Paul Elson and Karen Addy Foreword When litigating a road accident claim, travel anxiety and associated stress is one of the typical sub headings of damages. Depending on whether physical injuries exist, the severity and level of disruption socially and occupationally of any travel anxiety are crucial to accurate and viable quantum assessment. Paul Elson and Karen Addy both have considerable experience in differentiating clinical and sub-clinical types of ‘travel nerves’.
Travel nervousness following a road accident is almost a universal psychological consequence among those people unfortunate enough to suffer such an event. The level of nervousness displayed by individuals varies considerably. For some people it is very mild and soon disappears as they return to driving. This can essentially be considered a normal response that does not require treatment. For others however the level of nervousness suffered is more problematic. This group of people fall within three categories, namely those for whom the problem is considered ‘mild’, ‘moderate’ or ‘severe’. Mild travel nervousness describes those people who, while displaying a clear degree of travel anxiety, are nevertheless able to travel in a vehicle without too much difficulty and as such there is no avoidance behaviour. Those people with a moderate degree of travel nervousness display increased nervousness and have consequently reduced their level of travel, typically limiting their travel to essential journeys only.
Finally, those people whose problem is considered severe display both marked anxiety regarding the prospect of travelling in a vehicle and in addition have markedly reduced such travel or even avoid travel altogether. The level of travel anxiety suffered by those people for whom it is considered mild is unlikely to meet the criteria for a psychological disorder, ie it is not clinically significant.
The level of travel anxiety suffered by those people for whom it is considered moderate may or may not meet the criteria depending on the level of anxiety suffered and the degree of avoidance involved. For those who are suffering from severe travel anxiety it is likely that they will be suffering from a diagnosable psychological disorder, most commonly a specific phobia. There are various approaches to tackling these problems. First, a person may benefit from learning strategies to relax, such as deep breathing or progressive muscle relaxation. This may be available on the NHS (usually via the person’s GP), privately, or could be accessed through simply buying a relaxation tape that will talk the person through the skills needed. This approach would be of particular benefit for those people considered to be suffering from mild travel anxiety and could be sufficient to help the individual overcome their nervousness.
Behavioural approaches, such as encouraging an increase in travel practice, are essential to recovery as avoidance of travel maintains the nervousness and reduces confidence in travelling. Thus encouraging a person to increase the time or distance involved in their travelling would help them regain their confidence. Refresher driving lessons can also play a part in increasing confidence and reducing avoidance; this approach is likely to be beneficial to all three levels of travel nervousness. For people with more severe travel anxiety and those that meet the criteria for a specific phobia, more formal psychological treatment is often required. The most common and evidence-based therapy used in such cases is cognitive behaviour therapy. This is a well-established psychological treatment that seeks to teach people to overcome their nervousness by tackling both the individual’s thought processes (the cognitive component) and by working on the degree to which they actually travel or else avoid doing so (the behavioural component). It is practically-oriented, involving the teaching of skills and homework-type assignments. Its effectiveness is grounded in scientific research. This approach would be indicated in those individuals whose problem is moderate or severe and usually consists of a course of 8-10 sessions. Ideally, the person receiving the treatment should possess a degree of psychological mindedness, ie they possess the ability to reflect on their thoughts, feelings and behaviour.
Another form of psychological therapy used to treat travel nervousness is that of Eye Movement Desensitization Reprocessing (EMDR). This approach involves encouraging the client to bring into awareness distressing material (thoughts, feelings, etc) from the past and present and which is then followed by sets of bilateral stimulation, most usually side-to-side eye movements. Once the eye movements cease the individual is asked to let material come to awareness without attempting to ‘make anything happen’. After EMDR processing, clients generally report that the emotional distress in relation to the memory has been eliminated, or greatly decreased. EMDR is primarily used to treat post traumatic stress disorder (PTSD), for which there is some scientific evidence demonstrating its benefits, and although it may also be used to treat travel phobia, the research evidence supporting this is more anecdotal. The above approaches are not mutually exclusive and it is likely that in practice a combination of treatment approaches is needed. For example, a person undergoing cognitive behaviour therapy is also likely to benefit from being taught relaxation techniques and to increase their travel practice, components which usually form part of this therapeutic approach. They may also be receiving EMDR treatment. While the approach to tackling an individual’s particular problem is partially determined by the nature and severity of the problem, as outlined above, it is also dependent on the preference of the individual concerned, as some people would rather try tackling the problem themselves, having received some simple informal advice, while others would prefer something more formal, such as psychological therapy. Either way, the person needs to be motivated to tackle their problem and ideally possess some belief in the effectiveness of the approach that they are using.
The following case highlights a typical anxiety reaction to a car accident and the recommended treatment for such symptoms:
Mr. M was a 28 year old who was in an accident in May 2008. He was a front seat passenger, in a car driven by a friend. The car they were traveling in was hit from the rear by a lorry and pushed into another lorry whilst on a motorway. Mr. M was trapped in the car and was cut free by the fire service. He received whiplash injuries and burns to his legs as a result of the car’s water tank spilling on him. Early psychological symptoms (developed within 2 months of the accident) were stress symptoms of intrusive thoughts, nightmares, some avoidance phenomena and persistent arousal symptoms. These symptoms as described did not meet the full criteria for Post Traumatic Stress Disorder (PTSD) (DSM.IV 309.81).
However, he experienced mood disturbance with variable low mood reactive to pain, feelings of worthlessness and low self-esteem, sleep disturbance, reduced appetite and weight loss, lethargy and reduced motivation, consistent tearfulness, loss of interest in usual activities and consistent irritability, exacerbated by physical discomfort. He also stated that he was generally more anxious, describing worries about potential hazards and being more jumpy and hyper-vigilant to perceived danger.
Following the accident Mr. M avoided driving and at the time of the interview (15 months since the accident) he had not driven. In addition he avoided traveling as a passenger whenever possible. There was social withdrawal due to travel anxiety and low mood. He reported stopping usual activities such as going to the gym and going out with friends. Mr. M had not worked since the accident. He reported that he was physically unfit for approximately six months, however had not returned to work due to a fear of travelling in a car preventing him from accessing work. The symptoms described by Mr.M meet the criteria for a Specific Phobia (DSM.IV 300.29) related to travel and a Depressive Disorder (DSM.IV 311).
Mr M completed a course of cognitive behavioural therapy (12 sessions) which included a graded approach to increasing his travel practice and incorporated general relaxation techniques. After six months Mr M had significantly increased his driving and passenger travel, had started to work part time and no longer met the criteria for either a specific phobia or depressive disorder. It is unlikely that without appropriate psychological treatment such improvement in Mr M’s condition would have occurred as evidence suggests that maximum natural improvement in symptoms will occur 6-12 months following the index accident.
Travel anxiety, a common response to experiencing a distressing road traffic accident, is a well documented and understandable phenomenon. It can and does improve with self help, advice, and where appropriate, professional help.
Useful references:
Koch H.C.H and Kevan T. (2005) Psychological Injury XPL Press, St Albans.