Generalized Anxiety Disorder Exposure Hierarchy

Although there is not classically an exposure hierarchy for GAD, my patients often find it helpful to push their comfort zone using a "behavioral activation"/”anti-hibernation” model. In English? When people feel anxious or depressed, they have a strong urge to hibernate or become behaviorally inactive. They withdraw from work, social activities, exercise, even leaving the house or getting out of bed (when it’s really bad).  It’s a strange instinct because it only makes the anxiety and depression worse. The following hierarchy is designed to reverse that trend. After a week or two of pushing against and expanding your comfort zone, you should notice an improvement in your mood.

Assertiveness also tends to be difficult for people with anxiety, so there are items related to that on this hierarchy as well. Feel free to add any activities that you used to enjoy and/or that you would like to incorporate into your life in the near future.

Rate each activity on a 0-100 anxiety scale for how anxious it would make you feel on a typical day (with "100" being the most anxious you've ever felt and "0" being totally calm). Activities currently rated between a 20 and a 60 are usually good to try as Real-Life Exposures. With repetition, you should notice that any particular activity becomes easier with time. You can then move on to a harder activity on your list. You can also re-rate the hierarchy periodically to track your progress.

Generalized Anxiety Disorder Exposure Hierarchy

Getting dressed (i.e. out of pajamas/sleepwear) at some point during the day

Getting dressed (i.e. out of pajamas/sleepwear) upon awakening

Leaving the house (for any reason)

Staying out of the house for 2 hours or more

Returning texts/emails within a day

Returning tests/emails within an hour

Reaching out to a friend

Making plans with a friend

Exercising once a week

Exercising 3 times a week

Exercising 5 times a week

Doing an hour of work (job/job hunting/education and/or housework) a day

Doing 3 hours of work (job/job hunting/education and/or housework) a day

Doing 5 hours of work (job/job hunting/education and/or housework) a day

Doing 8 hours of work (job/job hunting/education and/or housework) a day

Saying “No” to a request from a friend

Saying “No” to a request from a family member

Saying “No” to a request from a supervisor/employer

Saying “No” to a request from a customer/client

Communicating a negative emotion to the person who caused it (a stranger)

Communicating a negative emotion to the person who caused it (a friend)

Communicating a negative emotion to the person who caused it (a family member)