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The When, Why, and How of Worry Exposure

Article  in  Cognitive and Behavioral Practice · November 2009

DOI: 10.1016/j.cbpra.2008.11.003

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Cognitive and Behavioral Practice 16 (2009) 386–393

www.elsevier.com/locate/cabp

The When, Why, and How of Worry Exposure

Colin van der Heiden, PsyQ and Erasmus University, Rotterdam
Erik ten Broeke, VISIE, Deventer

Worry is a component of many psychological disorders. Worry exposure is a technique that is useful in the treatment of excessive worry.
However, there is little in the psychological literature on worry exposure. This leads to the impression that clinicians do not make much
use of worry exposure. This paper offers a step-by-step description of the use of worry exposure, as well as a review of possible pitfalls.

W ORRY exposure is a specific variant of imaginal

exposure. This method was developed by Craske,
Barlow, and O′Leary (1992) as an intervention for the
treatment of pathological forms of worry. In their
treatment program for generalized anxiety disorder
(GAD), Brown, O′Leary, and Barlow (1993) also included
worry exposure. Since that time, reports on this technique
are scarce, giving the impression that it is seldom applied.
However, worry exposure could be a useful technique,
particularly for worries about hypothetical feared events.
This paper first describes the phenomenon of worry and
the types of worry that seem appropriate for this technique.
We then describe the technique and its application and
discuss some pitfalls related to worry exposure.
Worry: Theoretical Background
Similar to anxiety, worry is considered to be an
evolutionary, adaptive phenomenon. Just as mild levels
of anxiety can enhance achievement, worrying can
stimulate the search for important goals or solutions
(Hallowell, 1997). In this way, worrying can help one cope
with real problematic situations (Janis, 1958). However,
worry is often a reaction to unreal danger; in that case,
worrying does not lead to solutions and the worries and/
or feelings of anxiety may continue or even increase.
Worry itself can (eventually) be experienced as being
aversive and uncontrollable (Mennin, Heimberg, & Turk,
2004), leading to the development of symptoms and/or
impairment of daily functioning. As a result, the worrying
itself can become the subject of worry; this is known as
meta-worrying (Wells, 1995). Based on those insights,
Wells (1999) proposed the following definition of worry:

Although worry is a universal experience, there is no
consensus as to what it actually is. Based on their extensive
examination of the nature of the worry process, Borkovec
and colleagues tentatively defined worrying as “a chain of
thoughts and images, negatively affect-laden and relatively
uncontrollable; it represents an attempt to engage in
mental problem-solving on an issue whose outcome is
uncertain but contains the possibility of one or more
negative outcomes” (Borkovec, Robinson, Pruzinsky, &
DePree, 1983, p.10). Later, Borkovec (1994) expanded this
definition by stating that worrying consists more of thinking
in words (verbal-linguistic activity) and less of thinking in
images (sensory-perceptual activity). In addition, it was
stated that worriers are particularly concerned with feared
negative events (Borkovec, Ray, & Stöber, 1998).
1077-7229/09/386–393$1.00/0
© 2009 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
; Continuing Education Quiz located on p. 483.
Worry is a chain of catastrophising thoughts that are
predominantly verbal. It consists of the contemplation
of potentially dangerous situations and of personal
coping strategies. It is intrusive and controllable
although it is often experienced as uncontrollable.
Worrying is associated with a motivation to prevent or
avoid potential danger. Worry itself may be viewed as a
coping strategy but can become the focus of an
individuals concern (p. 87).
Given that worrying is a universal experience, it seems
plausible that the distinction between “normal” and
pathological worry cannot be made on the basis of the
content of the worrying (see Mennin et al., 2004, for an
overview). The difference seems to be defined by the
severity and the persistence of the worrying. These
findings suggest a dimensional conception of worrying,
in which pathological worrying is seen as a problematic
form of “normal” worrying (Ruscio, Borkovec, & Ruscio,
2001). In other words, worry can be seen as a continuum,
ranging from adaptive worry to maladaptive worry.
 Worry Exposure
Adaptive worry is a mild and transient cognitive activity
that is generally limited in scope and experienced by most
people (Ruscio, 2002); it is aimed at problem solving and
leads to problem-focused behavior. The maladaptive form
of worry generates a repetitive range of negative outcomes
in which the individual attempts to generate coping
solutions until some internal goal is achieved (e.g., “a
sense of control”; see Wells & Matthews, 1994). This latter
conception of worry is more in line with the view of worry
as an evolutionary, adaptive phenomenon.
Worries That Are Amenable to Problem Solving and
Worries That Are Not
Dugas and Ladouceur (2000) make a useful distinction
between two types of worry: worries about situations that
are amenable to problem solving, and worries about
situations that are not. The first type of worry often
concerns actual or current problems, such as the choice
of a particular mortgage arrangement when buying a new
house. The second type is about potential or hypothetical
problems (Dugas, Buhr, & Ladouceur, 2004). Worrying
about whether after 30 years (the duration of the
mortgage) the choice will prove to have been the right
one, and worrying about what will happen if it appears
that it was not, is an example of a hypothetical problem.
Provencher, Dugas, and Ladouceur (2004) found that
worries can reliably be divided into worries concerning
current problems and worries concerning hypothetical
situations. Two questions seem particularly helpful in
making this distinction: (a) What is the evidence that a
current problem already exists? (b) What is the evidence
that the hypothetical situation might actually happen in
the near future? (Provencher et al., 2004). It could be
argued, however, that not all actual problems are in fact
amenable to problem solving if they involve issues beyond
the worrier’s control (e.g., worries about the behavior of
an alcoholic parent, or about legal proceedings). There-
fore, an additional distinction between worries that are
and are not amenable to problem solving could be the
degree of control or influence one has over a particular
problem.
Worry interventions, such as a structured worry
program (Borkovec et al., 1983) or a step-by-step manual
for problem solving (D’Zurilla & Goldfried, 1971), seem
useful for the type of worries that are amenable to
problem solving. In structured worrying, the patient
consciously postpones the worrying until “set” moments
(so-called “worry hours”): during these planned
moments, the patient recalls the worry themes in order
to elaborate upon them. A step-by-step manual for
problem solving can help the patient to describe the
problem in concrete terms and then brainstorm possible
solutions. For every solution the advantages (or benefits)
and the disadvantages (or costs) are charted, on the basis
387
of which patients then choose the solution they wish to
implement.
However, the problem-solving technique is not appro-
priate for worries about hypothetical problems that may
never happen. For this type of worry, Dugas and
Ladouceur (2000) recommend imaginal exposure; this
is used to target cognitive avoidance, one of the suggested
functions of worry (Borkovec, Alcaine, & Behar, 2004).
According to the avoidance theory, threatening mental
images and their corresponding unpleasant emotional
arousal are avoided by worrying in words and sentences
(Borkovec, Shadick, & Hopkins, 1991). The successful
affective avoidance subsequently reinforces verbal-linguis-
tic worry, as well as the continued avoidance of images.
Several studies have provided support for this hypothesis.
First, thinking about feared images appears to lead to an
increase in the frequency and severity of aversive physical
reactions (Vrana, Cuthbert, & Lang, 1986); in contrast,
worrying in words (verbal-linguistic) leads to a decrease in
the frequency and severity of such reactions (Borkovec,
Lyonfields, Wiser, & Diehl, 1993; Lyonfields, Borkovec, &
Thayer, 1995). Moreover, thinking in images is experi-
enced as being more unpleasant than thinking in words
(Borkovec & Inz, 1990; Freeston, Dugas, & Ladouceur,
1996). In addition to this implicit cognitive avoidance,
imaginal exposure also addresses explicit or voluntary
attempts to avoid worrying, such as thought suppression
and distraction. Such strategies often have only temporary
(or even counterproductive) effects, and can interfere
with emotional processing and amplify negative beliefs
about anxiety and/or worrying (Dugas & Robichaud,
2007). An example of the counterproductive effect of
thought suppression is the “white bear” effect, named
after experiments by Wegner, Schneider, Carter, and
White (1987). In that study, the participants who were
asked to report their thoughts and were instructed not to
think of a white bear reported significantly more thoughts
of a white bear than the test subjects who did not receive
this instruction. The often-counterproductive effects (or,
at best, only short-term effects) can be seen as a
confirmation of the usefulness of exposure-based exer-
cises in the treatment of worrying. In the case of worries
about hypothetical events, imaginal exposure seems to be
the only option.
The way in which imaginal exposure is typically carried
out is appropriate for worry. Basically the patient is
exposed to two things: (1) the mental image of a feared
situation, and (2) the subjective feelings and physiological
indices of anxiety (Dugas & Robichaud, 2007). Patients
are asked to describe the frightening or worrisome images
related to important worry themes/subjects that they
normally try to avoid. The descriptions are recorded on a
looped tape or compact disc (CD). By regularly listening
to the recording, patients become exposed to the pre-
388 van der Heiden & ten Broeke
viously avoided images and the unpleasant physiological
reactions typically associated with that imagery. Along
with this exposure assignment, patients receive a
response-prevention instruction: attempts to neutralize
the image (e.g., by seeking distraction, or by thinking
about/doing something else) are not allowed. It is
hypothesized that prolonged exposure to the fear-evoking
images leads to habituation; thereby, the unpleasant
feelings that these images initially evoke will eventually
decrease in intensity. This enables the patient to (more
easily) develop a more balanced viewpoint about the
worrisome event or situation.
In 1992 Craske and colleagues introduced an
intervention for worrying—worry exposure—in which
exposure to a feared image of a worrisome situation is
the key element. Important differences compared to
imaginal exposure, as introduced by Dugas and
Ladouceur (2000), are that in worry exposure (a) the
patient is asked to conjure up an image of the most
feared outcome, and (b) the image holds an explicit
component of cognitive restructuring. After exposure
to the most feared image, time is dedicated to thinking
about alternative outcomes. This enables patients to
realize that, even if the worst scenario materializes, they
can appeal to some rescue and/or coping strategies.
Another difference is that listening to verbal-linguistic
accounts of images (i.e., such as in imaginal exposure)
may be a less effective exposure exercise than directly
imagining the fearful images (i.e., such as in worry
exposure), since verbal-linguistic worry tends to reduce
emotional arousal while fearful images tend to increase
arousal. A practical difference is that in worry exposure
no recording equipment is necessary; the feared image
is not recorded but is pictured as vividly as possible in
the patient’s mind. This avoids practical problems, such
as the patient not having a tape recorder or the
clinician not having a CD-burner. In view of the
differences in content, the practical differences, and
the fact that this intervention has remained relatively
underexposed in the psychological literature, worry
exposure is described in some detail below. We first
outline the rationale and then describe the steps of the
procedure.
Worry Exposure: Rationale
Patients are instructed to mentally expose themselves
to worry at set times, for a prolonged period, by thinking
about the feared events. The exposure takes place by
conjuring up an image of the most feared expectation,
and focusing on this for a period of 25 minutes. As
mentioned, the goal is twofold: habituation to the feared
image and the accompanying arousal, and changing the
meaning of the feared situation. Habituation can be
introduced to the patient by means of the following
metaphor:
By exposing yourself in your mind to a picture of the
most frightening expectation of a situation you are
worrying about, you will become accustomed to that
picture. After a while you will find the image less
scary and the feelings of fear will decrease. Compare
it to seeing a scary movie several times; the first time
you are scared much more than the tenth time you
see it, because you have become habituated to it.
After that, it is explained that prolonged exposure
often leads to another, more balanced, view of the feared
situation. Explicitly asking the patient to think about
alternative outcomes of the feared situation, after the
exposure period, enhances the process of cognitive
restructuring. Moreover, worry exposure enables patients
to regain control over their worrying because they are now
able to conjure up the worrying at set times, whereas
previously the worrying was suddenly “forced upon” them.
It is important to realize that worry exposure can be
extremely difficult and frightening for patients because
they are asked to do what they have tried to avoid for a
long time. Therefore, we emphasize the importance of
taking sufficient time to clearly explain to the patients why
they need to do such exercises.
Worry Exposure: Implementation
Worry exposure consists of five steps (Craske et. al,
1992); these are described below using a case example to
illustrate each step.
Step 1: Selecting the Worry Situation to Which a Patient
Will Be Exposed
To gain more insight into worrying and to make patients
more aware of their daily worries, they are asked to stop
whatever they are doing at set times each day and write
down what they are worrying about at that moment.
Patients are taught how to distinguish between worries that
are amenable to problem solving and those that are not; the
latter types are addressed with the help of worry exposure.
Case example. David is a 36-year-old married man with
two children (aged 4 and 8 years). He is a teacher in high
school. He has been nervous and anxious as long as he
can remember, but the unpleasant feelings have become
increasingly worse in recent years. He worries about
“almost everything almost all the time.” Examples of
recent worries are the birthday party of his oldest
daughter (“Will everybody enjoy it?”), the holidays
(“What if we get lost in France?”), the new school year
(“Will the new students be nice?”), and his own health
(“What if I have a heart attack because I’m so nervous all
the time?”). He describes himself as “a worrier as long as I
can remember.” During the times that he does not worry,
 Worry Exposure
he starts worrying about whether there is something he
should worry about, in order to be prepared. All this leads
to muscle tension (especially in neck and shoulders),
restlessness, irritability, and difficulty falling asleep. He
tries to stop worrying, but without much success. Some-
times he manages to get distracted, but as soon as he
relaxes the worrying returns. In the past 5 years he has
been treated twice for GAD symptoms, once with
medication (Paroxetine) and once psychologically (a
client-centered approach), both with only moderate
results. David was referred by his GP for cognitive
behavioral treatment. The treatment offered to David is
based on the “intolerance of uncertainty” model for GAD
(Dugas & Ladouceur, 2000), in which worry exposure is
used to address worries that are not amenable to problem
solving. One of the hypothetical worries to which David
will mentally expose himself is the unpleasant conse-
quences that would arise should he ever have financial
problems; currently he has no financial problems and
there are no current or future events (e.g. threatened
discharge) to justify this expectation.
Step 2: Identifying the Most Feared Expectation
The patient is asked to state the worst thing that could
happen in the selected situation, without putting anything
into any perspective. The point of this exercise is to
identify the most disastrous expectation. The patient
either writes this down, or draws a picture representing
the disaster. The therapist can help to identify the
scenario that the patient fears most using a series of
“what if” questions (similar to the so-called “downward
arrow” technique; see Burns, 1989). For every answer
given by the patient, the therapist replies, “. . . and if this
actually happens, what will happen next?” until the
patient can no longer supply any additional information.
THERAPIST (T): David, can you tell me what would be
the worst thing that could happen if you ran into
financial problems?
DAVID (D): Well, I don’t know exactly, but I think it
will be terrible.
T: Okay, I understand, that’s what you are worried
about. But I want to find out what exactly you are
afraid of. . . . Is that alright with you?
D: Yeah, sure.
T: David, what do you think will happen if you run
into financial problems?
D: I won’t be able to pay my bills.
T: Yes, that would be a problem, I can see that. But
what if you can’t pay your bills anymore?
D: Then I’d have to sell my car and maybe we’d have
to leave our house . . .
T: And what if that really happens, what will happen
then?
389
D: I think my wife and kids will leave me, so I’ll end
up all alone. . . .
T: And what if you really end up alone?
D: . . . ooohhh . . . I don’t like thinking about this . . .
I feel really bad now . . . I’m afraid I’ll end up
penniless in the gutter….
T: And what if you end up penniless in the gutter?
D: Well, that’s bad enough, don’t you think . . . I really
don’t want to think about this, if you don’t mind!
Step 3: Conjure Up an Image of the Most Feared
Expectation
Patients are asked to close their eyes and conjure up a
mental image (as vividly as possible) of their most feared
expectation in this situation. The image must be held in
mind for at least 25 minutes. If their thoughts threaten to
stray, patients can look at the noted most feared expectation
in order to get the image back in their mind. Patients are
told that they are not allowed to try to stop worrying or to
seek distraction. The point of this exercise is to experience
the unpleasant feelings (fear, tension, etc.) that the image
evokes, so that they become accustomed to them; the
unpleasant feelings will then decrease. For the same
reasons, patients are instructed not to make any attempt
to neutralize the frightening scenario in order to reduce
the anxiety. An example of such neutralizing information is
letting your loved one smile while imagining that he had a
serious car accident; the smile serves as a sign that he is not
seriously wounded and everything will be alright.
David describes the image he mentally exposed himself
to as follows:
I imagine myself walking in the rain on a dark and
cloudy day. I wear old, torn clothes, I look dirty. My
hair and beard are long and filthy. I smell like a
polecat. I’m all by myself, begging for food, or for
money. Some passers-by look compassionate, others
disapproving. I’m all alone, and feel very lonely. I’ve
become a very sad tramp!
Step 4: Think of Alternative Explanations or Outcomes
After 25 minutes patients are asked to open their eyes
and let go of the image. As many as possible alternative
explanations or outcomes for the most feared situation
are then thought of and written down.
David writes down that he never takes large financial
risks, thus minimizing the chance of serious financial
problems. He also notes that if he does get into trouble
his relatives would certainly help him and his family.
Another possible solution is that he could live in a
smaller house and/or sell his car if financial problems
arose.
390 van der Heiden & ten Broeke
Step 5: Evaluation
The exercise is evaluated during the next therapy
session. The clinician ascertains whether the patient had
unpleasant feelings when imagining their worst expecta-
tion and, if so, whether these feelings changed over time.
If the feelings did indeed change, the way they have
changed is discussed: Did the patient experience different
feelings? Did the intensity of the feelings decrease? or did
they increase? Then the clinician checks whether the
alternative explanations and/or outcomes are plausible
for the patient. If they are, the meaning of the alternative
explanations is discussed to determine the credibility of
the most feared expectation found in Step 2.
David states that he now understands that his feared
expectation is not very realistic. Of course he may have
financial problems at some time, but the chance is very
small. Moreover, they would not immediately be so large
that he would end up penniless in the gutter, and his
family would definitely help him. He believes that this new
point of view is more realistic than the envisaged most
frightening outcome. As a result, both the worrying and
the feelings of fear decrease.
If the exercise works well, worry exposure can be given
as a homework assignment; for instructions, see the
Appendix (van der Heiden & Ten Broeke, 2005).
Worry Exposure: Obstacles and Solutions
Some obstacles in the application of worry exposure
need to be addressed (see also Brown et al., 1993), as well
as their possible solutions.
1. The patient finds it frightening or difficult to
conjure up worrisome images. Solution: start with a
number of “small” worries, or even practice with
conjuring up positive or pleasant images. If that
works well, the patient can then try to conjure up
worrisome images.
2. The image creates little or no fear; this can be due
to various reasons:
(a) The conjured image is not lively enough.
Solution: make the image more vivid by asking
about colors, smells, physical sensations, and
other specific aspects of the feared situation.
(b) The image is too general, so that the focus is
not on the worst thing that can possibly
happen. An example is the image of a serious
car accident, without imagining the worst that
could possibly happen (e.g., your daughter
being seriously wounded or dead). I: continue
to ask about the meaning of the image for the
patient and/or their family.
(c) The patient applies coping techniques (e.g.,
cognitive restructuring or relaxation techni-
ques). Solution: outline the rationale again and
instruct the patient not to use any activities to
control the fear.
(d) The patient avoids exposure to the most
frightening elements of the feared outcome
(e.g., by seeking distraction). Solution: outline
the rationale again and give the response-
prevention instruction again.
3. The patient cannot think of any alternative explanations
and/or outcomes. Solution: use techniques from cogni-
tive therapy (see, for instance, Beck, 1995). For example,
use a Socratic dialogue to track down alternative
explanations, or ask the patient to interview important
others about their views on the most feared outcome.
4. The credibility of the most feared expectation remains
high, despite the worry exposure and/or alternative
explanations found. Solution: give an explanation
about making realistic evaluations of situations and
problems. The “formula” described by Salkovskis
(1996) for assessing danger is useful for this:
Seriousnessð0
100ÞChanceð0
100Þfproximityð0
100Þg
Danger =
Copingð0
100Þ + Helpð0
100Þ
Explain that, if an evaluation has to be made about
whether a certain situation is dangerous, people auto-
matically make an assessment of the seriousness of the
danger and the chance that this danger will actually occur.
Patients who worry excessively tend to constantly over-
estimate both the severity of the feared event and the
likelihood of it actually happening. With the help of
cognitive interventions (e.g. the Socratic dialogue) both
the assessment and the severity of the worry, as well as the
estimation of the likelihood it may happen, can be
examined and adjusted. In some cases it is also useful to
(learn to) pay attention to the estimation of the point in
time at which the “disaster” is expected to happen (the
“proximity” in Salkovskis’ formula). Theoretically, it does
make a difference whether the disaster will occur next
week or in (say) 35 years time.1 Furthermore, it is useful to
analyze whether patients make an adequate estimation of
their coping skills—more specifically, the extent to which
the patient (a) can prevent the “disaster” and (b) is able
to cope with the “disaster” once it happens. Finally, it may
be helpful to analyze which help may be available in case
the “disaster” should ever take place.
Discussion
This paper addresses a form of imaginal exposure
specifically designed for worrying, called “worry expo-
1
There is in fact a disaster for which both the seriousness and the
risk of occurrence is 100%, while coping and help is 0%, but which
most of us do not constantly worry about because most people believe
that it is still far away: i.e. death.
 Worry Exposure
sure.” There are few reports on this technique and its
effectiveness is not yet well established. Therefore, worry
exposure cannot claim the empirical support that has
been shown for imaginal exposure as applied in the
treatment of PTSD (see, for example, Roth & Fonagy,
2005). Although the mechanism associated with worry
exposure is not yet fully elucidated, the rationale
presented here is mainly derived from imaginal exposure
(i.e., patients’ prolonged exposure to their most frighten-
ing image leads to habituation and thus a change in their
perception of the situation). However, it is clear that
habituation alone does not provide a convincing expla-
nation for the effect of imaginal exposure in PTSD
(Hermans, Vansteenwegen, Baeyens, & Eelen, 2002; van
Etten & Taylor, 1998); this could also apply to imaginal
exposure in relation to worrying. It is also clear that
exposure does not necessarily have to be prolonged to be
an effective treatment for PTSD (Marks, Lovell, Noshir-
vani, Livanou, & Thrasher, 1998; van Etten & Taylor,
1998); again, this could also apply in the case of worry
exposure. Therefore, the chosen exposure period of 25
minutes is arbitrary.
Theoretically, in worry exposure the most effective
element may be the reevaluation of the most feared
expectation, which is stimulated by allowing the patient to
think explicitly about other potential outcomes of the
feared situation after the exposure phase. However, some
alternative explanations for the effectiveness of worry
exposure may also be involved. First, according to the
intolerance-of-uncertainty theory, one of the ways in
which worry is maladaptive is that it amplifies uncertainty.
People who are intolerant of uncertainty cannot stand the
chance that the feared outcomes can occur, no matter
how small they think the chance is that they actually will
occur. They want a guarantee that the bad things they
worry about will not happen, which is impossible because
uncertainty is part of everyday life. Thus, patients will
likely have negative reactions to uncertainty on a frequent
basis, which serve as important cues that maintain anxiety
and worrying. The clinical implication is that patients
should learn to accept uncertainties. From this point of
view imaginal exposure to worry topics helps to habituate
to anxiety while amplifying the uncertainty of not
knowing for sure whether or not a negative outcome
will occur. If this behavioral explanation is valid, exposure
to the most frightening image is not warranted. According
to Dugas and Robichaud (2007), in some cases this could
be even obstructive, because a clear negative outcome
could be less threatening than an uncertain one. From
their point of view, in such cases, asking for the most
feared expectation goes “too far.” A second, more
cognitive explanation is that worry exposure implicitly
falsifies specific unrealistic expectations about the con-
sequences of worrying itself, such as “I can't stand
391
thinking about frightening things” or “Worrying drives
me crazy.” Those kinds of thoughts reflect negative beliefs
about worrying, also known as negative metacognitions
(Wells, 1995). Again, conjuring up an image of the most
feared expectation is not warranted if this explanation is
valid. Then, it would be recommended to explicitly
formulate the negative belief about worrying that will be
tested by the worry exposure exercise, making worry
exposure more of a behavioral experiment than an
exposure exercise as such.
Despite the fact that the way in which imaginal
exposure works is still unclear, its effectiveness in PTSD
has been proven. Also, forms of imaginal exposure are
part of treatments for other anxiety disorders, such as
GAD and hypochondriasis, that have been proven
effective (Ladouceur et al., 2000; Langlois & Ladouceur,
2004; van der Heiden, 2008). Even more, imaginal
exposure alone has been proven efficacious in the
treatment of GAD patients for whom worries were
mostly related to hypothetical situations, as identified by
two independent clinicians (Provencher et al., 2004). It
has also been shown that adding imaginal exposure to
in vivo exposure in the treatment of OCD may
contribute to the maintenance of therapeutic gains
(Foa, Steketee, Turner, & Fischer, 1980). Therefore,
worry exposure seems useful not only in the treatment
of GAD in which excessive worry is the most prominent
feature (American Psychiatric Association, 2000), but
also for other disorders in which worry (about hypothe-
tical problems) is an important process (e.g., anxiety
disorders, depression, pain, sleeping and eating dis-
orders; Harvey, Watkins, Mansell & Shafran, 2004;
Purdon & Harrington, 2006).
Research is needed to establish first whether worry
exposure as an independent intervention is effective and,
if so, for what specific disorders and/or for which type of
worrying. If worry exposure proves to be effective, the
next step is to study the mechanisms that lead to its
effectiveness: Is worry exposure effective because of a
decrease in intolerance of uncertainty, or because of a
change in the beliefs about worrying, or perhaps due to
both? Or is it still habituation that accounts for the
effectiveness of worry exposure? In addition, research is
needed to answer some questions about the process of
worry exposure itself. Since the length of 25 minutes is
arbitrary, a first issue to examine is the optimal length of
exposure by testing alternate lengths. Future research
should also examine whether listening to verbal-linguistic
accounts of images (i.e., in imaginal exposure) is indeed
offering less effective exposures than directly imagining
the fearful images (i.e., in worry exposure), as we
suggested in this paper. This can be done by replicating
and extending the already mentioned Provencher et al.
(2004) study. GAD patients for whom worries are mostly
392 van der Heiden & ten Broeke
not amenable to problem solving, as identified by inde-
pendent clinicians, can be randomly assigned to either
an imaginal exposure condition or a worry exposure
condition, to determine possible differences in efficacy.
Meanwhile, worry exposure should be considered as an
experimental technique, that seems useful as an inter-
vention to target worrying about hypothetical problems.
Appendix: Worry Exposure – Instruction for
Patients
Step 1
Choose a worry situation (from your worry registra-
tion) that is not amenable to problem-solving.
Step 2
Ask yourself the question: “What is the worst that could
happen in this situation?” Write down the answer to this
question. Try not to put things into perspective: the point
is to track down your most feared image.
Step 3
Close your eyes and create a picture in your mind, as
vividly as possible, of your most feared expectation in this
situation. Hold the image in your thoughts for at least 25
minutes (don’t keep track of time yourself, this will only
distract you—set the alarm of your clock or mobile
phone). If you stray, look briefly at what you’ve written
down to get the image back into your mind. Don’t try to
stop worrying. Don’t look for a distraction from worrying.
The whole point of this exercise is for you to experience
the unpleasant feelings (fear, tension) the image evokes,
so that you will get used to them. The unpleasant feelings
will then decrease.
Step 4
Open your eyes after 25 minutes and let the image go.
Think of as many possible alternative explanations for, or
alternative outcomes of, the worry situation. Write down
everything you have just been thinking about under-
neath your most feared expectation that you wrote down
in Step 2.
Step 5
Think about what kind of effect the exercise had on you:
• Did you get unpleasant feelings when conjuring up
the image of your most feared expectation?
• Did these feelings change as time went by? If so, in
what way?
• Are the other alternative explanations and/or
outcomes credible for you? What does this mean
in terms of the credibility of your most feared
expectation?
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Address correspondence to Colin van der Heiden, Department of
Scientific Research, PsyQ, Van Vollenhovenstraat 3 (2nd floor), 3016 BE
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Received: June 9, 2008
Accepted: November 22, 2008
Available online 3 September 2009