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Auteurs

Introduction 

Subject

            A 42-year-old woman attended the Psychiatry Department for driving phobia. She was married with two children and worked as a driving instructor. She had an unremarkable medical history and was not taking any medication; she reported having suffered from depression three years previously.

Her fear of driving had developed over a period of three years. This fear began when, during a parking manoeuvre during a driving lesson with a pupil, a bus crashed violently into the back of her car. Both the patient and her pupil were slightly injured, but with no cranial injury or loss of consciousness. A neurological assessment carried out at the hospital at the time was normal. After two weeks of sick leave, the patient returned to work but was unable to carry out her normal duties. She found it difficult to get into her own car and drive to work or do the shopping, and began increasingly to avoid driving. She nonetheless decided to go on holiday with her son three months later, and took the motorway. She found it difficult to drive the first 100 km and suffered a panic attack in which she was afraid of swallowing her tongue and causing a serious accident. With difficulty, she made her way to a rest area, in a state of extreme stress and culpability, and realised that she could no longer drive. She phoned friends, who came to collect her and her son. During the following three years, she systematically avoided driving on motorways and felt able to drive only within a very limited radius of her home, in an area that she knew perfectly, and only in situations in which driving was absolutely necessary. In all cases, driving was associated with a very high level of anxiety. She did not suffer from flashbacks of the initial accident, ruling out a diagnosis of post-traumatic stress disorder, and the panic attacks only occurred in phobogenic situations, with no real anticipatory anxiety outside such situations, ruling out a diagnosis of panic disorder.

Evaluations

The principal diagnosis of agoraphobia with panic attacks, associated with the particular situation of driving, was made on the basis of DSM-IV criteria (APA,1994)  using the phobias section of the Anxiety Disorder Interview Schedule for DSM-IV (ADIS-IV) of Brown et al. (1994). The Mini International Neuropsychiatric Interview (Lecrubier et al., 1997) identified current comorbidity with a major depressive episode (independent of the anxiety problem), and past morbidity with a major depressive episode. None of the other diagnoses considered were retained: they included PTSD, schizophrenia and other psychotic disorders, chronic delirium, dementia, alcohol and substance abuse and dependence.

A series of scales assessing symptoms was completed before treatment, and then one week and one month after treatment. The Hospital Anxiety and Depression Scale (HAD) of Zigmond and Snaith (1983), the Phobia, Panic, Diffuse Anxiety  scale (PPA) of Cottraux (1993), the Fear Questionnaire (FQ) of Marks and Mathews (1979), the State-Trait Anxiety Index (STAI) of Spielberger (1983), the Perceived Stress Scale (PSS) of Cohen et al (1983), the Clinical Global Impression Scale (CGI) of Guy, (1976) measuring the severity of the problem, and a Behavioural Avoidance Test (BAT) with a three-point scale : no avoidance = 0, moderate avoidance = 1 and total avoidance = 2. The evaluation scales were completed, before and after treatment, by a clinician other than the therapist responsible for treatment.

Therapy 

The therapist was a senior clinical psychologist with full training in the use of EMDR (level II) who had been using this technique for three years under regular supervision.

Three to 12 sessions, each lasting 60 to 90 minutes, were initially planned, to be adjusted according to the results obtained. The first two sessions were devoted to collecting the patient's history, preparing the patient (teaching the coping skills/self control) and explaining the various steps in the protocol. The protocol used is conformed to the recommendations for the treatment of phobias published by Shapiro (1995) and De Jongh et al. (1999). A three-level approach was used, integrating the past, the present and the future (De Jongh and Ten Broeke, 1998).

Desensitisation methods were applied from the third session onwards, after the patient had begun training in self-control techniques (relaxation, construction of a "safe place", setting up a "stop" signal) to enable her to confront her fear, and after having determined the target for reprocessing the following six aspects: 1) all associated events contributing to the phobia, 2) the first time she had experienced this fear, 3) the most disturbing experiences, 4) the most recent experience in which she had felt this fear, 5) the associated stimuli and 6) physical signs and other signs of fear, including hyperventilation. After three sessions of EMDR (desensitisation and reprocessing), the patient had made good progress, making it possible to move on to the mental projection, in time and space, of a "video" of events in particular situations and the systematic treatment of the emerging disturbance. The treatment ended, after four sessions of EMDR, with a real confrontation with the phobogenic situation.

Detailed description of the EMDR

Session 1

The patient selected the scene of the accident as the target for the initial desensitisation by ocular movements (OM), because she considered this to be the starting point of her driving phobia.. The negative cognition (NC) of the patient focused on a theme of responsibility/guilt: "It's my fault, I'm guilty." The patient wished to replace this NC with the following positive cognition (PC) :  "I can be myself and make mistakes. I did what I could.". The emotion that she felt at that moment was fear. She evaluated her stress on the Subjective Unit of Distress (SUD) scale, with a the maximum score of 10. She compared this stress to a weight on her chest that prevented her from breathing normally. At this point in the protocol, densensitisation could begin. Since the patient was able to express ideas of guilt concerning the accident, the fear of dying, her anguish at the thought of panicking and causing a fatal accident. At this point, cognitive interweave was used for cognitive reconstruction, making it possible to distract the patient from this vicious circle of reasoning and enabling her to reflect on adaptive information and to connect this new information to her dysfunctional belief. In this case, it was the patient who provided an important piece of information that she had ignored in the preceding years. She remembered that the bus driver had come to help them and had asked the patient and her passenger to forgive her because she had not seen them. At this point, the therapist was able to help the patient to reactivate her information processing system to get over her feelings of guilt and responsibility. He asked appropriate questions to obtain positive responses, in association with OM, with the aim of making the patient confront the dysfunctional information in her memory with these new responses. In this case, he asked the patient if, as a professional driver, the person who had hit the car from behind would have come to apologise and to say that she hadn't seen them if she had done nothing wrong? The answer to this question is clearly "no", as the patient was able to recognise with this "decentring" approach. Finally, the therapist asked the patient if she had been held responsible by her insurance company or by her employer. The response to this question was also "no" because her employer had been entirely reimbursed for the damage caused to the car, without penalty. The patient gradually became more serene until eventually, she had no more to say, even when returning for an instant to the target.

Session 2

The EMDR/Phobia protocol recommends treating the most disturbing incidents next.. The situation can be summed up as follows: the patient decides to go on holiday with her son. During the journey, she suddenly has a panic attack in which she feels that she is in imminent danger of swallowing her tongue and causing a serious accident. During the desensitisation phase, it became clear that the patient's mother had frequently had epileptic seizures and that the patient had been living for many years with the secret conviction that she would be afflicted. She believed that this disease was inherited and that she would eventually have a seizure. These developments provided the required opportunity to work on this belief. Cognitive interweave made it possible for the patient to challenge this erroneous belief that had resulted in her conviction that she would inevitably inherit epilepsy and then to modify her beliefs, on the basis of pedagogical and physiological information concerning the probability of her spontaneously swallowing her tongue. From this moment onwards, the patient's stress evaluations (SUD) continually decreased, eventually reaching 0.

Sessions 3 and 4

The third session was devoted to the most recent experience in which she had felt fear of driving. At the end of this session, the patient expressed a desire to try to drive on the motorway accompanied by a friend before the next session. She was firmly dissuaded from doing so as this possibility could only be envisaged after a session entirely dedicated to preparation for a confrontation with the phobogenic situation and the associated conditional stimuli. The fourth session was therefore dedicated to the establishment of future orientations, moving towards fear-free action and the planning of appropriate measures. This stage in the therapy combined mental imaging and the PC, with OM used during VOC strengthening (De Jongh et al, 2002). In addition, the chosen target involved the positive mental projection, in time and space, from start to finish, of a "video" consisting of a motorway driving situation. At the end of the session, the patient appeared to be mentally prepared to confront the target situation of the treatment in vivo, and committed herself to doing so with one of her friends who was also a driving instructor. The patient arrived at the last consultation declaring that she had managed to drive on the motorway, accompanied by her friend the day after the previous consultation, without panicking and without feeling that she was in immediate danger of swallowing her tongue. On several occasions during the week, she had managed to drive her car alone and had rediscovered the sensations that she had lost since the accident.

Psychometric results

The results obtained after four EMDR sessions (table I) show a decrease in scores for all the evaluation scales, and particularly those for anxiety and phobia. In terms of DSM-IV anxiety disorder diagnoses (ADIS-R), the symptomatic criteria for driving phobia and agoraphobia with panic attacks were no longer present after treatment. In terms of comorbidity, we noted a slight improvement in the patient's mood.

                             Table I. Results of clinical scales measures, before and after treatment.

Discussion

Many authors remarked that subjective evaluations like SUDS and VOC used in EMDR might be biased by demand characteristics (Herbert & Mueser, 1992 ; Lohr et al1992). In this study we, focused on a result based on the treatment of avoidance behaviour. We used various scales, some completed by the patient and some by a clinician, and this multiple evaluation meets the quality criteria proposed in a previous study for demonstrating the efficacy of EMDR (Maxfield and Hyer, 2002).

The main advantage of EMDR for the treatment of anxiety problems of traumatic origin is that this method is easier to perform that the in vivo methods used in classical CBT, particularly in cases when the phobia concerns flying or electrical storms (Shapiro 1995 ; De Jongh et al, 1999). It is becoming increasingly clear that traumatic aetiology is a major prognostic factor for response to treatment, as in the cases that we have previously described (De Jongh et al, 1998). The patient reported here presented both a prior traumatic event and a real problem of secondary agoraphobia associated with panic attacks, which does not seem rare in this disorder (Ehlers et al, 1994; Raffray and Pélissolo, 2006). However, this patient experienced no reviviscence syndrom and so was not suffering from PTSD. The existence of a depressive episode, independent of the accident and the phobia and secondary to familial and conjugal factors, did not have a deleterious effect on treatment.

EMDR therapy brought to light a basic tendency of the patient to display anxious anticipation, an irrational fear of epilepsy and/or panic attacks in which she was afraid she might swallow her tongue and die; the therapy made it possible to modify these beliefs. We were able to treat the patient's erroneous beliefs rapidly, by the cognitive interweave method, with the use of ocular movements, as in the rest of the method, making it possible to obtain a therapeutic effect more rapidly than with the classical cognitive restructuring methods as noted by Montgomery and Aylon (1994). In this study, EMDR itself requires four sessions in addition to the consultations for evaluation and preparation for therapy. Previous studies on the subject have reported some therapeutic results in a single session (Muris et al 1997), but the method recommended by Shapiro (1995) initially includes 12 sessions. Our experience shows that a smaller number of sessions may be sufficient, provided that the duration of these sessions is not limited, particularly for the cognitive interweave work, which must be given all the time it requires once it has begun, and may take one and a half or even two hours. Nevertheless in the state of our knowledge, several authors have remarqued that the role of MO is not seems so clear and founded  (Dunn et al 1996 ; Devilly et al 1998 ; Pitman et al 1996), and no more the EMDR’s effectiveness based on its cognitive element (Cusack & Spates, 1999). If the cognitive reprocessing play some role in EMDR, this process already exist in cognitive techniques and can be arguably efficient in themselves (Sikes & Sikes, 2003).

In conclusion, this clinical case demonstrates the value of using EMDR for the treatment of complex phobias, such as driving phobia taking the form of agoraphobia with panic attacks and a traumatic component. Accordance with the empirical support of its indication in PTSD, EMDR may be efficient in the treatment of symptoms clearly related to a trauma situation, (De Jongh & Ten Broeke, 1998). Further controlled studies are now required to confirm this efficacy. Cognitive work seems to play a particularly important role in this type of management (De Jongh et al, 2002), and also merits further investigation.

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