Driving-Related Anxiety in Recently Deployed Service Members: Cues, Mental Health Correlates, and Help-Seeking Behavior

MILITARY MEDICINE, 178, 3:e357, 2013 Driving-Related Anxiety in Recently Deployed Service Members: Cues, Mental Health Correlates, and Help-Seeking Behavior Heidi M. Zinzow, PhD*; Johnell Brooks, PhD†; Erica B. Stern, PhD, OTR/L, FAOTA‡ ABSTRACT Recent military operations have involved repeated trauma exposure while driving vehicles. Combat deployment and post-traumatic stress disorder (PTSD) have been associated with risky driving practices, increasing the likelihood of fatalities and problems adjusting to civilian life. However, no studies have specifically examined the role of driving-related anxiety, including common cues and mental health correlates. This study conducted structured interviews with 46 recently deployed service members. Interviews assessed the prevalence of driving-related anxiety or hyperarousal (anger or irritation) in relation to civilian driving scenarios, combat exposure, post-traumatic stress symptoms, depression symptoms, and help-seeking behavior. The majority of participants reported high driving anxiety or hyperarousal in response to scenarios involving close proximity to other cars. Driving-related anxiety was positively correlated with PTSD and depression. Although PTSD and driving anxiety were positively associated with help seeking, only one-third of soldiers sought help for driving anxiety and most sought help from informal sources (i.e., friend and battle buddy). The findings underscore the need to address driving-related anxiety in combat-exposed service members with mental health symptoms, with a particular focus on specific anxiety-provoking situations. Furthermore, interventions that reduce stigma and improve access to formal care could improve help seeking and treatment for these problems. INTRODUCTION Recent military operations in Afghanistan and Iraq (Operation Enduring Freedom and Operation Iraqi Freedom [OEF/OIF]) frequently involved multiple deployments and high-intensity insurgent warfare, resulting in heightened exposure to traumatic events such as direct fire, witnessed violence, and physical injury.1,2 Combat exposure has been associated with a variety of psychiatric disorders, including post-traumatic stress disorder (PTSD) and depression. Research with recently deployed soldiers has found that approximately 14% to 28% meet current or past year criteria for PTSD3–5 and 13% to 14% meet criteria for depression.3–5 In comparison to prior conflicts, OEF/OIF deployments involve the chronic threat of roadside bombs and improvised explosive devices (IEDs).2 Many of these events take place during road patrols and convoys. Therefore, it is not surprising that many cues for PTSD symptoms arise while driving and that PTSD symptoms represent a significant predictor of risky driving practices among military personnel.6 Specifically, PTSD symptoms such as intrusive memories, avoidance of trauma-related cues, hyperarousal, and irritability can interfere with safe driving. Risk factors for trauma-related mental health symptoms, including deployment history and combat exposure, have also been associated with increased likelihood of risky driving behavior, as well as fatal motor vehicle accidents.7–9 A study of OEF/OIF veterans receiving residential treatment for PTSD found that this cohort was at greater risk *Department of Psychology, Clemson University, 418 Brackett Hall, Clemson, SC 29634. †Department of Automotive Engineering, Clemson University, 4 Research Drive, Greenville, SC 29607. ‡Program in Occupational Therapy, University of Minnesota, 276 Children’s Rehab Center, 426 Church Street SE, Minneapolis, MN 55455. doi: 10.7205/MILMED-D-12-00303 for unsafe and aggressive driving practices in comparison to veterans of Persian Gulf and Vietnam wars.10 Furthermore, one unpublished study found that deployed soldiers reported higher driving-related anxiety than a comparison group of never deployed Army cadets. Driving-related trauma exposure was significantly associated with driving-related anxiety.11 In sum, little research has been conducted on drivingrelated anxiety, and no studies have described the frequency of driving-related combat exposure or anxiety in OEF/OIF veterans. This information is needed to inform interventions and practices to reduce risky driving, mental health symptoms, and the public health burden associated with drivingrelated anxiety, injuries, and fatalities. Despite high rates of mental health problems in returning military personnel, more than half of OEF/OIF veterans with mental health symptoms do not seek mental health services, often as a result of concerns about stigmatization.4,12 Although studies of trauma-exposed civilians indicate a greater likelihood of seeking help from informal sources (e.g., friends, family), as opposed to formal sources (e.g., mental health clinicians13), studies have yet to examine these patterns in military service members. Understanding these patterns of help seeking will assist future efforts to develop accessible interventions that reduce driving-related anxiety and facilitate mental health treatment-seeking. The primary purpose of this study was to explore the nature of driving-related anxiety and its association with drivingrelated combat exposure and common trauma-related mental health outcomes (i.e., PTSD and depression) in recently deployed service members. We furthermore assessed which civilian driving situations evoked the most anxiety in returning veterans. A secondary purpose of this study was to examine patterns of help-seeking behavior among service members with driving-related anxiety. MILITARY MEDICINE, Vol. 178, March 2013 e357 Case Report METHODS Participants and Procedure A total of 46 recently deployed male service members completed structured interviews. Soldiers were recruited via e-mail through local and state service members and veterans’ organizations. Soldiers were also recruited during a battle assembly weekend for the Army Reserves. The study was approved by Clemson University Institutional Review Board. The average age of participants was 27.6 (SD = 6.2). Approximately 6% were active duty, 6% were veterans, and the remainder were in the Reserves. The average time deployed during the past 2 years was 9.6 months (SD = 2.8). The average time since last deployment was 9.6 months (SD = 10.3). A total of 91% had most recently been deployed to Afghanistan and 9% to Iraq. On average, participants reported moderate to heavy combat exposure (M = 25.8, SD = 6.0 on the Combat Exposure Scale.14 Measures Combat Exposure The Combat Exposure Scale is a 7-item self-report measure that assesses wartime stressors ranging from going on combat patrols to witnessing injury and death.14 Items are rated on a 5-point scale assessing frequency, duration, and degree of loss. The total score (ranging from 0 to 41) is a sum of weighted scores based on “light” to “heavy” categories. The measure has shown good internal stability and test–retest reliability.14 To estima (...truncated)