helplessness and sense of hopelessness when a patient is struggling to breathe, and the repeated exposure of patient death from COVID-19 over the course of not just days or weeks but now we’re talking about years, can take a real toll on the brain, increasing the vulnerability for something like PTSD to develop,” she said.

Effects on children

Despite claims that wearing masks and other public health guidelines negatively affect children’s self-esteem or that masking is difficult in school settings, mask requirements and other guidelines have caused a minimal effect on social interactions and anxiety among children and teens, according to Jeffrey Strawn, MD, professor of psychiatry and behavioral neuroscience in the UC College of Medicine and a UC Health child and adolescent psychiatrist. Strawn adds this includes those with anxiety disorders who were thought to be at higher risk for “mask anxiety.” 

Strawn said kids are sometimes more adaptable and flexible compared to adults and are doing “quite well” in many ways with the ongoing requirements.

“They still play, they still interact, they still joke with one another, they’re still able to maintain friendships,” said Strawn. “Particularly in my anxious patients, what we find is that for most, it’s not a big deal.”

Two children wearing masks run in a grassy field

Jeffrey Strawn, MD, said kids have adapted well to ongoing public health interventions like mask requirements. Photo/Unsplash

Strawn said he has seen some issues where students feel stress or anxiety when they are staying masked up to protect an immunocompromised loved one at home but others around them are not wearing masks.

“They tend to feel some degree of stigma if they’re wearing a mask,” he said. “Of course they’re not wanting to necessarily explain, ‘Look my mother’s a nurse or my dad has cancer.’ It’s tough to say those types of things when you’re interacting with same-age classmates at school.”

Other children not yet eligible to be vaccinated may also feel a stigma or stress when wearing a mask while interacting with older, vaccinated peers who are not masking, Strawn said.

“It can create some conflict, and that’s particularly difficult given that it’s often the younger individual within that pair that’s not following the norm,” he said.

Tips for managing stress

Researcher Birkley said particularly for those experiencing anxiety or stress related to mask-wearing, it is important to take breaks if possible.

“We call them ‘mask breaks’ at work. So if you are in a position where you have a mask on for a long period of time, intentionally take breaks either outside or solo in a closed room where you can take your mask off,” she said. “It’s helpful even if you’re able once an hour to have a mask break in a safe way.”

While taking a mask break or in other stressful situations, Birkley recommended slowing down your breath and having an extended exhale, which research has shown can meaningfully decrease anxiety and stress by reducing your heart rate.

Letting others around us know how we’re feeling, what we specifically need and when we need it is also an important aspect to help relieve stress and increase social support, Birkley said. Often those around us want to help, but guess wrong on what we need.

“I tend to show up with comfort food when somebody wants to go for a walk or a run,” Birkley said. “Each one of us needs to do something that might feel a little new or different or awkward at times and specifically let others know what we need to feel supported.”

Doctor sits at his desk looking at a picture of a brain and other data on a computer screen

Jeffrey Strawn, MD, said learning to tolerate uncertainty and taking time for yourself can help ease pandemic-related anxiety. Photo/Colleen Kelley/University of Cincinnati

Strawn recommends taking time for yourself and, where possible, try not to make every conversation revolve around the minutiae of the pandemic. Adults can take lessons from children and learn to be flexible as things continue to change, he said.

“I think another important piece is being able to tolerate uncertainty, and that's something that can be really difficult,” Strawn said. “It’s oftentimes not the disruption per se or the change that needs to happen, but rather it’s the not knowing whether that change is going to be needed or what might happen next. In other words, it’s the uncertainty about the change rather than the change.”

Aggression and de-escalation

Since wearing a mask can sometimes make it difficult to hear what others are saying and read nonverbal cues, Birkley said feelings of anger and frustration can quickly escalate into an urge to be aggressive. 

Birkley researches aggression and offers de-escalation training. She said when in a position where you are experiencing an urge to be aggressive, it is again helpful to start by slowing down your breath and shifting your thoughts away from the main source of your anger.

“You want to lower the arousal in your body,” she said. “In doing that, we allow the logical part of our brain that makes thoughtful decisions to have a little bit more time and resources to think broadly about what we value, what we care about and what the consequences might be of our decisions.”

Man wearing a mask picks up an item from a refrigerated grocery store shelf

Slowing your breath and finding common ground with those you are in conflict with can help to de-escalate urges to be aggressive, Birkley said. Photo/Unsplash

When dealing with others who are becoming angry or verbally aggressive, Birkley recommends trying to find areas of common ground so that the interaction becomes a collaboration to solve the problem rather than a one-on-one faceoff. This can begin by acknowledging their frustration and anger and then clearly communicating what your intentions are in the interaction.

“So specifically telling them, ‘My intentions are to help you. I’m only asking you to wear a mask not only because it’s part of my job or the rules, but also it helps keep people around us safe,’” Birkley said. “Acknowledge that the other person might likely be stressed and depleted. Most of us are stressed with the adjustment in life due to the pandemic. Ask if they need something or if you can talk. Validate that for most of us this is difficult and that your intention is not to make them more upset or to increase the burden on their day.”

Featured photo of masks at top courtesy of Unsplash.