Exercise: Identify Your Anxiety Triggers and Construct a Hierarchy (Ladder)
One two-column table, kept as long as you need it. Type into it here and print or save the result, or print a blank ladder and fill it in by hand. Nothing you type is saved, sent, or stored.
When developing an exposure strategy for OCD, specific phobia, or other anxiety disorder, we catalog every trigger, intrusive thought, or situation that evokes an anxiety response. Now that you have identified some of your anxiety triggers from your stress log and other exercises, you can begin developing a list and prepare for the next step of exposure.
Below, make your list of triggers and beside every item rate the level of anxiety or discomfort you experience with each trigger on a scale of one to ten, your subjective units of discomfort or SUD. A SUD rating of ten represents the highest level of discomfort and a SUD rating of one represents very little discomfort at all. Items within the four to six range would be considered moderately anxiety-provoking. The moderate range is the starting point of exposure therapy for most people. There isn’t any evidence that starting with a high, moderate, or low level of discomfort works best. Most people are more comfortable beginning with something that doesn’t appear overpowering, and yet they want to move as quickly as they can. Therefore, we usually begin with items in the four to six range.
List your specific personal anxiety triggers, phobic situations, or intrusive thoughts below. Using the scale from 1 (no distress) to 10 (maximum threat baseline), provide an objective SUD ranking for each item.
| Specific Trigger Variable / Intrusive Thought Concept | SUD Rating (1-10) |
|---|---|
Ten rows to start with, and more on the “Add a row” button. The blank printed ladder carries twenty-four. Nothing you type is kept — reloading or closing the page clears every row.
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Writing Instructions
The idea of writing a worst-case scenario can feel extremely daunting and overwhelming. Some worry about writing it “perfectly.” Some worry about the thought of putting their thoughts and fears down on paper. Some have a hard time trying to translate complex fears into words. Some have a hard time with writing in general. To help with this process, here is a general outline about what should be included in a worst-case scenario.
A complete worst-case scenario framework contains these 4 dynamic parameters:
- The Core Fear Variable: Focus directly on the intrusive thought concept (e.g., contamination leading to a daughter's injury).
- Visceral Emotional Labeling: Detail how you explicitly feel in your imagined scenario (e.g., distraught, terrified, deeply guilty).
- Vivid Descriptive Language: Do not write simple terms like "the counter"; write highly sensory phrases like “the dirty, sticky counter riddled with live viral strains.”
- Banish Coping Adjustments: Do NOT write any comforting safe-guards, silver linings, or positive outcomes. The narrative loop must plunge completely into the catastrophe.
Exercise: Active Imaginal Exposure Writing
Instructions can vary from individual to individual, but the core writing activity includes handwriting (not usually typing) in a narrative fashion exactly what you fear will happen when triggers, intrusive thoughts, or obsessions occur. Some clients type and report that they seem to do just as well as when they use longhand. Whether you write by hand or type, we recommend that you sit down and write exclusively about what you fear for up to ninety minutes. Begin by writing about a fear that evokes a SUD of four to six. If you do not have ninety minutes to write, you should write until your fear subsides to at least 50% of what you felt when your anxiety hit its peak.
It’s just fine to write the same narrative over again. Continue to write your triggers and fears in as many situations as you can imagine until you can no longer get your anxiety above a two or three on the SUD scale. Then, move on to items with SUD levels rated above six. Continue the same procedure until your triggers no longer evoke anxiety above a two or three. Some people find that recording and replaying an audio version of their worst-case scenario helps them to imagine their fears more clearly, as though they are watching a movie in their minds.
To get the most from exposure, you should continue to write your triggers, your fears and obsessive thoughts including your worst fears. Ultimately, you will write your worst fears and extend them to the worst-case scenario. Even if you know intellectually that the worst-case scenario will never happen you should write it down. You want your brain to have the experience of thinking clearly about the worst-case scenario. Let the anxiety go up; in fact, try to take the anxiety up as high as it will go or as much as you can stand. Anxiety will eventually go down. Your brain cannot sustain an intense level of fear forever. The intensity will eventually drop off. You may be worn out when you have completed the exposure task, but you will have taken one step closer to significantly reducing your anxiety long term.
Do the same activity on day two, three, four, and so on for at least fifteen days. If you cannot find the time to devote to the activity, remember that if you’re spending at least one hour every day worrying, obsessing, and/or engaging in ritual behaviors or have at least eight intrusive, anxiety-provoking thoughts per day, you might want to give that time over to something that has been found so helpful to others who have suffered with very high levels of anxiety. You may have a very good chance of significantly reducing your anxiety, plus the strong likelihood that your fears will occupy much less of your precious time.
Don’t stop just because you get bored. Most of us will forget to take medicine when we start to get over an illness because we feel better and just don’t remember to do it. Many of us have old antibiotics in our medicine cabinets for that reason. Stay with exposure and do booster sessions until you’ve kicked your triggers out the door. If you stop short of habituation, you may have to begin exposure all over again for specific triggers or thoughts.
One writing space, and the manuscript is clear that longhand usually beats typing. Type into it here if that is what you have, or print blank ruled pages and write it out. Nothing you type is saved, sent, or stored.
Exercise: Write your fears
Now it’s time to begin writing your fears away. Start as we did in the examples above by writing your triggers over and over. Then begin writing in narrative fashion as if you are telling a story about what you fear will happen. Begin writing here and continue your writing in the note section of this workbook or in a separate notebook, so that you can track your progress over time. Continue written exposure until your SUD level lowers to about two. Refer to the example narratives above to make sure you have a clear understanding of what to do. Remember, your writing should contain no coping thoughts or positive outcomes. This writing should focus on what you are afraid might happen. If you can tolerate the discomfort, go ahead and write the worst-case scenario related to the triggers you include in your narrative.
Continue writing your narratives in the notes section included in the appendix of this workbook, or obtain as many composition books you need to continue this exercise until you have decreased your SUD levels on all trigger items to about a SUD level two.
Select an item from your hierarchy sitting in the moderate range (4 to 6 SUDs). Dedicate at least 45 to 90 minutes to continuous writing, repeating the script loops until your active peak SUD level falls by at least 50%. Begin writing below:
Type into the box, or print the blank pages and write it in by hand. The manuscript's own instruction is to keep going until your peak SUD level drops by at least half.
This page runs entirely in your browser. There is no account, no database, and nothing you type is saved, sent, or stored — not here and not on a server. Reloading or closing the page clears every field. Print it or save it as a PDF to keep it.