Posttraumatic stress symptoms, fear and avoidance of driving, and aberrant driving behaviors. The moderating role of gender

Highlights

• PTSD symptoms were positively associated with nonintentional aberrant driving.

• Fear and avoidance of driving were associated with nonintentional aberrant driving.

• PTSD after RTC is different related with driving behavior among men and women.

• Drivers should be screened for PTSD, after an RTC, before driving again.

Abstract

Introduction

Previous literature supports the fact that posttraumatic stress disorder (PTSD) symptomatology, as well as fear and avoidance of driving are possible consequences of road traffic crashes (RTC). The aim of the present study is to assess the relations between PTSD symptoms, fear and avoidance of driving, and aberrant driving behaviors, in a sample of Romanian drivers that were involved in an RTC in the last two years before conducting the study. Further, we wanted to identify the moderating role of gender in the relations between PTSD symptoms, fear and avoidance of driving, and aberrant driving behaviors.

Method

A sample comprising 162 participants (62.3% were men, Mage = 29.37) was involved in the study.

Results

The results showed that PTSD symptoms and a composite score of fear and avoidance of driving were positively associated with slips and lapses on the road and with the number of reported errors while driving. The path analysis revealed non-significant relations between fear and avoidance of driving and driving behaviors. Furthermore, multi-group analysis showed that the relations between PTSD symptoms and aberrant driving behaviors are significant only for men.

Conclusions

The implications of the results for traffic safety are discussed.

Introduction

Many people lose their lives on the roads every day, and many more are left with long-lasting physical and psychological consequences (Heron-Delaney et al., 2013). A possible consequence is posttraumatic stress disorder (PTSD), characterized by intrusive thoughts, avoidance of stimuli associated with the trauma, alterations in mood and cognitions, and hyper arousal (American Psychiatric Association (2013)). Fear and avoidance of driving are also common at drivers involved in a road traffic crash (RTC) (Ehlers et al., 2007; Taylor and Deane, 2000). Previous studies offer some evidence for the associations of PTSD symptoms, fear and avoidance of driving, and driving behavior (e.g. e.g., Dula et al., 2010; Taylor and Koch, 1995). One of the most used taxonomies of driving behaviors distinguishes between four different classes of behaviors on the road: slips and lapses, errors, ordinary, and aggressive violations (Reason et al., 1990). Several studies found evidence for the fact that these traffic behaviors are positively correlated with traffic crashes (e.g. Özkan et al., 2006; Stanojevic et al., 2018; Winter and Dodou, 2010). Although previous studies confirmed the associations between anxious states and aberrant driving behaviors (Dula et al., 2010; Taylor and Koch, 1995), there is little evidence for the possible associations between PTSD symptoms, fear and avoidance of driving, and the four types of driving behaviors presented above. In this context, the aim of the present study is to assess the relations between PTSD symptoms, fear and avoidance of driving, and driving behaviors, in a sample of Romanian drivers who were involved in an RTC. The moderating role of gender was also explored given the documented gender differences both in terms of PTSD (e.g. Frank et al., 2018), but also in terms of driving behaviors (e.g. Stanojevic et al., 2018).

After a transport related crash, 42–55% of people present mental health symptoms (e.g., anxiety, depression) that persist in the first two years following injury (Giummarraa, Amoh-Gyimah, Saberi and Gabbe, 2019). Even in the cases of minor RTC-related injuries, studies documented poor recovery in the following two years after the RTC, particularly when the individuals also develop comorbid psychiatric disorders (e.g., PTSD) (Kenardy et al., 2015; Smits et al., 2019). The diagnostic of PTSD is not uncommon among victims of RTCs (Guest et al., 2016; Mayou et al., 2001), the prevalence being similar at different time points after the accident in the first two years following the accidents (e.g., 24%, 22%, and 25% at 6-, 12-, and 24-months, respectively, Kenardy et al., 2017; 26.1%, 24.7%, and 26.1% at 6-, 12-, and 24-months, respectively, Kenardy et al., 2018).

Previous studies claim that following an RTC, driver behavior can also be modified (e.g., decreased number of speeding violations) (Perez-Marín, Ayuso and Guillen, 2019). In the taxonomy of driving behaviors proposed by Reason et al. (1990), driving errors represent non-intentional failure of planned actions to achieve their goals (e.g., get into the wrong lane on approaching a roundabout), while deliberate violations are conscious, intentional, deviations from safety rules with a specific aggressive aim (aggressive violations; e.g., become impatient with a slow driver in the outer lane and overtake on the inside.) or without an aggressive aim (ordinary violations; e.g., excessive speed). Slips and lapses (e.g., misread the signs, attempt to drive away from traffic lights in third gear) were added later to this taxonomy, and focus on memory failures. Driving Behavior Questionnaire (DBQ) is a widely used instrument for measuring these driving behaviors. No previous study assessed the link between PTSD symptomatology and both nonintentional and intentional dangerous driving behaviors, although the potential relations between PTSD symptomatology and slips, lapses, errors, and violations on the road are supported by previous literature about: (1) the role of anxiety in traffic safety (e.g., Eysenck and Calvo, 1992; Lucidi et al., 2010; Oltedal and Rundmo, 2006), (2) the well-documented relation between PTSD symptomatology and difficulties in executive functions that are essential for avoiding unintentional aberrant driving behavior (i.e., errors, slips, lapses) (see Aupperle et al., 2012, for a review), (3) the relations between PTSD and different driving related behaviors and outcomes (e.g. Kuhn et al., 2010). These three lines of research that suggest a relation between PTSD symptomatology and aberrant driving behaviors will be presented below.

First, PTSD symptoms imply high levels of anxiety states (Cheng et al., 2015), and previous literature highlights the role of anxiety in traffic safety. Theoretical frameworks, like cognitive interference theory (Sarason, 1988) or processing efficiency theory (Eysenck and Calvo, 1992), sustain that trait anxiety determines disturbed attention to a specific task and impair performance on tasks that involve attentional or short-term memory demands. However, in relation to driving behaviors, the evidence for the implications of anxiety is mixed. Thus, some studies found that drivers with high and medium level of trait anxiety also reported higher scores on performance errors, lapses, and ordinary violations compared to drivers with low level of trait anxiety (e.g., Shahar, 2009). Other results sustain that trait anxiety is negatively related to driving violations and risky driving (e.g., speeding, rule violations) (Lucidi et al., 2010; Oltedal and Rundmo, 2006), and positively related to lapses, in samples of young drivers (Lucidi et al., 2010). However, trait anxiety was also found to be positively related to all aberrant driving behaviors measured by DBQ (i.e., errors, lapses, ordinary and aggressive violations) (Pourabdian and Azmoon, 2013). However, in a cluster analysis conducted with the scores provided by a sample of young drivers, low trait anxiety was a particularity of high-risk group of drivers (e.g., that reported speeding, rule violation) (Ulleberg, 2002). Similarly, in another study, lack of anxiety considered as a psychopathic personality trait was negatively related to driving violations on the road, measured with DBQ (Panayiotou, 2015). State anxiety was positively related to dangerous driving behaviors and aggressive driving in a sample of drivers with a mean of 0.53 crashes that occurred in the last 3 years before participating at the study (e.g., Dula et al., 2010). Finally, in another recent study, a distress composite score, consisting of symptoms commonly present in disorders such as PTSD (e.g., traumatic intrusions, insomnia, appetite loss, traumatic avoidance), was positively associated with DBQ errors and violations subscales, as well as with total DBQ score (Bernstein et al., 2019).

Second, in contrast to the deliberate driving violations that are governed by social norms and codes of rules, unintentional aberrant driving behaviors arise from deficiencies in cognitive processes involved in the selection of a goal and in the means to achieve it (Reason et al., 1990). It is well recognized that PTSD symptomatology is associated with difficulties in executive functions, including attention, memory, inhibition of automatic responses in order to achieve a goal, the ability to switch flexibly between two different tasks, and the ability to plan actions for obtaining a goal (see Aupperle et al., 2012, for a review). These executive functions are also required for avoiding unintentional aberrant driving behaviors (i.e., slips, lapses, and errors on the road) that represent memory and attention deficits or failure of planned actions (Reason et al., 1990). Results from the transportation psychology literature support the above mentioned literature, showing that individuals with PTSD subsequent to motor vehicle trauma evidenced greater performance deficits while driving (e.g., trouble finding the correct lane, pressing the wrong pedal) (Clapp et al., 2014). PTSD also generates difficulties with hypervigilance and affective dysregulation that may detract from driving attention and performance, leading to driving errors (Kraft et al., 2010; Lew et al., 2010).

Third, concerning the potential relation of PTSD with intentional violations of traffic rules, some previous studies found a positive relation between a specific measure of PTSD and aggressive driving (e.g. making verbal outbursts and angry hand gestures while driving, chasing, cutting off another driver) in a sample of veterans (e.g. Kuhn et al., 2010). In addition, PTSD was related to other traffic violation, which did not include an aggressive component, like tailgating (Kuhn et al., 2010). Because few studies assed the relation between PTSD symptomatology and both intentional and nonintentional aberrant driving behaviors, the aim of this study is to assess, in a sample of Romanian drivers that were involved in an RTC, the relations between PTSD symptoms and aberrant driving behaviors, comprised in Reason et al.’s (1990) taxonomy. Based on previous findings, the hypothesis is that a high level of PTSD symptoms will be related to a high level of the four aberrant driving behaviors, although a stronger relation is expected with slips, lapses, and errors.

After an RTC, many people develop fear of driving, associated with the tendency to avoid particular driving situations (Ehlers et al., 2007; Lucas, 2003; Taylor and Koch, 1995; Taylor and Deane, 2000). Findings from experimental studies also sustain that perceptions of fear increase when the levels of accident risk also increase (Barnard and Chapman, 2016). Studying the behaviors behind the wheel of persons who continue to drive despite their fear of driving received less attention, despite the potential danger associated with these behaviors, for drivers themselves and for other traffic participants. Furthermore, empirical evidences support the link between emotional distress and both driving errors and driving violations (Bernstein et al., 2019).

Some empirical evidence linked driving fear with a range of maladaptive behaviors in traffic like performance errors and attentional lapses (e.g. Taylor et al., 2007). In another study, conducted with drivers without a history of RTCs, travel avoidance (that also include driving avoidance) manifested positive associations with performance deficits and negative associations with perception of driving abilities in specific driving situations (Clapp et al., 2011). Moreover, driving related fears (i.e., panic-, accident-, and social-related driving fears) presented positive associations with performance deficits while driving (Clapp et al., 2011).

Concerning the relation between driving fear and avoidance and intentional violation of traffic norms, it was found that travel avoidance manifested positive associations with aggressive driving behaviors (Clapp et al., 2011). Moreover, accident-related fears were positively related to aggressive driving behaviors (Clapp et al., 2011). In another study, drivers who engage often in behaviors that deliberately violate the traffic rules are fearless (Panayiotou, 2015). In contrast, other results claim that fears composite score related to mood and anxiety disorders was positively associated with DBQ errors, DBQ violations, and DBQ total score, although this fears score did not predict DBQ errors, DBQ violations, and DBQ total score (Bernstein et al., 2019). The only previous study that focused on the relation between driving phobia, conceptualized as both driving fear and driving avoidance, and driving behavior found that drivers with high levels of driving phobia tend to be more cautions and to employ safer driving behaviors (e.g., Ehlers et al., 2007).

In order to advance the literature concerning the implications of fear and avoidance of driving for driving behavior, the second aim of the present study was to assess the relation between fear and avoidance of driving and slips, lapses, errors, ordinary, and aggressive violations. We anticipated that fear and avoidance of driving will be positively related to errors and lapses. However, given the tendency of drivers with fear and avoidance of driving to adopt safety behaviors (e.g., Ehlers et al., 2007), we anticipated that fear and avoidance of driving will be negatively related to both ordinary violations and aggressive violations in traffic.

Previous studies constantly sustained the fact that PTSD symptoms are more prevalent in women than in men, after different trauma life events (e.g. Frank et al., 2018; Olff, 2017). The same pattern of results was also obtained when the participants were victims of road traffic crashes (Chossegros et al., 2011; Fullerton et al., 2001; Kobayashi et al., 2018). Moreover, gender differences were documented in aberrant driving behaviors. Thus, some findings sustain that males commit more violations on the road, but fewer errors than females (Clapp et al., 2011; Moradia, Motevalian, Mirkoohi, McKay and Rahimi-Movaghar, 2013; Tabibi et al., 2015; Wickens et al., 2008). A study conducted with Romanian drivers also showed that being female is significantly negatively related to violations and significantly positively associated with errors (Stanojevic et al., 2018). However, according to our knowledge, no previous study analyzed gender differences in the relations between PTSD symptoms, fear and avoidance of driving, and aberrant driving behaviors. For traffic safety, it is critical to understand what types of drivers are more prone to commit risky driving behaviors. Thus, the third aim of the present study is assessing the moderating role of gender in the relations between PTSD symptoms, fear and avoidance of driving, and the four types of aberrant drivers assessed in the present study – lapses and slips, errors, ordinary, and aggressive violations. Based on previous studies, we hypothesized that the relations between PTSD symptoms and driving phobia with ordinary and aggressive violation will be stronger for male participants, while the relations between PTSD symptoms and fear and avoidance of driving with errors, lapses, and slips will be stronger for female participants.