EXPERIMENTAL REPORT: Driving difficulties among military veterans: clinical needs and current intervention status

CITATION: Possis, Elizabeth, Thao Bui, Margaret Gavian, Jennie Leskela, Effie Linardatos, Jennifer Loughlin, and Thad Strom. "Driving difficulties among military veterans: clinical needs and current intervention status." Military medicine 179, no. 6 (2014): 633-639.

 ABSTRACT: Military personnel deployed to Iraq and Afghanistan often develop mental health difficulties, which may manifest as problematic driving behavior. Veterans may be more likely to engage in risky driving and to subsequently be involved in motor vehicle accidents and fatalities. This article reviews literature on driving difficulties among military veterans and evaluates available research on the potential pathways that underlie risky driving behavior. Current interventions for problematic driving behaviors are considered, and the necessity of modifying these interventions to address the unique difficulties encountered by military veterans is highlighted. The review concludes with a discussion of clinical implications of these findings and identification of possible avenues for future research and intervention.

MY TAKE ON IT: This review identifies fear- or anxiety-related behaviors as a cause of unsafe driving behaviors in military veterans. This anxiety can be expressed in risky responses like drunk-driving and road rage. It may also be expressed as classic phobic behavior like avoiding highways and other situations perceived as dangerous. The recommended treatment for driving phobia is cognitive-behavioral therapy and counter-conditioning, although the authors note that their effectiveness specifically with veterans is not well studied.

EXPERIMENTAL REPORT On the road again after traumatic brain injury: driver safety and behaviour following on-road assessment and rehabilitation

CITATION: Ross, Pamela, Jennie L. Ponsford, Marilyn Di Stefano, Judith Charlton, and Gershon Spitz. "On the road again after traumatic brain injury: driver safety and behaviour following on-road assessment and rehabilitation." Disability and rehabilitation (2015): 1-12.

ABSTRACT: Purpose: To examine pre- and post-injury self-reported driver behaviour and safety in individuals with traumatic brain injury (TBI) who returned to driving after occupational therapy driver assessment and on-road rehabilitation. Method: A self-report questionnaire, administered at an average of 4.5 years after completing an on-road driver assessment, documenting pre- and post-injury crash rates, near-crashes, frequency of driving, distances driven, driving conditions avoided and navigation skills, was completed by 106 participants, who had either passed the initial driver assessment (pass group n = 74), or required driver rehabilitation, prior to subsequent assessments (rehabilitation group n = 32). Results: No significant difference was found between pre- and post-injury crash rates. Compared to pre-injury, 36.8% of drivers reported limiting driving time, 40.6% drove more slowly, 41.5% reported greater difficulty with navigating and 20.0% reported more near-crashes. The rehabilitation group (with greater injury severity) was significantly more likely to drive less frequently, shorter distances, avoid: driving with passengers, busy traffic, night and freeway driving than the pass group. Conclusions: Many drivers with moderate/severe TBI who completed a driver assessment and rehabilitation program at least 3 months post-injury, reported modifying their driving behaviour, and did not report more crashes compared to pre-injury. On-road driver training and training in navigation may be important interventions in driver rehabilitation programs.

MY TAKE ON IT: Driving anxiety can result from an acquired impairment to driving ability such as traumatic brain injury.

EXPERIMENTAL REPORT: The Unifying Creative-Meditation Technique and Physiological Measurement of Anxiety in Romanian Amateur Drivers

TITLE:  "The Unifying Creative-Meditation Technique and Physiological Measurement of Anxiety in Romanian Amateur Drivers."
AUTHOR: Mitrofan, Laurentiu, Mihaela Chraif, Florinda Golu, and Emil-Razvan Gatej.
JOURNAL: Procedia-Social and Behavioral Sciences
ABSTRACT: Nowadays, road accidents are very frequent. Anxiety plays an important role in traffic safety. In this study, we tried to prove that the Unifying Creative-Meditation Technique has a beneficial effect on anxiety which was measured through physiological parameters. The participants were 30 drivers (for the experimental group) and 30 drivers (for the witness group) that have been selected from our Department's students. The subjects had been part of the experimental group were asked to have the driving license for minimum one year. (Full text here).

MY TAKE: This is a not especially impressive paper. It is full of typos and poorly structured so that it omits most of the information it should include and put the rest in the wrong order. This only thing that is really clear is the authors pro-"Creative-Meditation" bias.  The tool used to choose the experiment group is a general anxiety scale rather than one relating specifically to driving anxiety. Even after combing through the whole thing twice I have no idea  what it has to do with driving behavior at all.  They seem to have left that part.  Along with explaining what "Creative Meditation" actually is.

TL;DR -- Skip this one entirely

EXPERIMENTAL REPORT: 1 Effect of alprazolam (0.5 mg) on driving performance of anxiety patients and healthy controls Effect of alprazolam (0.5 mg) on driving performance of anxiety patients and healthy controls

TITLE: Effect of alprazolam (0.5 mg) on driving performance of anxiety patients and healthy controls
AUTHOR: Katerina Touliou, Dr. Evangelos Bekiaris, Dr. Maria Panou
JOURNAL: International Conference on Alcohol, Drugs and Traffic Safety (T2013), 20th, 2013, Brisbane, Queensland, Australia.
ABSTRACT:In the present study the major objective was to investigate the effect of alprazolam in treated and untreated anxiety patients compared to a healthy control group after oral alprazolam administration (0.5 mg) (acute phase) in a simulated environment. Primary variables were the vehicle variables (driving performance measures). The secondary objective was to compare multiple cognitive and subjective measures collected for each participant in order to establish the whole range of driving impairment.(Full text here)

MY TAKE:This study demonstrates that a common medication used for anxiety reduces driving performance.

EXPERIMENTAL REPORT: Driver stress and performance on a driving simulator

TITLE: Driver stress and performance on a driving simulator
AUTHOR: Matthews, G., Dorn, L., Hoyes, T.W., Davies, D.R., Glendon, A.I., Taylor, R.G.
JOURNAL: Hum Factors. 1998 Mar;40(1):136-49.
ABSTRACT:  "Effects of stress on driving performance can depend on the nature of driver's stress reactions and on the traffic environment. In an experimental study, we assessed multiple dimensions of vulnerability to driver stress by a questionnaire that was validated in previous field studies and related those dimensions to performance on a driving simulator. Results were broadly consistent with prediction. A dimension of habitual dislike of driving was associated with reduced control skills, greater caution, and disturbance of moods. A measure of aggressive driving predicted more frequent and more error-prone overtaking, which are effects attributed to the use of confrontive coping strategies in interaction with other vehicles. An alertness measure predicted speed of reaction to pedestrian hazards. This research has practical applications for system design, automated monitoring of driver performance, selection and assessment of drivers, and training."
 
MY TAKE ON IT: One thing that seems to be missing for discussion of driving phobia is the extent to which it is not purely irrational.  This study shows that dislike of driving was associated with having poorer driving control skills making more frequent driving errors, caution when driving and stress. The suggestion is that stressed drivers might not have any more accidents, but this may be not because they have normal skill levels, but because the avoid taking risks.

EXPERIMENTAL REPORT: Salivary cortisol response during exposure treatment in driving phobics

Whenever a person become alert and ready to react they are experiencing "stress" (all so called the fight-or-flight response). A range of responses occur including physiological stress responses that prepare the body for strenuous activity. The following study measured one aspect of this physiological response, cortisol in saliva. Cortisol (shown right) is released by a part of the adrenal gland and its main function to to increase blood sugar

TITLE: Salivary cortisol response during exposure treatment in driving phobics
AUTHOR: Alpers GW et al
JOURNAL: Psychosomatic Medicine 65:679-687 (2003)
ABSTRACT: "OBJECTIVE: Extensive research on the hypothalamic-pituitary-adrenal (HPA) axis response to stress has not clarified whether that axis is activated by phobic anxiety. We addressed this issue by measuring cortisol in situational phobics during exposure treatment. METHODS: Salivary cortisol was measured in 11 driving phobics before and during three exposure sessions involving driving on crowded limited-access highways and compared with levels measured in 13 healthy controls before and during two sessions of driving on the same highways. For each subject, data collected in the same time period on a comparison nondriving day served as an individual baseline from which cortisol response scores were calculated. RESULTS: Cortisol levels of driving phobics and controls did not differ on the comparison day. Phobics also had normal cortisol response scores on awakening on the mornings of the exposures but these were already increased 1 hour before coming to the treatment sessions. Phobics had significantly greater cortisol response scores during driving exposure and during quiet sitting periods before and afterward. These greater responses generally paralleled increases in self-reported anxiety. At the first exposure session, effect sizes for differences in cortisol response scores between the two groups were large. Initial exposure to driving in the first session evoked the largest responses. CONCLUSION: The data demonstrate that the HPA axis can be strongly activated by exposure to, and anticipation of, a phobic situation." [abstract and full text]

TAKE HOME MESSAGE: People with a driving phobia suffer measurable physiological stress which starts in anticipation of the driving session and lasts for some time afterwards.

D'uh.

I'm sorry, but anyone suffering from a phobia can feel for themselves the racing heart rate, sweaty palms and all the classic symptoms of a physiological stress response. So even after reading the introduction to this paper (which outlined previous studies that had question the existence of a full stress response as part of phobic anxiety) I am having some trouble seeing this as a matter that was in an serious doubt. Inconsistent results are most likely caused by the fact that accurately measuring cortisol is a relative skilled task. Also cortisol is an good measure or stress experience over the course of minutes or hours, and people experiencing chronic stress might not show normal responses.

EXPERIMENTAL REPORT: Virtual Reality for the Psychophysiological Assessment of Phobic Fear: Responses During Virtual Tunnel Driving

PEER-REVIEWED

AUTHORS: Mühlberger, A., Bülthoff, H.H., Wiedemann, G., Pauli, P.
JOURNAL: Psychological Assessment 2007; 19: 340-346.

ABSTRACT: "An overall assessment of phobic fear requires not only a verbal self-report of fear but also an assessment of behavioral and physiological responses. Virtual reality can be used to simulate realistic (phobic) situations and therefore should be useful for inducing emotions in a controlled, standardized way. Verbal and physiological fear reactions were examined in 15 highly tunnel-fearful and 15 matched control participants in 3 virtual driving scenarios: an open environment, a partially open tunnel (gallery), and a closed tunnel. Highly tunnel-fearful participants were characterized by elevated fear responses specifically during tunnel drives as reflected in verbal fear ratings, heart rate reactions, and startle responses. Heart rate and fear ratings differentiated highly tunnel-fearful from control participants with an accuracy of 88% and 93%, respectively. Results indicate that virtual environments are valuable tools for the assessment of fear reactions and should be used in future experimental research."

SUMMARY: Most treatments for phobia involve some kind of counter conditioning. That is being placed in the feared situation, usually starting with low intensity, and replacing feelings of fear with feelings of relaxation. As the authors note, placing driving in a feared situation such as driving in a tunnel, is neither easy nor particularly safe.

This study further developed a virtual reality system as a fully controlled and safe substitute for real driving. The study shows that those with a specific fear of driving in tunnels did become more fearful during periods of simulation of tunnel driving, but not during open driving (there was also a control group that did not become afraid at all). this suggests that virtual reality systems may, in the future, have a useful role in treating driving phobias.

Fearfulness was measured from self-report, but also heart rate, and skin conductivity. Self report was the most useful measure, followed by heart rate with which it was moderately correlated. Skin conductivity was, well a bit rubbish all round.

MY THOUGHTS: This is all very nice... but can we move along with using it for actual treatments?

Mühlberger, A., Bülthoff, H., Wiedemann, G., & Pauli, P. (2007). Virtual reality for the psychophysiological assessment of phobic fear: Responses during virtual tunnel driving. Psychological Assessment, 19 (3), 340-346 DOI: 10.1037/1040-3590.19.3.340

See also:
Efficacy of virtual reality exposure therapy to treat driving phobia: a case report

Determining the Focus of Driving Fears

AUTHORS: J E Taylor, F P Deane & J V Podd
JOURNAL: Journal of Anxiety Disorders 2000, Volume 14, pages 453-470.

ABSTRACT: "Fear of driving has been recognized as a complex diagnostic entity. Studies on flying phobia have drawn similar conclusions, although increasing clarity has been gained through research that indicates that there may be subtypes of flying phobia based on the focus of fear. However, it is unclear if similar subtypes exist for fear of driving. The aim of the present study was to conduct a preliminary investigation of driving fear subtypes and to clarify further whether there were differences between driving-fearful respondents who had been in a motor vehicle accident (MVA) and those who had not. Eighty-five driving-fearful, media-recruited respondents completed a questionnaire that assessed anxiety, avoidance, and concerns related to their driving fears. The sample had high expectations of negative events while driving. There were no significant differences between those who had experienced an MVA and those who had not on various measures of fear severity. Cluster analysis revealed two main foci of fear, one characterized by danger expectancies and the other based on anxiety expectancies and unpleasant driving situations. This emphasizes the importance of assessing both internal and external foci of fear. Although this finding is consistent with the results obtained for flying phobia, more research is required to replicate and extend these results and to develop and evaluate differential treatment programs."

SUMMARY: The authors describe how flying anxiety has been found to include several distinct sub-types, and suggest that the same may be true for driving anxiety. They mention that it is already known that sufferers of driving anxiety differ in various ways, for example some have previously experienced a motor vehicle accident and others have not. This article is based on a written survey completed by 85 people who suffer from driving anxiety. In general the respondents had high expectations that bad things would happen when they drove. Those who had experienced an accident did not differ significantly in the severity and focus of their fears from those who have not. There were two clusters of different types of people in the study. One group was focused on dangers on the road such as accidents, injury, losing control of the vehicle, and dangerous road conditions. Another group was more focused on the unpleasant emotions they felt when driving, such as anxiety and fear. The authors suggest that different treatment approaches might be needed for these groups, rather than taking a 'one size fits all' approach.

MY THOUGHTS: I appreciate the attempt the authors make to look beyond a simple diagnosis and investigate how people suffering from driving anxiety may have developed it differently, experience it differently and need tailored treatment approaches. I particularly appreciate the acknowledgement that they see that people who have not experienced a motor vehicle accident "deserve as much research attention and assistance as their MVA counterparts..." This research sets the scene for developing an appreciation of driving anxiety sub-types and tailored treatment approaches, although no specific suggestions can be made based on this data.

TAKE HOME MESSAGE: Not all people who have driving anxiety experience it the same way.