ARTICLE IN PRESS

Behaviour Research and Therapy 43 (2005) 1467–1484

www.elsevier.com/locate/brat

Psychiatric and behavioral problems in aggressive drivers

Loretta S. Malta, Edward B. Blanchard, Brian M. Freidenberg
Center for Stress and Anxiety Disorders, University at Albany, State University of New York, 1535 Western Avenue,
Albany, NY 12203, USA

Received 2 July 2004; accepted 29 November 2004

Abstract

Motor vehicle accidents (MVAs) are a leading cause of accidental death and injury, and aggressive
driving has been identified as a risk factor for MVAs. Assessing psychiatric and behavioral disturbances in
aggressive drivers is germane to the development of prevention and intervention programs for this
population. The present study compared the prevalence of psychiatric diagnoses and behavioral problems
in young adult drivers with self-reported high driving aggression to that of drivers with low driving
aggression. Aggressive drivers evidenced a significantly higher current and lifetime prevalence of
Oppositional Defiant Disorder, Alcohol and Substance Use Disorders, and Cluster B Personality
Disorders, and a significantly greater lifetime prevalence of Conduct Disorder, Attention-Deficit/
Hyperactivity Disorder, and Intermittent Explosive Disorder. Aggressive drivers also had a significantly
greater prevalence of self-reported problems with anger, as well as a greater family history of anger
problems and conflict. The findings suggest that prevention and intervention programs designed to reduce
aggressive driving may need to address the presence of psychiatric and behavioral problems that could
potentially complicate treatment or impede responses to treatment.
r 2005 Elsevier Ltd. All rights reserved.

Keywords: Aggressive driving; Driving anger; Aggression

Corresponding author. Weill Medical College of Cornell University, Program for Anxiety and Traumatic Stress
Studies, Weill Medical College, 525 East 68th Street, Box 200, NY 10021, USA.

0005-7967/$ - see front matter r 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2004.11.004
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1468 L.S. Malta et al. / Behaviour Research and Therapy 43 (2005) 1467–1484

Introduction

Motor vehicle accidents (MVAs) are the leading cause of accidental deaths and injuries in the
United States, and the leading cause of death of people aged 5–29 years old (US Department of
Transportation, 2002). International estimates of annual incidence range from 300,000 to 500,000
deaths and 10–15 million injuries worldwide (US Department of Transportation, 1999). The
health and economic impact of MVAs underscores the importance of investigating aggressive
driving, which has been implicated as a risk factor for MVAs (Blanchard, Barton & Malta, 2000;
Chliaoutakis et al., 2002; Dula & Ballard, 2003; Hemenway & Solnick, 1993; Martinez, 1997;
Snyder, 1997; US Department of Transportation, 1998; Wells-Parker et al., 2002).
Despite the existence of a large literature on reckless and/or aggressive driving that dates back
to the 1940s (e.g., Tillmann & Hobbs, 1949), few studies have examined psychiatric diagnoses in
aggressive drivers, and most of the research has focused on MVA risk rather than aggressive
driving. In one early study, Conger et al. (1959) administered structured psychiatric interviews to
10 high-MVA frequency drivers and 10 controls. Interviews were rated by multiple assessors
unaware of driving status (MVA risk vs. control). The authors reported a high degree of inter-
rater agreement, but no reliability statistics. They found that high-MVA risk drivers were
significantly more belligerent, hostile, and had poorer tension tolerance. The study is limited by
the small sample, but it is one of the few relatively well-controlled early studies.
Selzer and associates found an association between MVA involvement and psychopathology,
including paranoia, a history of violence, depression, and suicidal ideation, in three studies (Selzer
& Payne, 1962; Selzer, Payne, Westervelt, & Quinn, 1967; Selzer, Rogers, & Kern, 1968). The
external validity of the first two studies was limited by the sample of psychiatric inpatients. The
1968 study compared 96 general population drivers involved in fatal MVAs to age-, gender- and
residence-matched controls. However, assessors were aware of participants driving status’ (fatal
MVA vs. control), and as the authors did not specify the instrumentation or conduct reliability
checks, the reliability and possibly the validity of the findings are questionable. It is also possible
that the depression and suicidality were secondary to having been involved in a fatal MVA, rather
than precipitants. Moreover, evidence that suicidal ideation increases MVA risk has been mixed,
with some reports of a positive association (Shaw, 1965; MacDonald, 1964), but null findings as
well (Isherwood, Adams, & Hornblow, 1982; Tabachnick, Gressen, & Litman, 1973). As noted by
Tsuang, Boor, and Fleming (1985), studies that found significant results did not employ objective
assessment instruments, and those that did (Isherwood et al., Tabachnick et al.) found no link
between suicidality and increased MVA risk.
Comparisons of the driving records of psychiatric patients to those of the general public have
revealed significantly higher rates of MVAs in the patients (Crancer & Quiring, 1969; Eelkema,
Brosseau, & Koshnick, 1970; Waller, 1965), and the most consistent findings are of an increased
MVA risk in patients with personality disorders or alcoholism. The use of patient samples limits
the generalizability of the findings. However, the results have been replicated with general
population drivers in studies examining alcohol abuse (cf. Tsuang et al., 1985) and antisocial and
borderline symptoms (cf. McGuire, 1976).
Research has demonstrated a consistent association between Attention-Deficit/Hyperactivity
Disorder (ADHD) and increased risk of MVAs (Barkley, Guevremont, Anastopoulos, DuPaul, &
Shelton, 1993; Barkley, Murphy, & Kwasnik, 1996; Murphy & Barkley, 1996; Nada-Raja et al.,
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1997; Weiss & Hechtman, 1986; Weiss, Hechtman, Perlman, Hopkins, & Wener, 1979).
Compared to controls, adolescents and young adults with ADHD drive more poorly in a
simulator, are self- and parent-rated as poorer drivers, and have more MVAs, traffic citations,
and suspended/revoked licenses, despite having a knowledge of driving skills and experience
comparable to controls (Barkley et al., 1993, 1996; Murphy & Barkley, 1996; Nada-Raja et al.,
1997). Richards, Deffenbacher, and Rosen (2002) also found that college students with ADHD
symptoms endorsed higher levels of aggressive and risky driving, driving anger, and hostile and
aggressive expression of driving anger than controls.
Only two recent studies have assessed psychopathology in drivers specifically identified as
aggressive. Fong, Frost, and Stansfeld (2001) compared drivers who reported having engaged in
an episode of driving aggression within the past 5 years with those who denied this. Participants
completed a structured telephone interview that assessed symptoms of psychopathology, alcohol
problems, stressful life events, anger, hostility, aggression, and screened for personality disorders
(Borderline, Histrionic, Avoidant, and Dependent only). Fong and associates found that
aggressive drivers endorsed more symptoms of psychopathology and higher levels of anger and
aggression. No other group differences were significant. The study was limited by potential sample
selectionbias, as participants were volunteers recruited through a medical practice, as well as
potential rater bias, as assessors were aware of participants’ driving behaviors. The use of an
interview that assessed symptoms rather than psychiatric diagnoses and a screening measure for a
limited number of personality disorders is also less than ideal. In a better-controlled study,
Galovski, Blanchard, and Veazey (2002) used structured, in-person clinical interviews to assess 30
treatment seeking aggressive drivers (20 court-mandated and 10 self-referred), and 30 age- and
gender-matched controls. Aggressive drivers exhibited a significantly greater prevalence of
Intermittent Explosive Disorder, current and past alcohol/substance abuse, and Antisocial and
Borderline Personality Disorder, with trends for a greater prevalence of mood and anxiety
disorders and Narcissistic Personality Disorder. This study is limited in that, because the
evaluations of aggressive drivers were conducted in the context of a treatment study (Galovski &
Blanchard, 2002), raters were aware of participants’ status (aggressive vs. controls). The use of
treatment-seeking sample might also limit the generalizability of the findings, as treatment seekers,
(especially those mandated to treatment), might represent the most extreme aggressive drivers,
and thus could present with more psychopathology. However, the findings were consistent with
previous research in non-treatment seeking samples (cf. McGuire, 1976; Tsuang et al., 1985).
To summarize the psychiatric morbidity literature, the most consistent findings are that
antisocial and borderline psychopathology, alcohol/substance abuse, and ADHD are associated
with aggressive driving and MVA involvement. The evidence that internalizing psychopathology
(depression, anxiety) or other types of psychiatric problems contribute to MVA risk and/or
aggressive driving is less convincing.
Psychotherapeutic inventions for aggressive drivers have been recently developed (Deffenba-
cher, Huff, Lynch, Oetting, & Salvatore, 2000; Deffenbacher, Filetti, Lynch, Dahlen, & Oetting,
2002; Galovski & Blanchard, 2002; Larson, Rodriquez, & Galvan-Henkin, 1998; Parker,
Stradling, & Manstead, 1996). Although they have been shown to be of some benefit, treatment
efficacy might be enhanced through a better understanding of the range of psychiatric and
behavioral disturbances that may be present in aggressive drivers, as such problems could
potentially complicate treatment and limit its benefits. With that goal in mind, in the present study
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the prevalence of psychiatric disorders in a sample of non-treatment seeking, college student

aggressive drivers was assessed and compared to that of a matched sample of non-aggressive
drivers. Although the assessment of a non-treatment seeking sample would somewhat limit the
generalizability of the findings to treatment-seeking/mandated samples, it enabled us to address
the question of whether increased psychiatric problems were only characteristic of drivers whose
aggressive driving was severe enough to motivate them to seek treatment, or resulted in court-
mandated treatment. The findings could also potentially help inform the development of
aggressive driving prevention programs for young drivers.
In addition to psychiatric diagnoses, the prevalence of personal and familial problems with
anger, conflict, aggression, and legal difficulties was also assessed. The investigators hypothesized
that aggressive drivers would demonstrate a greater prevalence of personality Disorders (in
particular, Antisocial, Borderline, and Narcissistic of Cluster B Personality Disorders), alcohol
and substance abuse, Intermittent Explosive Disorder and anger and aggression problems,
ADHD, Oppositional Defiant Disorder, and a greater history of Conduct Disorder and legal
problems. As the findings for internalizing psychopathology have been less consistent than those
for externalizing psychopathology, the study provided an opportunity to assess internalizing
disorders in a non-treatment seeking sample. Aggressive Drivers were also hypothesized to have a
greater family history of psychiatric problems, anger and aggression problems, and family
conflict.

Method

Participants

Participants were undergraduates from University of Albany, recruited from the Psychology
Department Introductory Psychology research pool. Most participants were recruited through
their involvement in a separate study in which they completed self-report questionnaires
about driving and personality characteristics. The majority of students received course credit
for their participation. Eighteen survey study participants who had initially volunteered had
already completed the required number of credits by the time they were contacted. These
students were invited to participate for payment, and were paid $20.00 to complete the interview.1
Three participants who had not participated in the survey study volunteered after learning
about the study from other paid participants. These participants were paid $10.00 to complete
the questionnaire packet from the survey study and $20 to complete the interview (see
footnote 1).
1
As noted by one of the anonymous reviewers, it would have been preferable to control for unequal distribution of
paid and non-paid participants across the aggressive and non-aggressive driving groups. However, as per the request of
the University at Albany Institutional Review Board, all identifying information that could link names to data was
destroyed immediately upon completion of the interview. Thus, during subsequent data analyses it was not possible to
determine the number of participants per group who had received course credit or payment. Although it is possible that
paid participants somehow differed from those who received credit required for course completion, as noted we made
efforts to reduce the misrepresentation of driving behaviors and self-selection bias. It was also the impression of the
interviewer (LSM) that students were forthcoming in their responses regardless of the type of compensation.
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All participants were told that they had to be current, licensed drivers to participate. They were
further told that the investigators were interested in assessing psychological problems in drivers, but
explicitly informed that the investigators were interested in assessing drivers with and without
problems and that they need not have problems to participate, so as to reduce possible self-selection
bias. Students were not told about the additional criterion of low or high driving aggression, as
measured by scores on the Driver’s Stress Profile (DSP; Larson, 1996), so as to not influence their
report of driving behaviors. The inclusion criterion for low aggression drivers was a DPS score of
less than or equal to 21, (at or below
1 SD), and the inclusion criterion for high aggression
participants was a score of greater than or equal to 53 (at or above +1 SD). These values were
selected on the basis of DSP norms (mean and standard deviation of 37 and 16.4, respectively), for a
sample of 92 University at Albany undergraduates (Blanchard et al., 2000). The sample consisted of
two groups (44 low aggression, 44 high aggression) of drivers matched according to age and gender.

Instruments

Demographics
Participants completed a questionnaire in which they provided the following information:
gender, age, and race/ethnicity, parental education level (each parent), and estimated annual
family income. Parental education was specified on an 8-point scale ranging from (1) elementary
school level to (8) Ph.D./medical degree/law degree. Each parent’s level of education was averaged
to create a Parental Education score. Family income was specified on a 4-point scale ranging from
(1) 0–$25,000.00 to (4) $100,000.00 and above.

Driving instruments
Participants completed a driving information questionnaire in which they reported years of
driving experience, number of driving hours/week, number of serious and minor MVAs as a
driver, number of citations for moving and non-moving violations, frequency of driving when
intoxicated or high, and frequency of driving within 45 min of having consumed alcohol or a
substance. For these two items, frequency was rated on an 8-point scale ranging from (1) never to
(8) three or more days/week.
Participants also completed the Driver’s Stress Profile (DSP; Larson, 1996). The DPS is a 40-
item instrument on which the frequency of driving behaviors is endorsed on a 0–3 scale
(0 ¼ never; 3 ¼ always). Items are grouped into four subscales: Anger, Impatience, Competition,
and Punishing Behaviors. Examples of items are ‘‘get angry at tailgaters; get angry when cut off’’
(Anger subscale); ‘‘impatient at stoplights; impatient when car ahead slows down’’ (Impatience
subscale); ‘‘challenge other drivers; compete on the road’’ (Competition subscale); and ‘‘make
obscene gestures; block cars trying to pass’’ (Punishing subscale). Scores are computed by
summing items. Blanchard et al. (2000) found that the DSP exhibited good internal reliability
(Cronbach’s alphas of .93 for total score) and that DSP scores were significantly correlated with
the frequency of MVAs and driving anger.

Diagnostic interview instruments

The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First, Spitzer, Gibbon,
& Williams, 1996) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II,
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First, Spitzer, Gibbon, Williams & Benjamin, 1996) are structured interviews widely used in
clinical research. Adequate test–retest and inter-rater reliability was demonstrated for the versions
based on DSM-III-R (American Psychiatric Association, 1987) diagnostic criteria (First et al.,
1995; O’Boyle & Self, 1990; Williams et al., 1992). In the present study, a disorder was scored as
present if the participant met full DSM-IV (American Psychiatric Association, 1994) criteria. A
disorder was scored as ‘‘subclinical’’ if the participant met criteria for one symptom less than the
full criteria and exhibited significant role impairment or distress, or if full symptom criteria were
met, but the symptoms were only exerting a mild level of interference in overall functioning or
creating a mild level of overall subjective distress.
The Structured Clinical Interview for DSM-III-R Axis II Disorders Screening Questionnaire
(Spitzer, Williams, Gibbon & First, 1990) is a personality disorder self-report screening
questionnaire that was used in the present study to reduce the duration of the assessment
interview. Individuals were assessed for a personality disorder if they endorsed the minimum
number of symptoms needed to meet DSM-IV diagnostic criteria for a particular disorder.
Although the 1990 questionnaire is based on DSM-III-R criteria, the symptoms are identical to
those of the DSM-IV criteria. Items are endorsed dichotomously and duplicate those in the
clinical interview, e.g., ‘‘Have you avoided jobs or tasks that involved having to deal with a lot of
people?’’ (Avoidant); ‘‘Have you often done things impulsively?’’ (Borderline).
The Attention Deficit Hyperactivity Disorder (ADHD)/Oppositional Defiant Disorder (ODD)
Interviews (Barkley & Murphy, 1998) are semi-structured interviews based on the authors’
Childhood and Current Self-Report Symptom scale (1998), a retrospective measure of childhood
(ages 5–12 years old) ADHD and ODD as well as current (adult) symptomology. The reliability of
the retrospective symptom report was demonstrated by establishing independent collaboration of
childhood history of ADHD for 76% of adult respondents (Downey, Stelson, Pomerleau &
Biordani, 1997). There does not appear to be any available psychometric data on the interview
version of the self-report scales, but satisfactory inter-rater reliability (patient vs. observer report)
was established for the self-report scales (Downey et al., 1997). The interview assesses DSM-IV
symptoms of ADHD (e.g., easily distracted, talks excessively, difficulty remaining seated) and
ODD (e.g., loses temper, argumentative, defiant). Barkley and Murphy (1998) presented different
diagnostic scoring approaches for the interviews, including the categorical approach used in the
present study. Symptoms endorsed at a frequency of at least ‘‘often’’ were scored as clinically
significant, and counted toward the number of symptoms required to meet DSM-IV diagnostic
criteria. In the present study, ‘‘subclinical’’ diagnoses were assigned if participants met criteria for
one symptom less than the full criteria and exhibited significant impairment, or if they met full
symptom criteria but the symptoms were only exerting a mild level of interference in functioning.
The Intermittent Explosive Disorder (IED) Interview (Galovski, Malta, Blanchard, under
review; loosely adapted from McElroy, Soutullo, Beckman, Taylor, & Keck, 1998) is a semi-
structured interview designed to assess IED and episodes of impulsive (non-premeditated)
aggression in drivers who participated in the Aggressive Driving Treatment Program at the
University at Albany Center for Stress and Anxiety Disorders. The interview assesses whether
individuals have ever behaved ‘‘in an impulsive, aggressive manner that resulted in harm to
someone or destruction of property,’’ the number of lifetime episodes of impulsive aggression,
descriptions of three episodes of impulsive aggression, including the most recent, and the number
of years for which the person has had such episodes. Following DSM-IV criteria, episodes had to
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involve serious assault or significant property destruction (i.e., punching a hole in a wall,
smashing furniture). As the DSM-IV does not specify the minimum number of episodes or the
episode frequency required to meet criteria for IED, in the present study the following
additional rationally determined diagnostic criteria were employed to facilitate diagnostic
reliability.2 In order to meet full criteria for the disorder, an individual had to have a lifetime
frequency of at least three episodes of impulsive aggression and an episode frequency of greater
than once/year. A diagnosis of ‘‘subclinical’’ IED was given if: (1) the individual met
episode frequency criteria but exhibited milder forms of aggression (e.g., slamming doors
hard enough to break them, throwing smaller objects that broke); or (2) the individual met
all other criteria, but episode frequency was only once a year; or (3) the person only had
two lifetime episodes that occurred within the same year. Because of the intermittent nature
of episodes, the disorder was diagnosed as current if the individual had exhibited episodes within
the past year.
The Personal and Familial Psychiatric and Anger/Aggression History Interview (Malta, 2001) is
a semi-structured interview that was created for use in the Aggressive Driving Treatment Program
at the Center for Stress Anxiety Disorders, and it is similar to that employed by Galovski et al.
(2002). The interview included questions assessing participants’ psychiatric treatment history, and
whether they had any problems with anger, general legal problems, and legal problems due to
aggression. The interview also included questions on family psychiatric history, and whether any
family members had problems with anger or aggression. The interview also assessed level of
family conflict, which was operationalized as the frequency and intensity of arguments between
parents, between parent and the participant, and between the participant and siblings.
Participants were asked how often arguments occurred and how intense they were. Frequency
scores ranged from (0) never/rarely to (6) daily/near daily and intensity scores ranged from (0)
none/very mild irritability to (5) physical assault. A Family Conflict Score was created by
summing the frequency and intensity scores.

Procedures

Initial screen
Participants completed the demographics and driving questionnaire and the DSP either during
their participation in the questionnaire survey study, or prior to the interview if they had not
participated in the survey study. As described, potential participants were not given any
information about the study inclusion criteria (i.e., driving behaviors or DPS scores), and were
told only that someone would contact them regarding the study. A research assistant scored the

2
Intermittent Explosive Disorder is under-studied and the extant literature consists of only a small number of
descriptive studies that lack comparison control groups (Coccaro, Kavoussi, Berman, & Lish, 1998; Mattes & Fink,
1987; McElroy et al., 1998). There is little information about age of onset or the lifetime frequency of episodes and the
minimum number of episodes per year that would be observed in non-treatment seeking young adults with IED. Thus,
in the present study the criteria for minimum episode frequency and minimum number of lifetime episodes were based
on the authors’ reasoning that episodes had to be infrequent enough to enable differential diagnoses with Antisocial and
Borderline Personality Disorders, but frequent enough to cause significant problems for the individual.
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DSP to determine eligibility, and no information regarding the score or driving behavior was
revealed to the interviewer.

Diagnostic interview
Prior to commencing the interview, participants were asked to refrain from discussing their
driving habits or any issues concerning driving either during or after the interview. Participants
then completed the SCID-II Screening Questionnaire (Spitzer et al., 1990), and the interviewer
reviewed this instrument to determine the need to assess for personality disorders. Participants
were then interviewed for approximately 90–120 min, with instruments administered in the
following standard order: (1) Personal and Familial Psychiatric and Anger/Aggression History;
(2) IED Interview; (3) ODD Interview; (4) ADHD Interview; (5) SCID-I; (6) SCID-II. Upon
completion of the interview, participants who were apparently in need of treatment were referred
to local mental health resources.
All interviews were audio taped. A rater unaware of status (aggressive vs. non-aggressive driver)
performed the diagnostic reliability checks. The rater was an advanced graduate student with over
3 years of experience in the assessment of psychiatric disorders.

Data analyses
For all tests, an alpha level of .05 was adopted. Chi-square tests were used to compare
aggressive and non-aggressive drivers in the prevalence of psychiatric diagnoses. A low prevalence
of certain disorders, (and, consequently, expected cell counts of less than 5), also required the use
of 2  2 Fisher’s Exact tests. To perform these analyses, full and subclinical diagnoses were
collapsed into a single category for the following disorders: IED, ADHD, ODD, and Conduct
Disorder. Also due to low prevalence of individual disorders, the following categorical variables
were created by collapsing disorders together to increase expected cell counts: (1) Alcohol and
Substance Abuse or Dependence; (2) Mood Disorders; (3) Anxiety Disorders; and (4) Cluster A
(Paranoid, Schizoid, Schizotypal), Cluster B (Antisocial, Borderline, Narcissistic, Histrionic), and
Cluster C (Avoidant, Dependent, Obsessive-Compulsive) Personality Disorders (one category per
cluster). For all diagnoses, comparisons of both current and lifetime prevalence were performed.
Within the aggressive driving group, gender differences in the prevalence of disorders were also
examined using chi-square and Fisher’s Exact tests. Aggressive and non-aggressive drivers were
also compared on driving variables, family history variables, and self-reported anger, aggression,
legal problems, and treatment history using chi-square and Fisher’s exact tests for categorical
variables and MANOVAs for continuous variables. Continuous variables were examined for
kurtosis and skew prior to analyses and Mann–Whitney tests were employed for all non-normally
distributed variables.
For the inter-rater reliability checks, kappa reliability coefficients were calculated for a sample
composed of 20 aggressive drivers and 20 non-aggressive drivers. For the checks, all anxiety
disorders were collapsed into a single category, but coded to permit comparison of the specific
disorders. Similarly, personality disorders were collapsed into categories according to cluster
(Cluster A, B, and C), but coded to permit comparison of the specific disorder. For the mood
disorders, because Major Depressive Disorder was the most prevalent disorder and there were
only a few cases of other types of mood disorders, the reliability checks were performed for Major
Depressive Disorder only.
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Results

Demographic and driving characteristics of the sample

Sample demographic characteristics and statistics for all analyses are presented in Table 1. Both
aggressive and non-aggressive drivers were approximately 19 years old, predominantly Caucasian,
middle to upper middle class (family income of 50,000–$100,000.00/year), and their parents had
approximately 2 years of college education. There were no significant group differences in any of
the demographic variables.
Driving variables and statistics for all analyses are also shown in Table 1. Both groups had been
driving approximately 3 years, and drove an average of approximately 9 h/week, with no
significant group difference in either variable. Mann–Whitney tests revealed that aggressive
drivers ranked significantly higher than non-aggressive drivers in number of Serious MVAs,
Moving Violations, and Non-Moving Violations, as well as in the Frequency of Driving Drunk/
High and in the Frequency of Driving Under the Influence. There were no significant group
differences for number of Minor MVAs.

Reliability check

All inter-rater reliability kappa coefficients were significant, po:001; and all were at .80 or
above, with the exception of current diagnosis of ADHD, whose kappa was .73, po:001: For this

Table 1
Demographic and driving variables

Aggressive drivers N ¼ 44 Non-aggressive N ¼ 44 Statistic (df)

N (%) N (%)

Gender (female/male) 24/20 (54.55/45.45) 24/20 (54.55/45.45) —

Minority/non-minority 7/37 (15.91/84.09) 11/33 (25.00/75.00) w2(1) ¼ 0.290
Mean (SD) Mean (SD)
Age 19.14 (1.65) 19.34 (2.06) Mann–Whitney U ¼ 956.500
Parental education (years)a 4.86 (1.50) 5.25 (1.74) F(1,86) ¼ 1.245
Annual family incomeb 3.09 (0.83) 2.95 (0.94) F(1,86) ¼ 0.521
Driver’s stress profile 64.52 (11.04) 16.18 (4.57) —
Number of years driving 3.35 (1.64) 3.25 (2.12) Mann–Whitney U ¼ 840.000
Driving hours/week 9.37 (8.18) 8.58 (7.09) Mann–Whitney U ¼ 900.000
Serious MVAs 0.50 (0.79) 0.20 (0.46) Mann–Whitney U ¼ 783.000*
Minor MVAs 1.07 (1.21) 0.68 (0.96) Mann–Whitney U ¼ 787.500
Moving violations 1.23 (1.78) 0.50 (0.95) Mann–Whitney U ¼ 764.500*
Non-moving violations 1.70 (2.73) 1.09 (2.66) Mann–Whitney U ¼ 721.500*
Driving drunk or highc 3.27 (2.55) 1.61 (1.28) Mann–Whitney U ¼ 585.500***
Driving under the influencec 3.66 (2.63) 1.66 (1.26) Mann–Whitney U ¼ 527.000***

*po.05; **po.01; ***po.001.

a
8-pt. scale: 1 ¼ elementary school, 4 ¼ 1–2 years of college; 5 ¼ associate’s degree; 8 ¼ doctoral/MD
b
1 ¼ 0–$25,000; 2 ¼ $25,000–$50,000; 3 ¼ $50,000–$100,000; 4 ¼ greater than $100,000.
c
8-point scale: 1 ¼ never; 3 ¼ once every 2 months; 8 ¼ 3 or more times/week.
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diagnostic category, the raters only disagreed on diagnoses in two cases, and in both cases the
disagreement was in ratings of full vs. subclinical ADHD.

Psychiatric morbidity

The prevalence of diagnoses in aggressive drivers and non-aggressive drivers and statistics for
all analyses are shown in Table 2. Aggressive drivers had a significantly greater lifetime prevalence
of full or subclinical ADHD, and a trend for a greater current prevalence of full or subclinical
ADHD. Aggressive Drivers also had a significantly greater history of full or subclinical Conduct
Disorder, and a significantly greater current and lifetime prevalence of full or subclinical ODD.
Almost half of the sample of aggressive drivers (47.73%) had a history of ODD, vs. only 2% of
non-aggressive drivers. Aggressive Drivers did not have a significantly greater current prevalence
of IED, but did have a significantly greater lifetime prevalence of IED. There were no significant
differences in current or lifetime prevalence of Mood Disorders or Anxiety Disorders. However,
aggressive drivers had a significantly greater current and lifetime prevalence of Alcohol or
Substance Abuse or Dependence. They also had a significantly greater prevalence of Cluster B
Personality Disorders (Antisocial, Borderline, Narcissistic, Histrionic), with trends (p ¼ :055) for
a greater prevalence of Cluster A (Paranoid, Schizoid, Schizotypal) and Cluster C (Avoidant,
Dependent, Obsessive-Compulsive) Personality Disorders.

Table 2
Psychiatric diagnoses of aggressive and non-aggressive drivers

Aggressive N ¼ 44 Non-aggressive N ¼ 44 Statistic (df)

Current prevalence N (%)
ADHDa 5 (11.36) 0 Fisher’s exact p ¼ :055
ODDa 12 (27.27) 1 (2.27) w2 (1) ¼ 10.921**
IEDa 4 (9.09) 1 (2.27) Fisher’s exact p ¼ .360
Mood disorders 4 (9.09) 4 (9.09) Fisher’s exact p ¼ 1.000
Anxiety disorders 14 (31.82) 8 (18.18) w2 (2) ¼ 2.498
Alcohol/substance
Abuse/dependence 13 (29.55) 0 w2 (1) ¼ 15.253***
Cluster a personality disorders 5 (11.36) 0 Fisher’s exact p ¼ :055
Cluster b personality disorders 6 (13.64) 0 Fisher’s exact p ¼ :026
Cluster c personality disorders 5 (11.36) 0 Fisher’s exact p ¼ :055
Lifetime prevalence N (%)
ADHDa 10 (22.73) 1 (2.27) w2 (1) ¼ 8.416**
Conduct disordera 12 (27.27) 2 (4.55) w2 (1) ¼ 8.494**
ODDa 21 (47.73) 2 (4.55) w2 (1) ¼ 21.249***
IEDa 9 (20.45) 1 (2.27) w2 (1) ¼ 7.221**
Mood disorders 13 (29.55) 15 (34.09) w2 (2) ¼ 1.143
Anxiety disordersb 21 (47.73) 16 (36.36) Fisher’s exact p ¼ :388
Alcohol/substance Abuse/dependence 19 (43.18) 3 (6.82) w2 (1) ¼ 15.515***

*po.05; **po.01; ***po.001.

a
Full and subsyndromal diagnoses combined into one category for analyses.
b
Due to a small number of subclincal cases, subclinical and non diagnoses were combined into one category for
analysis to permit the use of a Fisher’s exact test, required because of low expected cell counts.
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Within the aggressive driving group, gender differences in psychiatric morbidity were also
tested. The only significant results were that female aggressive drivers had a greater current
prevalence of full or subclinical ODD, w2 ¼ 5:515; p ¼ :019; and current Anxiety Disorders, w2 ¼
4:781; p ¼ :029: Ten of 24 female aggressive drivers (41.67%) met criteria for current ODD, vs.
two of 20 male aggressive drivers (10%), and 11 of 24 female aggressive drivers (45.83%) met
criteria for current Anxiety Disorder, vs. three of 20 male aggressive drivers (15.00%). There was
a trend for females to have a greater prevalence of and Cluster C Personality Disorders (Avoidant,
Dependent, Obsessive-Compulsive), Fisher’s Exact p ¼ :053; with five of 24 (20.83%) diagnosed
with a Cluster C personality disorder vs. none of the male aggressive drivers. No other aggressive
driver gender comparisons were significant.

Self-reported behavior problems and treatment; family history variables

Self-reported problems with anger, aggression, legal problems not due to aggression (i.e.,
delinquency), and history of mental health treatment are shown in Table 3, along with statistics
for all analyses. Aggressive drivers were significantly more likely to endorse anger management
problems, with a trend towards greater endorsement of Legal Problems Not Due to Aggression,
(p ¼ :062). There were no significant group differences in Legal Problems Due to Aggression and
History of Mental Health Treatment.
Family history of problems with anger management, aggression, legal problems, Family
Conflict score, and number of familial psychiatric disorders are also shown in Table 3. A
MANOVA comparing group differences in Number of Family Members with Anger Manage-
ment Problems, Number of Family Members with Aggression Problems, Number of Family
Members with Legal Problems (not due to aggression), and Family Conflict score was significant,
Pillai’s Trace F(4,83) ¼ 70.934, p ¼ :004: Univariate analyses revealed that Aggressive Drivers
had a significantly greater number of Family Members with Anger Management Problems and a

Table 3
Self-reported behavior problems, treatment, and family history variables

Aggressive Non-aggressive Statistic (df)

N ¼ 44 N (%) N ¼ 44 N (%)

Self-reported anger problems 18 (40.91) 2 (4.55) w2 (1) ¼ 16.565***

Self-reported legal problems due to aggression 2 (4.55) 1 (2.27) Fisher’s Exact
p ¼ 1:000
Self-reported legal problems not due to aggression 9 (20.45) 3 (6.82) w2 (1) ¼ 3.474
Mental health treatment 19 (43.18) 17 (38.64) w2 (1) ¼ 0.188
Positive family history of psychiatric disorders 16 (36.36) 10 (22.73) w2 (1) ¼ 1.965
Mean (SD) Mean (SD)
# of Family members with anger problems 1.16 (1.35) 0.48 (0.70) F(1,86) ¼ 8.897**
# Of family members with aggression problems 0.59 (1.28) 0.45 (1.17) F(1,86) ¼ 0.272
# Of family members with legal problems 0.82 (1.33) 0.43 (0.93) F(1,86) ¼ 2.492
Family conflict score 11.66 (5.53) 7.82 (5.20) F(1,86) ¼ 11.271**
# Of familial psychiatric disorders 0.55 (0.79) 0.34 (0.68) F(1,86) ¼ 1.692

po:05;   po:01;   po:001:

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1478 L.S. Malta et al. / Behaviour Research and Therapy 43 (2005) 1467–1484

Table 4
Episodes of impulsive aggression

Aggressive drivers Non-aggressive drivers

N ¼ 44 N (%) N ¼ 44 N (%)

Throwing object 1 (2.27) 0

Forceful push 3 (6.82) 0
Property damage due to throwing 2 (4.55) 1 (2.27)
Property damage due to slamming 1 (2.27) 2 (4.55)
Property damage due to vandalism 1 (2.27) 0
Property damage due to punch/kick 8 (18.18) 2 (4.55)
Self-injury 3 (6.82) 1 (2.27)
Severe physical fights with siblings 0 1 (2.27)
Assault with object 2 (4.55) 0
Assault–punching 7 (15.91) 2 (4.55)
Assault–biting 1 (2.27) 0
Non-fatal choking 1 (2.27) 0
Mean (SD) number of lifetime impulsive aggression episodes 11.14 (29.24) 1.82 (9.05)

significantly higher Family Conflict Score. (See Table 3 for univariate test statistics.) No other
group differences were significant, and there were no significant group differences in Familial
Psychiatric History.
The number and types of lifetime impulsive aggressive episodes are shown in Table 4. The
sample described behaviors ranging from mild (throwing object, forceful push) to severe (assault,
non-fatal choking). A Mann–Whitney test found that aggressive drivers ranked significantly
higher than non-aggressive drivers in the number of lifetime impulsive aggressive episodes,
Mann–Whitney U ¼ 451:500; po:001:

Discussion

To summarize the findings, aggressive drivers ranked significantly higher than non-aggressive
drivers (on Mann–Whitney tests) in their number of serious MVAs, traffic violations, and in their
self-reported frequency of driving drunk, high, or under the influence of alcohol or drugs. As
hypothesized, aggressive drivers had a greater prevalence of current and lifetime ODD, as well as
Alcohol/Substance Abuse or Dependence. They also exhibited a significantly greater lifetime
prevalence of ADHD, Conduct Disorder, and IED, and a trend towards a greater current
prevalence of ADHD. In addition, aggressive drivers had a significantly greater prevalence of
Cluster B (Antisocial, Borderline, Narcissistic, Histrionic) personality disorders, with trends
towards a greater prevalence of Cluster A (Paranoid, Schizoid, Schizotypal) and C (Avoidant,
Dependent, Obsessive-Compulsive) Personality Disorders. It is also noteworthy that none of non-
aggressive drivers were diagnosed with a personality disorder. There were no significant group
differences in the prevalence of mood and anxiety disorders.
The results largely replicated those of Galovski et al. (2002) in their sample of treatment-seeking
self-referred and court-mandated drivers. Although the analyses did not replicate Galovski and
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associates’ finding of a greater current prevalence of IED, aggressive drivers had a significantly
greater prevalence of lifetime IED. It is possible that the null finding for current IED was due to
this sample being composed of non-treatment seeking college students, as the treatment-seeking/
mandated drivers in Galovski et al.’s study could be expected to have more severe problems with
aggression.
The prevalence of ODD and lifetime prevalence of Conduct Disorder have not previously been
examined in this population. The finding of a greater prevalence of these disorders is consistent
with robust findings of aggressive drivers’ problems with anger management (Deffenbacher,
Deffenbacher, Lynch, & Richards, 2003; Deffenbacher, Filetti, Richards, Lynch, & Oetting, 2003;
Malta et al., 2001) and antisociality (Galovski et al., 2002; MacMillan, 1975; McFarland, 1968;
McGuire, 1976). These findings have implications for group treatment modality of adolescent and
young adult aggressive drivers. Dishion, McCord, and Poulin (1999) found that conduct-
disordered adolescents in group treatment actually showed increases in problem behaviors. These
authors suggested that as adolescents are vulnerable to peer pressure, group treatment could
potentially have iatrogenic effects through peer reinforcement of maladaptive behaviors. The
findings of greater ODD, antisociality, and history of disordered conduct in aggressive drivers
suggest that aggressive driving interventions might be enhanced by the addition of treatment
components that address readiness and motivation for change such as motivational interviewing
(Miller, Zweben, DiClimente & Rychtarik, 1992). Increasing motivation for behavior change
could potentially help reduce peer reinforcement of reckless and aggressive driving that could
occur in group treatment.
The finding of only a trend towards a greater current prevalence of ADHD again might have
been due to the sample composition of college students, as individuals with ADHD who were able
to enroll in a university might be expected to have milder symptoms than those whose academic or
conduct problems resulted in failure to complete high school or achieve acceptance into a
university. However, it is noteworthy that the current ADHD prevalence of 11.36% in the
aggressive drivers was greater than double the general population estimated prevalence of
5% of school children (cf. DSM-IV, American Psychiatric Association, 1994). The finding
of a significantly greater lifetime prevalence of ADHD was consistent with studies that have found
an association between ADHD and reckless driving (Barkley et al., 1993, 1996; Murphy &
Barkley, 1996; Nada-Raja et al., 1997; Richards et al., 2002; Weiss & Hechtman, 1986; Weiss
et al., 1979).
Aggressive drivers did not show a significantly greater current or lifetime prevalence of mood
and anxiety disorders. Moreover, despite their greater prevalence of psychiatric disorders, they
were not more likely to have received mental health treatment. Interestingly, the within-group
comparison of male and female aggressive drivers revealed that female aggressive drivers had a
greater prevalence of current anxiety disorders and ODD, with a trend for a greater prevalence of
Cluster C (Avoidant, Dependent, Obsessive-Compulsive) personality disorders. The greater
prevalence of anxiety disorders may be due to the greater general prevalence of females with these
disorders (cf. DSM-IV, American Psychiatric Association, 1994). However, the finding of a
greater prevalence of ODD was consistent with Crick’s (1997) finding that youngsters who
engaged in forms of aggression that were not gender normative (i.e., physically aggressive girls
and relationally [indirectly] aggressive boys) had a greater number of behavioral problems
compared to peers who expressed gender normative forms of aggression.
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Aggressive drivers were more likely to endorse general problems with anger management, and
were ranked significantly higher (on Mann–Whitney tests) in their number of lifetime episodes of
impulsive aggression. Some of the episodes were surprisingly aggressive, and included choking
and biting. Aggressive drivers showed only a trend towards a greater prevalence of legal problems
not due to aggression, and they did not endorse a greater prevalence of legal problems with
aggression in themselves or their families, or have a greater number of family members with legal
problems not due to aggression. As previous research has demonstrated that aggressive and
reckless drivers were more likely to have had contact with the courts and social service agencies
than drivers who did not drive in an aggressive or reckless fashion (McFarland, 1968; MacMillan,
1975; Tillmann & Hobbs, 1949), the null findings in the present study may have been due to the
sample being composed of college students from relatively well-educated middle to upper middle
class families, rather than a general population sample with more variability in socio-economic
status and education level. The null finding might also be due to the combination of a low base
rate phenomenon (criminal activity) and a relatively small sample. Moreover, the sample was
relatively young (average age of 19) and it is possible that group differences in criminal activity
might emerge over time. Aggressive drivers did endorse a significantly greater level of family
conflict and had a significantly greater number of family members with anger management
problems. To the investigators’ knowledge, this is the first study to examine and demonstrate a
relationship between family conflict and familial anger problems and aggressive driving.
The results of the present study need to be interpreted in light of the study’s limitations. The
study relied upon self-report of driving behaviors, and the study would have been improved had
resources permitted the direct observation of driving. However, Panek et al. (1978) found that
self-reported MVA information was as reliable as information from police reports, insurance
companies, and state agencies. Moreover, participants were told that all information would
remain anonymous (i.e., no identifying features were recorded), and this hopefully reduced
responses based on social desirability (Joinson, 1999). It is also unlikely that the same individuals
who described fairly severe aggressive episodes (biting, choking, assault) in a face-to-face
interview would under-report their aggressive driving on an anonymous questionnaire.
The study is also limited in its use of a young, college student sample that was predominately
Caucasian and middle class, and therefore some of the results may not generalize to drivers with
disparate demographic characteristics. However, as research has consistently implicated young
drivers as engaging in the most aggressive and reckless driving (e.g., Evans, 2002; Jonah, 1986;
Williams, 2003), drivers in this age group are especially at risk and therefore worthy of study.
Moreover, the results were consistent with other psychiatric morbidity findings with a variety of
samples (e.g., Barkley et al., 1993, 1996; Fong et al., 2001; Galovski et al., 2002; Murphy & Barkley,
1996; Galovski et al., 2002; see also McGuire, 1976; Tsuang et al., 1985). As we have discussed, the
use of a non-treatment seeking sample also limits generalizability to treatment seeking/treatment
mandated samples, which may differ from the current sample along many dimensions. However, as
noted, our findings were similar to those of Galovski et al. (2002), who assessed a treatment seeking
(self-referred and court-mandated) sample. Moreover, our findings suggest that the presence of
serious psychiatric problems does not appear to be restricted to drivers whose aggressive driving is
severe enough to motivate them to seek treatment or to result in court mandated treatment.
Despite the limitations of the present research, to the investigators’ knowledge, this is the first
study of the psychiatric morbidity of aggressive drivers that employed structured clinical interviews
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and controlled for potential rater bias and driving behavior selection bias. To reiterate the main
findings, aggressive drivers had a significantly greater current and lifetime prevalence of externalizing
disorders and alcohol and substance use disorders, as well as a greater self-reported prevalence of
impulsive aggressive episodes, anger problems, family conflict, and familial anger problems.
The implications of the findings are threefold. The sample was composed of young drivers,
many of whom had recently obtained licenses, and as noted, MVAs are the leading cause of death
of people in this age group (US Department of Transportation, 2002). Typically, drivers are
referred for treatment after committing multiple violations, or felonies such as personal/vehicular
assault or vehicular manslaughter. As ‘‘an ounce of prevention is worth a pound of cure,’’ the
results of this study suggest that parents, schools, and driver education programs should be
mindful of the presence of behavioral disorders that are associated with aggressive driving, and
should perhaps refer at-risk drivers for treatment prior to licensure. Such drivers may also require
interventions that address readiness and motivation to change.
The second implication concerns clinical research. Taken together, the results of this study and
those of Galovski et al. (2002) suggest that clinical scientists who develop treatments for
aggressive drivers should consider the range of psychiatric disorders and behavioral problems
with which they may present. Treatment development could potentially be enhanced by research
examining the effect of chronic externalizing disorders and problems with drug or alcohol use on
short-term treatment outcomes, and both group and individual treatment effectiveness could
potentially be improved through the addition of components that address readiness and
motivation for change.
The final potential implication concerns clinicians. Certain psychiatric disorders are associated
with known fatality risks, such as elevated suicidality in individuals with psychotic and mood
disorders, alcohol and substance-related disorders, and pathological gambling (cf. DSM-IV,
American Psychiatric Association, 1994). Through its contributions to MVAs (Blanchard et al.,
2000; Chliaoutakis et al., 2002; Dula & Ballard, 2003; Hemenway & Solnick, 1993; Martinez,
1997; Snyder, 1997; US Department of Transportation, 1998; Wells-Parker et al., 2002),
aggressive driving constitutes a serious health and fatality risk, and the present study
demonstrated that aggressive driving was associated with a greater prevalence of chronic
externalizing disorders and abuse of alcohol and drugs. The results of this study and those of
Galovski et al. (2002) suggest that clinicians who treat individuals with these disorders may need
to assess whether their clients are driving aggressively, and either address this potentially life-
threatening behavior in treatment, or refer clients to specialized interventions.
Although aggressive driving is not a new societal problem, over the past decade society has
become more aware of it. Understanding the characteristics of aggressive drivers is germane to the
development and implementation of efficacious prevention and intervention programs, and future
research should continue to investigate the range of psychiatric and behavioral problems in
diverse samples of aggressive drivers.

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