Driving anxiety and anxiolytics while driving: Their impacts on behaviour and cognition behind the wheel

The study addresses how anxiety relates to driving behavior and cognition, and how anxiolytic medications influence driving performance. Driving anxiety—fear of driving-related stimuli perceived as threatening—varies in intensity and consequences, from situational avoidance (e.g., highways, bad weather) to complete driving avoidance, with impacts on mental health, quality of life, and work. Anxiety interacts with cognitive processes critical for driving (sustained/selective attention, inhibition, error sensitivity), potentially degrading attentional control and perceptual-motor performance. Given these interactions, the review poses two questions: (1) What cognitive and behavioral impacts does driving anxiety have while driving? (2) What are the effects of legal anxiolytics on driver cognition and performance? The purpose is to synthesize evidence, identify gaps, and guide countermeasures and policy.

Early research on driving anxiety often focused on post-traumatic contexts (e.g., crash-related PTSD), but anxiety can arise without crashes (e.g., panic attacks, criticism from passengers/instructors). Anxiety is characterized by heightened arousal, negative affect, attentional biases toward threat, increased sensitivity to errors, and impaired inhibitory control. Some evidence suggests faster responses to hazards, but disengagement from threat and distractor inhibition are poorer. Anxiety can degrade perceptual-motor performance in stressful contexts. Epidemiological studies suggest psychotropic medications, including anxiolytics, can elevate crash risk, though causality is difficult to infer retrospectively. These literatures motivate a systematic synthesis of (a) driving anxiety’s cognitive/behavioral effects and (b) anxiolytics’ experimental impacts on driving performance.

Systematic review conducted per PRISMA. PICO framework guided data extraction, especially for the legal drugs question. Databases: Scopus, Web of Science, TRID, PubMed. Search (08/06/2021) combined concepts of driving, anxiety, and cognition using truncated keywords (e.g., driv*, anxi*, cognit*), excluding irrelevant fields when possible. Eligibility: Included studies addressing (1) influence of driving anxiety on cognitive or behavioral processes (beyond subjective feeling), with explicit driving anxiety measurement; (2) effects of legal anti-anxiety medications on any driving activity. Exclusions for question 1: specific populations with confounding cognitive/emotional characteristics (e.g., ADHD, GAD, chronic stress, depression), neurological/motor disorders, older adults with age-related factors, severe PTSD with cranial trauma or war-related driving, studies on anger/aggression without explicit driving anxiety, and non-driving anxieties (e.g., range anxiety, public transport phobia). Publication years 1990–2021; English only; included research articles, chapters, brief reports, conference proceedings; excluded books, reviews/meta-analyses, theses, editorials, patents, authorless works. Screening and selection were independently performed by two reviewers; Cohen’s kappa for full-text screening κ = 0.853, with third-reviewer adjudication for 7 articles. Records identified: 16,273; total included: 29 (18 for driving anxiety effects; 11 for legal drugs/anxiolytics effects). Data from included studies encompassed populations, interventions (anxiety measures or drug types/doses), comparators, outcomes, and driving tasks (simulator or on-road).

• Overall corpus: 29 studies retained; 18 on driving anxiety; 11 on anxiolytics and driving.
• Driving anxiety effects (n = 18):
  • Study types: mostly surveys/focus groups (n = 17); one on-road study.
  • Measurements: Common instruments included DBQ, DBS, DCQ, DRAS, DSQ; driving anxiety often measured by one-item scales or DBS/DCQ/DSQ subscales.
  • Behavioral impacts: consistent associations with exaggerated caution and anxiety-related performance deficits (more lapses/errors), sometimes hostile/aggressive behaviors; effects on safety appear moderated by personality. The most salient effect is avoidance of specific contexts (traffic, adverse weather, certain road types) or total avoidance; avoidance often higher among women. The single on-road study reported impaired performance per expert ratings in anxious drivers.
  • Cognitive processes: scarcely examined; objective in-situ measures largely absent.
• Anxiolytics and driving (n = 11; predominantly European studies; small N per experiment):
  • Drugs: Primarily benzodiazepines (alprazolam, lorazepam, diazepam); some comparisons with hypnotics or alternative agents (e.g., tandospirone, captodiamine). Doses generally therapeutic/moderate.
  • Driving tasks: Standard highway driving tests (~100–200 km), simulator tasks (lane tracking, car-following, braking), and closed-circuit maneuvers; some surveys.
  • Behavioral outcomes: Increased standard deviation of lateral position (SDLP) after benzodiazepines observed in multiple studies, reaching clinically relevant impairment in some (e.g., hypnotics users in van der Sluiszen et al., 2019). Detrimental effects on lateral/longitudinal control and increased weaving; impaired harsh-braking with diazepam; some agents (e.g., tandospirone, captodiamine) showed less impairment.
  • Cognitive outcomes: Slower reaction times and reduced alertness reported in several studies; divided attention and tracking impairments noted. One study found shorter RT to auditory stimuli with captodiamine versus lorazepam.
  • Modulators/heterogeneity: Effects vary by user type (healthy volunteers vs. patients; occasional vs. long-term users), specific drug, formulation (IR vs. XR), timing, and co-medications.
• Quantitative highlights: 16,273 records screened; κ = 0.853 interrater agreement at full-text screening; 18 studies indicate consistent avoidance/caution patterns; 6 studies reported SDLP increases with anxiolytics.
• Evidence gaps: Paucity of objective, in-situ cognitive/behavioral measures for driving anxiety; limited generalizability from small, controlled drug studies to complex driving; lack of direct tests of anxiolytics’ efficacy for driving anxiety per se.

Findings address the two research questions by showing that driving anxiety is linked to consistent behavioral patterns—exaggerated caution, performance deficits, and widespread avoidance—that can influence exposure and potentially safety, yet current evidence relies heavily on self-report with minimal objective driving metrics. This limits causal interpretation and understanding of specific cognitive mechanisms (e.g., attentional control, inhibition) during real driving. For anxiolytics, experimental and on-road paradigms demonstrate that benzodiazepines can impair lane-keeping (increased SDLP), alertness, and reaction time, implicating attention and psychomotor functions central to safe driving. However, heterogeneity in populations, dosing regimens, and tasks complicates risk characterization and policy guidance. Collectively, the results underscore the need for standardized assessments and objective performance indicators to better quantify how anxiety states and their pharmacological treatments affect driving. These insights are relevant for traffic safety policies, clinical guidance on driving while medicated, targeted interventions (e.g., CBT/VRET), and public-awareness efforts, especially given the high prevalence of anxiety and medication use among drivers.

This review consolidates evidence that driving anxiety is associated with exaggerated caution, performance deficits, and strong avoidance of specific driving situations, while highlighting a major gap in objective, in-situ measures of cognitive and behavioral impacts. It also shows that benzodiazepine anxiolytics commonly impair driving-relevant functions (e.g., SDLP, alertness, reaction time), with effects depending on drug, dose, and user characteristics. The paper contributes by integrating these perspectives, identifying methodological shortcomings, and outlining actionable research and policy directions. Future work should: (1) employ simulation and virtual reality to probe specific cognitive processes with objective metrics before naturalistic validation; (2) examine specific populations (older adults, ADHD, neurological or psychological comorbidities) and non-benzodiazepine treatments pertinent to mobility; (3) consider emerging vehicle technologies and contexts (e.g., EV range anxiety, automated driving); (4) design and evaluate awareness campaigns on driving anxiety and medication effects; and (5) conduct prevalence studies and develop standardized instruments for assessing driving anxiety.

Potential omissions due to search constraints: only four databases queried; grey literature and non-English studies excluded. Exclusion of specific populations (e.g., ADHD, depression, older adults) limits generalizability. Medication-focused searches did not include specific drug-class keywords, potentially missing studies. Publication bias may affect the evidence base, particularly given the scarcity of experimental studies with objective driving metrics; null or non-significant results may be underreported. Many anxiolytic studies used small samples, healthy volunteers, heterogeneous patient regimens, and cross-sectional self-reports, limiting causal inference and generalizability to complex driving scenarios.