Exposure to Uncomfortable Sensations
197Step 2: Developing Symptom Exposure Hierarchies
Just as the situational exposure hierarchy described in chapter 8 is used to guide your 
situational exposure practices, symptom exposure hierarchies  are useful for choosing appropri -
ate symptom exposure exercises. In most cases, we recommend that you develop two 
symptom exposure hierarchies: one for practicing the exercises outside of social situa -
tions (see step 3) and a second hierarchy for practicing symptom exposure while in (or 
immediately before entering) social or performance situations (see step 4). If you are 
not at all fearful of experiencing anxiety sensations outside of social situations, then 
developing a hierarchy for practicing symptom exposure in nonsocial situations is less 
important. Instead, you should focus on exercises to practice while exposed to social and 
performance situations.
To develop a hierarchy for symptom exposure, ﬁrst eliminate any exercises that 
you know will not make you anxious (based on the results of your symptom induction 
testing, completed in step 1). For example, if the sensations created by physical exercise 
(something like jogging) are not frightening to you at all, eliminate this exercise from 
your list. Next, take the remaining exercises and put them in order of difﬁculty, with the 
least anxiety-provoking exercise at the bottom and the most anxiety-provoking item at 
the top. Record your level of expected fear for each exercise, using a scale ranging from 
0 (no fear) to 100 (maximum fear). Examples of symptom exposure hierarchies reﬂecting 
practices outside of social situations and practices in social situations follow. We have 
also included space to record your own hierarchies.