Introduction

Fear while driving on a highway, like fear of flying, is classified, in the DSM 5, as a situational specific phobia. This fear, however, is a complex phenomenon that consists of two very different diagnostic categories. Under this umbrella there is true driving phobia (Vehophobia), characterized by fear of accident and distrust of skill and fear of having a panic attack while behind the wheel as well as post-traumatic stress disorder (PTSD) subsequent to a motor vehicle accidents (MVA) This page will cover the first two:

  • Fear of accident and distrust of skill
  • Fear of panic when driving
Incidence

A review of research on fear of driving revealed a paradox: clinical attention to this phobia is not proportionate to the high rates of prevalence. A full 17-20 % have mild driving phobia but 4-6% of the population experience severe, debilitating forms of this condition. These are high rates compared to those of many other form of anxiety. Yet the literature on this condition is relatively sparse and limited to only a few countries, principally New Zealand.

Gender distribution is similar to that seem in other anxiety disorder with, affecting twice as many women as men. Age of onset can vary from very early in one’s driving career to mid or later in life. Given the limited data, there is not a clear picture of the risk factors. It does appear that driving phobics almost always have a history of anxiety that predates the condition. Those who fear panic while driving can have history of panic that evolves into when driving or can experience their first panic attack while driving.

Given that MVAs are over represented in the literature, conclusions about the distribution of subtypes should be cautious. Moreover many studies do not parse out subtypes and only describe the general prevalence of the condition. With this caveat in mind, it does appear that fear of accident/skill distrust is more common than fear of panic. Both groups often avoid highways but more than secondary roads. Those with fear of panic, however, can avoid secondary roads or congested traffic situations where they can feel "trapped" while true driving phobia rarely spreads to off road, and even less so to dense traffic.

Driving Phobia and Fear of Accidents

People with true driving phobia, do not fear that a panic attack will compromise their safety, rather, they worry about the possibility of accidents while driving. Driving phobics avoid highways more than secondary roads because they fear accident fatality, owing to the higher velocity. If they are able to do limited highway driving, they superimpose irrational assumptions of danger that color their interpretations and reactions on the road. For example, driving phobics are hyper-vigilant of other vehicles; they have distorted perceptions of distance, erroneously assume that vehicles behind them are dangerously close and conversely believe that they are too close to vehicles they are following. As a result of this distortion, just seeing a brake light from cars in front can trigger impulsive, unnecessary breaking which can put themselves and other drivers at risk.

Other distortions involve assuming a car could be cutting into their lane. Driving phobics are intimidated by trucks and view them by default as a threat because of their size. As a result they can change lanes or move to the edge of the lane they are in to create as much distance from the truck as possible. They are also extremely tentative during lane changes and avoid them if at all possible, preferring to hug the far right slow lane. They do not trust their ability to merge onto the highway or navigate around rotaries. Consequently, they slow down excessively and often "get stuck" trying to merge, often coming to a complete stop rather than accelerating.

In my practice, I no longer treat this form of driving phobia.I have found helping this group to be extremely challenging. Because treatment involves executing a complex action that elicits fear, the precise behavioral changes required during exposures are extremely difficult to complete and tolerate. Not surprisingly, I receive few inquiries from people with fear of driving, and over the past 10 years, I have had only one true success unfortunately,

In that one case, I observed certain characteristics which set that person apart and, I believe, contributed to success: 1) a remarkably high level of level of motivation 2) less front end fear- that is, fear was not as extreme initially as in other cases; 3) although limited, some HW driving was tolerated 4) age-appropriate mastery of driving skills that predated onset of the phobia 5) There were no co-occurring psychiatric conditions of significance 6) no history of traumatic MVAs and 7) supportive family and friends who were understanding, patient and collaborative.

Early intervention is the key to preventing the progression of this phobia before fear and avoidance become entrenched and chronic. Specifically, seeking help during the teen drivers education phase of skill acquisition would be ideal. I believe that a team approach involving both driving instructor and therapist working in concert would ideal. Also, virtual reality training and habituation on the therapy side would very likely increase treatment success.

Highway and Driving Agoraphobia Related To Fear Of Panic

In driving agoraphobia avoidance is organized around the primary fear of having a panic attack while driving a car or sometimes being in a car as the passenger. Unlike driving phobics, driving panikers do not fear accident or death, owing to the recklessness of other drivers or distrust of their driving skills; rather, this group fears that during a panic attack they could lose control of the vehicle or not be able to get immediate medical attention for a condition they fear panic could cause. Again, it is important to emphasize that this condition is NOT a phobia of driving; rather it is a subtype of panic disorder that has developed while driving. This occurrence of classic panic in such a complex and fluid context presents unique challenges. Nonetheless, it is important to remember at the core of this phenomenon reside the clinical characteristics of classic panic disorder. As described on the Panic and Agoraphobia page, these are:

  • Respiratory panic with fear of suffocation
  • Cardiac related panic
  • Fear of fainting
  • Derealization and fear of loss of mental loss of control

Clearly, these core thematic categories are primary in shaping what driving situations become panic triggers and the safety behaviors one comes to rely on. Nonetheless, the specific geography of how driving panic plays out is unique to the person. Likewise, there is a wide arc of behavioral responses to these perceived driving "treats" that is equally idiosyncratic. Below, I have organized some of the more common examples of driving situations feared and safety behaviors relied on that I come across in my practice:

Situations and Conditions Avoided
  • Highways in General
  • Fast Highway Conditions
  • Congested Highways
  • Wide, multi-lane Highways
  • Bridges with high barriers
  • Bridges with low barriers
  • Easy Pass fast lanes
  • Narrow highways
  • Long distances between exits on highways
  • Rain when driving (exacerbating blurred vision during panic)
  • Full stop traffic jams on the highway
  • Full stop traffic jams on
  • Police cruisers
  • Emergency vehicles
  • secondary roads
  • Long traffic lights
  • High traffic volume at long traffic lights
  • Tractor trailers on either side in full stop traffic
  • Tractor trailers on either side waiting at a traffic light
Safety Behaviors
  • Complete avoidance of highways
  • Complete or partial avoidance of any feared situation or condition
  • Taking a break
  • Pulling car over
  • Only driving with a trusted person
  • Repeated reassurance seeking from a trusted person
  • Keeping panic medication in the car
  • Using panic medication when driving or as a passenger
  • Drinking water
  • Talking on cell phone with a trusted person
  • Fidgeting
  • flicking hair, touching face or acting on any habit type behavior
  • Tapping steering wheel or gear shift
  • Avoiding swallowing
  • Swallowing in excess
  • Avoidance of beverage or food
Treatment

When thinking about this type of driving agoraphobia, it is always important to remember that it is NOT about fear of driving itself; is about fear of panic when behind the wheel. Driving panikers do not experience fear related to the mechanics of driving while driving. They are thus able to focus on desensitizing to panic while driving. While this indeed a challenge, it pales in comparison to what driving phobics must accomplish: tolerate intense fear while simultaneous having to engage in a complex visual motor task that is the source of the fear . As a result, the rate of success for this group is quite high.

Treatment of driving panic agoraphobia, blends standard panic control therapy with methods adapted to the context of travel by vehicle. Clients with this subtype agoraphobia may experience panic elsewhere and driving can be one of several agoraphobic triggers. Typically in my practice past general panic has resolved or is minor in nature and driving and/or travel by vehicle is the central problem and focus of treatment.

The therapy should first identify the cognitive and behavioral features of the core panic subtype in question and and begin to address these with the appropriate PCT methods. In parallel, the specific ways panic is played out in the driving context is mapped out with careful attention to the triggers, fears and safety behaviors that are unique to that person. From these a hierarchy of feared situations is developed. This guides how driving exposures will be structured and paced as well as informing which safety behaviors will be dropped and when. Nonetheless, Almost all clients I have treated, with this subtype, who have followed through with treatment achieve HW mastery and complete symptom remission.

Driving Agoraphobia and Exposure Therapy

Live driving exposure sessions are offered for treatment of highway, bridge and tunnel agoraphobia related to fear of panic attacks. These sessions are only offered on a private-pay basis, as health insurance will not cover this service.

Please note that I no longer treat highway driving phobia related to fear of accident and distrust of driving skill. The difference between phobia of driving and fear of panic while driving-as well as why I no longer treat this type of phobia- is explained on the Highway Agoraphobia page of this site.

Panic and Agoraphobia Treatment Summary Points
  • Learning core concepts of panic control therapy, particularly
  • education about the nature and physiology of anxiety and panic
  • Defining the panic symptom profile
  • Mapping of avoidance and safety-seeking behaviors specific to driving
  • Self-soothing techniques such as breathing control strategies and relaxation training adapted to the driving environment
  • Progressive desensitization through graded exposure to driving and highway environments
  • Progressive dropping of safety behaviors when driving
  • Frequent practice and repetition between sessions, both alone and with supportive friends or family, who are educated in how to coach
  • Monitoring of anxiety reactions during exposures
  • Increased practice and repetition driving alone between sessions
  • Constant debriefing of exposures with particular attention to return return of fear and/or recurrence of safety behaviors
  • Progressive steps to further driving independence
  • Revisiting life goals with the recovery of driving
  • Treatment termination
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© 2018 Robert Safion, LMHC

Treatment of Obsessional Spectrum Anxiety

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