Nation & World

PALO ALTO, Calif. — Before going to war, Susan Max loved tooling around Northern California in her maroon Mustang. A combat tour in Iraq changed all that.

Back in the States, Max, an Army reservist, found herself avoiding cramped parking lots without obvious escape routes. She straddled the middle line, as if bombs might be buried in the curbs. Gray sport-utility vehicles came to remind her of the unarmored vehicles she rode nervously through Baghdad in 2007, a record year for U.S. fatalities in Iraq.

"I used to like driving," Max, 63, said. "Now my family doesn't feel safe driving with me."

For thousands of combat veterans, driving has become an ordeal. Once their problems were viewed mainly as a form of road rage or thrill seeking. But increasingly, erratic driving by returning troops is being identified as a symptom of traumatic brain injury or post-traumatic stress disorder, PTSD — and coming under greater scrutiny amid concerns about higher accident rates among veterans.

The insurance industry has taken notice. In a review of driving records for tens of thousands of troops before and after deployments, USAA, a leading insurer of active-duty troops, discovered that auto accidents in which the service members were at fault went up by 13 percent after deployments. Accidents were particularly common in the six months after an overseas tour, according to the review, which covered the years 2007-2010.

The company is now working with researchers, the armed services and insurance industry groups to expand research and education on the issue. The Army says that fatal accidents — which rose early in the wars — have declined in recent years, in part from improved education. Still, 48 soldiers died in vehicle accidents while off duty last year, the highest total in three years, Army statistics show.

The Pentagon and Department of Veterans Affairs are also supporting several new studies into potential links between deployment and dangerously aggressive or overly defensive driving. The Veterans Affairs health center in Albany, N.Y., last year started a seven-session program to help veterans identify how war experiences might trigger negative reactions during driving. And researchers in Palo Alto are developing therapies — which they hope to translate into iPhone apps — for people with PTSD who are frequently angry or anxious behind the wheel.

"I can't talk with somebody who is a returned service member without them telling me about driving issues," said Erica Stern, an associate professor of occupational therapy at the University of Minnesota, who is conducting a national study for the Pentagon of driving problems in people with brain injuries or PTSD.

Though bad driving among combat veterans is not new — research has found that Vietnam and Persian Gulf war veterans were more likely to die in motor vehicle accidents than nondeployed veterans — experts say Iraq and Afghanistan veterans are unique, for one major reason: Their combat experiences were frequently defined by dangers on the road, particularly from roadside bombs.

"There is no accepted treatment for this," said Dr. Steven H. Woodward, a clinical psychologist with the Veterans Affairs Palo Alto Health Care System who is leading a study of potential therapies for veterans with PTSD-related driving problems. "It's a new phenomenon."

Experts note that driving problems are not always the result of the disorder. In some cases, returning troops may be reflexively applying driving techniques taught in Iraq during the height of the insurgency — for example, speeding up at intersections to avoid gunfire or scanning the roadside for danger instead of watching the road ahead.

In a study of Minnesota National Guard soldiers who returned from Iraq in 2007, Stern and fellow researchers found that a quarter reported driving through a stop sign and nearly a third said they had been told they drove dangerously in the months immediately following their tours. Both results were higher than the answers reported by National Guard cadets who had not been deployed.

Though driving problems seemed to decrease the longer the troops were home, they did not always vanish. Stern found that many Guard members remained anxious about certain roadway situations, including night driving or passing unexpected things.

"Those are things they associated with threats they saw in combat," she said.

Max, a grandmother of four, was deployed at the age of 60 to Iraq, where one of her jobs was to carry large sums of cash to Iraqi reconstruction projects outside fortified U.S. bases. She said she learned to be hypervigilant on those trips.

Upon returning to California, she struggled with PTSD and took time off from her nursing job. She also noticed feeling nervous for the first time in her life about driving — a major problem because she had to drive to visit patients.

"My whole driving behavior changed," she said. "I live in a state of anxiety when I'm driving."

Max recently participated in a clinical trial to develop and test therapies, such as deep breathing, that might overcome such anxieties. In a Pontiac Bonneville sedan outfitted with equipment to track the driver's visual focus, heart rate and breathing, as well as measure changes in the speed and direction of the car, the researchers take patients onto local highways and observe their reactions to traffic hazards, real and imagined.

On a recent spin through the hills of Palo Alto, Max drove while Woodward monitored her heart rate and breathing on a laptop in the back seat. In front, Marc Samuels, a driving rehabilitation specialist who offers one of the few programs for PTSD-related driving problems in the nation, directed her along a planned route, prepared to grab the wheel if anything went awry.

Max mostly drove fine, but was startled slightly when passing a construction site and then again when two cars momentarily boxed her in. Finally, when her stress level spiked in a small parking lot, Samuels told her to stop the car and regain her composure.

Max said that the clinics have made her more aware of the things that make her nervous, a first step to conquering them. But she says she does not expect to ever feel truly comfortable driving again and has no plans to replace her beloved Mustang, which she sold just before her deployment.

"Why get a hot car?" she said. "I'm not going to enjoy it."