DRIVING PHOBIA AFTER TBI: FEARS, FALLACIES AND FACTS

Fear of driving is a common type of anxiety condition/disorder following traumatic brain injury particularly in the absence of significant memory loss for the traumatic event as would be associated with a period of anterograde/posttraumatic amnesia.  It can certainly also be a consequence of injuries not involving TBI where the injury occurred in the context of a driving accident.  Fear of driving or driving phobia, also known as hamaxophobia, amaxophobia or vehophobia, is an understudied phenomena following traumatic brain injury and in particular concussion.

Although it is a topic that should be asked about in the context of taking any history from any individual involved in a vehicular related accident, it is often not inquired about.  This psychological condition can affect individuals who have been in accidents not just in the context of being a driver but also a passenger. Driving phobia can be mild, in which case it may not meet criteria for phobic disorder but rather just an increased level of guardedness/concern but can also reach phobic disorder thresholds and be quite functionally disabling impacting social and vocational activities.  Even when mild, it can be a disturbing persisting symptom if not treated early and appropriately.

The faces of driving phobia are multiple and much depends on the person affected, the nature of the injury or injuries sustained, the nature of the accident or accidents that the patient was involved in, whether someone died in the accident, and their degree of psychological resilience to general life traumas.  Symptoms of driving phobia can be mild to severe and may include typical anxiety related physiological reactions with specific external triggers including lightheadedness, sweating, tachycardia (fast heart rate), shortness of breath, shaking and nausea among other symptoms.  Some individuals may have comorbid post-traumatic stress disorder (PTSD) that may involve reexperiencing intrusive thoughts regarding the accident whether in the form of flashbacks or nightmares. On occasion, patients who experience more significant vehicular accidents may present with so-called “phantom brake syndrome” which involves involuntary motor behavior and reflex braking when in a car as a passenger.

Clinicians will often hear patient reports involving the fact that they do fine driving except when in heavy traffic, around large trucks and/or in the specific area where the accident occurred.  Some individuals will be so phobic that they cannot even tolerate the idea of getting back into a vehicle.  Some may report doing better as a passenger particularly when the driver is someone they know and trust whereas others may report feeling more in control as the driver but more anxious when someone else is driving.  These individuals may even experience anxiety symptoms when thinking about their accident, thinking about driving or “reexperiencing” feelings related to their accident including looking at pictures of accidents with vehicles, watching things on TV or at the movies that remind them of the accident and vehicle specifically, hearing horns honk etc. clinical presentations are often quite disparate, yet a common thread is a fear of reinjury, death or another vehicular collision/accident.

Individuals with pre-existing psychological vulnerabilities such as anxiety related issues due to other types of phobias, panic attacks, PTSD, etc. tend to be more likely to develop driving phobia after traumatic experiences as new individuals with family histories involving phobic/anxiety disorders. These individuals also are more likely to develop other post-traumatic phobic disorders including claustrophobia and agoraphobia.

There are a number of assessment tools that may be helpful in the context of evaluating persons with suspected driving phobia, as well as tracking symptom severity over time, including the Driving Cognition Questionnaire, the Driving and Riding Avoidance Scale, the Gutierrez Questionnaire, the Accident Fear Questionnaire, the Vehicle Anxiety Questionnaire, the Driving Anxiety Questionnaire and the Automobile Anxiety Inventory.

The good news is there are a number of treatments that have shown effectiveness for post-traumatic driving phobias including systematic desensitization techniques such as exposure therapy, cognitive behavioral therapy, hypnotherapy and certain medications that specifically modulate anxiety symptoms. Exposure therapy is a type of psychotherapy that involves repeated exposure to images, thoughts and/or situations that typically trigger symptoms with the goal of extinguishing the phobic response.  Techniques involving progressive exposure are used to facilitate resuming driving activities. For example, the patient may think about driving, then just sit in a car without turning on the engine, then sit in the car and turn the engine on without driving, then drive very short distances, etc. till the anxiety fades. Some clinicians are also using virtual reality as a means of some planting exposure therapy protocols for driving phobia. Another psychotherapeutic technique that has been found to be beneficial for treatment of driving phobia is cognitive behavioral therapy or CBT which is typically used in conjunction with exposure therapy and teaches the individual how to alter their way of reacting to situations that typically trigger symptoms of anxiety as related to driving.  Hypnotherapy has also been used for treatment of driving phobia and can be helpful in exploring and processing thoughts and feelings associated with the traumatic memories that serve as phobic triggers and assist in dissociating these memories from the fear responses.  For those that are open to medication management typically selective serotonin reuptake inhibitors (SSRIs) are the drug class of choice for assisting with driving phobia symptoms.  Generally, this clinician recommends avoidance of benzodiazepines for these types of anxiety related problems as this class of medication not only has addictive properties but generally has some degree of adverse cognitive side effects as well as potential depressogenic effects, the latter with longer term use. Medications are not meant to be lifetime commitments but rather serve as a bridge during which behavioral techniques as noted above are used to extinguish the phobic responses to driving.  That is not to say that in some situations that individual may not need longer-term treatment with such medication.

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