Anxiety: Symptoms, Treatment, and When to Seek Help

Anxiety is the most common class of mental health condition in South Africa. National survey data (SASH, the South African Stress and Health study) estimate that 15.8% of adults will experience an anxiety disorder in their lifetime, and 8.1% in any given year. More recent national surveys suggest probable anxiety symptoms affect over 20% of adults. Most never receive treatment. This guide covers what anxiety actually is, how it presents, how it is diagnosed, and what evidence-based treatment involves.

What anxiety actually is

Anxiety is a normal adaptive response to perceived threat. It becomes a clinical disorder when it is persistent, disproportionate to the situation, and interferes with daily functioning. The underlying mechanism involves the brain's threat-detection systems (amygdala, hippocampus, prefrontal cortex) firing more readily and de-escalating less efficiently than they should.

The DSM-5 recognises several anxiety disorders, each with a distinct pattern:

• Generalised anxiety disorder (GAD): persistent, excessive worry across multiple domains (work, health, relationships, finances), difficult to control, present more days than not for at least six months. Physical features include muscle tension, restlessness, fatigue, irritability, concentration difficulty, and sleep disturbance.
• Panic disorder: recurrent unexpected panic attacks (sudden episodes of intense fear with physical symptoms peaking within minutes), followed by persistent worry about further attacks or avoidance of situations where attacks have occurred.
• Social anxiety disorder: marked fear of social or performance situations where the person may be scrutinised or judged, leading to avoidance or distress that interferes with life.
• Specific phobias: marked fear of specific objects or situations (heights, flying, injections, specific animals).
• Agoraphobia: fear of situations where escape would be difficult or help unavailable, often leading to housebound patterns.
• Separation anxiety disorder in adults: more recognised since DSM-5, involving distress about separation from attachment figures.

Most patients with one anxiety disorder have features of others. Many also have coexisting depression. The disorders share more biology than they differ, and treatment overlaps substantially.

How anxiety presents

Presentations vary but share common elements:

• Emotional: persistent worry, apprehension, dread, feeling on edge, irritability.
• Cognitive: racing thoughts, difficulty concentrating, mind "going blank", catastrophic thinking, sleep-onset insomnia.
• Physical: muscle tension (jaw, shoulders, neck), headache, racing heart, palpitations, shortness of breath, chest tightness, dizziness, nausea, tingling, sweating, tremor, gastrointestinal upset.
• Behavioural: avoidance of anxiety-triggering situations, reassurance-seeking, checking behaviours, inability to delegate or let go of control, increased alcohol or substance use as self-medication.

Physical symptoms often dominate. This is why anxiety disorders frequently present first to emergency departments, cardiology services, or GP surgeries rather than mental health services. Between 28 and 46% of emergency department patients with cardiopulmonary symptoms (chest pain, palpitations, dyspnoea) have comorbid anxiety or panic disorder.

Panic attacks specifically are often experienced as medical emergencies. The sudden-onset chest pain, racing heart, shortness of breath, and sense of impending doom closely mimic cardiac events. Many patients have multiple emergency visits and normal cardiac workups before anxiety is recognised.

Anxiety in South Africa: the under-recognition problem

Anxiety is the most common psychiatric condition class in SASH data (lifetime 15.8%, 12-month 8.1%), ahead of substance use disorders and mood disorders. More recent surveys using probable-anxiety screening tools suggest over 20% of adults are symptomatic in any given year.

Treatment rates are low. Reasons include:

• Under-recognition in primary care, especially when physical symptoms dominate
• Stigma and reluctance to describe symptoms as "anxiety"
• Lack of mental health service capacity, especially in rural areas
• Financial barriers to specialised psychology services
• Cultural frames that do not map neatly onto DSM anxiety disorders

The regional distribution in SASH is uneven: Western Cape has the highest anxiety prevalence, Northern Cape among the lowest. Clinical services need to be configured for this distribution rather than assumed to be uniform.

How anxiety is diagnosed

Anxiety is a clinical diagnosis. No blood test or scan confirms it. Assessment involves:

• Detailed history: symptom pattern, duration, triggers, functional impact, substance use, caffeine intake, sleep, medication use, medical history, family history of anxiety or mood disorders.
• Differential diagnosis: hyperthyroidism, phaeochromocytoma, caffeine or stimulant use, alcohol withdrawal, cardiac arrhythmias, and some medications can mimic anxiety. Baseline bloods (TSH, FBC, electrolytes, glucose) are often appropriate; ECG where palpitations are prominent.
• Comorbidity screening: depression (often coexists), substance use disorder, other anxiety disorders, PTSD.
• Screening tools: validated instruments such as the Generalised Anxiety Disorder-7 (GAD-7) help standardise severity assessment. Tool scores support clinical judgement; they do not replace it.
• Suicide risk assessment: anxiety disorders, particularly when combined with depression or substance use, carry meaningful suicide risk. Direct enquiry is standard.

A proper assessment typically takes 45 to 60 minutes. Follow-up appointments monitor response to treatment and adjust as needed.

Evidence-based treatment

Anxiety disorders are highly treatable. First-line options are well-supported by evidence.

Cognitive behavioural therapy (CBT)

CBT has the strongest evidence base of any psychological treatment for anxiety. Effect sizes are particularly large for GAD (Hedges' g around 1.0 versus placebo in meta-analyses), moderate for social anxiety disorder, and meaningful for panic disorder. See Carpenter et al. 2018 for the meta-analysis of CBT across anxiety and related disorders. CBT-based treatment gains are more durable than pharmacotherapy gains after treatment ends; patients typically maintain benefit over 12 months or longer.

For mild to moderate anxiety, CBT alone is a reasonable first-line choice. For moderate to severe anxiety, combination with medication often works better, particularly for panic disorder where combination is clearly superior to medication alone.

Access to registered psychologists for CBT is limited in the South African public sector. In private practice, CBT is available through clinical and counselling psychologists. Online CBT platforms with some evidence base include iCBT programmes delivered through apps and websites; these are not a full substitute for in-person therapy but can supplement it.

Medication

First-line pharmacotherapy for anxiety disorders is an SSRI or SNRI. A 2019 network meta-analysis of 89 trials and 25,441 patients (Slee et al., Lancet 2019) identified duloxetine, venlafaxine, and escitalopram as among the most effective agents for GAD, with effect sizes around 0.37 to 0.44. Response rates are typically 30 to 50% for adequate dosing over 8 to 12 weeks.

• Sertraline or escitalopram are commonly first-line SSRIs in South African practice. Both are widely available, familiar, and tolerable.
• SNRIs (venlafaxine, duloxetine) show slight efficacy advantages but higher discontinuation due to side effects.
• Pregabalin is an alternative, particularly where SSRIs have failed or been poorly tolerated. It works faster (1 to 2 weeks) but can cause sedation, weight gain, and has dependence risk with prolonged use.
• Buspirone is a non-sedating option with modest efficacy, typically slower onset than SSRIs.

Response is gradual. Meaningful improvement usually appears at 2 to 4 weeks, full effect at 8 to 12 weeks. Early deterioration (temporary worsening of anxiety in the first 1 to 2 weeks of SSRI treatment) is common and should be anticipated rather than cause discontinuation.

Once response is established, treatment is continued for at least 6 to 12 months to reduce relapse. Some patients need longer courses; some can taper after 12 months. Tapering should always be gradual.

Benzodiazepines: a bridge, not a solution

Benzodiazepines (diazepam, lorazepam, alprazolam, clonazepam) provide rapid symptomatic relief and can be useful in specific situations: acute crisis, bridging while an SSRI takes effect, or short-term management of severe panic.

Long-term benzodiazepine use is not recommended. Risks include:

• Dependence: clinically significant withdrawal symptoms develop rapidly, often after as little as 4 weeks of daily use.
• Cognitive impairment: memory, attention, and psychomotor speed are affected even at therapeutic doses.
• Falls and fractures: risk increases 1.3 to 2.6 times in older adults.
• Overdose: risk is amplified in combination with alcohol or opioids.
• Disinhibition: can worsen impulsive behaviour and occasionally increase suicide risk.

Current international guidelines (FDA 2020 boxed warning, NICE, American Psychiatric Association) recommend restricting benzodiazepine use to the shortest necessary duration, typically not exceeding 4 weeks. In SA, with concerning patterns of benzodiazepine and opioid co-prescription, primary-care guidelines increasingly emphasise avoiding routine benzodiazepine use for chronic anxiety.

Lifestyle

Several non-pharmacological interventions have meaningful effects:

• Caffeine reduction. Caffeine is an anxiogenic stimulant. Many patients with anxiety consume levels that would reliably provoke anxiety symptoms in healthy volunteers. A trial of reduced caffeine is low-cost and often clinically useful.
• Regular aerobic exercise. Effect sizes for anxiety reduction with structured exercise are moderate to large. Group-based, supervised programmes tend to work better than unsupervised solo exercise.
• Sleep hygiene. Insomnia both worsens and is worsened by anxiety. Structured sleep-restriction approaches or CBT for insomnia can help.
• Alcohol reduction. Alcohol is often used as self-medication and typically worsens anxiety over time.
• Mindfulness-based approaches. MBCT and MBSR have moderate evidence for anxiety, though they are usually less effective than CBT as monotherapy.

When specialist referral is needed

GP-level management is appropriate for most anxiety. Psychiatrist referral is indicated for:

• Severe anxiety with marked functional impairment.
• Treatment-resistant cases (inadequate response to two adequate SSRI or SNRI trials).
• Significant comorbidity: bipolar disorder, active substance use disorder, severe personality disorder, PTSD, eating disorder.
• Active suicidality.
• Complex medical context: pregnancy, cardiovascular disease, advanced HIV, drug interactions requiring specialist expertise.
• Diagnostic uncertainty, especially around PTSD, OCD, or bipolar features.

At NeoHealth, Dr Chellan conducts anxiety assessments and manages anxiety at GP level as part of his mental health scope. Cases that require specialist-led care are referred to a psychiatrist with a clear handover letter.

Crisis support

If you are in crisis, or have thoughts of harming yourself:

• SADAG: 0800 567 567 (24 hours, free, confidential)
• Lifeline: 0861 322 322
• Suicide Crisis Line: 0800 567 567 / SMS 31393
• Your nearest emergency unit if you are in immediate danger

Anxiety attacks are not emergencies in themselves, but if you cannot tell whether you are having an anxiety attack or a cardiac event, treat it as a cardiac event and seek emergency care. Being wrong in the safer direction is fine.

Booking an assessment at NeoHealth

For anxiety assessment, medication management, CBT coordination, or ongoing follow-up, book a consultation with Dr Chellan at NeoHealth as part of our mental health service. For crisis situations, go to your nearest emergency unit or call SADAG on 0800 567 567 immediately.

If your anxiety is accompanied by depressive symptoms, Discovery Health members may qualify for the Mental Health Care Programme or the Depression Risk Management Programme, depending on whether you meet the clinical threshold for episodic major depression or are identified as higher-risk through Discovery's mental wellbeing assessment.

For related topics, see Depression: a clinical guide for South Africans.

Sources and references

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision. APA 2022 (DSM-5-TR).
• Williams DR et al. SASH. Twelve-month mental disorders in South Africa. Psychological Medicine 2008 (PubMed).
• Slee A et al.. Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis. The Lancet 2019 (PubMed).
• Carpenter JK et al.. Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo-controlled trials. Depression and Anxiety 2018 (PubMed).
• NICE. Generalised anxiety disorder and panic disorder in adults: management CG113. NICE 2020.
• FDA. Drug Safety Communication: FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. US Food and Drug Administration 2020.
• South African Depression and Anxiety Group. SADAG clinical resources and crisis helpline. SADAG.

Content on this page is based on these sources and current clinical practice at NeoHealth. It is general health information, not personalised medical advice. Book a consultation for individual assessment.