Injury (1991) 22, (S), 365-368 Printed in Great Britain 365

The effects of road traffic accidents on driving behaviour

R. Mayou’, S. Simkinl and J. ThrelfallZ ‘University Department of Psychiatry, Wameford Hospital, Oxford, UK and 20xford Road Accident Group, Oxford, UK

Questionnaires about fk effects of accidents on subsequent driving behaviour were sent to 869 people admitted consecutively to a general hospital as a result of involvement in road frajic accidents 4-6 years previously. 7%ere were 418 (48 per cent) q&es, 67 per cenf of delivered questionnaires. One-fifth of fhe moforcyclisfs had stopped using a motorcycle. Nearly one-half fk motorcyclists and vehicle drivers reported that they now drove more slowly and that they were more caufiaus. A considerable proportion of replies desm’bed emotional distress, avoic&ce and limitation of activities. Lack of conjiaknce in driving was common immediately after tk accident. After 4-6 years, one-third of respondents reported that they still suj$red spefjic anxiety about the pk~ce $of fk accident and about situations similar to fk accident. Many people were anriow about being passengers. The findings have implications for road safety, for fk recognition and management of a common, and often disabling, clinical problem, and for tk assessment of disabilities in medical reports for compensation proceedings.

Introduction

Road traffic accident victims often tell their friends and their doctors that they have become anxious about driving or being a passenger, and such problems are often mentioned in medical reports for compensation proceedings. A Canadian survey reported that 18.5 per cent of 524 hospitalized road accident victims suffered ‘phobias’ 3-4 years after accidents and that 3 I per cent reported they now drove more ‘defensively’ (Interministerial Task Force, 1981). Post-traumatic stress disorder as described after major disasters is an occasional complication (Malt, 1988; Burstein, 1989). There has been no systematic account of the occurrence and nature of changes in driving and of changes in confidence following accidents.

This paper reports a 4-6 year follow-up of consecutive admissions of road traffic accident survivors to the ]:ohn Radcliffe Hospital, Oxford. The Oxford Road Accident Group have collected systematic data on all such admissions (Tunbridge et al., 1988).

Methods

In 1989 a questionnaire was sent to all surviving subjects (aged 17-65 years) who had been vehicle drivers or

0 1991 Butterworth-Heinemann Ltd OOZO-1383/91/050365-04

passengers or motorcycle (or moped) riders, admitted during a 2-year period between 1983 and 1985. Subjects with incomplete addresses and highly mobile groups such as students or members of the armed forces were excluded. Enquiries were made about perceived effects of the accident on driving. The questions being based on clinical experience and the preliminary findings of a current prospective study of psychosocial aspects of major road accidents.

A total of 869 questionnaires were sent out and 418 (49 per cent) completed questionnaires returned. There were 248 envelopes returned undelivered, often marked as ‘gone away’ or ‘not known’. Replies were received for 67 per cent of delivered questionnaires. The reasons for lack of response include false addresses and considerable geographical mobility, especially among younger accident victims. Non- respondents were younger but did not differ in other characteristics. One-half of the replies provided extra details and comments (often extensive). We use ‘motorcyclists’ as a general term for the 118 motorcycle, 23 moped and 2 scooter drivers; and ‘car drivers’ for the 143 car, 10 goods vehicles and 3 unspecified drivers.

We obtained Oxford Road Accident Group data about the nature of the accident, age, length of admission, duration of unconsciousness and Injury Severity Score (ES). The first 400 questionnaires returned were analysed using the Statis- tical Package for Social Sciences (Nie et al., 1975) for x2 and f tests, as appropriate.

Results

The characteristics of the respondents are summarized in TableI. Over one-half were still suffering physical conse- quences of the accident, problems that were blamed for the loss of jobs and businesses, and for deterioration of family life.

Caution and awareness. Many people felt they had become safer, better drivers as a result of their accident, driving more slowly, carefully and considerately (Tub,% I). One-quarter commented that they were more alert to safety, road conditions, weather, the behaviour of other drivers and took more care about judging distances and junctions.

For some, increased awareness meant a change from reckless to more sensible driving. Others had become

366 Injury: the British Joumal of Accident Surgery (1991) Vol. tHNo.5

Table I. Characteristics of the respondents and general consequences. Number (%)

Motorcycle/ moped driver

(N= 946)

Pillion passenger

(N=9)

Car driver

(N= 953)

Car passenger (N=9.2)

Total (N=400)

Sex Male Female

Mean (years) age

ISS Score l-5 6-10 11+

Physical Nil consequences: Mild

Considerable

Further Nil

accidents: 1 2+

124 3 (33) 110 (72) 43 (47) 280 (70) 22

I?:;

216.2 (67) 43 (28) 49 (53) 120 (30)

28 34.5 32.6 31.4 (SD 13.4) (SD 3.2) (SD 14.6) (SD 15.2) (SD 14.2)

54 I:;; 1 (11) 58 (38) 50 (54) 163 (41) 59 4 42 (28) 23 (25) 128 (32) 33 (23) 4

I::; 53 (35) 19 (21) 109 (27)

63 (43) 4 15:; 73 (49) 41 (45) 181 (48) 67 (46) 3 67 (45) 41 (45) 178 (45) 16 (11) 1 (13) 10 (7) 70 (11) 37 (9)

131 (90) 8 (100) 137 (90) 86 (94) 362 (91)

13 (9) - 12 5 (5) 2 (1) - 3 1:; 1 (1) 30 I;; 6

Caution No change 77 (55) 5 (63) 75 (52) 35 (49) 192 (53) as a driver: Bit slower 56 (40) 3 (38) 61 (43) 33 (47) 153 (42)

Lot slower 6 (4) 7 (5) 3 (4) 16 (4)

Table II. Consequences for motorcycle/moped riders. Number (%)

Drivers (N = 942)

Pillion passengers

(N=9) Total

Change in motorcycle riding Increase No change Decrease Stopped

Lack of confidence in motorcycling (now)’ General impairment Nervous in similar situations Nervous at place of accident

Avoid place of accident

10 (7) 2 (22) 12 (8) 27 (19) 1 (11) 28 (19) 76 (54) 4 (44) 80 (53) 29 (20) 2 (22) 31 (21)

18 (17) 2 (29) 20 (17) 35 (34) 5 (71) 40 (36) 20 (19) 4 (57) 24 (21)

5 (5) 1 (14) 6 (5)

*Percentages for those still riding motorcycle.

excessively cautious, sometimes to an extent which made it difficult for them to drive other than at very quiet times or in quiet areas. Many of those who felt they had been innocent victims said they became very aware of the unpredictable behaviour of other drivers. In contrast, several drivers said that as the accident had not been their fault, there were no changes they could make.

Motorcycle riders Motorcyclists were young, and mainly male (Table I). Most reported a decrease in motorcycling after their accident, giving as reasons: the belief that cars are safer (37 per cent); lack of confidence in motorcycling (30 per cent); physical disability (15 per cent) and changes in work (14 per cent). One-fifth, including nearly one-half of the women riders, had stopped motorcycling altogether, several because their families had persuaded them to give up. Those with persistent physical disability were especially likely to have given up and to have become more cautious.

Nearly one-quarter of those still motorcycling reported that they had suffered some general, but usually temporary, lack of confidence. Specific worries were more persistent (Table U), concern varying from mild minor distress to marked anxiety. Lack of confidence was most frequent in those who had suffered serious injuries as assessed by the

Injury Severity Score (P<o.o~), those with persistent disability (P < 0.005) and in women (NS).

One-half of the motorcyclists had increased their car driving since the accident, often for unrelated reasons such as extra comfort or a growing family (TffbZe111). Some saw changing to a car as a part of becoming older and more prosperous. Some motorcyclists had also suffered lack of confidence on driving a car. They often mentioned that the accident had made them much more aware of the safety of motorcyclists when themselves driving cars.

Car drivers

Injuries had often prevented driving for considerable periods of time. Although very few car drivers had stopped driving following the accident, almost one-quarter reported changes, principally because of changes in work, but also for lack of confidence, financial reasons and disability. A number of car drivers had changed to safer cars (larger or lower performance models). Older drivers were more likely to describe a decrease in driving following the accident.

Lack of confidence. General lack of confidence was frequent (38 per cent), in the early weeks and months of returning to driving after an accident, but often temporary. Specific anxieties were more common and had persisted in

Mayou et al.: Road traffic accidents and driving behaviour 367

Table III. Changes when driving a car. Number (%)

Driving Non-driver Driver: before and since Started since accident Given up since

Change in driving Increase No change Decrease Considerable decrease

Lack of confidence Nil Temporary Persistent

Lack of confidence (now) Nervous in situations similar to accident Nervous at place of accident Avoidance of place of accident Prefer when driving company

Motorcyclist

22 (16) 77 (54) 39 (28)

4 (3)

59 (50) 44 (37)

7 (6) 8 (7)

90 (77) 19 (16)

8 (7)

25 (23) 13 (12)

2 (2) 2 (2)

Car driver

- 150 (98)

3 (2)

36 (24) 81 (54) 21 (14) 12 (8)

92 (63) 43 (29) 12 (8)

60 (41) 46 (31) 11 (7)

8 (5)

Cai passenger

21 (24) 57 (64) 10 (11)

1 (1)

30 (44) 29 (43)

4 (6) 5 (7)

46 (68) 20 (29)

2 (3)

32 (49) 20 (30)

6 (9) 2 (3)

Table IV. Effects on being a vehicle passenger. Number (%)

Motorcyclist Pillion rider

Car driver

Car passenger

Anxiety while a passenger None Slight Considerable

93 (68) 3 86 (59) 27 (29) 31 (23) 1 I::; 39 (27) 38 (41) 12 (9) 4 (50) 21 (14) 27 (29)

about one-third of drivers (TableIII), especially concern about situations similar to their accident (41 per cent). Some 4 per cent said that they preferred to have others with them when driving. For some people the persistent nervousness was a mild inconvenience, but for others (15-20 per cent) it resulted in considerable distress, avoidance and limitation in everyday life.

Lack of confidence was greatest in those with high Injury Severity Scores (PC 0.05), and those with persistent disabi- lity (P<O.OOl). Women (28 per cent of drivers) were especially likely to describe loss of confidence following the accident (P < 0.05) and anxiety in situations reminding them of the accident (P < 0.001).

Those who had been injured as passengers described just as much anxiety and lack of confidence when driving themselves as did those who had been drivers in the accident.

Travelling as a passenger

Anxiety about being a passenger was the commonest problem reported in the survey (Gable IV), varying from mild discomfort to unwillingness to ever again be a passenger. Many gave vivid accounts of the physical and psychological symptoms of anxiety that they had suffered since the accident. They frequently commented that what they especially disliked about being a passenger, was being aware of many possible dangers but not being in control. Some people preferred sitting in the front and some in the back. A number said that they often shouted out warnings and gave advice to drivers. Many people were very careful and selective about drivers with whom they would travel. A few said they were also worried about public transport.

Concern about being a passenger was most commonly reported by women (P<O.OOl), and those who had been passengers in the traffic accident (PC 0.001).

Discussion

The survey achieved a good response rate 4-6 years after a road accident. The proportions of disabling difficulties remain striking, even when calculated as a proportion of all the questionnaires sent out. However, it is essential to be cautious in drawing conclusions from a retrospective postal survey. Any group of road users could be expected to describe changes in driving behaviour over a 5-year period, especially young motorcyclists. Anxiety about driving may have preceded the accident. However, the questionnaire asked about ‘changes’attributed by subjects to their accidents and the detailed comments described specific fears that were new and were seen as related to the circumstances of the accident and injury. Our findings are consistent with clinical impressions and are supported by the results of a current prospective study of 190 interviewed road accident victims on admission to hospital and at 3- and 12-month follow-up.

Although many people reported improvement over a period of time which varied from weeks to years, a sizeable minority were still lacking in confidence 4-6 years later, especially at the place of their accident or in situations similar to those of the accident. There was considerable variation in patterns and severity of anxiety and of associated avoidance behaviour. These were sometimes highly specific, some- times generalized to all driving and being a passenger in any sort of vehicle. Several respondents also described very considerable worry about journeys by their children and

368 Injury: the British Journal of Accident Surgery (1991) Vol. 22/No. 5

other relatives, sometimes being unable to relax until a safe arrival had been confirmed.

Descriptions emphasized both the psychological and somatic symptoms of anxiety, including panic attacks. The best psychiatric description is phobic anxiety induced by classical conditioning. Post-traumatic stress disorder with intense intrusive memories of the accident appeared much less common and less severe than reported after major disasters (Malt, 1988; Burstein, 1989).

Anxiety about driving was particularly common in women and in those with physical problems. It is difficult to draw firm conclusions in a retrospective study about other probable determinants of lack of confidence, such as not being responsible for the accident, previous nervousness and lack of any memory of the accident. Those who saw themselves as innocent victims often added angry com- ments about the accident itself, arguments over compensa- tion and their continuing worry about the unpredictable and dangerous behaviour of other drivers. Several respondents mentioned that they had always been nervous about driving or being a passenger, but the majority of current problems were clearly attributed to the 1983-1985 road traffic accident.

A number of people commented that having been unconscious and having no memory of the accident meant that there had been no reason for them to become worried about particular situations or places. Surprisingly, the 208 subjects who had been unconscious after the accident (all except I 7 for less than IS min) described similar patterns of change in driving behaviour and confidence to those who had not lost consciousness. One person had avoided the place where she knew she had had her accident because she feared returning might bring back upsetting memories.

Our survey was confined to people admitted to hospital. It seems probable that many others suffering less severe injuries (for example, limb fractures and whiplash neck injuries), and even those who are not injured, also change their driving behaviour and experience loss of confidence. There is a need for prospective research, which should include long-term follow-up and observational research to determine consequences for road safety.

It is worrying that disabling lack of confidence and avoidance are common, persistent and usually untreated

after road accident injury. The period after an accident should be a favourable opportunity to encourage better, safer driving. Much could be done to prevent and treat this anxiety. Simple advice to all road accident victims about the difficulties to be expected in resuming driving and the importance of a regular graded return to normal driving. Even so, a minority will require extra specialist help, and it is probable that standard psychological treatments of phobic anxiety would be effective. Our findings also have implica- tions.for the full assessment of handicaps in writing medical reports for compensation proceedings.

Acknowledgements

The research was funded by The Transport and Road Research Laboratory. We are grateful for advice from Professor R. Duthie, Dr R. Tunbridge and Mr J. Everest.

References

Burstein A. (1989) Post-traumatic stress disorder in victims of motor vehicle accidents. Hasp Community Psychiatry, 40,295.

Interministerial Task Force on Motor Vehicle Injuries. (1981) An Ontario Survey of the societal ana’ Personal Cosfs of Hospitalized Motor Vehicle Accident Victims (Technical Reporf). Ontario: Ontario Ministry of Transport and Communications.

Malt U. (1988) The long-term psychiatric consequences of accidental injury. Br. J Psych&y 153, 810.

Nie N. H., Hull H. C., Jenkins J. G. et al. (1975) SPSS: Statistica Package for the Sociul Sciences. New York: McGraw-Hill.

Tunbridge R. J., Everest J. T., Wild B. R. et al. (1988) An In-depth Study of Road Accident Casualties and their Injury Patterns. Department of Transport (TRRL) Research Report 136. Crowthome: Transport and Road Research Laboratory.

Paper accepted 18 February 1991.

Requesfs for reprinfs shouti be aa%ssed to: Dr R. Mayou, University Department of Psychiatry, Wameford Hospital, Oxford 0x3 i’JX, UK.