SUDS in ERP for OCD: How to Track Anxiety & Improve Exposures

In my recent articles I’ve mentioned SUDS; Subjective Units of Distress and today I want to explain them in detail as I refer to them often when I teach or talk about Exposure and Response Prevention (ERP) for OCD. I’ll try to distill two decades of clinical experience working with individuals with OCD, and provide you with a clear understanding of why SUDS matter, how to use them correctly, and how they can support your progress in therapy.

What Are Subjective Units of Distress (SUDS)?

SUDS (sometimes called the “anxiety thermometer”) stands for Subjective Units of Distress Scale. It is a numerical scale—commonly 0 to 100 or 0 to 10, I normally ask clients to use 0-10 —used to gauge how intensely you feel anxiety or distress in a given moment.

• 0 on the scale means you feel absolutely no distress.
• 100 (or 10 on a 0–10 scale) represents the worst, most intense anxiety or distress you can imagine.

Subjective means exactly that: your rating is personal, and it can fluctuate based on circumstances, mood, time of day, or the nature of your trigger. There are no “right” or “wrong” numbers, only your own best estimate of how distressed you feel at that moment.

Why SUDS Matters

Tracking distress levels using SUDS is an integral part of ERP. The International OCD Foundation explains how gradual exposure and distress tracking can help reduce OCD symptoms over time (IOCDF on ERP).

1. Guides Therapy Targets: In ERP, we often create an exposure hierarchy—situations or triggers that elicit anxiety, ranked from least distressing to most distressing. SUDS helps you map out these steps with more accuracy.
2. Tracks Progress: SUDS is a quick, reliable way for both the client and therapist to see if, over time, exposure to a feared situation becomes less distressing.
3. Builds Self-Awareness: Regularly checking in with yourself on the scale encourages mindfulness and a deeper understanding of how triggers and thoughts affect your distress.
4. Encourages Engagement: Having a simple rating helps both you and your therapist adjust exposures to maintain an optimal challenge—pushing your comfort zone just enough, without overwhelming you.

The Role of SUDS in ERP for OCD

Exposure and Response Prevention (ERP) is widely regarded as the gold-standard psychological treatment for OCD, with multiple studies demonstrating its effectiveness in reducing compulsions and obsessive fears. In essence, you purposely confront the feared object, thought, or situation (the exposure) and resist performing the usual compulsion (the response prevention). The goal is to reduce the anxiety connected to the obsessive fear and ultimately break the cycle of obsessions and compulsions.

Learn more about the rationale for ERP.

How to Use SUDS in ERP for OCD (Step-by-Step Guide)

1. Hierarchy Building: When creating a hierarchy, each feared situation is rated on the SUDS scale. “Standing near an unwashed dish in the sink” might be rated around 40, while “Intentionally touching a dirty door handle and not washing my hands” might be rated 80. Learn how to build your exposure hierarchy.
2. Real-Time Feedback: During the exposure, you check in with your SUDS periodically to track how distress changes (which often peaks, plateaus, and then begins to decrease).
3. Data for Decision Making: After each exposure, reviewing SUDS ratings helps you and your therapist decide if it’s time to move to a more challenging exposure or if you need more practice at the current level.

The Nuances: Going Beyond the Basics

Many articles on the internet will simply tell you: “Rate your distress from 0 to 100.” But in 20+ years of clinical practice, I’ve seen important nuances that can make or break your success with SUDS.

1. Normal Variation
   • Day-to-Day Changes: People often feel frustrated if they rate an exposure as a 50 on one day and a 70 on another day—even though the situation hasn’t changed. Remember, stress levels vary due to poor sleep, mood, hunger, or even the weather. It’s perfectly normal to have some fluctuation.
   • Acute vs. Baseline: Sometimes, your overall stress baseline is higher (e.g., a tough week at work, lack of sleep). This can cause your SUDS ratings to jump even for exposures that previously felt easier.
2. The “Overthinking” Trap
   • Looking for the ‘Perfect’ Number: Some clients get stuck trying to find the “exact” rating for their distress, worried they might be off by 5 or 10 points. The scale is not a laboratory measure; it’s a tool. A rough estimate (e.g., “high 60s” or “around a 7 out of 10”) is plenty accurate.
   • Comparisons to Other People: There is a temptation to compare SUDS with friends or fellow group members. Because SUDS is subjective, your “80” could feel like someone else’s “60.” It’s apples and oranges—stick to your own scale.
3. Heightened Awareness = Increased Anxiety?
   • In the Short Term: Some individuals notice that thinking about their level of distress can increase it briefly. That’s normal. Over time, consistent use of SUDS actually empowers you to remain present and objectively observe changes in your emotional state.
4. SUDS as a Self-Monitoring Tool
   • Between-Session Practice: When your therapist isn’t around, SUDS can still help you gauge your response to triggers in daily life. If you notice you’re rating your distress as a 70 every day at lunchtime, that’s a clue you might benefit from an exposure exercise or a coping strategy around that time or situation.
   • Journaling: Recording these ratings, along with contextual notes (where you were, what you were thinking, any compulsions you carried out), helps you see patterns over time.

How to Use SUDS Effectively

1. Keep the Scale Simple

Most people use 0–100 or 0–10. Either way is fine—just pick one and stick to it. If 0–100 feels overwhelming, choose 0–10. The difference is more about personal preference than correctness.

2. Do Quick Check-Ins

When you’re about to do an exposure:

1. Rate your distress before you start.
2. Begin the exposure, staying in the situation that triggers your anxiety.
3. Note your distress at a set time interval (e.g., every 5 minutes) or at key moments.
4. Observe and record how it rises and falls without trying to forcibly reduce it.

3. Use SUDS to Foster Self-Compassion

A rating of 80 is not a failure; it simply means you are human and experiencing significant discomfort. When we label it as “an 8 out of 10,” we transform overwhelming anxiety into a quantifiable experience—something you can still manage and approach, even if it feels intense.

4. Adjust as Needed

If you started an exposure that you expected would be a 40 but it skyrocketed to an 80, you and your therapist might break that exposure into smaller steps or provide additional coping tools. SUDS ratings guide these practical, real-time decisions.

Common Pitfalls and How to Avoid Them

1. Using SUDS as the Only Measure of Progress
   • Pitfall: Over-reliance on a single number might cause you to miss other indicators of growth (e.g., better mood, fewer compulsions, improved daily functioning).
   • Solution: Combine SUDS ratings with qualitative observations—like noticing if tasks that once felt impossible now just feel uncomfortable.
2. Becoming Discouraged by “High” Numbers
   • Pitfall: Feeling disappointed or overwhelmed if your rating is consistently high.
   • Solution: High ratings can be an opportunity. The fact you’re identifying the distress and staying in it (rather than fleeing) is a major victory in OCD treatment. Over time, repeated exposure to the same trigger should lower these numbers.
3. Ignoring Emotional Nuances
   • Pitfall: Some people only think in terms of “anxiety,” missing other emotions—like guilt, shame, or even frustration.
   • Solution: While SUDS focuses on distress, take a moment to recognize any other emotions that arise. This can deepen your self-understanding and guide more tailored interventions.
4. Not Staying in the Exposure Long Enough
   • Pitfall: Ending the exposure as soon as the distress feels intense. This can reinforce avoidance.
   • Solution: Use SUDS to notice the natural “peak and drop” of anxiety. Stick around in the exposure until your SUDS has had a chance to decrease somewhat. Experiencing that natural reduction in distress is key for learning you can handle the anxiety without resorting to compulsions.

Final Thoughts: SUDS as a Tool for Empowerment

At its core, the Subjective Units of Distress Scale is about empowering you to understand and track your emotional landscape. By regularly checking in with yourself, you cultivate the awareness that distress fluctuates and, crucially, that you do survive these fluctuations. Over time, this awareness builds confidence in your ability to face and ride out the storm of anxiety.

Remember: The number on a scale is not a measure of your worth, progress, or success. It is simply a snapshot of how you feel in that moment—an invaluable piece of information that helps guide your next step. Whether you’re just starting ERP or have been practicing for a while, SUDS can remain a steadfast companion in your journey toward managing OCD effectively.

Key Takeaways

1. SUDS is highly personal: Don’t compare your numbers to others’.
2. Consistency is more important than precision: Regular check-ins trump worrying about a perfect rating.
3. Use SUDS to inform (not dictate) therapy: View them as data points to guide exposures and measure changes in distress.
4. Expect highs and lows: Anxiety can fluctuate for many reasons; variability is normal.
5. Embrace it as a learning tool: Each rating provides insight into your triggers and coping style, helping you and your therapist refine your treatment plan.

With time, patience, and deliberate practice, SUDS will become an integral part of your self-monitoring toolkit—helping you navigate the ups and downs of OCD and empowering you to forge a path toward lasting recovery.