Tagged Anxiety and Stress

April 8, 2021

Need to Dust Off Your Social Skills?

After a year of virtual gathering, getting back to real-life relationships can be intimidating. These eight simple exercises can help.

As we move through the spring of The Great Vaccination, many of us are feeling cautious optimism, and also its flip side: creeping dread.

Maybe you have a sense of ambivalence about how to interact with others again. If you used to work in an office, you might be worried about returning to work — but eager to see people again. Or you find yourself having to confront a neighbor about a longstanding problem — but you’re out of practice with conflict resolution. (I’m not sure I remember how to talk to another human anymore, let alone one I disagree with.)

Whatever the specifics, “there will be new forms of social anxiety, said Dacher Keltner, a professor of psychology and the director of the Social Interaction Lab at the University of California, Berkeley.

“People are really anxious about being out in restaurants with friends, or about dancing with a big sweaty group of people — or even about sharing a yoga mat,” he said. “It’s always good to remember individual differences — there’s a lot of variability. But there will be a lasting societal legacy around intimacy, the noise that comes with returning to school, the complexity of the playground and of work.”

Dr. Keltner has studied human behavior and the biological and evolutionary underpinnings of emotions for decades, with a focus on “pro-social” states — behavior that strengthens connections between individuals — that are especially good for society.

“We’re hyper-social mammals — it’s our most signature strength,” said Dr. Keltner, a co-founder of the Greater Good Science Center who was also a scientific consultant on emotions for the Pixar film “Inside Out.” “It’s what sets us apart from other primates: We help, we laugh, we collaborate, we assist.”

Lately, we’ve been living our lives siloed away online, missing many of the essential face-to-face experiences that are key to human interaction. It’s notable that Dr. Vivek Murthy, the newly reappointed U.S. Surgeon General, has talked not only about the physical and economic toll of the pandemic, but also of “the social recession.”

Before Covid, this kind of post-isolation anxiety was most often suffered by people who re-enter the civilian world after prison, wartime deployment, humanitarian aid work or remote expeditions. The challenge now is that so many more of us will be experiencing some aspect of this all at once, and coming back to social situations with others who likely have their own fears too. It is stalled social development, on a societal level.

Debra Kaysen, a clinical psychologist and a professor of psychiatry and behavioral sciences at Stanford University, said that coming back to so-called “civilian life” can be disorienting, surreal and difficult — and not just for combat veterans. Her clinical and research work focuses on anxiety disorders and trauma, and she has worked on developing coping strategies for health care workers dealing with mental health concerns during the pandemic.

Now, everyone is trying to navigate conflicting threat levels in a way that used to be specific to those populations, she said. Cues that used to be neutral or positive, like being around other people (I love my friends and family!) are now associated with threat (my friends and family might infect me with Covid!). And we are confronting the challenge of how to turn off that alarm. “What’s a true alarm and what’s a false alarm has gotten more confusing for all of us,” Dr. Kaysen said.

So how do we relearn how to be together?

Give yourself permission to set small, achievable goals. And accept that other people are going to have different responses than you — the friend or family member who wants to eat inside the restaurant when you don’t, for example, or who is ready to get on a plane and take a vacation.

Accept that certain activities may feel tough for awhile. Driving an hour to a meeting. Flying a red-eye to a conference. Attending a family reunion, say, or four pandemic-postponed weddings in one month.

All of this can prompt you to ask, of your family or your boss or even yourself: “Is it really worth the time?” and “Now that I know things can be different, do I want to go back to my old life?”

Recovering doesn’t mean you go back to the way you were before, Dr. Kaysen said, using kintsugi, the Japanese technique of repairing broken pottery with gold, as an analogy for coming out of hard times with awareness of the change, and stronger than before. “It’s that you create a new normal, one that’s functional and beautiful — and different.”

Dr. Keltner agreed that we may need to “re-educate ourselves” — “like, how do we hug again?” Your timing might be off for a hug, or a joke or even a compliment. “How do you look someone in the eye so that it’s not intrusive? How do you compliment someone? You might not have done it for a year.”

Rather than be overwhelmed by everything at once — for example, going to a party where you have to adjust to greeting acquaintances, eating with others and attempting to make small talk — all at the same time — why not take things step by step? This moment can be an opportunity.

8 Exercises to Strengthen Your Social Muscles

Here are eight small, science-based exercises Dr. Keltner recommends to help ease back into your community. Go at your own pace.

Share food with someone.

Eating a meal together boosts mood and is a potent antidote for loneliness — aiming for in-person interaction around the ritual of eating is a great goal, even if you don’t meet it every single day. An outdoor picnic or a distanced backyard happy hour is a great and safe option for reconnecting with friends and family.

Tell someone a joke in person.

You may be out of practice and have to work on your timing. But making eye contact and laughing together is essential to feeling connected to someone else — even if the joke falls flat, being silly together will feel really good.

Ask someone what they’re listening to or reading right now.

Music and literature can be a community-building gift. Listen to music together; exchange books and have an in-person discussion afterward. This is a social exercise, but also one that will give you a much-needed hit of novelty along with the insight.

Reach out to someone you’ve lost touch with.

Make a phone call, send a meaningful text, write an email. It’s time to start rebuilding the larger social infrastructure outside our immediate circles.

Strike up a conversation with a stranger.

Pick someone with whom you have passing contact: a fellow dog-walker, the cashier at a grocery store, a delivery person on your doorstep. Make eye contact; talk to each of them as a person rather than as a function. It’s so easy to ignore the human behind a mask. Make the effort to ask something outside the normal transaction — what’s changed since the last time you saw each other, what they’re looking forward to.

Move with someone.

Dance, walk, run, swim, bike — or even do the dishes and fold the laundry together. Physical synchronicity is one of the most important ways we have to connect with someone else.

Sit quietly with someone …

and remember how to comfortably be, without talking, in companionable silence, with someone else. Let the other person know it’s OK to not always fill the air. Nonverbal communication is important to practice — and it’s a way to deepen your relationship.

Make a date for the future.

Think of something fun to do with someone you love — it could be a summer beach weekend, or maybe a ski trip next winter. Having something to look forward to is essential for well-being. Practice optimism, in anticipation of normalcy. Plan with hope.

Bonnie Tsui’s books include “Why We Swim” and “The Uncertain Sea.”

April 8, 2021

Music Therapy: Why Doctors Use it to Help Patients Cope

Music therapy is increasingly used to help patients cope with stress and promote healing.

“Focus on the sound of the instrument,” Andrew Rossetti, a licensed music therapist and researcher said as he strummed hypnotic chords on a Spanish-style classical guitar. “Close your eyes. Think of a place where you feel safe and comfortable.”

Music therapy was the last thing that Julia Justo, a graphic artist who immigrated to New York from Argentina, expected when she went to Mount Sinai Beth Israel Union Square Clinic for treatment for cancer in 2016. But it quickly calmed her fears about the radiation therapy she needed to go through, which was causing her severe anxiety.

“I felt the difference right away, I was much more relaxed,” she said.

Ms. Justo, who has been free of cancer for over four years, continued to visit the hospital every week before the onset of the pandemic to work with Mr. Rossetti, whose gentle guitar riffs and visualization exercises helped her deal with ongoing challenges, like getting a good night’s sleep. Nowadays they keep in touch mostly by email.

The healing power of music — lauded by philosophers from Aristotle and Pythagoras to Pete Seeger — is now being validated by medical research. It is used in targeted treatments for asthma, autism, depression and more, including brain disorders such as Parkinson’s disease, Alzheimer’s disease, epilepsy and stroke.

Live music has made its way into some surprising venues, including oncology waiting rooms to calm patients as they wait for radiation and chemotherapy. It also greets newborns in some neonatal intensive care units and comforts the dying in hospice.

While musical therapies are rarely stand-alone treatments, they are increasingly used as adjuncts to other forms of medical treatment. They help people cope with their stress and mobilize their body’s own capacity to heal.

“Patients in hospitals are always having things done to them,” Mr. Rossetti explained. “With music therapy, we are giving them resources that they can use to self-regulate, to feel grounded and calmer. We are enabling them to actively participate in their own care.”

The Healing Power of Music

“A Song for Wayne,” performed by Edie Elkan and written as she played at the bedside of a student who was dying.

Even in the coronavirus pandemic, Mr. Rossetti has continued to perform live music for patients. He says that he’s seen increases in acute anxiety since the onset of the pandemic, making musical interventions, if anything, even more impactful than they were before the crisis.

Mount Sinai has also recently expanded its music therapy program to include work with the medical staff, many of whom are suffering from post-traumatic stress from months of dealing with Covid, with live performances offered during their lunch hour.

It’s not just a mood booster. A growing body of research suggests that music played in a therapeutic setting has measurable medical benefits.

“Those who undergo the therapy seem to need less anxiety medicine, and sometimes surprisingly get along without it,” said Dr. Jerry T. Liu, assistant professor of radiation oncology at the Icahn School of Medicine at Mount Sinai.

A review of 400 research papers conducted by Daniel J. Levitin at McGill University in 2013 concluded that “listening to music was more effective than prescription drugs in reducing anxiety prior to surgery.”

“Music takes patients to a familiar home base within themselves. It relaxes them without side effects,” said Dr. Manjeet Chadha, the director of radiation oncology at Mount Sinai Downtown in New York.

It can also help people deal with longstanding phobias. Mr. Rossetti remembers one patient who had been pinned under concrete rubble at Ground Zero on 9/11. The woman, who years later was being treated for breast cancer, was terrified by the thermoplastic restraining device placed over her chest during radiation and which reawakened her feelings of being entrapped.

“Daily music therapy helped her to process the trauma and her huge fear of claustrophobia and successfully complete the treatment,” Mr. Rossetti recalled.

Some hospitals have introduced prerecorded programs that patients can listen to with headphones. At Mount Sinai Beth Israel, the music is generally performed live using a wide array of instruments including drums, pianos and flutes, with the performers being careful to maintain appropriate social distance.

“We modify what we play according to the patient’s breath and heart rate,” said Joanne Loewy, the founding director of the hospital’s Louis Armstrong Center for Music & Medicine. “Our goal is to anchor the person, to keep their mind connected to the body as they go through these challenging treatments.”

Edie Elkan plays the harp as part of the music therapy program at Robert Wood Johnson Hospital in New Jersey.Edie Elkan

Dr. Loewy has pioneered techniques that use several unusual instruments like a Gato Box, which simulates the rhythms of the mother’s heartbeat, and an Ocean Disc, which mimics the whooshing sounds in the womb to help premature babies and their parents relax during their stay in noisy neonatal intensive care units.

Dr. Dave Bosanquet, a vascular surgeon at the Royal Gwent Hospital in Newport, Wales, says that music has become much more common in operating rooms in England in recent years with the spread of bluetooth speakers. Prerecorded music not only helps surgical patients relax, he says, it also helps surgeons focus on their task. He recommends classical music, which “evokes mental vigilance” and lacks distracting lyrics, but cautions that it “should only be played during low or average stress procedures” and not during complex operations, which demand a sharper focus.

Music has also been used successfully to support recovery after surgery. A study published in The Lancet in 2015 reported that music reduced postoperative pain and anxiety and lessened the need for anti-anxiety drugs. Curiously, they also found that music was effective even when patients were under general anesthesia.

None of this surprises Edie Elkan, a 75-year-old harpist who argues there are few places in the health care system that would not benefit from the addition of music. The first time she played her instrument in a hospital was for her husband when he was on life support after undergoing emergency surgery.

“The hospital said that I couldn’t go into the room with my harp, but I insisted,” she said. As she played the harp for him, his vital signs, which had been dangerously low, returned to normal. “The hospital staff swung the door open and said, ‘You need to play for everyone.’”

Ms. Elkan took these instructions to heart. After she searched for two years for a hospital that would pay for the program, the Robert Wood Johnson University Hospital in Hamilton, N.J., signed on, allowing her to set up a music school on their premises and play for patients at all stages in their hospitalization.

Ms. Elkan and her students have played for over a hundred thousand patients in 11 hospitals that have hosted them since her organization, Bedside Harp, was started in 2002.

In the months since the pandemic began, the harp players have been serenading patients at the entrance to the hospital, as well as holding special therapeutic sessions for the staff outdoors. They hope to resume playing indoors later this spring.

For some patients being greeted at the hospital door by ethereal harp music can be a shocking experience.

Recently, one woman in her mid-70s turned back questioningly to the driver when she stepped out of the van to a medley of familiar tunes like “Beauty and the Beast” and “Over the Rainbow” being played by a harpist, Susan Rosenstein. “That’s her job,” the driver responded, “to put a smile on your face.”

While Ms. Elkan says that it is hard to scientifically assess the impact — “How do you put a number on the value of someone smiling who has not smiled in six months?”— studies suggest that harp therapy helps calm stress and put both patients and hospital staff members at ease.

Ms. Elkan is quick to point out that she is not doing music therapy, whose practitioners need to complete a five-year course of study during which they are trained in psychology and aspects of medicine.

“Music therapists have specific clinical objectives,” she said. “We work intuitively — there’s no goal but to calm, soothe and give people hope.”

“When we come onto a unit, we remind people to exhale,” Ms. Elkan said. “Everyone is kind of holding their breath, especially in the E.R. and the I.C.U. When we come in, we dial down the stress level several decibels.”

Ms. Elkan’s harp can do more than just soothe emotions, says Ted Taylor, who directs pastoral care at the hospital. It can offer spiritual comfort to people who are at a uniquely vulnerable moment in their lives.

“There is something mysterious that we can’t quantify,” Mr. Taylor, a Quaker, said. “I call it soul medicine. Her harp can touch that deep place that connects all of us as human beings.”

April 1, 2021

Depression in Young Children

We tend to think of childhood as a time of innocence and joy, but as many as 2 to 3 percent of children from ages 6 to 12 can have serious depression.

When parents bring their children in for medical care these days, there is no such thing as a casual, “Hey, how’s it going?” We doctors walk into every exam room prepared to hear a story of sadness and stress, or at the very least, of coping and keeping it together in this very hard year, full of isolation, loss, tragedy and hardship, with routines disrupted and comfort hard to come by.

Parents have carried heavy burdens of stress and responsibility, worrying about themselves but also watching their children struggle, and there is worldwide concern about depression and suicidality among young people. But it isn’t only the adults and the young adults and teenagers who are suffering and sad; young children can also experience depression, but it can look very different, which makes it challenging for parents — or doctors — to recognize it and provide help.

Rachel Busman, a clinical psychologist at the Child Mind Institute in New York City, said that it can be hard to think about depression in younger children because we picture childhood as a time of innocence and joy. But as many as 2 to 3 percent of children ages 6 to 12 can have serious depression, she said. And children with anxiety disorders, which are present in more than 7 percent of children aged 3 to 17, are also at risk for depression.

Dr. Helen Egger, until recently the chair of child and adolescent psychiatry at N.Y.U. Langone Health, said that according to her epidemiologic research, between 1 and 2 percent of young children — as young as 3 — are depressed

Depression was originally conceived of as an adult problem. Maria Kovacs, professor of psychiatry at the University of Pittsburgh School of Medicine, said that in the 1950s and ’60s, there were child psychiatrists who believed that children did not have sufficient ego development to feel depression, but that research that she and other colleagues did in the ’70s showed that “school age children can suffer from diagnosable depression.”

Before adolescence, depression is equally common in girls and boys, though among adolescents, it is twice as common in girls, and that predominance then lasts across most of adult life, until old age, when it again appears to equalize.

What does depression look like in younger children?

When young children are depressed, Dr. Kovacs said, it’s not unusual for “the primary mood to be irritability, not sadness — it comes across as being very cranky.” And children are much less likely to understand that what they’re feeling is depression, or identify it that way. “It almost never happens that they say, ‘something’s wrong because I’m sad,’” Dr. Kovacs said. It’s up to adults to look for signs that something is not right, she said.

The best way for parents to recognize depression in young children is not so much by what a child says as by what the child does — or stops doing. Look for “significant changes in functioning,” Dr. Kovacs said, “if a child stops playing with favorite things, stops responding to what he used to respond to.”

This might mean a child loses interest in the toys or games or jokes or rituals that used to be reliably fun or entertaining, or doesn’t seem interested in the usual back and forth of family life.

“You’ve had a kid who was one way and then you see that they’re more irritable and sad,” said Dr. Egger, who is now the chief medical and scientific officer at Little Otter, a new online mental health care company for children. Children may seem flattened, have less energy or tire easily. And they may start complaining about physical symptoms, especially stomach aches and headaches. They may sleep more — or less — or lose their appetites.

A preschool-aged child might be depressed if she is having daily tantrums, with behaviors that risk hurting herself or other people. Depression “may look like a behavior problem but is really being driven by what the kid is feeling inside,” Dr. Egger said.

“It’s like walking through the world with dark-colored glasses,” Dr. Busman said. “It’s about myself, about the other person, and the world — I suck, this sucks, everything sucks.”

Should I ask about suicidal thoughts?

The irritability and the anger — or the flatness and the shutting down — can be signs of profound sadness. And while suicide attempts by elementary school-aged children are rare, they do happen and have increased in recent years. Suicide was the second leading cause of death in children 10 to 14 in 2018, and a 2019 JAMA study showed increasing emergency room visits by children for suicidal thoughts or actions from 2007 to 2015 — 41 percent in children under 11 years old. The presence of suicidal thoughts should be seen as a call for help.

The most problematic myth about suicide is the fear “that if you ask about suicide you’re putting the idea in their heads,” said Dr. Kovacs, who developed the Children’s Depression Inventory which is used all over the world.

“If you’re dealing with a child for whom this is not an issue, they’re just going to stare at you like you’re out of your head,” Dr. Kovacs said. “You cannot harm somebody by asking them.”

But what if children say they have thought of suicide? As with adults, this suggests the child is living with pain and perhaps thinking about a way out. Dr. Kovacs said, children may imagine death as “a release, a surcease, a relief.”

Dr. Busman said that she works with children who may say, “I don’t want to kill myself but I feel so bad I don’t know what else to do and say.”

If a child talks about wanting to die, ask what that child means, and get help from a therapist if you’re concerned. A statement like this can be a real signal that a child is in distress, so don’t dismiss it or write it off as something the child is just saying for attention, she said.

How can treatment help?

“Parents should take child symptoms very seriously,” said Jonathan Comer, professor of psychology and psychiatry at Florida International University. “In serious forms it snowballs with time, and earlier onset is associated with worse outcomes across the life span.”

In a 2016 longitudinal study, Dr. Kovacs and her colleagues traced the course of depression starting in childhood, and found recurrent episodes in later life.

So if you see changes like withdrawal from activities, irritability or sadness, fatigue, or sleep disturbances that persist for two weeks, consider having the child evaluated by someone who is familiar with mental health issues in children of that age. Start with your pediatrician, who will know about resources available in your area.

Parents should insist on a comprehensive mental health evaluation, Dr. Busman said, including gathering history from the parent, spending time with the child and talking to the school. An evaluation should include questions about symptoms of depression as well as looking for other problems, like attention deficit hyperactivity disorder or anxiety, which may be at the root of the child’s distress.

Early treatment is effective, Dr. Comer said, “There’s terrific evidence for family-focused treatment for child depression — it focuses on family interactions and their impact on mood.” With children from 3 to 7, he said, versions of parent-child interaction therapy, known as PCIT, are often used — essentially coaching parents, and helping them emphasize and praise what is positive about their children’s behavior.

As much as possible, parents should try to keep children going outside, taking walks, even playing outdoor games, even if they are less enthusiastic about their usual activities. As with adults, physical exercise has both mental and biological benefits — as do fresh air and sunshine.

Depression does not necessarily lend itself to simple cause-and-effect explanations, but Dr. Kovacs emphasized that with a first episode in a child, there is almost always a particular stressor that has set off the problem. It could be a change in the family constellation — a parental divorce, a death — or it could be something more subtle, like an anxiety that has spiraled out of control. If a child does begin therapy, part of the treatment will be to identify — and talk about — that stressor.

How can I find help for my child?

If you’re concerned that your child might be depressed, start with your pediatrician or other primary care provider. Some clinics and health centers will have in-house mental health services, and you may be able to have your child seen there. Some doctors will have links to local therapists with experience with young children. Mental health specialists can be in short supply (and there’s a lot of need right now), so be open to the possibility of care being delivered remotely, through telehealth. Dr. Kovacs also suggested that parents who are looking for treatment consider clinical psychology department clinics at a local university, where students in psychology and counseling are supervised by licensed psychologists; she said such clinics often have good availability.

[The Society of Clinical Child and Adolescent Psychology has advice on how to know if treatment is evidence-based.]

“Parents should see children’s struggles as opportunities to intervene,” Dr. Comer said. “The majority of early child mood problems will go away with time, sensitive parenting and supportive environments.”

March 28, 2021

Closing the Social Distance

After a year spent social distancing, mask wearing and sheltering in place, the prospect of readjusting to in-person social engagements can be a daunting one.

As the days grow warmer and vaccination shots reach more arms, you may be looking ahead to getting out and about. An Axios-Ipsos poll released this month found that “the number of Americans engaging in social interactions outside the home is increasing.” And the Centers for Disease Control and Prevention recently issued new recommendations that individuals who have been vaccinated against the coronavirus can start to gather in small groups, without masks, offering a measure of hope in particular to those who have missed the intimacy of double dates and dinner parties.

But after a year spent internalizing public health precautions for social distancing and mask-wearing, the prospect of readjusting to in-person social engagements may be a daunting one. For many, it provokes a sense of profound discomfort, apprehension or ambivalence.

“It’s a new version of anxiety,” said Dr. Lucy McBride, an internist in Washington who writes a newsletter about managing the coronavirus crisis. You may discover that your continuing concerns about the virus are colliding with a new set of worries about seeing others more regularly: What am I comfortable with? How do I act? What do I say?

“There’s two feelings that are continuing to exist for me,” said Allison Harris-Turk, 46, an events and communications consultant and mother of three in San Diego. Mrs. Harris-Turk created the Facebook group Learning in the Time of Corona, where many among the roughly 16,700 members are discussing the pros and cons of re-entry. “There’s the excitement and the optimism and the hope, and then there’s also the grief and the trauma and ‘oh, my goodness, how are we going to recover from this?’”

Here’s how some individuals and experts are starting to think about closing the social distance.

Start small.

Though you may be chafing at the confines of the lockdown, remember that it’s still not entirely safe to resume social activities as before. Across most of the country, the risk of coronavirus transmission remains high.

If you’re wary of re-entry, begin with a lower-stakes outing. “It’s like little baby steps getting back into it,” said Dr. David Hilden, a Minneapolis-based internist who hosts a weekly radio show during which he answers listeners’ pandemic questions. He’s observed this firsthand: Earlier this month, he met up with a friend to share a beer for the first time since the onset of the pandemic. “Now that we’ve dipped our toe in the water, a lot of Zoom meetings end with, ‘Hey, I think we can get together now,’” he said.

Understand that hanging out might take more effort.

After receiving her first shot of a coronavirus vaccine, Aditi Juneja, a New York-based lawyer, expected to feel the same flood of relief that some of her peers had described after getting theirs. While on the phone with a friend, she started to consider future late nights and travel to far-off destinations. “I was like, ‘Man, I want to dance on bars,’” Ms. Juneja, 30, said. “There was a euphoria about imagining the possibilities.”

But after 10 minutes, she found even the fantasy versions of these scenarios exhausting. The reality can be, too; she described the sensory overload and disorientation she felt while dining outdoors with a friend for the first time in months. “I think our ability to take inputs has really lowered,” Ms. Juneja said.

This is especially true for individuals suffering from social anxiety, for whom the lockdowns have offered some relief, and for whom reopening presents new stressors. But even extroverts may experience an adjustment period as our brains adapt to planning and monitoring responses to unfamiliar situations. At the beginning of the pandemic, people had to change their behaviors to comply with social distancing, mask-wearing and sheltering in place. But learning those new behaviors — and now, relearning old ones — can take a cognitive toll.

“Social settings are particularly demanding,” said David Badre, the author of the book “On Task: How Our Brain Gets Things Done” and a professor of cognitive, linguistic and psychological sciences at Brown University. “When we have to really focus and plan what we’re doing, that comes with an experience of mental effort,” he continued. “It feels like a mental fatigue.”

There is good news, however: You’ll most likely find it easier to relearn old behaviors than learn entirely new ones. “The key is to not avoid that effort,” Dr. Badre said. “By re-engaging, you will get used to it again.”

Set boundaries for yourself.

Though the past month has seen a spate of reopenings across the country, some scenarios might still set off a siren in your head. And because these facilities are open, doesn’t mean you need to go.

But what if a friend or family member does want to see a movie, or dine out? If you express disagreement over what is safe, you might feel as though you are implying your companions are less responsible or unethical.

Sunita Sah, a professor at University of Cambridge and Cornell University has researched this phenomenon, which she calls “insinuation anxiety.” In studies, Dr. Sah has found that patients frequently follow medical advice from their doctor even if they believe their doctor to have a conflict of interest, and that job candidates often answer interview questions they know are illegal to ask. These reactions come partly out of concern that to disagree would suggest the other person — the doctor or the job interviewer — is not trustworthy.

A similar situation can play out if you’re confronted with someone whose attitude toward public-health protocols differs from your own. Dr. Sah’s research has shown that when individuals have the opportunity to weigh their decisions in private, they are less likely to experience this anxiety and do something that makes them uncomfortable. She recommended writing down the boundaries that you would like to adhere to and taking time before agreeing to someone else’s plan.

“Assess your own risk level and comfort,” Dr. Sah said, “so you’re very clear about what you would and would not like to do.” This will also provide you with a clear document of how your comfort levels are changing over time as you readjust.

Brace for tough conversations.

Over the past year, public-health guidance often wildly varied on federal, state and even city levels, with some areas flinging open their doors while experts still advised caution. This has also been reflected in interpersonal relationships. It’s created friction between couples, families and friends, and prompted individuals to ask challenging, sometimes seemingly intrusive questions. Now, you may be adding “Are you vaccinated?” to that list. (On Twitter, one woman recently proposed “re-entry doulas” to help families navigate conversations about setting boundaries.)

Still, it will continue to be important to have these conversations in the coming months. “This isn’t abstract,” said Marci Gleason, an associate professor in the Department of Human Development and Family Sciences at the University of Texas at Austin whose lab has been surveying relationships in quarantine. “It comes directly to the question of whether we can socialize with others or not, in the way that they want to.” Sometimes, it can feel like a proxy battle over how much you value each other’s friendship. Be open about your own fears and vulnerabilities, and make it clear that when you disagree, you’re expressing your own preference and not rejecting the other person. Keep it simple, too, especially with friends or relatives with whom you don’t frequently have emotional, candid talks.

This empathy and candor will also be an asset if you find that your friends and peers have developed the tendency to over share, either out of anxiety or being starved for conversation. (You may be doing it yourself, too.) If a conversation subject makes you uncomfortable or anxious, say so.

“Being really open and direct is the best way,” said Dr. Danesh Alam, a psychiatrist and the medical director of behavior health services at Northwestern Medicine Central Dupage Hospital. Dr. Alam suggested studying up for conversations, preparing some questions and topics in order to chat with more intention and keep things on topic.

Take your time.

It’s OK if you don’t feel ready to see people socially again. Through the challenges of the lockdown period, you may have found that “your mental health is served best when you have time for calm and rest and introspection,” Dr. McBride said.

So pace yourself while considering the benefits of getting back out there: Even casual interactions have shown to foster a sense of belonging and community. “Social interaction is critical to our existence,” Dr. Alam said. Remember, too, that there are bound to be some weird moments as you start seeing others more regularly and your pandemic instincts (no hugging) and before-times instincts (“Do you want a bite of this?”) collide.

“If you’re comfortable going to a dinner at a small family restaurant, you can do that,” Dr. Hilden said. “If you want to wait a month or two, that’s OK, too.”

March 27, 2021

Learning to Connect With My Male Friends

For some men, long-term, meaningful relationships are harder to build and maintain into adulthood.

I was 20 when I learned that my parents were splitting up.

Two and half years later, I hold no hard feelings against them and have loving relationships with both of them. But, in the immediate aftermath of their split, I was a mess.

I cried in my car. I cried in my bed. I cried while picking up cold meat at the grocery store.

Despite my very public displays of distress, I did my best to maintain a stoic exterior when I was around people I knew. I didn’t tell my closest male friend and former college roommate, Tim, about my parents’ separation for weeks. Instead, I bantered about the latest sports news as if nothing had happened.

I’ve always regarded my sensitivity as one of my greatest weaknesses.

At my high school outside of Vancouver, British Columbia, the boys with quick jokes, often about other boys, were the most popular. I was someone who skirted on the periphery of social circles, wanting to be a part of the group, but desperate not to attract attention that would subject me to ridicule.

I started counseling for anxiety and depression in 11th grade. My therapy sessions were directly after school, so they conflicted with my routine walk home with two of my male friends.

Rather than telling them that I was seeking help, I came up with excuses — a doctor or dentist appointment — to explain why I couldn’t join them. Eventually, I got in the habit of simply saying I had an “appointment.”

Years later, when I learned about my parents’ separation, I similarly struggled to confide in my roommate.

Why was that? Why, even after counseling, was I still so scared to open up to other men my age?

Although research has shown that maintaining friendships as you age leads to a healthier life, men often struggle to have personal conversations and to keep friends.

In a 2020 study of more than 46,000 participants from 237 countries and territories led by researchers from the United Kingdom, young men living in “individualistic” societies, cultures that place a higher value on self-reliance rather than a collectivist mind-set such as the United States or United Kingdom, were more likely to report loneliness than older people or women.

In 2015, Dr. John Ogrodniczuk, the director of the psychotherapy program at the University of British Columbia, launched an online program called HeadsUpGuys that helps men manage depression. Looking to understand why men have trouble seeking mental health help, the organization developed an online survey to identify stressors that can contribute to depression.

Even before the Covid-19 pandemic, loneliness was consistently ranked at the top of its survey for stressors on men. According to Dr. Ogrodniczuk, the pandemic has only compounded feelings of isolation for men.

Why might men be lonelier than women — both in normal times and during the pandemic? After talking with experts in the psychology field, they reiterated it may have to do with a hesitancy to be vulnerable, which can come at the cost of intimacy in relationships.

Holding in my emotions contributed to the demise of my first (and only) romantic relationship. Entering university, I was self-conscious about partying, since I never attended parties in high school. I was also nervous about living on my own and I was insecure about studying creative writing, a field that seemed impractical compared to the science and math degrees that most of my friends were pursuing.

Rather than telling my ex-girlfriend about those anxieties, I consistently shut her out when she tried to help me cope, until we broke up.

Niobe Way, a professor of developmental psychology at New York University, believes that boys are conditioned to view emotional vulnerability as a weakness. As they grow up, boys are told that men should suppress and hide their emotions. “It’s a tragedy,” Dr. Way said in a phone interview.

In 2005, when Dr. Way was grappling with her crumbling marriage, she decided to pretend that all was well in front of her 5-year-old son, Raphael.

After work one day, when she greeted Raphael with an ear-to-ear grin, he asked, “Mommy, why would you smile when you are feeling sad?” His question struck Dr. Way because it demonstrated Raphael’s recognition of both her real, internal state and her performative, outward demeanor.

“Boys start off in the first decade being remarkably emotionally astute and attuned,” Dr. Way said.

Unfortunately, according to Dr. Way, when boys are socialized to become men, they learn to avoid disclosing difficult emotions, especially to other men.

In high school, I played basketball with Ben Wezeman. We both played on the varsity team, an arena where I never felt comfortable sharing my anxieties for fear of losing my starting spot in the lineup and appearing mentally weak in front of my teammates. I was a year older than Ben and we rarely talked. Years later, I found out that Ben, like me, silently battled with depression and social anxiety in high school.

Last year, I noticed he started a GoFundMe and planned to run at least three miles every day for one year to raise money for breast cancer research after his mother received the diagnosis in 2019. I met with him last summer for the first time since high school and wrote about his run streak, but we didn’t discuss our shared mental health struggles in adolescence.

In January, Mr. Wezeman posted on his Instagram about a manic episode that ended his running goal and caused him to spend nine days in a hospital. He was diagnosed with bipolar disorder.

Reading his message, I reached out to him again to finally discuss our shared anxieties.

“I was fearful about what would happen if I told a friend. Would they want to be friends with me anymore?” he said to me in a phone interview days after he published his post.

It wasn’t until after he received positive comments and direct messages from strangers on his Instagram post that he began feeling comfortable discussing his vulnerabilities with friends — and began encouraging other young men to do the same.

“There will always be people in someone’s life that will care,” he said. “They might just not know. So that’s why we have to talk about it.”

Four years after the only romantic relationship in my life ended, I’ve realized that all relationships require a certain degree of vulnerability.

I remember when I finally told my roommate about my parent’s separation. One evening, in one breath, I opened up about their split and my pain. It felt like a weight was lifted off my chest.

Having gone years believing “real men” suppressed their feelings, I felt extremely relieved and comforted when he listened and showed empathy.

It strengthened our relationship. Sharing that intimate detail played a key role in him becoming my closest friend, and why we still regularly talk.

In my conversation with Dr. Way, she emphasized how boys — like her son — at young ages have the emotional astuteness to comprehend when someone is feeling sad.

Those emotions must be nurtured, not altered by cultural stereotypes and perceptions of manhood. She says boys and men have the ability to understand emotions, their feelings are just waiting to be valued.

“This is not a depressing story,” Dr. Way said.

I agree.

Josh Kozelj is a writer based in Victoria, British Columbia. He is a senior at the University of Victoria studying Creative Writing.

March 25, 2021

Teenagers, Anxiety Can Be Your Friend

Think of it as a personal warning system that will help you notice when things are on the wrong track.

For many teenagers, anxiety is riding high these days.

A new report from the University of Michigan’s C.S. Mott Children’s Hospital National Poll on Children’s Health found that one in three teen girls and one in five teen boys have experienced new or worsening anxiety since March 2020.

And a year into the pandemic, there’s certainly plenty to worry about. Maybe you’re feeling nervous about catching or spreading Covid-19, or about returning to in-person school. You might be feeling tense about where things stand with your friends or perhaps you’re on edge about something else altogether: your family, your schoolwork, your future, the health of the planet.

While I wish there were fewer reasons to be anxious right now, I do have good news for keeping yourself steady. Psychologists actually understand a lot about anxiety — both the mechanisms that drive it and interventions that get it under control — and what we know is quite reassuring. So if you’re looking to feel more at ease, start by letting go of these common myths.

Myth: I’d be better off if I never felt anxious.

Without question, anxiety feels bad — it’s no fun to have a pounding heart, sweaty palms and tightness in your chest — and for that reason, it’s easy to assume that it must be bad. But the discomfort of anxiety has a basic evolutionary function: to get us to tune into the fact that something’s not right.

You can think of anxiety as the emotional equivalent of the physical pain response. If you accidentally touch a hot burner, the pain makes you pull your hand away. In the same way, if your friends want to take a Covid-safe outdoor event and move it into a cramped indoor space, you should feel a surge of discomfort. That odd feeling in the pit of your stomach will help you to consider the situation carefully and be cautious about your next step.

Try to view anxiety as your own personal warning system. It’s more often a friend than a foe, one that will help you notice when things are on the wrong track.

Given this, when is anxiety unhelpful? While most of the anxiety you feel is likely to be healthy and protective, psychologists agree that anxiety becomes a problem if its alarm makes no sense — either going off for no reason or blaring when a chime would do.

In other words, you should not feel anxious when all is well, and when you do feel anxious, the intensity of your nerves should match the scale of the problem before you. Feeling a little tense before a big game is appropriate and may even improve your performance. Having a panic attack on the sidelines means your anxiety has gone too far. It may be worth talking to a mental health care provider for advice on how to manage it, but first you can try the proven techniques below.

Myth: There’s not much I can do about anxiety.

You do not need to feel helpless when your anxiety alarm goes off, and even when anxious feelings cross the line from healthy to unhealthy, there’s a lot you can do to settle your nerves. Keep in mind that anxiety has both physical and mental components. At the physical level, the amygdala, a primitive structure in the brain, detects a threat and sends the heart and lungs into overdrive getting your body ready to fight or flee that threat. This is helpful if you’re dealing with a problem that calls for attacking or running — you’re about to miss the school bus and need to break into a sprint to catch it — but bothersome if your one-note-Johnny amygdala gets your heart pounding and your lungs hyperventilating while you’re trying to take a test.

A really good way to curb the physical symptoms of anxiety? Controlled breathing. Though it can sound like a daffy approach to managing tension, breathing deeply and slowly activates a powerful part of the nervous system responsible for resetting the body to its pre-anxiety state. There are many good breathing techniques. Find one that you like. Practice it when you’re feeling calm. Put it to work when your amygdala overreacts.

For the mental component of anxiety, watch out for thoughts that are extremely negative. Are you thinking, “I’ll probably get sick if I go to school,” or “I’ll never find someone to sit with at lunch”? Such intense pessimism will almost certainly set you on edge. Counter your own catastrophic thoughts by asking yourself two questions: Am I overestimating the severity of the problem I’m facing? Am I underestimating my power to manage it? Weighing these questions will help you keep your concerns at healthy levels.

Myth: If something makes me anxious, I should avoid it.

Understandably, if we’re scared of something, we’re inclined to stay far away from it. Avoidance alleviates anxiety in the short term, but here’s the rub: In the long term, avoidance entrenches it. There are two separate factors at work here. The first is that it feels great when we steer clear of the things we dread. If you’ve been doing school remotely this year and get nervous when you picture your return to in-person learning, resolving to stay home will cause your worries to instantly drain away. It’s human nature to want to repeat any behavior that leads to feelings of pleasure or comfort, but every boost of avoidance-related relief increases the likelihood that you’ll want to continue to avoid what you fear.

The second factor in the avoidance-feeds-anxiety double whammy is that you rob yourself of the chance to find out that your worries are exaggerated. For example, the realities of in-person school are sure to be more manageable than the harrowing scenarios your imagination can create. Going to school would likely bring your worries down to size.

Facing our fears can reduce anxiety. But you don’t have to dive into nerve-racking experiences when wading in is an option. If social distancing has left you feeling unsure about the status of your friendships, you might be tempted to isolate yourself. Instead, come up with a small first step, such as making a plan to hang out with just one or two buddies before returning to the broader social scene. Get your feet wet and then take it from there.

With the world beginning to open up, it makes sense that you might feel nervous about easing back into it. Knowing what’s true about anxiety — and not — will make it easier to navigate the uncertain times ahead.

March 24, 2021

Is Ringing in the Ears a Symptom of Coronavirus?

Researchers are just beginning to untangle how Covid might be linked to a ringing in the ears. Here’s what we know.

Shortly after she fell ill with Covid-19 last April, Andrea Ceresa, an office manager and singer in Branchburg, N.J., noticed an unusual sensation in her ears: a ringing and buzzing that had never been present before. Now, nearly a year later, Ms. Ceresa, 47, said that of all the debilitating post-Covid symptoms that have lingered — the heart palpitations, headaches, stomach troubles, numbness and weakness in her hands and feet — the most frustrating one is the tinnitus, a condition that can cause sufferers to hear phantom ringing, buzzing, whistling, chirping or other sounds.

“There’s never not a time when I don’t have noise running through my head,” Ms. Ceresa said. “It makes it hard to concentrate, it makes it hard to hold conversations with others, it makes it almost impossible to lie down and go to sleep. It’s maddening, and you can’t fully understand it unless you experience it yourself.”

Following the recent death of Kent Taylor, the founder and chief executive of the Texas Roadhouse restaurant chain who took his own life at age 65 after suffering from post-Covid-19 symptoms, including severe tinnitus, many are wondering how Covid and tinnitus may be linked. Also, how might tinnitus — a vexing condition that afflicts as many as 60 million people in the United States — influence mental health?

While some early research and anecdotal evidence suggest an association between tinnitus and Covid-19, experts caution that it’s still too early to make a definitive link. “Am I seeing patients who come in saying they noticed tinnitus after developing Covid-19? Yes,” said Dr. Douglas Hildrew, an ear, nose and throat specialist and surgeon at Yale Medicine. But, he noted, it may also be exacerbated by other factors, like stress.

Here’s what we know.

What causes tinnitus?

According to Dr. Maura Cosetti, an ear, nose and throat specialist at Mount Sinai Hospital in New York City, the most common cause of chronic tinnitus is age. As the hair cells inside your inner ear become damaged over time, she said, they may no longer send sound waves to your brain, so your brain tries to recreate them on their own, which is what might cause the ringing.

But experts have long known that some viruses can temporarily cause hearing loss or ringing in the ears, too. When the body fights an infection, the overall inflammation from the virus can damage the nerves or hair cells in the ear, Dr. Cosetti said.

“Sometimes, a patient has already had mild tinnitus that they never really noticed before,” said Dr. David Friedmann, an ear, nose and throat specialist at NYU Langone Medical Center. “But once it’s temporarily exacerbated by a virus, they continue be bothered by it even after the initial infection has resolved.”

Can Covid-19 cause tinnitus?

There’s not enough research to say for sure. “There haven’t been any studies yet that I’m aware of that compare rates of tinnitus among survivors of Covid-19 with those in the general population,” Dr. Hildrew said.

In one review, published Monday in the International Journal of Audiology, researchers pooled data from nearly 60 case reports and studies and found that nearly 15 percent of adults diagnosed with Covid-19 reported tinnitus. Another study, published in the same journal in July, followed 138 patients for eight weeks after they had been discharged from a hospital in the United Kingdom after suffering severe symptoms of Covid-19. Among them, 16 (13 percent) reported either a change in hearing or tinnitus.

Natalie Lambert, an associate research professor of biostatistics and health data science at the Indiana University School of Medicine, surveyed nearly 5,200 “long-hauler” Covid-19 patients and found that nearly 17 percent reported new tinnitus, with more than three-quarters of those people saying it was ongoing. She cautioned that more research is needed to confirm the results, which have not yet been peer-reviewed or published in a medical journal.

There’s also evidence that Covid-19 symptoms can exacerbate existing tinnitus. In one online survey of about 3,100 people from 48 countries who suffer from tinnitus, researchers found that among the 237 people who experienced Covid-19 symptoms, 40 percent said that their tinnitus symptoms had been significantly worsened. Nearly a third of all the respondents also reported the stress of the pandemic itself exacerbated their tinnitus, even if they hadn’t contracted Covid-19. “We know that anxiety can worsen tinnitus, and it becomes a vicious cycle: The worse your tinnitus, the more anxious you are,” Dr. Hildrew said. “It becomes a very aggressive loop that can be difficult to break.”

How does tinnitus affect mental health?

When Marlene Suarez contracted Covid-19 during the second week of January, her symptoms of fever, cough and difficulty breathing weren’t so severe that she needed to be hospitalized, but they were bad enough to warrant treatment with monoclonal antibodies to reduce her risk of serious complications. About a week after her diagnosis, while watching TV, she noticed a ringing in her left ear, and that she couldn’t hear anything in her right.

“I went to the emergency room, where the E.N.T. on call said it was probably from Covid-19,” said Ms. Suarez, 62, an attorney in Collinsville, Ill. The ringing continued for weeks. “I was so depressed and scared I’d never get better,” Ms. Suarez said. “I speak and talk for a living — how was I going to be able to have a conversation with a client or present in court if it constantly sounded like bells were exploding on my left side?”

Ms. Suarez was given oral corticosteroids for several weeks, and now, more than two months later, her tinnitus and hearing loss have mostly resolved. But for many with more chronic ringing in the ears, the result can be devastating.

Tinnitus has been linked to several mental health conditions, including anxiety and depression, and mostly in women. “It can be particularly challenging for many people initially because it’s something they have absolutely no control over,” said Richard Tyler, an audiologist at the University of Iowa Carver College of Medicine. “No one can tell them if it will get worse, or if it will eventually go away. Suddenly, they have trouble sleeping, they can’t carry on a conversation, and they can’t concentrate. It can seem an overwhelming challenge.”

The condition has also been linked to an increased risk of suicide. In a research letter published in JAMA Otolaryngology–Head & Neck Surgery in 2019, researchers found that among more than 16,000 adults in Sweden who had ever experienced tinnitus, women — and in particular, those with severe tinnitus — had a small increased risk of suicide. However, those who had been diagnosed, and possibly treated for, the condition were not at increased risk.

“For most people with tinnitus, the worst time is the first six to nine months after it begins,” Dr. Tyler said. “After that, most people adjust and learn to live with it, especially if they’re given the right treatments.”

How is tinnitus treated?

If you are diagnosed with Covid-19 and you experience tinnitus that lasts for more than two days, tell your doctor right away. “The same treatment that can help you recover from tinnitus and sudden hearing loss is a steroid, which can also help treat Covid-19,” Dr. Hildrew said. Nonsteroidal anti-inflammatories, like ibuprofen, can also temporarily cause tinnitus, Dr. Cosetti added. This usually resolves within a few days once you stop taking them.

If your tinnitus persists after you’ve recovered from the virus, make an appointment with an ear, nose and throat doctor, who can check for blockages in your ears (like from fluid or ear wax), which can cause symptoms. If no blockage exists, you might be sent to an audiologist to check your hearing.

If your tinnitus does persist and is related to hearing loss, your E.N.T. may refer you back to an audiologist to get fitted for a hearing aid, Dr. Friedmann said. Your audiologist may be able to add a device to it that produces low-level sounds to help mask tinnitus noise.

There’s also good evidence that cognitive behavioral therapy, a type of talk therapy that can help you strategize ways of ignoring your tinnitus or dealing with the stress of it, can help. One study found that incorporating C.B.T. with mindfulness techniques, like meditation, significantly reduced tinnitus-related distress.

After many months of dealing with the tinnitus that began last spring, Ms. Ceresa is now being treated for her constellation of lingering symptoms at the Center for Post-Covid care at Mount Sinai Hospital in New York City. Tinnitus is still near the top of her list of complaints. “It’s always there and with me all the time — I can never escape it,” she said, adding that she has to take sedatives now to fall asleep. “I have days when I don’t know if I can handle this anymore. But I have to go on being hopeful.”

Hallie Levine is a health journalist who lives with her three children and two Labrador retrievers in Fairfield, Conn.