Driving Phobia Summary

Fear of driving is classified in the DSM-5 as a situational specific phobia where the thought or experience of driving triggers intense fear and may reliably trigger panic attacks. Driving phobia frequently co-occurs with panic disorder (fear of untriggered panic attacks), acute stress disorder or post-traumatic stress disorder after a motor-vehicle accident, or other anxiety disorders. Recent studies show that driving fears are prevalent (Beck & Coffey, 2007). Approximately 17-20% of the U.S. population meet criteria for mild driving phobia symptoms and ~4-6% suffer from severe driving phobia.

Exposure is an essential component in the treatment of any phobia. Virtual reality exposure therapy (VRET) is empirically supported as an effective means of exposure (McMahon, 2017; Wiederhold & Wiederhold, 2005), it supplements imaginal and in vivo exposure, and it offers unique advantages over those exposure options. The treatment protocol below offers tips on incorporating VRET into standard evidence-based CBT using Limbix virtual reality and discusses ways to help patients benefit from VR exposure and reduce driving anxiety.


Recommended Session Plan

All Sessions

  • Maintain a strong therapeutic relationship; demonstrate warmth, empathy, and respect; strengthen patient motivation, hope, and self-efficacy
  • Assess relevant symptoms and measure progress and skill mastery
  • Review homework; plan, assign, and solicit feedback

Intake and Preparation (session 1)

  • Intake and case conceptualization
  • CBT socialization/psychoeducation creating a shared understanding of anxiety and treatment
  • Identify treatment goals and expectations
  • Assign, agree to and ensure patient writes out relevant homework (e.g. thought records, basic imaginal or in-vivo exposures, research avoided scenarios)

CBT Skills to Prepare for Successful Exposure (often sessions 2-4)

  • Teach anxiety management skill(s), (muscle relaxation, diaphragmatic breathing, mindfulness, grounding, etc.)
  • Identify fears and any relevant core beliefs that contribute to the phobia
  • Collaboratively develop credible counter-statements to fears and core beliefs
  • Create exposure hierarchy of driving environments. See below on how to create a driving exposure hierarchy using Limbix VR videos
  • Assign, agree to and ensure patient writes out relevant in vivo, imaginal or other homework
  • Consolidate learning by reviewing session, progress, plan, and CBT highlights

Exposure (may begin session 2 or later depending on skills)

  • Move through the patient’s exposure hierarchy using VRET in session
  • Before, during, and after VR exposure, check patient’s ability to successfully tolerate exposure, reduce anxiety, and change thinking about the phobic situation using CBT skills previously taught
  • As needed, model skills, coach the patient, or teach additional skills (cognitive restructuring, distress tolerance, mindfulness, etc)
  • Assign, agree to and ensure patient writes out relevant in vivo, imaginal or other homework
  • Consolidate learning by reviewing session, progress, plan, and CBT highlights

Final Session(s)

  • Consolidate learning by collaboratively reviewing key takeaways and strategies
  • Relapse prevention
  • Prepare for treatment completion


Create a Driving Phobia Exposure Hierarchy

Based on your patient’s fears and phobic triggers, create an exposure hierarchy. This may be done formally (asking the patient to give an estimated distress rating for each) or informally. Informally creating a hierarchy is done by selecting two or more videos or sections of videos that you feel would be a reasonable next exposure step, describing them to the patient, and having the patient choose. This emphasizes the collaborative, respectful nature of therapy and enhances patient feelings of control and self-efficacy. Here is a sample hierarchy used for driving phobia.

Treatment Tips: Driving Phobia

Tips for preparing and working with patients through VR exposure therapy sessions follow. Ideally VR evokes at least some anxiety so patients can practice tolerating and decreasing fear. Active engagement with patients during VR exposure is encouraged earlier in treatment so you can monitor their SUDS level and prompt to use skills as needed. As they gain the ability to raise and then lower SUDS on their own, you will become less active.

Prior to a first VR exposure, confirm that the patient has tools to manage anxiety:

  • “Remember, anxiety can be automatically triggered even when unneeded. Anxiety, fear, and panic are uncomfortable, but not dangerous. What coping tool(s) will you use to cope with any fear?” [Have patient demonstrate]

Review patient fears and how s/he will cognitively counter those fears:

  • “Describe your biggest fears about what might happen when you get into the car and drive today. How will you cope?”
  • “What fears are likely to come up in this situation? What will you say back to them?”
  • It can be illuminating to periodically check the patient’s current level of belief in the fears using a 0-10 scale where lower is better (less belief in fears) and level of belief in the counter statements using a 0-10 scale where higher is better (more belief in counter statements, new core beliefs, facts, cognitive restructuring, etc).

Encourage immersion while in VR:

  • “Make it real. Imagine that you are really driving. Look around. Get completely involved.”

You can describe the driving environment the patient is about to enter:

  • “You’ve done a great job so far. The next step is a driving scene where you’ll pull onto a highway and drive alongside other cars at very high speeds. Tell me when you are ready.” [Exposure is always done with patient permission and collaboration.]
  • “Let’s elevate the challenge to a task you predicted would be an 8 on the 0 to 10 anxiety scale. You’ll be driving over the Golden Gate Bridge in lots of traffic. Tell me when you are ready.”

Before or during VR exposure, you may encourage the patient to activate fear or feared memory such as:

  • “I want you to think about driving on a road just like the one that you had your bad accident on last year.”
  • “Describe your accident to me. Tell me the details you remember.”

You can also describe details you are aware of about your patient’s specific fears:

  • “I know you have real fears around driving near bikers and buses. What skills will you use in this next scene on your exposure hierarchy?"
  • “Close your eyes and imagine that you are going to be driving at night in a minute. You are in your home, grabbing your keys and walking out the door to pick up your children. Tell me when you are ready to get into your car.”

During VR exposure, check SUDS level often to monitor response and guide treatment interventions: 

  • “What is your anxiety level right now, from 0 not at all to 10 extremely?”

If the SUDS rating is decreasing: 

  • Point out the decrease and reinforce the patient’s use of skills: “Wow. Your anxiety dropped from a 6 to a 4. You decreased it by a third in only 2 minutes. How did you do that? What does that tell you about your ability to overcome this fear?”

If the SUDS rating is staying the same: 

  • More actively prompt, model, and coach your patient during exposure. Check that they understand and are able to use their anxiety tolerance technique(s). Look for any previously undiscovered fears and/or other interfering factors such as negative core beliefs, distress intolerance, etc. 
  • Explore whether they are engaging in safety actions or other actions that undermine the benefit of exposure: “What is happening in your body?” “What are you doing and thinking when you feel anxious?” “What fears come to mind? Are there any fears we haven’t talked about?”

If the SUDS is stable but relatively low (1-4 or so): 

  • Try asking “If your anxiety level stayed at this level when driving in real life, would you be okay with that?” 

If the SUDS rating is increasing: 

  • Prompt the patient to use their skills.
  • Explore for previously uncovered fears. Consider dropping to a less anxiety-provoking VR environment. Depending on patient skills, motivation, and anxiety tolerance, consider shortening exposure (to avoid sensitization or discouragement) or lengthening exposure (to give more time to desensitize):
  • “Your anxiety is elevated right now. What do you do? Practice your best strategies now.” “Do belly breathing.” “Practice mindful acceptance.” “Remember the facts [prompt or remind them]. Remember what you’ve learned about anxiety.” “What is your fear telling you? What is the fear predicting or assuming?” “What is your worst nightmare scenario about what might happen? What will you say back? Why is that not likely or realistic? What can you tell yourself?”

During VR exposure, as your patient shows increasing skill, you can strengthen self-efficacy, treatment impact, and work to reduce relapse by pushing the patient:

  • “Deliberately bring on your anxiety. How anxious can you make yourself? Tell me using the 0 to 10 anxiety scale….Okay, great. Now use your tools to bring down the anxiety and talk back to the fear….That’s terrific.”
  • “What would you do if you felt a panic attack coming on right now?”
  • “How would you react if you saw an accident about to happen in front of you right now?"
  • “Your anxiety is elevated right now. What do you do? Practice your best strategy now.”

Additional techniques (apply as appropriate based on clinical judgment):

  • Guide interoceptive exercises for your patient before or during VR exposure so somatic sensations similar to panic / anxiety sensations will be present during VR.
  • Voice your patient's fears or negative core beliefs and have your patient voice the counter statements.


REFERENCES

Beck, J. G., & Coffey, S. F. (2007). Assessment and treatment of PTSD after a motor vehicle collision: Empirical findings and clinical observations. Professional Psychology, Research and Practice, 38(6), 629–639.

McMahon, E. (2017) Virtual Reality Exposure Therapy: Bringing ‘in vivo’ into the Office. Journal of Health Service Psychology, (Spring 2017), 43, 46-49.

Sullivan, S. (2018) Is Virtual Reality Ready to Help Patients? The California Psychologist. (Winter 2018), 51, 16-19. 

Wiederhold, B. K., & Wiederhold, M. D. (2005). Fear of Driving. In B. K. Wiederhold & M. D. Wiederhold, Virtual reality therapy for anxiety disorders: Advances in evaluation and treatment (pp. 147-155). 

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