Psychiatrist Thomas Uhde has treated celebrity actors, athletes and business executives for the kind of social anxiety and depression that tennis star Naomi Osaka suffers from.
“As long as they’re in their professional role, they’re fine. But you take them out of that context, they may have extraordinary difficulty interacting with other people. If they have to give a press conference, it can just be disabling.”
Uhde, chair of the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina, wasn’t surprised that Osaka withdrew from the French Open. “I don’t know her, but I’ve had many years of experience investigating and treating people with social anxiety disorder. It’s actually common for them to drop out of situations that are overwhelming for them.”
Those situations may seem harmless to other people. But that doesn’t make them any less stressful for someone suffering from social anxiety.
Uhde had one patient who was on the professional fast track — but tapped the brakes on a new job offer over his discomfort with using public restrooms. “He was being promoted to executive level, in a leadership role. I think it was a Fortune 500 company — either vice president or president. He had to have a bathroom in the executive suite, otherwise he was not going to take the job. He said, ‘It’s not worth it to me.’”
Another patient got what most people would consider great news — she was about to receive an award. “It was in a group of people that they knew well. But the idea of standing up and just receiving an award and recognition was so overwhelming to them that they quit.”
The National Institutes of Health defines the problem at the heart of those fears, social anxiety disorder, as persistent worry about being around strangers or being scrutinized, and doing something embarrassing and humiliating. About 12% of adults in the U.S. suffer from social anxiety disorder at some point. It’s worse in women than men, and peaks between the ages of 18 and 29. Osaka is 23.
The NIH defines depression as a period of at least two weeks where there’s a negative change in the way a person feels, thinks and handles activities such as sleeping, eating and working. About 7% of all adults in the U.S. have had at least one major depressive episode. Again, it’s worse in women and peaks in young adulthood.
Osaka said she had long periods of depression following the 2018 U.S. Open. She won the tournament but was left in tears after a dispute between her opponent and an umpire, over a controversial call, caused the crowd to boo and jeer.
The discussion about Osaka’s mental health comes at a time when more and more famous figures are speaking out about their own struggles. Serena Williams said she’s felt the same type of anxiety as Osaka. Prince Harry has talked about panic attacks, and his wife Meghan has described having suicidal thoughts. Regular people are talking more openly about mental health, too, recognizing it as a legitimate reason for time off from school or work.
Uhde, who did his residency at the Yale School of Medicine and his fellowship at the National Institute of Mental Health, said there are several ways to handle mental health challenges. In the case of social anxiety, if you can, start by doing what Osaka did: Let people know.
“In my working with clients who suffer from this condition, they are so concerned about what other people are thinking. The first thing I say is just be yourself. If you are shy and you have a lot of difficulty in these situations, just let people know. Tell your friends, ‘This is overwhelming to me. I have a really, really difficult time in these situations.’”
Uhde said cognitive behavioral therapy — talk therapy — can help people change thinking patterns. They learn to face fears instead of avoiding them, see where their thinking is distorted and become more confident.
There are also medications, both modern — such as Zoloft, Effexor and Paxil — and old school. One in particular stood out to Uhde. “There’s a class of medications, rarely used any more for the treatment of depression, that are called the MAO inhibitors. They’re actually extraordinarily effective in people that have the most severe forms of social anxiety disorder.”
Uhde said anxiety can be strongly linked to depression. “I like to think of it as demoralization. You feel foolish about your anxiety. That can lead to secondary issues like alcohol and substance abuse. You’re trying to take substances that reduce your anxiety.
“And then you have some cases where a person — it could even be a friend — views shyness and social anxiety as endearing, and then, in an attempt to be helpful, minimizes or even jokes about the problem. This only worsens the anxiety and leads to future avoidance of that person or similar situations.”
But it’s all treatable, Uhde said. “You have a responsibility to take care of yourself when you have a viral infection to not come to work and make other people sick. And so you also should have a responsibility to take care of your mental health needs as well.”
Osaka’s decision to go public with her mental health needs may make that a little easier for others with similar worries. After some initial backlash, support has been swelling for one of the biggest names in tennis.
“People have no idea how classic that is for someone with social anxiety disorder to leave a situation that’s truly frightening to them,” Uhde said. “And then you have organizations that don’t understand that it, and other mental illnesses, are truly disabling. That needs to change.”