Unmasking the Moving Threat: Reckless Driving, Borderline Personality Disorder, and the Impact on Motor Vehicle Accidents

...............................................................................................................................................4 INTRODUCTION .....................................................................................................................................6 PURPOSE STATEMENT .......................................................................................................................7 REVIEW OF THE LITERATURE ......................................................................................................7 MOTOR VEHICLE ACCIDENTS (MVAS) .................................................................................................................. 7 ROADS: BREEDING GROUNDS FOR MISCOMMUNICATION .................................................................................... 8 AGGRESSIVE DRIVING, ROAD RAGE, AND RECKLESS DRIVING: DANGEROUS ACTS ....................................10 PSYCHIATRIC DISORDERS AND DRIVING ............................................................................................................. 11 BORDERLINE PERSONALITY DISORDER AND RECKLESS DRIVING ................................................................... 15 METHOD ................................................................................................................................................. 17 PARTICIPANTS ........................................................................................................................................................ 17 PROCEDURE ............................................................................................................................................................ 18 Study survey. ........................................................................................................................................................... 18 Statistical analyses............................................................................................................................................... 19 RESULTS ................................................................................................................................................. 20 CHARACTERISTICS OF SAMPLE ............................................................................................................................. 20 PREVALENCE OF BORDERLINE PERSONALITY DISORDER IN THE SAMPLE .....................................................20 BORDERLINE PERSONALITY DISORDER AND DRIVING CITATIONS .................................................................. 20 DISCUSSION .......................................................................................................................................... 22 UNDERSTANDING BPD AND RECKLESS DRIVING .............................................................................................. 22 LIMITATIONS AND IMPLICATIONS ........................................................................................................................ 25 PUBLIC HEALTH IMPACT....................................................................................................................................... 27 REFERENCES........................................................................................................................................ 29 TABLE 1 ................................................................................................................................................... 35 APPENDICES ......................................................................................................................................... 36 A. DRIVING SURVEY .............................................................................................................................................. 36 B. IRB APPROVAL.................................................................................................................................................. 46 C. PUBLIC HEALTH COMPETENCIES................................................................................................................... 47 4 Unmasking the Moving Threat Abstract Background: Motor vehicle accidents (MVAs), a leading cause of mortality in the United States have an enormous impact on public health. Researchers contend that approximately 90% of all MVAs are, to some extent, a result of driver characteristics and behavior (Lewin, 1982). One of the least researched driver characteristics is psychiatric comorbidity, especially borderline personality disorder (BPD), a disorder that is characterized by impulsivity and emotional volatility. Objective: The purpose of this study is to examine the relationship between BPD and driving citations. Method: Using two measures for BPD, we surveyed a consecutive sample of patients who were being seen at a primary care setting (N = 419) and examined self-reported histories of being charged with, not necessarily convicted of, 12 moving and 11 non-moving traffic violations as well as automobile/motorcycle accidents, driving while intoxicated, vehicular manslaughter, leaving the scene of an accident, and having ever had one’s driving privileges suspended or been refused a driver’s license in any state. Results: There were statistically significant correlations between both measures of BPD and the number of moving violations, number of non-moving violations, driving whileBackground: Motor vehicle accidents (MVAs), a leading cause of mortality in the United States have an enormous impact on public health. Researchers contend that approximately 90% of all MVAs are, to some extent, a result of driver characteristics and behavior (Lewin, 1982). One of the least researched driver characteristics is psychiatric comorbidity, especially borderline personality disorder (BPD), a disorder that is characterized by impulsivity and emotional volatility. Objective: The purpose of this study is to examine the relationship between BPD and driving citations. Method: Using two measures for BPD, we surveyed a consecutive sample of patients who were being seen at a primary care setting (N = 419) and examined self-reported histories of being charged with, not necessarily convicted of, 12 moving and 11 non-moving traffic violations as well as automobile/motorcycle accidents, driving while intoxicated, vehicular manslaughter, leaving the scene of an accident, and having ever had one’s driving privileges suspended or been refused a driver’s license in any state. Results: There were statistically significant correlations between both measures of BPD and the number of moving violations, number of non-moving violations, driving while intoxicated, and ever having had driving privileges suspended. There were no between-group differences with regard to automobile or motorcycle accidents. No participant reported vehicular homicide, and too few endorsed leaving the scene of an accident or having been refused a driver’s license to warrant analyses. 5 Unmasking the Moving Threat Conclusions: Compared to those without BPD, individuals with BPD appear to be at a greater risk for reckless driving, particularly with regard to moving and non-moving violations, driving while intoxicated, and having one’s driving privileges suspended. 6 Unmasking the Moving Threat Introduction Motor vehicle accidents (MVAs) are a leading cause of morbidity and mortality in the United States. The impact of these deaths on the years of potential life lost (YPLL) is significant. A recognized risk factor for causing vehicular collisions is reckless and aggressive driving (Asbridge, Smart, & Mann, 2006; Bjorklund, 2008; Mann et al., 2007; Tsuang, Boor, & Fleming, 1985). In these respects, both MVAs and reckless driving are identified as serious public health concerns (Asbridge et al., 2006). Understanding which individuals are disposed to reckless driving may lead to further insight on how to prevent this type of driving behavior as well as MVAs. While a number of characteristics of a reckless driver have been explored, specific psychiatric comorbidities disposing one towards reckless driving have not been fully examined. Borderline Personality Disorder (BPD), an Axis II psychiatric disorder, has been indicated as possibly contributing to reckless driving behavior because of these individuals’ proclivity towards impulsive, reactive, and volatile behavior. However, the prevalence of reckless driving among BPD patients has not been well researched. In order to further examine the scope of these public health concerns, we will explore the impact of MVAs, especially on young adults, and the way that dangerous driving behaviors such as aggressive and reckless driving results in MVAs. Next, we will examine the road as a venue for communication between drivers and how it is especially conducive to poor communication. Miscommunications often lead to anger and irritability, resulting in aggressive or reckless driving. We will further define and clarify the terms of aggressive driving, road rage, and reckless driving. Then, we will review the characteristics of BPD. Finally, by reviewing key recent literature on psychiatric disorders and driving, we will integrate the role of research on BPD and reckless driving in 7 Unmasking the Moving Threat relationship to understanding mental illness and MVAs. This is important for physicians in terms of counseling patients and facilitating public health interventions. Purpose Statement The purpose of this study is to determine whether individuals with BPD demonstrate a higher frequency of reckless driving than individuals without this disorder. We will examine this issue through a self-report survey that explores moving and non-moving traffic violations as well as automobile/motorcycle accidents, driving while intoxicated, vehicular manslaughter, leaving the scene of an accident, and having ever had one’s driving privileges suspended or been refused a driver’s license in any state among internal medicine outpatients in a primary care clinic. Review of the Literature Motor Vehicle Accidents (MVAs) According to the Centers for Disease Control and Prevention (CDC), from 1991 to 2000, transportation accidents were the third leading cause of death in the United States for people under the age of 65. Between those years, there was an annual average of 36,000 mortalities due to transportation accidents. Furthermore, motor vehicle accidents (MVAs) are the leading cause of death in people age 5-29 years (CDC, 2005). The National Highway Traffic Safety Administration (NHTSA) reports that young adult drivers ages 15 to 21 are five times more likely to be in fatal crashes than adults (The State Attorneys General, 2007). As the leading cause of death for young adults, MVAs are the single, greatest public health threat in that population stratum (Shope & Bingham, 2008). Researchers propose that young drivers are more likely to engage in reckless driving, making them more susceptible to MVAs. However, some contend that younger, novice drivers are involved in MVAs because of 8 Unmasking the Moving Threat inexperience in detecting and responding to hazards, controlling the vehicle, and integrating speed, rather than engaging in risky behaviors (Dumais et al., 2005). Regardless of causative factors, in terms of social and economic implications, deaths in this young population stratum are especially devastating. This can be measured through total years of potential life lost (YPLL), which is a measure of premature mortality. Individuals who die of fatalities from MVAs tend to be younger than those who die because of other causes. Therefore, the total of years of potential life lost is higher among MVAs (CDC, 2003). The high YPLL associated with MVAs demonstrates that MVAs result in the loss of productive, healthy individuals. As a relevant health and safety concern for this population, there has been a public health trend for greater public awareness regarding high-risk behaviors, such as reckless driving, among adolescents and young adults (Wagner, 2001). The cause of MVAs are complex and can be dissected in multiple ways such as environmental variables, characteristics of drivers, or current stress or life events of drivers while driving (Tsuang et al., 1985). Understanding the traits of drivers who are predisposed to aggressive and reckless driving is important. In support of this view, the American public perceives aggressive and reckless driving as a serious threat to safety (Neuman et al., 2003). In a telephone survey conducted by the NHTSA, more than 60 percent of drivers reported that unsafe driving is a major personal threat to themselves and passengers (NHTSA, 1999). In addition, approximately 75% of drivers believe that it is very important to do something about unsafe driving (NHTSA, 1999). Roads: Breeding Grounds for Miscommunication Driving provides a unique forum that brings individuals from diverse backgrounds into contact with each other as they attempt to negotiate the road (Roberts & Indermaur, 2008). 9 Unmasking the Moving Threat Purposeful communication in traffic is limited to drivers’ mutual desire to find their destination, thereby, forcing interaction. Communication between individuals in traffic tends to be ambiguous because individuals are relatively anonymous (Bjorklund, 2008). Interactions are brief and the venue for communication is restricted. These poor conditions for communication breed misunderstanding and misinterpretation among drivers, resulting in irritation and aggressive behavior. Regardless of how insulated one may feel in their vehicle, his/her actions affect other drivers and passengers, alike. An angry, irritated driver is an impaired driver. These emotions interfere with driving as it affects attention, perception, information processing, judgment, and motor skills, thus contributing to MVAs (Bjorklund, 2008). Studies show that emotional reactions while driving such as anger and fear consume our attention, diverting attention away from the primary task of driving (Britt & Garrity, 2006). Ironically, despite poor communication conditions, body language such as minor expressions of hostility is easily observable and may escalate to a more serious incident. An irritated driver who is more disposed to exhibiting aggressive behavior may also provoke other drivers, causing reactive irritation in them, as well. Like a domino effect, without much effort, there are suddenly two drivers who are angry, with both becoming hazards to others on the road. In support of this, several studies have demonstrated that the emotion of anger while driving is correlated with traffic violations and accidents (Britt & Garrity, 2006; Lajunen, Parker, & Stradling, 1998; Lawton, Parker, Manstead, & Stradling, 1997; Parker, Lajunen, & Stradling, 1998; Wells-Parker et al., 2002). Typically, attention has been attributed to the perpetrators of aggressive driving. However, the victims of aggressive driving are equally at risk for collisions. Mann and colleagues suggest that both victims and perpetrators are significant contributors to collisions and 10 Unmasking the Moving Threat have an increased risk of collisions (Mann et al., 2007). In comparing those who did not report road rage, those who were victimized, and those who perpetrated road rage, the odds of collision involvement is 157% higher overall, 87% higher among those who reported only victimization, and 83% who reported only perpetration (Mann et al., 2007). This demonstrates how aggression and frustration on the road influences all drivers regardless of status as perpetrator or victim. Aggressive Driving, Road Rage, and Reckless Driving: Dangerous Acts The terms aggressive driving, road rage, and reckless driving are terms that have been used interchangeably in popular media. According to the NHTSA, aggressive driving is situationally defined as “when individuals commit a combination of moving traffic offenses so as to endanger other persons or property” (Mann et al., 2007). Some examples of aggressive driving include exceeding the speed limit, following another vehicle too closely, changing lanes in an erratic or unsafe manner, excessive horn honking, improper signaling of lane changes, and failing to obey traffic control devices (i.e., stop signs, yield signs, traffic signals, railroad grade cross signals). The NHTSA further notes that running red lights is one of the most dangerous forms of aggressive driving (NHTSA, n.d.). As noted previously, other drivers fear aggressive drivers and believe that it is a personal threat (NHTSA, 1999). Road rage, a term popularized by the media since the mid-1990s, refers to a more severe, specific form of aggressive driving behavior (Mann et al., 2007; Roberts & Indermaur, 2008). Smart and Mann define road rage as a form of interpersonal aggression in which “a driver attempts to intimidate, threaten, or injure another driver, pedestrian, or passenger or to damage their vehicle in a traffic incident” (Smart & Mann, 2002, p. 761). The impact of aggressive driving on MVA morbidity and mortality is comparable to impaired driving due to alcohol use. Traffic safety authorities contend that one-third of all 11 Unmasking the Moving Threat personal injury MVAs, two-thirds of MVA fatalities, and half of all MVA crashes are due to aggressive driving (Martinez, 1997; Snyder, 1997). Aggressive drivers have also been found to have a higher degree of anxiety, hostility, competitiveness, and anger, especially at slow drivers and traffic obstructions (Galovski & Blanchard, 2002). The term “reckless driving” is more often used in the context of a moving traffic violation and has a meaning similar to aggressive driving. Reckless driving is commonly defined as “willful or wanton disregard for the safety of persons or property” ("Reckless driving," n.d.). It indicates that any driver who operates a vehicle in a dangerous fashion, without concern, or that may cause an accident, is at risk for a citation. While specific citable actions vary depending on location, some examples include excessive speeding, driving with malfunctioning brakes, driving with obstructed vision, or failing to use proper signals. In the United States, all 50 states have similar statutes that prohibit reckless driving. For example, the state of Ohio does not have a “reckless driving” clause but rather a “willful or wanton operation on street or highway” clause, which essentially covers the same violation ("Operation in willful or wanton disregard of the safety of persons or property"). Psychiatric Disorders and Driving While not completely clear, there appears to be an empirical association between some forms of mental illness and aggressive driving behaviors. For instance, Dumais and colleagues (2005) demonstrated that borderline personality disorder, antisocial personality disorder, and substance abuse are risk factors for young male deaths in MVAs. However, the amount of research on the psychiatric contributors to dangerous driving behaviors is notably limited. Specifically, there is no study that addresses borderline personality disorder (BPD) and hazardous driving. 12 Unmasking the Moving Threat Malta, Blanchard, and Freidenberg (2005) sampled 88 undergraduate students to compare the prevalence of psychiatric diagnoses and behavior problems in young adult drivers with reported high aggression versus those with low aggression. They hypothesized that aggressive drivers might have a greater prevalence of psychotic diagnosis and behavior problems (Malta, Blanchard, & Freidenberg, 2005). The researchers surveyed and interviewed a young, undergraduate student population who were mostly Caucasian and middle class. With the potential methodological limitations (i.e., small sample size, mean age of 19 years suggesting inexperienced drivers, difficulty in detecting criminal activity or diagnosing personality disorders because of young age), researchers found that aggressive drivers have higher rates of oppositional defiant disorder, alcohol and substance use disorders, and cluster B personality disorders (i.e., borderline, narcissistic, antisocial, histrionic personalities), conduct disorder, attention-deficit/hyperactivity disorder, and intermittent explosive disorder (Malta et al., 2005). Galovski, Blanchard, and Veazey (2002) examined intermittent explosive disorder (IED) and other psychiatric morbidities in convicted aggressive drivers. They sampled 30 treatment seeking aggressive drivers (20 court-mandated and 10 self-referred) and 30 ageand gendermatched controls to assess the psychiatric problems in identified aggressive drivers. They found that aggressive drivers have a greater prevalence of intermittent explosive disorder, alcohol and substance abuse (past and current), cluster B personality disorders (especially antisocial, borderline, and narcissistic personality disorders), and mood and anxiety disorders (Galovski & Blanchard, 2002). The limitations of this study included the lack of concealment of the status as an “aggressive driver” (i.e., clinical interviewers were aware of the status of the participant). In addition, this sample may reflect an extreme population because they were either convicted of aggressive driving or they believed that their driving was a problem, prompting self-referral. 13 Unmasking the Moving Threat Therefore, the sample characteristics make generalization to other types of populations problematic. A 1994 study observed women incarcerated for drunk driving, who were receiving treatment at an alcoholism treatment facility (Lex, Goldberg, Mendelson, Lawler, & Bower, 1994). The participants were interviewed for alcohol and substance abuse, somatoform disorders, and borderline and antisocial personality disorders, using the Structured Clinical Interview for the DSM-III. When excluding behaviors while intoxicated, they found that only 1 of the 33 women met the criteria for antisocial personality disorder. However, seven women met the criteria of antisocial personality disorder when including behavior while drinking. Furthermore, women with antisocial personality disorder and history of conduct disorder tended to a have a higher rate of BPD compared to those with only antisocial personality disorder. At the end of the study, the researchers concluded that the relationship between antisocial personality disorder, prodromal behaviors, and substance abuse was more complicated than expected. The limitations of this study include the small sample size and limited ability to generalize findings. In a 2005 study, Dumais and colleagues conducted a case-control study that compared the psychopathology of 61 young males involved in fatal MVAs to living males matched for age. Their hypotheses were two-fold. First, younger men would be more likely to be involved in MVAs due to inexperience in detecting and responding to hazards, controlling the vehicle, and integrating speed rather than risky behaviors. Secondly, drivers aged 25 to 34 would be more likely to have a higher prevalence of substance abuse/dependence and cluster B personality disorders compared to their younger counterparts (Dumais et al., 2005). The results demonstrated that cluster B personality disorders (borderline and antisocial personality disorders) 14 Unmasking the Moving Threat and substance abuse disorders were indeed more prevalent among those older than 26 years of age in MVAs fatalities. The limitations in the study include the small sample size, limited ability to generalize findings, and the recruitment of controls. Due to the criteria of matching cases to their controls, the small sample size possibly limited the power needed for more precise univariate analysis by age. Furthermore with such small sample size, there may be some unknown difference in psychopathology between accident and control subjects. The low participation rate (55.4%) also limits the generalizability. The control subjects were also originally collected for suicide research thus the driving status is not available for this group. The control subjects were matched for suicide research, which may lead to reduction in power, by the increased likelihood of higher levels of psychopathology than in a general public (Dumais et al., 2005). In a 2001 study, Fong and colleagues examined the relationship between road rage and four groups of patients recruited from a primary care setting: perpetrators of road rage (n = 16), victims of road rage (n = 38), both perpetrators and victims of road rage (n = 14), and controls (n = 63). With regard to borderline, histrionic, avoidant, and dependent personality disorders (i.e., the personality disorders under investigation), there were no between-group differences (Fong, Frost, & Stansfeld, 2001). To summarize, note that four out of five of the previous empirical endeavors suggest a possible association between BPD and hazardous driving, with the one exception being a study based on low statistical power (Dumais et al., 2005). However, these past studies have been limited in a number of ways. First, sample sizes have been consistently small (30-131 participants in the various samples). Also, the unique characteristics of several samples make the generalization of findings questionable (e.g., women incarcerated for drunken driving, court­ 15 Unmasking the Moving Threat referred individuals, males involved in motor vehicle fatalities, college students taking psychology classes). Similarly, one study limited participants to males only (Dumais et al., 2005) and one to females only (Lex et al., 1994). In addition, all past studies have operationalized reckless driving into one variable for study, such as convictions or road rage. Finally, one study did not tease out the specific Axis II disorders, but affirmed cluster B relationships in general. While all of these studies seem to suggest there may be a higher prevalence of reckless driving among patients with BPD, it is necessary to understand the entity of BPD and the potential explanations behind the link between BPD and reckless driving. Borderline Personality Disorder and Reckless Driving BPD is a complex personality dysfunction that is classified in the Diagnostic and Statistical Manuel of Mental Disorders, fourth edition, text revision (DSM-IV-TR) as a cluster B disorder (American Psychiatric Association, 2000). As a group, cluster B disorders are typified by dramatic, erratic, and emotional characteristics. As noted previously, other cluster B disorders include antisocial, narcissistic, and histrionic personality disorders (American Psychiatric Association, 2000). The prevalence of BPD in the general population is approximately 2% to 10% (American Psychiatric Association, 2000; Stone, 1986). Many mental health professionals believe that this disorder is actually increasing in prevalence (Sansone & Sansone, 2007). The DSM-IV-TR states that women are more often diagnosed with BPD than men (American Psychiatric Association, 2000). However, some researchers contend that this is due to sampling bias and that there are distinct symptom presentations based on gender (Sansone & Sansone, 2007; Skodol & Bender, 2003). With all personality disorders, there is no psychiatric treatment that provides an absolute cure. Therefore, symptoms tend to emerge in young adulthood and continue to persist into older 16 Unmasking the Moving Threat adulthood (Sansone & Sansone, 2007). However, the way the disorder manifests may differ depending on age. For example, Stevenson, Meares, and Comerford (2003) suggest less impulsivity is seen in elder BPD patients. As for clinical features, BPD is characterized by a transient intact social façade, chronic emotionally lability, impulsivity, unstable interpersonal relationships, and repetitive self-harm behavior. Indeed, the DSM-IV-TR (American Psychiatric Association, 2000) defines BPD as “a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts.” The diagnostic criteria involves any five of the nine criteria present for a significant amount of time: (1) frantic efforts to avoid real or imagined abandonment, (2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, (3) identity disturbance: markedly and persistently unstable self-image or sense of self, (4) impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving), (5) recurrent suicidal behavior, gestures, threats, or self-mutilating behavior such as cutting and interfering with the healing of scars, (6) affective instability due to a marked reactivity of mood, (7) chronic feelings of emptiness, worthlessness, (8) inappropriate anger or difficulty controlling anger, (9) transient, stress-related paranoid ideation, delusions or severe dissociative symptoms (American Psychiatric Association, 2000). In diagnostic support of the DSM sub-criterion of reckless driving, there are a number of other measures for BPD that includes this behavioral item. However, reckless driving is typically positioned in the midst of a general inquiry about other types of impulsivity (e.g., binge eating, sexual impulsivity). For example, the Diagnostic Interview for Personality Disorders 17 Unmasking the Moving Threat (Zanarini, 1983) contains the item, “[Have you] driven far too fast or while you were under the influence of alcohol or drugs?” This item is also present in the Zanarini Rating Scale for Borderline Personality Disorder (Zanarini & Frankenburg, 2001). The borderline personality scale of the Personality Disorder Examination queries, “Have you ever been stopped by the police for speeding or reckless driving (when you were not intoxicated with alcohol or drugs)?” (Loranger, 1988). The Diagnostic Interview for Borderlines-Revised asks respondents, “[Have you]...driven far too fast? How about while you were under the influence of alcohol or drugs?” (Zanarini, Gunderson, & Frankenburg, 1989). The borderline personality scale of the Personality Diagnostic Questionnaire-4 (PDQ-4) contains the item, “I have done things on impulse that can get me into trouble...such as...reckless driving” (Hyler, 1994). The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) asks, “How about driven recklessly?”(First, Spitzer, & Gibbon, 1995). Finally, the Self-Harm Inventory (SHI) contains the item, “Have you ever intentionally, or on purpose, driven recklessly?”(Sansone, Wiederman, & Sansone, 1998). These ubiquitous and consistent diagnostic queries strongly suggest that reckless driving is a potentially relevant clinical feature of BPD. While the DSM-IV-TR states that BPD patients may manifest their impulsivity difficulties through reckless driving (American Psychiatric Association, 2000), no study has precisely evaluated BPD and its relationship with reckless driving. The purpose of the following study is to examine the relationship between MVAs, reckless driving, and BPD.