Adjustment disorder triggered by a unique and pervasive urban stressor, traffic cones: A case report

Abstract

BACKGROUND

The “Montreal syndrome” is an emerging urban stress-related condition characterized by rage and anxiety triggered by the sight of construction cones, particularly prevalent in Montreal, Canada. This case represents the first medically documented instance of conophobia-induced road rage.

CASE SUMMARY

A 52-year-old man experienced an episode of intense anger and impulsive driving after encountering a series of orange traffic cones near his home. The event included verbal aggression, a traffic violation, and lingering emotional distress. He reported no prior psychiatric history, and imaging confirmed that a coincidental scalp mass was a benign lipoma, ruling out organic causes. The episode led to symptoms consistent with adjustment disorder with mixed emotional features, without meeting criteria for intermittent explosive disorder. This case illustrates how environmental stressors in urban settings can provoke atypical behavioral responses in otherwise mentally healthy individuals. The “Montreal syndrome”, defined by conophobia, avoidance, mood disturbance, and impulsive behavior, offers insight into how chronic urban disruption may impact public mental health. The phenomenon is further contextualized alongside other city-named syndromes such as Stockholm and Florence syndromes.

CONCLUSION

The “Montreal syndrome” underscores the psychological impact of urban infrastructure. This case highlights the need for clinicians to recognize novel forms of situational distress and for urban planners to consider the mental health consequences of the built environment.

Key Words: Urban stress; Syndrome with city name; Conophobia; Phobia; Road rage; Lipoma; Montreal syndrome; Stockholm syndrome; Violence; Case report

Core Tip: This report presents the first medically documented case of “Montreal syndrome” cone-induced urban rage (conophobia) in an otherwise healthy adult. A salient built-environment trigger (ubiquitous orange traffic cones) precipitated impulsive driving and acute affective distress; organic causes were excluded (benign scalp lipoma). The phenotype spans anxiety, avoidance, mood disturbance, and road-rage behavior, remaining distinct from recurrent intermittent explosive disorder. The case reframes urban infrastructure as a psychiatric stressor, situates it among city-named syndromes, and urges clinician awareness and urban-planning responses; cognitive behavior therapy/arts-based coping proved helpful.

INTRODUCTION

Road rage is generally caused by situations that occur while driving and provoke the driver’s anger. In Montreal, the pervasive presence of orange construction cones has led to a phenomenon termed “Montreal syndrome” characterized by anxiety and rage triggered by these cones, leading to incidents of road rage and public distress[1]. Of course, it may be premature to define a new “syndrome” named after a city based solely on a single case. The conventional criteria for establishing a new syndrome, requiring a reproducible cluster of symptoms observed across multiple individuals, are not met by the available evidence.

However, for several years, Montrealer have been subjected to frustrations related to the difficulties of driving in the Quebec metropolis due to the presence of orange cones on most streets. The phenomenon has been observed increasingly, sometimes with an intensity of reactive behavior such as social media, TV channels, news and radio have reported almost clinical testimonies and rage against these cones or the workers installing them[1]. This has led to the preliminary description of the “Montreal syndrome”, which joins the list of geographically named syndromes such as Stockholm or Florence syndromes.

Conceptually, this phenomenon can be understood as conophobia, an anxiety or irritability associated with the perception of traffic cones as symbols of obstruction and loss of control. This reaction may manifest as avoidance behavior, insomnia, fatigue, or even panic symptoms during driving. However, the evidence remains insufficient to classify “conophobia” as a distinct psychiatric disorder, as the reported symptoms may be better conceptualized as situational rage or difficulty adjusting to an environmental stressor rather than a novel clinical entity.

To date, no case of conophobic road rage has been described in a medical journal, even though cases have been seen thousands of times on social media videos with angry people getting out of their vehicles and throwing cones in the air to clear them from their lane or view. People prone to road rage tend to be hyper focused on situations and perceive them as obstacles to their goals. The most common trigger for road rage is hindered progress, such as being slowed down by other drivers. In the following case, it’s not other drivers per se, but rather a specific object. The focus of this article is to describe the uniqueness of this Canadian syndrome and to provide clinical guidance for management. To our knowledge, this is the first medically documented case of cone-induced urban age.

CASE PRESENTATION

Chief complaints

A 52-year-old man reported a disturbing episode of impulsive and aggressive driving behavior. He described the following situation: He was returning late from a show outside of Montréal in the evening with his car heading towards his neighborhood to go home. At the exit of highway from an access road he was forced to turn into a street which took him away from his address because of orange cones which blocked the usual street. After several detours in his neighborhood, he noticed that several streets were closed, including the main street which led to his address due to cones placed there and which prevented traffic in one direction. He was going around in circles and he had been trying to find an access route to his address for 10 minutes. He made a wide detour on a long street (Notre-Dame in Montreal is 34 km long). While he was stopped at one of the intersections in front of the red light, he saw a truck full of orange cones arrive and workers got out and began arranging them at the corner of the intersection.

He saw in front of him diminishing his access to the street which would take him home again. At that moment impulsively he burned the red light accelerated and rushed towards the street which would soon be closed. As he entered the street at the crossroads, he opened his door and insulted one of the workers who was already placing the cones halfway across the width of the street. The tone rose and the insults were shared, and he continued his way, leaving behind the shocked worker who completely closed the street again. Arriving home after parking his car, he was still upset, tense as if angry. It took about ten minutes to calm down in front of the TV. As he went to bed, he began to reflect on the event that had just happened: Having burned a light, having accelerated dangerously at the intersection with a red light, having almost knocked over an orange cone and insulted the person who installed it and he questioned this behavior.

He reported poor sleep that night, followed by anxiety, fatigue, and sadness the next day. Coincidentally, he consulted his primary care physician for a small occipital scalp mass, which was later confirmed by ultrasound and magnetic resonance imaging (MRI) to be a benign lipoma (Figure 1). The neurological examination was unremarkable. An ultrasound revealed a homogenous, hyperechoic and avascular tumor, moderately depressed under probe pressure. Then a magnetic resonance suggested by the radiologist was performed. Any malignant process was ruled out. The image showed a simple small lipoma.

Figure 1 Magnetic resonance imaging brain and neck normal with a well-defined, homogeneously hyperintense mass on both T1- and T2-weighted sequences, which is fully suppressed on fatsaturated images-consistent with mature adipose tissue confined to the subcutaneous layer without infiltration into adjacent structures. There is no evidence of thick septations, nodularity, enhancement, or bone involvement, supporting its benign nature as a simple lipoma. A and B: Sagittal slice; C: Axial slice.

The patient did not receive any psychotropic medication. Psychotherapy was offered to the patient, who finally opted for art therapy. This suited his personality, and he thus had the opportunity to create cones in pictorial art, in photographic art and finally in writing. He also engaged in yoga classes. His symptoms gradually improved over several weeks.

History of present illness

Since the nocturnal incident the patient had felt uneasiness, sometimes a feeling of revolt, sometimes a feeling of anxiety or sadness when he saw the cones dotting the streets he had to frequent to get to work. He also found himself forcing himself to avoid certain journeys from now on. However, the situation at work regained a certain quality, his sleep became normal again.

History of past illness

The patient had no criminal or psychiatric history. In his medical history we noted hypertension well controlled for 6 years with candesartan and taking rivaroxaban, anticoagulant for a history of episodes of atrial fibrillation, the last episode of which was more than 10 years ago.

Personal and family history

The patient had no particular family history of mental health issues.

Physical examination

Apart from the scalp lipoma in the occipital region, the patient's physical examination was normal.

Imaging examinations

MRI brain and neck normal with a well-defined, homogeneously hyperintense mass on both T1- and T2-weighted sequences, which is fully suppressed on fatsaturated images-consistent with mature adipose tissue confined to the subcutaneous layer without infiltration into adjacent structures. There is no evidence of thick septations, nodularity, enhancement, or bone involvement, supporting its benign nature as a simple lipoma.

FINAL DIAGNOSIS

The behavioral event could not be attributed to the occipital lipoma, which was superficial, asymptomatic, and benign on imaging. Organicity was therefore easily ruled out[2]. His symptoms instead aligned more closely with an adjustment disorder with mixed emotional features, triggered by a specific and repeated environmental stressor.

The primary differential diagnosis considered was intermittent explosive disorder (IED), defined in Diagnostic and Statistical Manual of Mental Disorders as recurrent, disproportionate outbursts of aggression not better explained by another mental or medical condition[3,4]. However, this patient's behavior was reactive to a specific environmental trigger (the cones), and he had no prior history of recurrent episodes. He did not meet the diagnostic frequency criteria for IED (e.g., verbal outbursts twice weekly for three months or three physical outbursts in 12 months).

TREATMENT

Recent literature[3] supports cognitive behavior therapy as the most effective treatment for anger dysregulation, outperforming pharmacologic approaches in multiple randomized trials. Selective serotonin reuptake inhibitor particularly fluoxetine, may provide benefit in cases with marked irritability, though medication was not indicated in this case.

OUTCOME AND FOLLOW-UP

The patient did not receive any psychotropic medication. Psychotherapy was offered to the patient, who finally opted for art therapy. This suited his personality, and he thus had the opportunity to create cones in pictorial art, in photographic art and finally in writing. He also engaged in yoga classes. His symptoms gradually improved over several weeks. He gave his consent for publication.

DISCUSSION

This report describes a potential subtype of urban stress-related anger disorder, informally referred to as “Montreal syndrome”, or “conophobia”[5]. It exemplifies how environmental saturation and a perceived lack of control can provoke disproportionate emotional and behavioral responses. The orange cone has become a symbol of dysfunction, delay, and municipal disorganization in Montreal, akin to a trigger object for some residents (Figure 2).

Figure 2 Images of T-RV-7 orange cone used to mark public works zones in Montreal: The T-RV-7 model is a channelizing drum (or construction cone) used for road signaling, made of bright orange polyethylene with white or orange retro-reflective bands, ensuring 360° visibility in work zones. In urban environments such as Montreal, this cone has become almost a visual symbol of the city’s perpetual construction, marking areas of roadwork, street repairs, and public works, while representing both immobility and efficiency within the city. A: Downtown Montreal; B: St Cunégonde street, Montreal.

The syndrome is considered a form of “conophobia”, an irrational fear or anger toward traffic cones, triggered by feelings of helplessness and obstruction during navigation, particularly when cones block familiar routes. Clinicians express concern over the lack of training in mental health and public health education to address and prevent such rare but deadly behaviors (car ramming), emphasizing the importance of differentiating them from common road rage incidents. Road rage is commonly triggered by driving-related stressors, especially those that impede a driver’s progress[6,7]. In Montreal, a city infamous for its prolonged and ubiquitous road construction, the presence of orange traffic cones has become a symbol of frustration. New cones have indeed appeared on the streets, by the thousands, like orange barrels, scattered throughout the neighborhoods, cones dubbed T-RV-7. In the context of this invasion, the first behavioral anomalies observable in the population appeared, the signs of suffering, the citizens’ feelings of helplessness and the media coverage. Over recent years, multiple incidents of extreme driver reactions have been shared on social media and reported in the news. These episodes have led to the conceptualization of a unique condition termed “Montreal syndrome”, a “conophobia” induced urban rage syndrome[1]. Unlike general road rage, “Montreal syndrome” involves anxiety, avoidance behavior, and occasional panic attacks directly linked to the sight or presence of orange cones. This report presents the first medically documented case of this phenomenon.

The literature has previously addressed road rage and its psychiatric implications. Predictors of such behaviors include noncompliance with traffic laws, excessive honking, yelling, and reckless driving[8-10]. Some authors have proposed incorporating impulsivity assessments into driver’s license evaluations, emphasizing the need to consider psychiatric factors in traffic safety. Anger remains an underrecognized mental health concern compared to anxiety and depression[8]. Yet, when dysfunctional, it can impair daily functioning and social interactions. Distinguishing normal from pathological anger involves assessing chronicity, severity, reactivity, and functional impact[9-11].

The cone has become a caricature of Montreal, with key chains, t-shirts, coffee cup, and is sold in mascot shops as souvenirs. A web search easily reveals more than 20 articles in the press and about thirty moments in the media. A big-hearted walking cone has even become the hero of a famous weekly comic strip that implicitly illustrates the relationship Montrealer have with construction sites and traffic obstructions, which are turning into a collective obsession. “Montreal syndrome” offers a compelling lens through which to examine the impact of urban infrastructure on mental health. Viral videos from the city depict residents physically removing cones, shouting at road workers, or recording breakdowns from traffic-related stress. These reactions may reflect a deeper issue, citizens feeling powerless in the face of systemic inefficiency and arbitrary obstructions to daily life.

Syndrome with a city name

Clinicians could be familiar with Stockholm syndrome, which describes a victim’s sympathy for their attacker[12]. This phenomenon refers to a famous bank robbery in the Swedish capital in 1973, during which the hostages developed an attachment to their captors[13]. There’s also Lima syndrome[14], which describes the empathy an attacker may feel toward his victim. Florence syndrome or Stendhal syndrome, for its part, refers to the discomfort caused by contemplating the works exhibited at the Uffizi Gallery[15]. This discomfort really exists: The guards at the Florentine Museum are even trained to intervene with tourists who fall victim to it, overwhelmed by such beauty[16].

“Montreal syndrome” describes another kind of discomfort. This phobia, characterized by intense anxiety towards a specific object, the T-RV-7 orange cone used to mark public works zones, has caused growing suffering among Montreal citizens[17-20]. Although not yet fully defined as a clinical entity, the disorder deserves to be explored due to its impact on the mental health of the city’s inhabitants, as well as its link with the urban[21-24] and social identity of Montreal (Table 1).

Table 1 Different syndromes linked to the name of a city.

Name	Date	Events/context	Signs
Stockholm syndrome	1973	Criminals invade the Swedish Credit Bank in an attempt to rob it and hostage-taking occurs	Victim’s sympathy for the attacker
Stendhal syndrome or Florence syndrome	1817, 1979	Trip to Italy. Contemplation of works of art	Dizziness, suffocation, rapid heartbeat, hallucinations, loss of sense of identity and direction, severe chest pain, fainting, amnesia
Havane syndrome	2016	American diplomatic personnel stationed in Cuba	Nausea, hearing, balance, and sleep disturbances
Paris syndrome	1986	Tourists are greatly shocked when they see that Paris is not looking its best. Particularly Japanese	Various symptoms with anxiety or psychosis. Sometimes requiring repatriation to the country of origin
Pisa syndrome	1972	Tardive dystonia with trunk flexion. Antipsychotics	The body leans to one side like the Tower of Pisa
Lima syndrome	1996	Hostage-taking in 1996 at the Japanese embassy in lima, Peru. Opposite of Stockholm syndrome	Hostage takers show empathy for their victims
Two copenhague syndrome	1991, 2010	Two different syndromes, one biological: Non-infectious fusion of the vertebrae, the other linked to the political context during an international meeting	Scoliosis; political indecision and the new world order
Detroit syndrome	1996	Reputation as a manufacturing hub for automobiles	Feeling of discrimination in which workers of a certain age are replaced by those who are younger, faster, and stronger
Jerusalem syndrome	1930	Religious in focus	Delusion that the subject is an important Biblical figure
Venice syndrome	2001		Express intention of killing themselves in the city
Lisbon’s phantom limb syndrome	2025	Urban condition with fragmentation, as cities enter less and less fathomable circuits of financial speculation	Making physically distant neighbourhoods overlap and physically adjacent neighbourhoods drift apart
Brasilia syndrome	2011	Also called “Helicopter Urbanism”. Urban planning that prioritizes how a city looks from above-its aerial aesthetics-rather than the everyday experiences of its residents	The concept, named after Brasilia, highlights the stress and problems that arise when planners ignore people’s needs in favor of highly designed, pre-planned visuals
Montréal syndrome	2023	Invasion of traffic cones in the streets, sometimes for no reason. Powerlessness of citizens	Conophobia. Road rage. Avoidance. Mood disorders. Insomnia. Impatience. Aggression

Limitations

While Montreal is often highlighted for the proliferation of its orange traffic cones, road maintenance and urban reconstruction are global phenomena associated with aging infrastructure, climatic challenges, and ongoing urban expansion. The frustration experienced by Montreal residents is therefore not unique but reflects broader patterns observed in other major cities undergoing continuous development.

What distinguishes Montreal, however, is the cultural transformation of this urban inconvenience into a local symbol. The omnipresence of cones has permeated popular culture, inspiring mascots, merchandise, artistic expression, and social media satire. This phenomenon illustrates how collective annoyance can evolve into a distinctive element of civic identity and urban discourse.

CONCLUSION

“Montreal syndrome” illustrates how persistent urban infrastructure and environmental stressors can contribute to atypical forms of psychological distress. Though the concept may appear anecdotal, it raises important questions about the mental health consequences of prolonged exposure to disorganized or unpredictable urban environments. Clinicians should remain attentive to emerging patterns of situational anger and adjustment difficulties linked to environmental stimuli. Urban planners, in parallel, should consider the psychological dimensions of infrastructure design. Recognizing the interface between environment and emotion enriches the biopsychosocial understanding of mental health in modern metropolitan contexts.