How to Conquer Mask Anxiety
Psychological Strategies to Improve Your Comfort Wearing a Mask
With many regions around the world adopting mandatory mask policies to combat the spread of coronavirus, it’s become clear many people may find that mask-wearing poses a considerable challenge for non-political reasons. These difficulties include both medical and mental health related factors. One of the main mental health reasons is anxiety.
Given that clinical psychologists regularly help people manage anxiety related to shortness of breath and feeling claustrophobic (the main sensations described by some people struggling to wear a mask), I thought it worthwhile to offer guidance on building tolerance to these sensations. I often work with patients who fear shortness of breath, such as those with Panic Disorder or even people who are sensitive to anxiety symptoms.
One thing these individuals have in common is a fear that feeling short of breath is dangerous or threatening. As such, experiencing this sensation causes increased anxiety and other related physiological sensations such as increased heart rate, light-headedness or hot flushes, and produces a strong desire to quickly escape the situation (like taking off the mask or leaving a store) and to avoid such situations in the future. In reality, although shortness of breath can feel dangerous, it’s not the same as actually lacking sufficient oxygen, which can occur in certain medical conditions (ex: COPD).
In fact, when patients feel anxious it’s not a lack of oxygen that’s the problem, it’s actually a lack of carbon dioxide! Whenever we feel stress and anxiety our bodies tend to unconsciously start to breathe at a faster rate, which causes increased release of carbon dioxide as we breathe out. The loss of carbon dioxide is detected by the body/brain leading to increased anxiety. Therefore, psychologists regularly teach anxious patients to slow down their breathing — it’s not to catch their breath and get more oxygen, it’s to increase their CO2 levels.
The emotion of anxiety also tends to act as a mental filter; the brain starts to interpret things as being more threatening than they actually are. Patients who develop anxiety over having panic attacks, for example, will tend to misinterpret regular body sensations (e.g., normal changes in heart rate or temperature) as threats. In the case of mask wearing, it would be normal to notice a change in breathing sensation (I certainly perceive a difference), which gets interpreted by anxious individuals as a lack of oxygen. However, this is a misperception– if wearing a mask induced actual hypoxia, all people wearing masks would experience a range of symptoms (ex: headache; confusion; changes in skin colour). Professionals who require the regular use of masks (surgeons; dentists) aren’t lacking oxygen.
Despite knowing logically that we’re not actually running out of oxygen, many are still left with the discomfort of anxiety and in some cases panic (which although not dangerous, is highly aversive). As I noted earlier, this problem can be fixed by building up a tolerance to the sensation of feeling shortness of breath. I will outline how I do this with my patients, which is based on exhaustive research from cognitive behavioural therapy (CBT) showing that humans’ brains and bodies can learn to feel calm in response to things that cause us fear.
My favourite approach to anxiety exposure and tolerance building is to have patients breathe through a straw. Breathing through a straw literally reduces oxygen intake and will induce shortness of breath and some level of anxiety in many people. How much straw breathing is needed to induce anxiety will vary across individuals. Some individuals experience a lot of anxiety (for example, a 7/10 on a scale from 0 to 10, with 10 being panic) after breathing through a straw for only 15 seconds. Others will max out at a 3 after a full minute. For some patients, I have to use tape to block half of the straw to induce an even stronger sensation of breathlessness.
In any case, if you feel a lot of anxiety and shortness of breath wearing a mask, I’d wager you will have little problem inducing such symptoms by breathing through a straw. I’d recommend practicing first to see how long it takes to get your anxiety to a medium level (4–6/10). Note the time because this will be your starting point. You want to practice breathing through the straw for that amount of time repeatedly until it causes very little anxiety (at the end of the article, I provide an example of how this would look).
For example, if it took 45 seconds to get your anxiety to a 5/10, then keep breathing through the straw in blocks — do 45 seconds, then take a 1 minute break, then do 45 seconds again, and so forth. You’ll likely notice that your anxiety will start to slowly decrease across blocks of practice.
When you get your anxiety down to a 1–2/10, then move the level of difficulty higher. Try adding 20 to 30 seconds to the previous time and repeat the above steps to lower your anxiety back down to 1–2/10 (gradually lowering anxiety in this way is called habituation). If you can eventually get to 2 minutes with little anxiety, then a mask will likely be easier to use because the sensation of breathlessness will be better tolerated. Please check out the sample exposure I include at the end of this article.
If straw breathing is not up your alley, or if you want to practice exposure with masks directly, then you could simply practice wearing a mask at home using the same tolerance building exercises described with straw breathing. Start by figuring our how long it takes to get your anxiety to a 4–6/10. Then keep wearing the mask in those blocks of time until you reduce your anxiety, and then increase the time limit.
My wife (also a clinical psychologist) and I are using a similar approach with our children (at the very end of the article I’ve included our schedule). We are getting them to start by wearing a mask for 30 minutes each day (usually while they watch TV or play video games) to start building their tolerance. We’ll then add more mask wearing time and in different situations like reading and talking over the next several weeks to get them adjusted so that they’ll be more prepared for the start of the school year (their school district will require masks to be worn by children).
Building tolerance to symptoms is very feasible for most people — I’ve been successfully treating patients for many years using this approach, and it’s backed by decades of science. If you find the above suggestions are not working, then contact a psychologist to work on figuring out an exposure plan that will work for you. For some of my patients we need to get creative to find a plan that works best for them.
Also, if you have reason to believe that inducing a sensation of breathlessness could pose a medical threat, consult with a physician before moving forward. I’ve never had a patient experience a medical problem with these types of exposure exercises (it’s fairly benign), but I want to make sure readers are taking precautions they believe are necessary.
We don’t know how long masks will be required during this pandemic, and with many children and adults returning to school and work in the Fall and Winter, taking a bit of time to adjust to masks is worth the effort.
Sample Exposure Plan
This is an example of what someone’s exposure plan (a fictional person named Donald) might look like for the first week:
Donald’s Day 1 Exposure Plan
1. Engage in straw breathing test to identify length to time to induce medium anxiety. Donald finds that his anxiety hits about a 5/10 after 35 seconds.
2. After a minute break, he practices for 35 seconds again and notes no changes in anxiety.
3. Donald takes another minute break and repeats the 35 seconds. He then repeats 6 more times (called blocks) until he notices that the anxiety now only causes a 2/10. He then repeats a few more blocks of 35 seconds.
4. Donald takes a break for the day.
Donald’s Day 2 Plan
1. He starts by retrying 35 seconds to test if it still causes any anxiety. He notices it now causes a 4/10. He then practices 35 second blocks a few times and notices it quickly reduces to near zero.
2. Donald now jumps to 1 minute. He notices that his anxiety actually hits a 5/10 at around 55 seconds, so he stops just short of 1 minute (it’s ok to be flexible).
3. He practices 55 seconds until it reaches about a 1–2/10 (this takes about 7 blocks).
4. He breaks for the day.
Donald’s Day 3 Plan
1. He starts by checking how much anxiety 55 seconds causes. He notices a rebound back to 5/10. So he repeats the exercise and after 5 blocks he notices that it is back down to 1/10. He then jumps to 90 seconds.
2. Donald notices that he can push himself to get to 90 seconds, which makes his anxiety go to a 7/10. Donald decides he wants to try exposure at this level even though it’s a bit scary. He tries 9 blocks of straw breathing and notices the anxiety has come down to a 3/10. He tries 3 more blocks and notices it’s staying at a 3/10. That’s OK — Donald has noticed a decrease from 7 to 3, and decides to break for the day.
Donald’s Day 4 Plan
1. Donald tries 90 seconds and notices it causes a 6/10. He then needs 6 blocks of straw breathing to bring it down to a 2/10. He repeats a few more blocks and then tries 2 minutes.
2. Donald notices that 2 minutes causes 5/10. He needs 4 blocks to bring it down to 2/10.
3. Donald decides it’s time to start transferring his improved tolerance to mask wearing. He puts on a mask and watches a Netflix program in the living room. He notices that he can wear a mask for 15 minutes which causes anxiety to be at a 5/10. He breaks for the day
Donald’s Day 5 Plan
1. Donald puts on a mask while watching Netflix and keeps it on for 15 minutes, which causes anxiety to be at a 4/10.
2. He breaks and puts on the mask in the evening while having a conversation with his wife Hilary. He notices that his anxiety is a 3/10 after 15 minutes, so he decides to push the envelope and keep the mask on for another 5 minutes, which brings his anxiety up to a 5/10.
Donald’s Day 6 Plan
1. He wears a mask for 20 minutes in the morning while distracted (scrolling social media) and notices anxiety is a 5/10.
2. He takes a 10-minute break and then tries to wear the mask again for 15 minutes while he works. He notices that his anxiety is quite low and that he actually forgot about the mask at one point. So, he keeps it on for 10 more minutes. His anxiety ends at a 4/10.
3. In the evening, he wears a mask 25 minutes while chatting politics with Hilary, and notices that his anxiety is getting high — a 6/10 after 20 minutes. He reminds himself that although he feels anxious, there is no threat. He is actually not short of oxygen. This allows him to complete the 25-minute block. He breaks for the day.
Donald’s Day 7 Plan
1. He starts by wearing a mask while watching SportsCentre for 25 minutes and notices his anxiety is at about a 5/10.
2. He practices wearing the mask a few times during the day for 25-minute blocks. He notices his anxiety usually doesn’t go beyond 5/10.
3. He wears a mask for 35 minutes in the evening while cuddling and watching movies with Hilary. He notices his anxiety is about a 6/10, which is annoying but the movie and Hilary are a nice distraction and allows him to tolerate the anxiety.
In fact, after 1 week of exposure Donald has learned that he can tolerate breathlessness at medium levels of anxiety much better than when he started. Donald continues to progress in his exposure work in the coming weeks until wearing a mask and feeling short of breath are not much of an issue. Notice
Notice that with this approach, fear is like a virus and the exercises are like little doses of virus (like a vaccine) that increase your ability to ward off the fear.
Here is the schedule we’re using with our children to prep them for school (you may have to zoom in a bit to read the text):