Original Research

Driving-Related Coping Thoughts in Post-9/11 Combat Veterans With and Without Comorbid PTSD and TBI

Veterans with a history of PTSD, TBI, and combat driving may experience driving anxiety on their return home and may benefit from using targeted coping strategies.

Fed Pract. 2017 December;34(12):20-24

Author(s):

Jillian M. Tessier

Elizabeth K. Whipple, PhD

Keith M. Robinson, MD

Maria T. Schultheis, PhD

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References

1. Belmont PJ, Schoenfeld AJ, Goodman G. Epidemiology of combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom: orthopaedic burden of disease. J Surg Orthop Adv. 2010;19(1):2-7.

2. Zinzow HM, Brooks J, Stern EB. Driving-related anxiety in recently deployed service members: cues, mental health correlates, and help-seeking behavior. Mil Med. 2013;178(3):e357-e361.

3. Whipple EK, Schultheis MT, Robinson KM. Preliminary findings of a novel measure of driving behaviors in veterans with comorbid TBI and PTSD. J Rehabil Res Dev. 2016;53(6):827-838.

4. Adler AB, Bliese PD, McGurk D, Hoge CW, Castro CA. Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: randomization by platoon. J Consult Clin Psychol. 2009;77(5):928-940.

5. Amick MM, Kraft M, McGlinchey R. Driving simulator performance of veterans from the Iraq and Afghanistan wars. J Rehabil Res Dev. 2013;50(4):463-470.

6. Classen S, Cormack NL, Winter SM, et al. Efficacy of an occupational therapy driving intervention for returning combat veterans. OTJR (Thorofare NJ). 2014;34(4):177-182.

7. Hannold EM, Classen S, Winter S, Lanford DN, Levy CE. Exploratory pilot study of driving perceptions among OIF/OEF veterans with mTBI and PTSD. J Rehabil Res Dev. 2013;50(10):1315-1330.

8. Lew HL, Kraft M, Pogoda TK, Amick MM, Woods P, Cifu DX. Prevalence and characteristics of driving difficulties in Operation Iraqi Freedom/Operation Enduring Freedom combat returnees. J Rehabil Res Dev. 2011;48(8):913-925.

9. Arthur DC, MacDermid S, Kiley KC; Defense Health Board Task Force on Mental Health. An Achievable Vision: Report of the Department of Defense Task Force on Mental Health. Falls Church, VA: Defense Health Board; 2007.

10. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation; 2008.

11. Independent Review Group. Rebuilding the Trust: Independent Review Group Report on Rehabilitation Care and Administrative Processes at Walter Reed Army Medical Center and National Naval Medical Center. Arlington, VA: Independent Review Group; 2007

12. Bailie JM, Cole WR, Ivins B, et al. The experience, expression, and control of anger following traumatic brain injury in a military sample. J Head Trauma Rehabil. 2015;30(1):12-20.

13. Campbell TA, Nelson LA, Lumpkin R, Yoash-Gantz RE, Pickett TC, McCormick CL. Neuropsychological measures of processing speed and executive functioning in combat veterans with PTSD, TBI, and comorbid TBI/PTSD. Psychiatr Ann. 2009;39(8):796-803.

14. Classen S, Levy C, Meyer DL, Bewernitz M, Lanford DN, Mann WC. Simulated driving performance of combat veterans with mild tramatic brain injury and posttraumatic stress disorder: a pilot study. Am J Occup Ther. 2011;65(4):419-427.

15. Lew HL, Amick MM, Kraft M, Stein MB, Cifu DX. Potential driving issues in combat returnees. NeuroRehabilitation. 2010;26(3):271-278.

16. Vasterling JL, Brailey K, Allain AN, Duke LM, Constans JI, Sutker PB. Attention, learning, and memory performances and intellectual resources in Vietnam veterans: PTSD and no disorder comparisons. Neuropsychology. 2002;16(1):5-14.

17. Kimble MO, Kaufman ML, Leonard LL, et al. Sentence completion test in veterans with and without PTSD: preliminary findings. Psychiatry Res. 2002;113(3):303-307.

18. Kuhn E, Drescher K, Ruzek J, Rosen C. Aggressive and unsafe driving in male veterans receiving residential treatment for PTSD. J Trauma Stress. 2010;23(3):399-402.

19. Stein MB, McAllister TW. Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury. Am J Psychiatry. 2009;166(7):768-776.

20. Hill JJ III, Mobo BH Jr, Cullen MR. Separating deployment-related traumatic brain injury and posttraumatic stress disorder in veterans: preliminary findings from the Veterans Affairs traumatic brain injury screening program. Am J Phys Med Rehabil. 2009;88(8):605-614.

21. Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69(4):621-632.

22. Hope DA, Burns JA, Hayes SA, Herbert JD, Warner MD. Automatic thoughts and cognitive restructuring in cognitive behavioral group therapy for social anxiety disorder. Cognit Ther Res. 2010;34(1):1-12.

23. Deffenbacher JL, Petrilli RT, Lynch RS, Oetting ER, Swaim RC. The driver’s angry thoughts questionnaire: a measure of angry cognitions when driving. Cognit Ther Res. 2003;27(4):383-402.

24. Beck AT, Emery G, Greenberg RL. Anxiety Disorders and Phobias: A Cognitive Perspective. Rev. paperback ed. New York, NY: Basic Books; 2005.

Combat veterans who have served in Iraq and Afghanistan in the post-9/11 era face unique reintegration challenges, one being the transition from driving in combat zones to driving at home.¹ Relative to previous conflicts, post-9/11 combat involves increased participation in road patrols and convoys along with more prevalent threats of improvised explosive devices (IEDs).^1,2 Roadside ambushes designed to destroy or stop vehicles became a common warfare strategy, meaning that driving became an inherently dangerous combat maneuver.³

The modern combat driving framework includes cognitive tools (eg, targeted aggression and tactical awareness) combined with specific behaviors (eg, driving unpredictably fast, using rapid lane changes, and keeping other vehicles at a distance to avoid IEDs).⁴ This framework is adaptive and lifesaving in combat zones, but it can be maladaptive and dangerous in civilian environments. Service members face difficulty in updating this cognitive framework after leaving combat zones and may continue to experience specific cognitions (eg, “the world is dangerous”; “that car holds an IED”) while driving on civilian roads.^3,5-8

The high prevalence of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) in post-9/11 veterans may complicate reintegration. Both PTSD and TBI are considered signature wounds of these conflicts.^8-11 Traumatic brain injury may be sustained as a result of blast injury or other mechanism, including a closed head injury or penetrating brain injury.¹⁰ Previous literature indicated that both PTSD and TBI across all severities are related to deficits in executive functioning, attention, and memory.^12-16

In addition to cognitive deficits, veterans with PTSD also may experience cognitive misappraisal, in which they are more likely to perceive ambiguous stimuli as threatening because of an inability to suppress trauma-related schema and associations.^5,17,18 Examples of roadside-specific trauma triggers include busy highways, traffic, loud or distracting noises, and vehicles of similar make and model as those commonly rigged with IEDs in Iraq or Afghanistan.^2,7

Blast injury, often from IEDs, is the most common cause of TBI reported in U.S. service members, so veterans that have experienced such an injury may become hyperaware of vehicles that may appear to hide IEDs.^7,19 Cognitive dysfunction and misappraisal of neutral stimuli may have an additive effect on behaviors and experiences behind the wheel.^7,15,20 As a result, veterans with comorbid PTSD and TBI may drive unsafely, self-restrict driving time, or avoid driving completely.^5,8,18

Prior research suggests that veterans with PTSD and/or TBI experience significantly higher levels of anxiety in response to common roadside stimuli (ie, an overpass or stop sign) while driving than do veterans without either PTSD or TBI.³ Cognitive behavioral therapy (CBT) interventions have been developed and systematically evaluated for treating anxiety.²¹ The goal of CBT is to identify and change dysfunctional cognitions that result in biased information processing. Cognitive restructuring, the process by which problematic cognitions (negative automatic thoughts) are identified and examined for distortions, is one method of accomplishing this goal. Distortions then are disputed and rebutted with assistance from the clinician.²² A strategy for restructuring negative automatic thoughts is coping self-instruction, which centers on identifying when negative automatic thoughts are focused on others’ behavior, accepting that their behavior cannot be changed, and using positive coping behaviors to minimize negative automatic thoughts.²³

The link between history of comorbid PTSD and TBI and combat driving, current driving anxiety, and coping strategies has not yet been extensively studied in veterans. Thus, the aim of the current study is to determine whether veterans with comorbid PTSD and TBI utilize coping self-instruction behind the wheel. Driving-specific coping self-instruction involves generating thoughts that are adaptive and accepting of others’ driving behaviors (eg, “Just turn up the radio and tune them out”). It was hypothesized that veterans with comorbid PTSD and TBI would endorse fewer coping self-instruction thoughts than would veterans without either PTSD or TBI.

Methods

The current project is part of a larger study that examines driving behaviors of post-9/11 combat veterans at the Michael J. Crescenz Veterans Affairs Medical Center in Philadelphia, Pennsylvania. Thirty-two male veterans aged between 22 and 48 years (M = 31.6, SD = 6.9) were included in the sample. Twenty-three were diagnosed with comorbid PTSD and TBI and 9 veterans with no major psychiatric or physical

diagnoses served as controls. Of the 23 with comorbid PTSD and TBI, 43% experienced blast injury and closed head injury (n = 10), 43% experienced blast injury alone (n = 10), and 13% experienced closed head injury alone (n = 3). Of those who sustained a closed head injury (n = 13), 12 were classified as mild and 1 was classified as moderate. Demographic variables for each group are reported in Table 1.