Reentry Anxiety

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The last week of June 2021 was a momentous one.

After the cancellation of last year’s residency graduation, I was tasked with planning an event to celebrate both the 2020 graduates and those advancing in July. I had never planned an event like this before, especially during a global pandemic. I had no idea how much preparation and effort it would take—the room, food, decorations, tables, chairs, etc. To say it was a little daunting is an understatement.

And while I successfully planned for all the minutiae needed for the event, my wife pointed out a small detail that I had been avoiding as I finally neared the big day: I needed a haircut

The last time I had gone to my friendly local barber, it had been pretty awkward. The shop was full of frustrated, angry workers strained from closures and boasting that they had no intention of following any COVID-19 guidelines. I kept quiet and tried to be polite but was eventually asked what I did for a living. After sharing that I worked in leadership at a local hospital, the demeanor changed. Suddenly the man cutting my hair began to smile almost apologetically, gently touching my shoulder as I paid him and left.

This time, I did not know what to expect. Do I wear a mask? Do I try a new shop? Do I skip it altogether? The earlier experience was making me apprehensive. After talking to my wife, I decided I would go to the same barber. Entering the shop without a mask felt almost alien to me, and I must admit, it was slightly unsettling to sit with 15 or so others waiting on cuts.

Why Is it Hard to Get Back to Normal?

I have learned that my experiences in the barbershop were in no way unique, and many of our patients and staff are dealing with similar situations on a daily basis. It is time to embrace the fact that reentry anxiety is affecting more individuals than ever before. This kind of anxiety is frequently seen in the severely isolated, the hypervigilant, and those confined to only certain places over a long period of time.¹ Doesn’t that describe almost all of us? Lockdowns and social isolation may have been necessary, but they are not something our brains are used to, nor can we easily flip a switch back to normal.

The data is there. According to the American Psychological Association, Americans are now experiencing the highest levels of stress since April 2020, with 84% of adults reporting feeling at least one emotion associated with prolonged stress in the past 2 weeks (anxiety 47%, sadness 44%, and anger 39%).² One study found that 13% of individuals screened positive for posttraumatic stress disorder, despite COVID-19 not fitting Criterion A. Thirteen percent felt they had difficulty with lockdown, 11% feared difficulty obtaining supplies, 10% had significant difficulty self-isolating, and 22% had significant fears of falling ill.³

And now I needed to plan a graduation for 2 cohorts of graduates, doubling the event’s normal prepandemic attendance. Graduation is supposed to be a time of celebration and togetherness, but as I am sitting here uneasy about just getting a haircut, I am wondering if it is really a good idea to do this event. This is supposed to be fun; why am I not looking forward to this?

We are supposed to be excited. We are supposed to feel good about doing more things. But reentry anxiety will not allow us to simply enjoy it.

Cognitively, it makes perfect sense: fear of contagion, feelings that the world has changed. I have even heard people joking that their social skills have atrophied, or they no longer know how to dress for various occasions.

A Necessary Period of Adjustment

What can we do about this? Like most solutions in the field, we need to understand the risk factors for those more likely to struggle with reentry. Look for patients with a history of mental illness, as well as those likely to have been stressed or dealing with trauma over the last year: front-line workers; people of color; parents; and children, teens, and young adults displaced from school.

The mechanism of action is a hard one, described by Gullahorn and Gullahorn in their Extended U-Curve Hypothesis.⁴ When individuals repeatedly end a honeymoon phase only to be met with a new crisis, they then must recover from said crisis and adjust to the new situation. The hardest part is that individuals tend to suffer from these crises repeatedly, prolonging the discomfort.⁵

Although many consider reentry anxiety an anxiety disorder, it is really more of an adjustment disorder—especially when it is short term and related to a pandemic that forced us all to adjust. That being said, ruling out other causes for anxiety should be considered if symptoms persist.

But what do we do for these patients with this unique adjustment disorder? One of the first steps is diagnosis. The DSM’s description of adjustment disorder can guide providers in understanding the clinical symptoms and how to diagnose them appropriately.⁶

Personally, my first step is the same as for all patients with anxiety—to help them give themselves permission to feel anxious. We get anxious—if we did not, we would fail to study for exams or forget to look both ways before crossing a street. Anxiety helps us make good choices in our day-to-day lives, as well as during rapidly changing times. It is important to permit feeling anxiety and to remind ourselves that everyone will deal with this differently. Comparing your feelings and coping skills to others is not productive. Just because certain individuals take longer to readjust, or their feelings are more intense, does not mean anything has gone wrong.

Practical Tips

Of course, if patients’ symptoms persist or become disabling, it is important to offer help. Here are a few options that I recommend as appropriate:

Seek therapy. Cognitive behavioral therapy is the gold standard for anxiety disorders, and exposure therapy will likely help a lot. With the variety of options in obtaining it nowadays, it is easier to fit therapy into a busy schedule.

Practice mindfulness. Some research suggests that mindfulness practices can actually mimic exposure therapy by helping patients feel and desensitize troubling emotions and physical sensations.

Ease your way back to normal. Gradual exposure to more challenging situations will likely begin to extinguish these symptoms. In addition, strong social support through family and friends is always beneficial.

Leverage pharmaceuticals if needed. From a pharmacologic standpoint, I would hold off in mild cases. But for patients with disabling symptoms, a selective serotonin reuptake inhibitor might help them push through while undergoing therapy.

Concluding Thoughts

Looking back to my recent trip to the barbershop, I think it is important to acknowledge that many of us have experienced some trauma during this pandemic. There is no single method for getting back to normal. Equally important is that we seek to understand and embrace these feelings of trauma. Start with small outings at first, but start soon. Start with a haircut before you host a large party. Learn from my mistakes. Graduation was fun, but hosting over 100 guests indoors was indeed overwhelming.

Admittedly, a week later, I am more comfortable going outside of my bubble; however, I still feel more comfortable wearing a mask at the grocery store. We must all take steps that make us feel personally safe, but we should also push ourselves to get back to our lives.

Dr. Seigler is chair of Behavioral Health at Arrowhead Regional Medical Center. He also serves as medical director for the Behavioral Health Department at Arrowhead Regional Medical Center. In addition to San Bernardino, Dr. Seigler has practiced clinically in Riverside and across the West Coast as a Vituity telepsychiatrist since 2017. He received his medical degree from the UCLA David Geffen School of Medicine and completed his postgraduate training at the UCLA/San Fernando Valley residency program. He has a passion for patients’ rights and returning stabilized patients back into the community from long-term placements and conservatorship.

References

1. Hyde J, Bolton R, Kim B, et al. "I've just never done that:" The influence of transitional anxiety on post-incarceration reentry and reintegration experiences among veterans. Health Soc Care Community. 2021.

2. American Psychological Association. Post-inauguration stress survey: More than 8 in 10 Americans (84%) report feeling emotions associated with stress in the last two weeks. January 2021. Accessed July 27, 2021. https://www.apa.org/images/sia-january-emotions-infographic_tcm7-283972.jpg

3. Bridgland VME, Moeck EK, Green DM, et al. Why the COVID-19 pandemic is a traumatic stressor. PLoS One. 2021;16(1):e0240146.

4. Gullahorn JT, Gullahorn JE. An extension of the U-curve hypothesis. Journal of Social Issues. 1963;19(3):33-47.

5. Purtill J. Anxious about going back to normal? It's called 'reverse culture shock'. Australian Broadcasting Company. May 7, 2020. Accessed July 20, 2021.

6. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (US); 2016.