Development of a graded anxiety scale (suds)

Once the feared situations have been identified, an essential component in preparing for exposure therapy is the creation of an exposure hierarchy.

This hierarchy is constructed by ordering the feared situations from least to most anxiety-provoking, using a subjective distress scale known as SUDS (Subjective Units of Distress Scale) or USA (Subjective Anxiety Units).

The SUDS/USA Concept

The SUDS or USA scale is a simple but effective tool that allows an individual to quantify their subjective anxiety level on a numerical scale, usually from 0 to 100 (or sometimes from 0 to 10).

On this scale:

• 0 represents a complete absence of anxiety or complete relaxation.

• 100 (or 10) represents the highest level of anxiety imaginable, extreme panic.

Intermediate numbers reflect increasing degrees of anxiety.

This scale is personal and subjective; What is a 50 for one person may be a 30 or a 70 for another.

The important thing is consistency in the assessment for the same individual.

Constructing the Exposure Hierarchy

To construct the hierarchy, the person is asked to rate each of the previously identified feared situations using the SUDS scale.

For example, for someone with social phobia:

• "Asking a stranger on the street for the time" could be a SUDS of 30.

• "Attending a party where you only know a few people" could be a SUDS of 60.

• "Giving an oral presentation to a large group" could be a SUDS of 90.

The goal is to identify a variety of situations that cover different levels of anxiety, from low to high levels. (e.g., SUDS 20-30) to very high levels (SUDS 80-90 or higher), with several steps in between.

Ideally, the increments between items in the hierarchy should not be too large to facilitate gradual progression.

Usefulness of the Hierarchy and SUDS

The exposure hierarchy serves as a road map for therapy.

Exposure begins with situations that generate low to moderate anxiety, and as the person becomes habituated and their anxiety decreases in those situations, they gradually advance to higher items in the hierarchy.

The SUDS are used not only to construct the hierarchy, but also to monitor anxiety levels during exposure exercises.

The person is asked to rate their SUDS before, during, and after each exposure, allowing the therapist and patient to assess progress and adjust the pace of therapy.

The decrease in SUDS in a particular situation over repeated exposures is an indicator of habituation and success.