Patric Mattek, Ph.D.

“Nothing diminishes
anxiety faster than action.”
-Walter Anderson
 Anxiety disorders, as a group, are the most
common mental health disorders in America.

About 40 million American adults are affected

by these debilitating illnesses each year. That’s
18.1% of the population.
 Anxiety Disorders-
*Panic Disorder
*Specific Phobia
*Social Phobia
*Generalized Anxiety Disorder
*Separation Anxiety Disorder
*Selective Mutism
 *Anxiety disorders are highly treatable,
yet only 36.9% of those affected receive
treatment.

*People with an anxiety disorder are 3

to 5 times more likely to go to the doctor
and 6 times more likely to be
hospitalized for psychiatric disorders
than those who do not have anxiety
Anxiety disorders.

Statistics *Social Anxiety Disorder affects 15

million adults, or 6.8% of the U.S.
population.
SAD is equally common among men and
women and typically begins around age
13. According to a 2007 ADAA survey,
36% of people with social anxiety
disorder report experiencing symptoms
for 10 or more years before seeking help.
 Statistics cont. *Anxiety-based school refusal
affects 2-5 % of school-age
*About 40% of Americans experience children. It commonly takes
a panic attack at some point in their place between the ages of 5 and
life, but only about 4% develop Panic 6 and between 10 and 11, and at
Disorder. times of transition, such as
entering middle and high
*About half of those diagnosed with school.
an anxiety disorder are also
depressed.
*Anxiety is the top presenting
*Anxiety disorders affect 25.1% of concern among college
children between 13 and 18 years old. students (41.6 %), followed by
Research shows that untreated
children with anxiety disorders are at depression (36.4 %) and
higher risk to perform poorly in relationship problems (35.8 %).
school, miss out on important social
experiences, and engage in substance
abuse.
 Anxiety Statistics
According to NIMH, less than 43% of those with anxiety
seek treatment, and only 33.8% of those people seek
treatment considered "minimally adequate." That means
that of all the people living with anxiety, only 14.3% are
currently engaged in an effective treatment - and that
number excludes those with daily manageable anxiety.
 Clinical Example #1
10-year-old Corey stepped off of the bus and felt his heart
race, stomach become nauseous, and began having
difficulty breathing. He became dizzy and his chest
hurt, so he called his friend to get the principal. By the
time the principal came Corey was sitting on a chair
and his face was very red. He was breathing very fast.
He said everything was spinning. He told the principal
he thought he was dying, and to call an ambulance. By
the time the Corey arrived at the hospital he was
scared, but all of the other symptoms were gone.
Routine medical tests showed nothing.
 Clinical Example #2
14-year-old Alexis has missed 8 days of school the
past month. The reason is that every day she is
ready to get going she feels very nauseated starts
to gag. Her stomach becomes very upset, she gets
a headache and acid reflux, her heart races and she
starts shaking. She has had this “condition” since
getting over the flu a little over a month ago.
Alexis used to enjoy school and was very active in
sports. She has become increasingly irritable and
withdrawn.
 Clinical Example #3
Rumeal, age 16, was in his math class. All of a sudden he felt
like he had to get out or he was going to go nuts or lose
control. Rumeal felt his body explode with terrifying
sensations. He started breathing hard, felt his heart race,
became hot and sweaty, and was trembling. He raised his
hand to tell his teacher that he had to leave. When his
teacher said no, Rumeal started screaming that he was
going anyway and knocked over his desk and then slammed
the door so hard they could hear it upstairs. By the time he
ended up in the vice-principal's office, it was over and he
was sorry, but he ended up with detention.
 Clinical Example #4

9-year-old Jessica has been to the family doctor six times

in the last two weeks. She has insisted that her mother
take her ever since she had a dizzy spell, felt like her
stomach was turning inside out, and couldn't breathe.
She thought she was going to die. The family doctor
couldn't find anything, but she believes that the doctor
missed something. Jessica becomes unable to focus on
her schoolwork because she is worried about her body
sensations and fearful that she will have an attack. She
begins to miss more and more school with assorted
physical complaints and becomes increasingly
oppositional.
 Clinical Example #5

17-year-old John used to be a social and confident young man. He had a

number of friends and did well in school. Over the past couple of
years he has become increasingly worried about what other kids
think of him and he has stopped doing things that may call attention
to himself, such as raising his hand in class, for fear that he might
embarrass himself. He is dreading an upcoming project that requires
a presentation in front of his class and spends all his time thinking of
ways to avoid the ordeal. He is willing to fail the project, rather than
endure the discomfort of speaking in front of the class.
The Scream, 1893 – Edvard Munch
It is common for an anxiety
disorder to accompany
depression, eating disorders,
substance abuse, or another
anxiety disorder. Anxiety
disorders can also co-exist
with illnesses such as cancer
or heart disease.
 Treatment for anxiety
Cognitive-Behavioral Therapy
Behavioral Therapy
Relaxation Therapy
Medication (SSRIs – Prozac, Paxil, Celexa, Zoloft,
Luvox; Tricyclics – Desiprimine, Imiprimine;
Benzodiazapines – Xanax, Ativan, Valium)
Panic Inoculation Treatment
4 components
1. Psychoeducation
2. Breathing retraining
3. Cognitive Restructuring
4. Behavioral Experiments/Exposure
5. Relapse Prevention

80% show “dramatic improvement in frequency of panic

attacks, agoraphobic avoidance, and anxiety
symptomatology” (Telch, Lucas, Schmidt, Hanna, Jaimez, &
Lucas, 1993)
 Initial Session

Traditional intake – background information,

MMSE, etc.
Offer Miracle Question
Begin psychoeducation
 Dragon metaphor
 handout on anxiety/panic
Imagine that a MIRACLE happens while you are
sleeping tonight and all you are coming here for
is miraculously all better…how would you know?
What would it look like?
 HOMEWORK:
Handout prior to or after first
session
Define panic & anxiety terms

Education Function of anxiety & panic

 Alarm system
Physiology of anxiety
Theoretical model of Panic
Myths and Misinterpretations
http://www.algy.com/
anxiety/files/barlow.html
 Phase 1 - Education
Dragon metaphor - Alarm system
Tactics For Easing Anxiety
Dragon Metaphor
(The Anxiety Cure for Kids; DuPont Spencer, DuPont,
and Dupont)
 Dragon Metaphor
Inform about the dragon
Learn about the dragon
Make your own
Know it’s tricks
Make child the Dragon Master
 Dragon Metaphor
We all have a dragon in the back of our mind.
They can hurt us because they are in our mind.
All they can eat? Fear and worries.
They want us worried all the time – Old Country Buffet
All they can do is trick us, so they are watching and
waiting and learning the things that make us afraid.
Then, they mess with us…whispering and then shouting to
us the things that make us afraid.
Make clients “dragon masters” – differentiate between true
threats and dragon tricks.
 Tactics For Easing Anxiety
Therapeutic Story
(Little Bird Who Was Afraid of
Dragons)
 Conquering the Dragon
HOMEWORK:
Logging Fears/Dragon Tricks
Log dragons
Identify specific fears
Small, Medium, Large Stickers
 Anxiety
Definitions
Education - 3 systems of
anxiety
Alarm Theoretical Model
Metaphor of Panic
Panic myths
 Definitions
Stress – The general response to perceived pressures and
demands.
*Potluck/picnic metaphor

Anxiety – A natural, normal, and built-in alarm system for

dealing with perceived future threat or danger.
*Examples

Panic – An alarm response to react to perceived immediate

threat or danger.
*Examples

Panic Disorder- A learned pattern of false alarms.

*True Threat vs. False Alarm

Agoraphobia – A method for coping with false alarms by

avoiding situations.
3 Systems of Anxiety
Physical
Physical Sensations
Mental
Internal change in focus -
Hypervigilance
Worry/Mental Rehearsal

Behavioral
Avoidance
Escape Tendency
Sympathetic vs. Parasympathetic Nervous System
Do car alarms go off only when people are breaking in???

NO….We need to recalibrate your alarm system!!!

Physical Arousal “Triggers”
Hyperventilation
Exercise
Stress
Drugs
etc.

Physical Sensation Symptoms

Heart racing/pounding
Breathlessness
Dizziness
Sweating
etc.

“Faulty” Appraisal of Threat

I’m dying
I’m having a heart attack
I’m losing my mind
I will lose control of my senses
etc.
 Heart attack…..heart racing
 Fainting…..lightheadedness, dizziness
 Suffocation…..breathlessness
 Seizure…..lightheadedness
 Lose control….hyperventilation, body changes
 Vomit…..stomach distress
 Go crazy…..de-realization
 Make a fool of myself…..high arousal=behavior
changes
What’s Cooking?

PANIC ATTACK 40% of population

Ingredients:
1. Uncomfortable physical sensations
2. The belief that something bad will happen

Directions:
Mix well, and panic!
 While ANXIETY and PANIC, by nature, are
unpleasant, they are NOT harmful or dangerous.
They are necessary for survival and protection.
 Avoidance
Avoidance is a form of self-medication
May develop certain rules
I will only go if with special person.
I don't go to birthday parties.
I don't go to the mall.
I am driven to school.
I don't wait in lines.
I don't ride the bus.
Significantly effects functioning or
relationships
 An anxiety response is
no more than:

Fight, Flight, Sympathetic Arousal

Cognitive Attribution

or Freeze Emotional Labeling

 Tactics For
Easing
Anxiety

Separating our
“FEELINGS”
Phase 2 – Breathing Retraining
No control over sympathetic!!
What do we have control over?

Our PARASYMPATHETIC Nervous System

(Relaxation Response)
 Hyperventilation:
A physical state where you take in more
oxygen than your body needs.

Breathing too …or breathing too

fast… deeply.
 Breathing
Assessment
Diaphramatic Breathing
 Inner balance/EmWave (Heartmath.com)

https://www.thinkpacifica.com/app#/app/h
ome

http://
www.doasone.com/BreathingRooms.aspx?RoomID=1
Phase 3 – Cognitive
Restructuring
 STORMY SUNNY RAINBOW

Negative Clear Positive

Thinking Thinking/Reality Thinking-Not
necessarily “happiness”

Brain Channels
The Handbook for Helping Kids with Anxiety and Stress;
(Frank & Frank)
 Brain Channels
 Thoughts are very powerful, not that they can make things happen, but they
can powerfully affect our emotions.
 Stormy channel = negative thinking. Examples? What emotions do those
thoughts lead to? Do you do the greatest job of problem solving in stormy
channel? NO
 Sunny channel =seeing things clearly/reality. “It is what it is channel.” Lots of
it is what it is in life….practice/death/taxes…Not that things are great, but not
stormy channel.
 Rainbow channel = positive thinking. Not happiness…easy to think positively
when everything is great. Harder when bad things happen or adversity. How
do people even think positively when bad things happen or challenges? 1)
what we have to be thankful for, 2) hopefulness, 3) growth mindset. + thinking
helps us better problem solve…this is what builds confidence because we
know we can handle things.
 Neuroplasticity
The brain's ability to reorganize itself by forming new
neural connections throughout life. Neuroplasticity
allows the neurons (nerve cells) in the brain to
compensate for injury and disease and to adjust their
activities in response to new situations or to changes in
their environment.

Our brain is an organ, but functions

like a muscle: the more you use it
the stronger it gets.
Old theory =
The adult brain is a static
organ or hard-wired after
critical developmental
periods in childhood.

New theory =
Neuroplasticity. Brain is
changing/adapting. We
can re-wire our brain.
Examples of ●Neural networks….Patch over eye

Neuroplasticity ●Davidson’s work – New technology -

Tibetan monks

●Stroke – brain remaps

●Dumbbell metaphor
a.k.a. “POSITIVE THINKING”
Rainbow Thinking Cards
Cognitive Restructuring
Thinking Errors
Overestimation – believing something bad is way more
likely to happen than it really is.
Catastrophizing – believing something would be way
worse than it actually is
Dragon Busting Worksheet
Dragon Busting Worksheet
 Yesterday

Woke up and getting dressed and stomach hurt

The dragon was telling me that I was going to get sick and throw up
on the bus or at school.

X
 x

YES The dragon made

me believe it would happen when it most likely won’t.

YES
me believe it would be worse than it would be.
The dragon made

When I get worried my stomach aches, but I’ve never thrown up

and it always feels better when I relax and don’t think about it.
Even if I did get sick at school everyone would feel bad for me
I’ll be fine! I’m smarter than the dragon!
Dragon Busting Worksheet
How Bad Would It Really Be?
0 100
 Phase 4 –
Behavioral
Exposure/Exp
eriments
Exposure Behavioral Experiments
Play a key role in
eliminating false alarms
Interoceptive Exposure
Familiarize and habituate
body sensations
“Panic Pill”
Caffeine induction
 Experiment Cards
The Key to getting over phobias
Write task on front – complete task
– write outcome on back
Encourage with + reinforcement
Gradual steps
Keep going
The Girl and the Rope
 Visualization Skill

Mental Rehearsal

Visualize getting through feared situation

Incorporate breathing

Break conditioned response

 o f ● You Tube: The Best Way to
e s
l ion
Visualize-Performance Psychology-

m p t Visualization/Imagery
x a li z a
E ua ● You Tube: Mental Monday
V i s Athlete Spotlight Lindsey Vonn

Let’s Practice (Refer to Handout)

Additional Tactics For Easing
Anxiety

Super HeroMachine 2.5

Powers Helpful with intrusive thoughts

Fun way to help with thought

stopping
Additional Tactics For Easing
Anxiety
Use true Helpers
Like experiments
Way to help stop compulsive
behavior
Parents, siblings, therapist
Additional Tactics For Easing
Anxiety
Worry Box Initial logging promotes
teamwork/ID worries
Later takes focus off
fears
Encourages use of
coping skills
 MINDFULNESS
Mindfulness is simply… noticing what is
happening right now.
Mindfulness is about paying attention in a particular way
– 
on purpose, in the present moment and without judgment.

Mindfulness is an awareness of your thoughts,

emotions,
how your body feels, and what you see, smell ,taste,
touch and hear.
 Interoceptive
Assessment:
Carrying out exercises that bring
about the physical sensations of a
panic attack, such as hyperventilation
and muscle tension, in an attempt
to remove our conditioned response
that the physical sensations will cause
a panic attack to happen.
 Automatic Conditioning
Classical Conditioning – Pavlov’s Dog

Paired Learning
BODY PHOBIAS

Hypervigilance

Hypersensitivity to
physical sensations

Trigger
Anxiety and Panic
 Intensity Intensity Similarity
Exercise Sensations of of to Natural
Sensation Fear Panic
(0-10) (0-10) (0-10)

Shake head from side to

side (60 seconds)

Place head between legs

(30 seconds)

Interoceptive
Run in place
(60 seconds)

Assessment Hold breath

(60 seconds)

Gag response
(1 trial)

Spin
(60 seconds)

Push Up
(60 seconds)

Breathe through straw

(60 seconds)

Hyperventilate
(60 seconds)
If we could give you a pill to PANIC,
would you take it??
What would be the worst thing about taking a
panic pill?
Could you handle that? How?
 Caffeine
Induction
Caffeine=Trigger for unpleasant bodily sensations

Why is caffeine better than other exercises for

eliminating fears of bodily sensations???

Sensations produced by caffeine cannot be

stopped once started unlike other exercises.
This is a
behavioral
experiment
designed to show
you that the
physical
sensations
produced by
caffeine are not
dangerous.
Resistance to caffeine induction is common.

The dosage levels you are being asked to try is nowhere

near a toxic level for caffeine:
Non caffeine drinkers-2 strong cups of coffee
Caffeine drinkers-4-6 cups of coffee
**If you prefer, you may consume other caffeinated
beverages instead of coffee (Mt Dew, Energy Drinks, etc.)

Cool coffee and drink rather quickly, It will take 10-15

minutes for the caffeine to get into your system.

Use your skills to help with anxiety if it starts to get high.

Caffeine Monitoring Form
Date/Time:
Amount consumed:
Level of sensations/anxiety every 10 minutes
after drinking
(0-10, 0 being none and 10 being the most
intense):
 
10 minutes: ______
20 minutes: ______
30 minutes: ______
40 minutes: ______
50 minutes: ______
60 minutes: ______
70 minutes: ______
80 minutes: ______
90 minutes: ______
Phase 5 - Relapse Prevention
Address safety maneuvers/safety nets
Companions
Alcohol
Medication
Avoidance
Safety rituals
Define success
Review Miracle
Safety Maneuvers

Actions designed to :

A. Prevent a threatening event from occurring

B. Allow one to cope with a threat

 Until recently treatment may have taken the “If it helps, do it”
approach. However, now research very clearly tells us that this
approach is NOT beneficial.

If we continue with the safety maneuvers, we continue to reinforce the

idea that there is actually something wrong that we need safety from.

The safety maneuvers reinforce the FALSE

ALARM of danger.
 Identification of Safety Maneuvers
1.Use of a companion to Example: I will only    
perform certain activities go grocery shopping
if my mom is along
due to my anxiety
when standing in
line.
2. Use of Alcohol, Drugs,  Example: Smoking    
Medication weed before the
football game because
I’m uncomfortable in
crowds.
Why get rid of Safety Maneuvers?
● They help maintain false alarms

● They contribute to chronic anxiety

●Interfere with your life

●Failing to do so slows down your recovery

1. I should never have another panic
attack.

2. I should never have anxiety.

3. I should never feel stressed.

4. I should never have any emotional

difficulties.

5. My life should be completely happy.

 Temporary step
backwards
(false alarms)

Setbacks
vs.
Relapse
Going back to where
you were prior to
treatment
What can you do to cope in the event of a
false alarm or relapse?
Reflecting back………

Imagine that a MIRACLE happens

while you are sleeping tonight and all
you are coming here for is miraculously
all better…how would you know? What
would it look like?
 “Nothing diminishes
anxiety faster than action.”
-Walter Anderson
Thank You!!
Patric Mattek, Ph.D.

patric@mattek.solutions
In Oconomowoc – In Muskego –
Inside Lake
Home Office
Country Pediatrics
(262)971-5015
(262)569-7100