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Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions
Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

Section 25
Overcoming Driving Phobia

CEU Question 25 | CEU Test | Table of Contents | Phobias
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Driving phobia, defined as a situational type of specific phobia in DSM-IV, is characterized by intense and persistent fear of driving, which increases in anticipation of, or exposure to driving stimuli. People with driving phobia recognize that their fears are excessive, yet are unable to drive, or tolerate driving with considerable distress. In turn, these symptoms cause significant distress and interference with daily activities. Common driving concerns typically concern the potential dangers of driving (e.g., motor vehicle accidents, injury), unpleasant driving situations (e.g., traffic jams), and to a lesser degree, anxiety symptoms while driving, and criticism by other people. Additional fears indirectly related to driving may also be present (e.g., fear of enclosed spaces, fear of speed).

Driving phobia typically arises in early to middle adulthood and is more prevalent in women. Driving phobia can develop following a motor vehicle accident and may be part of the clinical presentation of posttraumatic stress disorder, and may evolve through other anxiety disorders, such as panic disorder, agoraphobia, and social phobia. In some cases, people cannot recall, or identify, a specific reason for developing the phobia. Without treatment, driving fear typically does not diminish and may become chronic, leading to further lifestyle restrictions and distress.

There has been relatively little controlled treatment research on driving phobia. Systematic desensitization has been found to be effective in several case reports of accident and non–accident-related driving fear. In other case reports and an uncontrolled case series, various combinations of in vivo and imaginal exposure were sucessful. Results from recent studies using virtual reality exposure therapy (VRET) suggest that this treatment medium might be suitable for driving phobia. A number of case reports have examined the efficacy of VRET for a range of specific phobias, including acrophobia, flying phobia, spider phobia, and claustrophobia. Results from controlled research suggest that VRET is effective for acrophobia, agoraphobia, and flying phobia.

Study 1
A pilot study examined the efficacy of VRET to treat driving phobia using a case report design. In this study, a 35-year-old woman with a long-standing driving phobia was recruited to our research study through a community counselling centre. The Structured Clinical Interview (SCID) confirmed a specific phobia diagnosis, and she did not meet criteria for any other current Axis 1 disorders. Treatment outcome measures included diagnostic status of the driving phobia at post-treatment using the SCID, Driving Anxiety Test (an in vivo behavioral measure), and Driving Frequency (minutes of driving per day). Following the pre-treatment assessment, she completed a 7-day baseline phase.

Treatment consisted of three 1-hr sessions using the standardized VRET protocol, in which she practiced two highway and two residential driving scenarios. Her peak anxiety decreased within and across sessions. Her real-life driving duration (mean driving time per day) increased during treatment and her mean peak anxiety while driving decreased. At the post-treatment assessment, her phobia-related symptoms had diminished and she no longer met criteria for driving phobia. Clinical improvement was maintained at 1-, 3-, and 7-month follow-up assessments.

Study 2
To further examine the efficacy of VRET for driving phobia, the next phase of the research consisted of a multiple baseline across-subjects experimental design. Sequence of the design included: a pre-treatment assessment, baseline phase (non-concurrent schedule ranging from 8 to 16 days), an intervention phase consisting of eight weekly treatment sessions, a post-treatment assessment, and follow-up assessments (at 1-, 3- and 12-months). It was hypothesized that VRET would reduce driving anxiety and avoidance between pre- and post-treatment assessments. Outcome measures consisted of three ratings: Main Target Phobia (to assess severity of phobic avoidance) and Global Phobia (to assess overall phobia severity on a scale) items from the Fear Questionnaire, and Driving Frequency (minutes of driving per day). Participants recorded this information on a daily basis during baseline and treatment phases, and for 1-week recording periods during the posttreatment and follow-up phases. Maintenance of gains on these measures was expected at the followup assessments. The SCID (specific phobia portion) was used for obtaining additional clinical evidence regarding the diagnostic status of the driving phobia at post-treatment and follow-up assessments (1-month and 3-month).

Seven adults (six females, one male) with a specific phobia diagnosis were recruited from community and media advertisements. The SCID was used to identify current and lifetime Axis 1 disorders. Only individuals with a primary disorder of a specific phobia (driving) were included in the study. None of the individuals met criteria for a concurrent disorder. The participants’ ages ranged from 31 to 57, and they all possessed valid driver’s licenses. All of the patients reported a longstanding history of driving fear and avoidance and none had received prior treatment for their driving phobia. Three of the individuals described a history of being in a motor vehicle accident. Five participants completed the treatment and 1- and 3-month follow-up assessments, and two withdrew during the initial phase of the study. The male participant withdrew at the pre-treatment assessment due to lack of treatment credibility (e.g., he did not find the scenarios realistic). A female withdrew after the first session because she was unable to arrange transportation for attending treatment sessions. The results of this study are briefly summarized in the following paragraph.

Three participants (P1, P2, and P5) showed the strongest treatment outcome at the post-treatment assessment. Post-treatment visual data revealed a decrease in scores on many of the outcome measures and they no longer met criteria for a driving phobia. In contrast, there was little improvement in P3 and P4 from baseline to post-treatment assessment scores, and they continued to meet diagnostic criteria.  This measure is an overall indicator of the driving phobia severity. In the initial weeks of treatment, there was a gradual decrease in weekly ratings across all participants, with the largest magnitude of change occurring for P1, P2, and P5. At post-treatment, P3 and P4 showed the least amount of change. Similar results were found on mean Main Target Phobia ratings, which is a measure of the extent of efforts to avoid driving. Although there was some variation in driving frequency during treatment, none of the participants showed a noticeable change in their actual driving frequency at the post-treatment assessment.

These findings suggest that VRET shows promise as a treatment for driving phobia, although it may not be sufficient for some patients. Although it was expected that in Study 2 driving frequency would increase between pre- and post-treatment assessments, the failure to obtain such results is an important finding. It implies that VRET alone may not be sufficient in the treatment of driving phobia for some individuals. VRET may be most fruitfully used as a first step in treatment to reduce driving fear to a sufficient degree so that the patient could readily progress to in vivo exposure therapy.

Who is best suited for VRET? Exploratory measures administered at pre- and post-treatment assessments identified potential variables that may be related to the VRET outcome. These measures included the Driving Concerns Questionnaire and Presence Questionnaire. Participants who clearly improved at posttreatment (P1, P2, and P5) showed a greater sense of presence (e.g., subjective involvement) in the virtual environment, and had lower severity of driving concerns on the Driving Concerns Questionnaire as compared to the other two participants who responded more poorly. These suggest that particular subject characteristics, such as presence levels in the virtual environment and cognitive factors, may have played a role in the pattern of treatment outcome. Although concerns about performance anxiety and simulator driving skills were not objectively measured in this study, these factors may also have affected some individual’s ability to become engaged in the virtual environment. We found that the two participants who responded more poorly were particularly concerned about their driving performance on the simulator throughout treatment. In contrast, the other individuals who showed a stronger treatment response did not express these concerns and appeared to learn simulator driving with less effort.

In conclusion, preliminary studies revealed reduced driving anxiety and avoidance symptoms for several individuals with chronic driving phobia. The lack of improvement in driving frequency, the variation in treatment response, and the loss of treatment gains in some participants are other notable results, suggesting that VRET may need to be followed by a course of in vivo exposure. Additional controlled trials are needed and further research on the predictors of VRET (e.g., subject characteristics, simulator characteristics) outcome may help delineate those individuals who would most benefit from this treatment.
- Wald, Jaye, Taylor, Steven; Preliminary Research on the Efficacy of Virtual Reality Exposure Therapy to Treat Driving Phobia; CyberPsychology & Behavior;Oct 2003; Vol. 6, Issue 5

Personal Reflection Exercise #11
The preceding section contained information regarding a study on the treatment of driving phobia.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 25
In Study 2, no difference was found in driving frequency between the pre- and post-treatment questionnaires. What may be implied about VRET from this result? Record the letter of the correct answer the CEU Test.

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Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

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