The Interface substance misuse, whereas possible

Axis II disorders include borderline

and antisocial personality
disorders. Being aware of these
contributory factors to road rage
may improve general clinical
awareness of the nature and
treatment of perpetrators.

KEY WORDS
road rage, reckless driving, alcohol
abuse, drug abuse, borderline
personality

INTRODUCTION
Road rage is fairly well known to
most of us, either through direct
experience or news reports.
According to epidemiological data,
about one-third of the citizenry
report committing road rage at one
time or another. While most of
these incidents involve shouting
and gesturing at other drivers, a
small minority of encounters
escalate to direct and damaging
contact. Offenders are most often

ROAD RAGE: young and male. Contributory

factors to road rage may include
various environmental factors,
psychological factors, and Axis I
What’s Driving It? and II psychiatric disorders. In this
installment of The Interface, we
review these data.
by Randy A. Sansone, MD, and Lori A. Sansone, MD
ROAD RAGE: A WORKING
Psychiatry (Edgemont) 2010;7(7):14–18 DEFINITION
Road rage encompasses a variety
This ongoing column is dedicated to the challenging clinical interface between psychiatry and of aggressive behaviors by the
primary care—two fields that are inexorably linked. driver of a motor vehicle, which
seem well beyond the perceived
ABSTRACT young and male. A number of offense committed by the victim.
Up to one-third of community factors may contribute to road These behaviors range from
participants report being rage, including environmental shouting, screaming, and yelling at
perpetrators of road rage, factors (e.g., greater number of another driver to using a weapon,
indicating that various forms of miles driven per day, traffic including the vehicle, to incite
road rage are relatively density), nonspecific psychological damage to the victim or the victim’s
commonplace. However, only two factors (e.g., displaced aggression, vehicle. While road rage is an
percent or less of incidents attribution of blame to others), and intuitively recognized phenomenon
culminate in serious damage to bona fide Axis I and II disorders. for most of us, for research
persons or vehicles. The most The most common Axis I disorders purposes, a consistent definition of
common offenders appear to be appear to be related to alcohol and the term appears to be lacking.1 As

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a working definition for this article, examining temporal relationships, alcohol6,7 and substance misuse,
road rage may be described as a rates for road rage appear to be especially marijuana.7,21 Only one
constellation of thoughts, emotions, fairly stable.8 study9 has reported contradictory
and behaviors that occur in Gender and age profiles of findings in this regard, concluding
response to a perceived unjustified offenders. A number of studies that there was no association
provocation while driving.2 Road have examined the epidemiological between road rage and alcohol/drug
rage may also be defined as those characteristics of individuals who misuse. As for other forms of Axis I
driving behaviors that endanger or perpetrate road rage. In a study by psychiatric disturbance, Smart et
potentially endanger others and are Smart and Mann,9 individuals with al22 found that individuals with
accompanied by intentional acts of road rage were predominantly severe forms of road rage
aggression toward others, negative young (33.0 years of age on evidenced higher scores on the
emotions while driving, and risk- average) and male (96.6%)— General Health Questionnaire,
taking.3 Interestingly, one author4 findings that have been reported by which is a screening tool for several
has proposed that road rage be other investigators.10,11 Being a current psychiatric disorders (i.e.,
recognized as a bona fide predominantly male behavior, other anxiety, depression, somatic
psychological disorder and labeled investigators have found that road symptoms).
as “road rage disorder.” rage behavior may extend across all Associations with Axis II
age groups with the exception of disorders. Borderline
THE EPIDEMIOLOGY OF seniors.12 personality disorder. Borderline
ROAD RAGE personality disorder (BPD) is an
Prevalence of road rage. The CONTRIBUTORY FACTORS TO Axis II dysfunction that seems to
prevalence of road rage has ROAD RAGE harbor the relevant prerequisites
undergone relatively limited Environmental/ for road rage. This disorder is
examination, but data are available nonpsychological factors. A characterized by impulsivity (e.g.,
from several Canadian studies. number of environmental or reckless driving), intermittent
According to the findings of a nonpsychological factors may intense dysphoria, inappropriate
Canadian telephone survey of 1,395 contribute to road rage incidents. intense anger, difficulty controlling
individuals, 31.7 percent reported These include a greater number of anger, and transient paranoid
shouting or cursing at another miles driven per day and busy ideation.23 In addition, a number of
driver and 2.1 percent reported roads;10 carrying a firearm;11,13 and assessments for BPD have a sub-
threatening to hurt someone or traffic density.14,15 Other factors may criterion for reckless driving, a
damage a vehicle.5 In another include the context of anonymity as related behavior, which is typically
Canadian study of more than 2,500 well as aggressive environmental positioned in the midst of a general
adults, the 12-month prevalence stimuli in the form of billboards and inquiry about other types of
rate for admittedly shouting at building signs.16 impulsivity (e.g., binge eating,
another driver was 32 percent, General psychological sexual impulsivity). Assessments
threatening another driver 1.7 factors. A number of nonspecific with this criterion include the
percent, and attempting to damage psychological factors may Diagnostic Interview for Personality
or actually damaging another contribute to road rage, as well. Disorders,24 the Zanarini Rating
driver’s vehicle 1.0 percent.6 In a These include the tendency to Scale for Borderline Personality,
Canadian study of nearly 2,500 displace anger17 and attribute blame the borderline personality scale of
adults, researchers found that to others18 as well as unrewarding the Personality Disorder
frequent road ragers accounted for and stressful employment Examination,26 the Diagnostic
five percent of participants in their situations.15,19 Several authors15,16,20 Interview for Borderlines-Revised,27
sample.7 These data indicate that have also underscored the role of the borderline personality scale of
around one-third of community high levels of general stress as well the Personality Diagnostic
drivers have engaged in aggressive as the strains of modern urban Questionnaire-4 (PDQ-4),28 the
behavior toward another driver living.15 Structured Clinical Interview for
while on the road, but far fewer Associations with Axis I The Diagnostic and Statistical
(≤2%) actually report serious disorders. Studies indicate that Manual of Mental Disorders,
threatening behavior or damage to various Axis I disorders may Third Edition, Revised (DSM-III-
another person or vehicle. In contribute to road rage, particularly R) Personality Disorders (SCID-

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II),29 and the Self-Harm Inventory involved in fatal motor vehicle reckless driving and antisocial
(SHI).30 The ubiquitous and accidents, college students taking personality disorder. For example,
consistent diagnostic queries about psychology classes); and Lex et al31 encountered antisocial
vehicular recklessness strongly nonspecific Axis II assessments personality features in women who
suggest that reckless driving is a (i.e., Cluster B relationships). were incarcerated for drunken
potentially relevant clinical feature Only two previous studies35,36 driving—a form of reckless
of BPD. have examined the explicit behavior. Likewise, Galovski et al33
Several studies have examined relationship between road rage and encountered antisocial personality
the relationship between reckless BPD. In a 2001 controlled study, features among aggressive drivers
and/or aggressive driving, features Fong et al35 found no between- who were referred for court-
likely related to road rage, and group differences in prevalence ordered treatment. Finally, Malta et
BPD. In a 1994 study, Lex et al31 rates using the Clinical Interview al34 found that aggressive drivers
examined 33 incarcerated women Schedule-revised version for were more likely to harbor a
and found associations between personality disorder assessment Cluster B personality disorder,
antisocial behavior, BPD, and drunk (N=131). In the other study, which includes antisocial
driving. In a 2002 study, using the Sansone et al36 examined a large personality disorder.
SCID-II for diagnosis, Galovski et sample of internal medicine
al32 found that, compared with outpatients in a mid-sized, mid- CONCLUSIONS
nonaggressive drivers referred for western city. Using a consecutive, Approximately one-third of
treatment, court-referred cross-sectional sample, the authors drivers in the community
aggressive drivers were surveyed 419 individuals. The acknowledge various forms of road
significantly more likely to harbor prevalence of self-reported road rage, with the majority being young
an Axis II disorder, most often rage in this sample was 35.3 and male. Contributory variables to
antisocial personality or BPD (the percent, which seems to be road rage include environmental
total number of participants was consistent with the findings of variables, such as crowded roads
30). In a 2005 Canadian controlled Canadian researchers. According to and high levels of traffic density;
study, investigators found that BPD the borderline personality scale of psychological factors, such as
was significantly more prevalent the PDQ-4,28 BPD was significantly displaced anger, illogical
among young male drivers in fatal more prevalent among participants attributions, and high life stress;
accidents (N=122).33 In another with road rage than those without and bona fide psychiatric disorders.
2005 study, Malta et al34 examined road rage (24.8% versus 9.8%). Regarding psychiatric disorders,
students in college psychology These findings indicate that a those with road rage appear to
courses and found that, in substantial minority of individuals have high rates of alcohol and drug
comparison with nonaggressive with road rage have BPD. In difficulties; high general psychiatric
drivers (n=40), aggressive drivers addition, we found that compared symptomatology (anxiety and
(n=40) were more likely to to those without road rage, those depression) as measured by the
evidence Cluster B personality with road rage reported statistically General Health Questionnaire; rates
disorders as determined by the significantly higher numbers of of BPD that are four times that
SCID-II Screening Questionnaire. different types of driving citations, encountered in the general
To summarize these studies, note including moving and nonmoving population, given a community rate
that all four suggest a possible violations, as well as having had a of six percent;37 and possible
association between hazardous driver’s license suspended. These antisocial features. These findings
driving and BPD. However, the latter findings confirm that those suggest that individuals with road
potential limitations of these past with road rage tend to be reckless rage come from a variety of
studies include small sample sizes drivers. psychological substrates, all of
(no more than a total of 122 Antisocial personality which may culminate in an event
participants in the various disorder. While far more data exist that not only places the victim at
samples); relatively unique on the possible relationships risk, but also the perpetrator.
samples, making the generalization between aggressive driving, road
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Sci. 1994;708:49–58. 2001;36:277–286. AUTHOR AFFILIATIONS: Dr. R. Sansone is a

32. Galovski T, Blanchard EB, Veazey 36. Sansone RA, Lam C, Wiederman professor in the Departments of Psychiatry
C. Intermittent explosive disorder MW. Road rage: relationships with and Internal Medicine at Wright State
and other psychiatric comorbidity borderline personality and driving University School of Medicine in Dayton,
among court-referred and self- citations. Int J Psychiatry Clin Ohio, and Director of Psychiatry Education
referred aggressive drivers. Pract. 2010;40:21–29. at Kettering Medical Center in Kettering,
Behav Res Ther. 37. Grant BF, Chou SP, Goldstein RB, Ohio; Dr. L. Sansone is a family medicine
2002;40:641–651. et al. Prevalence, correlates, physician (government service) and
33. Dumais A, Lesage AD, Boyer R, et disability, and comorbidity of Medical Director of the Primary Care Clinic
al. Psychiatric risk factors for DSM-IV borderline personality at Wright-Patterson Air Force Base. The
motor vehicle fatalities in young disorder: results from the Wave 2 views and opinions expressed in this
men. Can J Psychiatry. National Epidemiologic Survey on column are those of the authors and do not
2005;50:838–844. Alcohol and Related Conditions. J reflect the official policy or the position of
34. Malta LS, Blanchard EB, Clin Psychiatry. the United States Air Force, Department of
Freidenberg BM. Psychiatric and 2008;69:533–545. Defense, or US government.
behavioral problems in aggressive
drivers. Behav Res Ther. FUNDING: There was no funding for the ADDRESS CORRESPONDENCE TO:
2005;43:1467–1484. development and writing of this article. Randy A. Sansone, MD, Sycamore Primary
35. Fong G, Frost D, Stansfeld S. Care Center, 2115 Leiter Road,
Road rage: a psychiatric FINANCIAL DISCLOSURES: The authors Miamisburg, OH 45342; Phone: (937) 384-
phenomenon? Soc Psychiatry have no conflicts of interest relevant to the 6850; Fax: (937) 384-6938; E-mail:
Psychiatr Epidemiol. content of this article. [Link]@[Link].

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