Post-traumatic Stress Disorder Symptom Severity Attenuates Bi-directional Associations between Negative Affect and Avoidant Coping: A Daily Diary Study

Abstract

Introduction:

Avoidant coping plays an important role in the maintenance of post-traumatic stress disorder (PTSD). However, existing investigations have been limited in their assessment of coping as a static process – despite evidence that the coping strategies individuals use to manage stressors vary across time and contexts. Further, research has relied on cross-sectional designs, precluding determination of the directionality of the negative affect-avoidant coping association. The current study addresses these limitations by using a daily diary method to examine the moderating role of PTSD symptom severity on reciprocal relations between negative affect and avoidant coping.

Methods:

Participants were 1,188 trauma-exposed adults (M age = 19.2, 56% female, 79% White) who provided daily diary data for 30 days via online surveys. Multi-level models were tested to evaluate the moderating role of PTSD symptom severity in the daily relations between negative affect and avoidant coping during the 30-day period.

Results:

Levels of daytime negative affect were assoicated with use of evening avoidant coping. Use of evening avoidant coping were associated with levels of next-day daytime negative affect. PTSD symptom severity moderated these relations. For individuals with more (vs. less) severe PTSD symptoms, the association of negative affect to avoidant coping was weaker and the association of avoidant coping to negative affect was stronger.

Limitations:

Findings must be interpreted in light of limitations, including self-report measures and assessment of a alcohol using sample of college students.

Discussion:

These findings advance our understanding of the negative affect-avoidant coping association among trauma-exposed individuals.

Post-traumatic stress disorder (PTSD) is a serious and debilitating psychiatric disorder characterized by intrusions, effortful avoidance of external and internal trauma-related cues, negative alterations in cognitions and mood (NACM), and alterations in arousal and reactivity (AAR) following traumatic experiences (American Psychiatric Association [APA], 2013). PTSD is highly prevalent, with lifetime, past 12-month and past 6-month rates in the general population of 8.3%, 4.7%, and 3.8%, respectively (Kilpatrick et al., 2013). Further, PTSD is linked to a wide range of physical (e.g., chronic pain; Pacella, Hruska, & Delahanty, 2013), psychological (e.g., depression; Rytwinski, Scur, Feeny, & Youngstrom, 2013), and behavioral health (e.g., substance use; Tull, Weiss, & McDermott, 2015) concerns, as well as impairment in functioning, even among individuals who do not meet full PTSD diagnostic criteria (Hellmuth, Jaquier, Swan, & Sullivan, 2014). Thus, investigations that improve our understanding of the development and maintenance of PTSD have clear clinical relevance and public health significance.

The strategies individuals use to cope with stressors may characterize risk for PTSD following traumatic exposure. Coping refers to purposeful efforts to manage internal and external stressors that are appraised as taxing or exceed one’s resources (Lazarus & Folkman, 1984). A review by Skinner, Edge, Altman, and Sherwood (2003) indicated that the most frequent approach for discriminating among the types of coping is by categorizing such attempts as approach (i.e., behaviors that are directed toward threat including problem solving or seeking support) or avoidant (i.e., behaviors that are directed away from threat including denial or behavioral avoidance). While there are some immediate benefits to avoidant coping (e.g., stress reduction, dosing of threat; Roth & Cohen, 1986), a growing body of research suggests that this type of coping in particular has a deleterious impact on post-trauma outcomes (for reviews, see Aldwin & Yancura, 2004; Olff, Langeland, & Gersons, 2005; Roth & Cohen, 1986).

PTSD is characterized by avoidance of trauma-related internal (e.g., thoughts, emotions) and external (e.g., people, places) cues. Thus, individuals with PTSD may use avoidant coping more frequently as a means of managing their PTSD symptoms and related distress. Moreover, over time, individuals with PTSD may be motivated to use this strategy to cope with other types of experiences, including negative affect stemming from non-trauma-related internal and external events, given evidence that avoidant coping is reinforcing (Fischer, Smith, Spillane, & Cyders, 2005). Consistent with these assertions, more frequent use of avoidant coping has been shown to be associated with greater PTSD symptom severity (e.g., Dempsey, Stacy, & Moely, 2000; Krause, Kaltman, Goodman, & Dutton, 2008; Pineles et al., 2011). For instance, a longitudinal study of female victims of partner violence found that baseline levels of avoidant coping predicted PTSD symptom severity at one-year follow-up, even after controlling for baseline symptoms and covariates (e.g., revictimization; Krause et al., 2008). Likewise, Pineles et al. (2011) found that female victims of assault who reported greater use of avoidant coping at baseline (i.e., within one month of their assault) had greater PTSD symptom severity three months post-assault. Avoidant coping also has been shown to predict response to PTSD treatment. For instance, Boden, Bonn-Miller, Vujanovic, and Drescher (2012) found that decreases in avoidant coping from pre- to post-treatment were associated with lower PTSD symptom severity following residential treatment for PTSD. These findings are consistent with theoretical accounts of PTSD that have proposed that avoidant coping interferes with psychological mechanisms that underlie PTSD, including the emotional processing of traumatic memories, habituation to the aversive emotions associated with these memories, and extinction of trauma-related fear responses (Foa & Kozak, 1986; Foa & Rothbaum, 1998; Keane & Barlow, 2002). Thus, the natural recovery process may be thwarted among individuals who engage in greater avoidance of trauma memories or reminders (Foa & Kozak, 1986).

The aforementioned litertaure suggests that the strength of the association between negative affect and avoidant coping may be stronger among individuals with PTSD. Specifically, it shows that truama-exposed individuals who use avoidant coping to manage negative affect experience more PTSD symptoms post-trauma and show fewer improvements in PTSD symptoms following treatment. The current study extends existing research in this area by examining the potential moderating role of PTSD symptom severity on daily, bi-directional relations between negative affect and avoidant coping among trauma-exposed individuals. Specifically, two important gaps in the current literature were addressed. First, while a plethora of studies have examined coping as a dynamic process in everyday life (for reviews, see Litt, Tennen, & Affleck, 2010; Park & Iacocca, 2014; Tennen, Affleck, Armeli, & Carney, 2000), a dearth of research has assessed the impact of PTSD on individuals’ use of avoidant coping in their natural environments. Coping is a dynamic process – the specific strategies used to manage stressors can vary across time and contexts for an individual (Frydenberg, 2014; Lazarus & Folkman, 1984; Revenson & Lepore, 2012). Thus, to understand nuances in the association between negative affect and avoidant coping among trauma-exposed individuals with varying levels of PTSD symptom severity, it is critical that researchers employ methods that allow for examination of how this relation unfolds day to day. Micro-longitudinal methods capture data frequently and in near real-time, and assess experiences and behaviors as they unfold in their natural environment – which is critical to examining within-person, proximal relationships (Bolger & Laurenceau, 2013; Tennen et al., 2000). As such, these methods are vastly superior to cross-sectional and traditional longitudinal designs in that they reduce recall error and bias (participants are only asked to recall up to 24 hours in micro-longitudinal designs versus up to months or even years in cross-sectional and traditional longitudinal designs). Moreover, these methods allow for examination of rapid changes in behavior, not possible with cross-sectional and traditional longitudinal designs. Notably, micro-longitudinal methods have demonstrated validity and reliability in the study of psychological phenomena including affect and coping (for a review, see Csikszentmihalyi, 2014).

Second, much of the research in this area has relied on cross-sectional designs, so little is known about the directionality of association between negative affect and avoidant coping among trauma-exposed individuals with varying levels of PTSD symptom severity. Historically, coping has been viewed (and empirically tested) as a response to emotion. However, there is evidence that the relation between negative affect and avoidant coping is bi-directional, with each affecting the other (Folkman & Lazarus, 1988b). Specifically, negative affect has been theorized to influence succeeding avoidant coping through motivation or impediment mechanisms, which in turn alter the person-environment relationship, resulting in changes in the quality (e.g., intensity, duration) of negative affect (Folkman & Lazarus, 1988a). Because higher intensity of negative affect is more difficult to modulate (Mennin, Heimberg, Turk, & Fresco, 2005), individuals may be more likely to use strategies that function to immediately alleviate these emotional experiences, such as avoidant coping (Roth & Cohen, 1986). Additionally, it is possible that heightened levels of negative affect may increase the likelihood of using coping strategies that require fewer cognitive resources, such as avoidant coping (Kool, McGuire, Rosen, & Botvinick, 2010). For instance, although the exact mechanisms are unknown (Grandey, Frone, Melloy, & Sayre, in press; Inzlicht & Schmeichel, 2012), there is some evidence that high levels of negative affect may reduce one’s capacity for self-control (e.g., adaptive coping).

While understudied relative to the unidirectional link from negative affect to avoidant coping, initial empirical work also provides support for a bi-directional relation of avoidant coping to negative affect (e.g., Dickson, Ciesla, & Reilly, 2012; Fagundes, Berg, & Wiebe, 2012). For instance, laboratory studies have found that avoidant coping is less effective at diminishing negative affect than coping strategies that require individuals to approach their emotions such as acceptance (Campbell-Sills, Barlow, Brown, & Hofmann, 2006; Dan-Glauser & Gross, 2015; Tull, Jakupcak, & Roemer, 2010). Moreover, avoidant coping has been shown to result in persistence of negative affect post-event compared to acceptance (Campbell-Sills et al., 2006), consistent with the suggestion that avoidant coping may be followed by a rebound in distress (Hayes et al., 1996). Yet, research on the bi-directional effect is scarce, and has yet to test whether this association varies as a function of PTSD symptom severity, despite evidence for a relation between PTSD and both negative affect (Miller, Kaloupek, Dillon, & Keane, 2004; Miller & Resick, 2007) and avoidant coping (Dempsey et al., 2000; Krause et al., 2008; Pineles et al., 2011). Such findings would inform intervention efforts for trauma-exposed populations.

Addressing these limitations of prior research, the present study utilized daily diary data collected over 30 days among 1,640 college students to test whether (a) daytime negative affect influences the likelihood of evening avoidant coping, and (b) evening avoidant coping influences the likelihood of next-day negative affect, as well as the moderating role of PTSD symptom severity in these bi-directional associations. We hypothesized bi-directional relations such that (a) levels of daytime negative affect would influence the likelihood of evening avoidant coping, and (b) evening avoidant coping would influence the likelihood of levels of next-day negative affect. We expected that PTSD symptom severity would moderate these relations, such that they would be stronger among individuals with greater PTSD symptom severity.

Methods

Participants

Undergraduate psychology students were recruited as part of a project examining daily experiences and alcohol use. Eligibility criteria were: (a) ≥18 years of age, (b) alcohol use at least twice in the past 30 days, and (c) no past treatment for alcohol problems. The final sample included 1,640 students. This subsample was restricted to individuals who reported a history of traumatic exposure (n = 1,188); a traumatic exposure prevalence rate of 65% is consistent with past research in this population (e.g., 67% using DSM-IV PTSD criteria; Elhai et al., 2012). A little over half (55.7%) of the participants were female and the average age was 19.24 (SD=1.54). In terms of race/ethnicity, 79% were White, 12% Asian American, 4% Black, 4% Latino/a, and 1% Native American or other.

Procedures

Procedures were approved by the institutional review board at the University of Connecticut. Students were recruited through the undergraduate psychology participant pool and an email-based campus-wide announcements system. Students provided informed consent and completed an online baseline survey assessing demographics (e.g., gender, age, race/ethnicity) and a variety of behavioral and personality measures (e.g., lifetime traumatic exposure, baseline PTSD symptom severity). Students were then instructed to provide daily diary data for 30 days via online surveys, available from a secure website between 2:30pm and 7:00pm. Our reporting time window was selected to coincide with naturally occurring end of regularly scheduled academic activities, but before typical evening activities begin (including drinking). Surveys assessed behaviors ―since waking until the time of the report‖ (daytime) and ―since completing yesterday’s survey until you fell asleep‖ (i.e., evening) to cover the entire daily period.

Daily Measures

Negative Affect.

Negative affect items were extracted from the Positive and Negative Affect Schedule – Expanded Form (Watson & Clark, 1999). Negative affect items included: “nervous, “ “irritable, “ “hostile, “ “guilty, “ “sad, “ “ashamed, “ and “angry. “ Items were rated from 1 (not at all) to 5 (extremely) and were averaged to create daily negative affect scores. Participants were asked to report on daytime and evening negative affect. This subscale had good internal consistency in the current sample (ω = .93).

Avoidant coping.

Given the intensive nature of daily data collection, to reduce participant burden, and consistent with recommendations for daily data methods (Stone & Shiffman, 2002; Stone, Shiffman, Alienza, & Nebeling, 2007), avoidant coping was measured by asking a single item (“I avoided dealing with a situation”), rated from 0 (not at all) to 3 (a lot). Participants were asked to report on evening avoidant coping in response to any stressful events or experiences.

Baseline Measures

Demographic questionnaire.

Information regarding age, gender, and racial/ethnic status was obtained.

Trauma exposure.

The Traumatic Experiences Screening Instrument (TESI; Ford et al., 2000) is an 18-item, self-report measure designed to screen for trauma events in a respondent’s lifetime. Consistent with DSM-IV guidelines for determining Criterion A trauma exposure for PTSD, participants were asked only to endorse an event if it elicited fear, helplessness, or horror. The TESI has shown evidence of adequate reliability and validity. Individuals who endorsed at least one trauma event on the TESI were classified as “trauma-exposed.” TESI items have shown evidence of retest reliability (.50–.70) and criterion and predictive validity (Ford et al., 2000).

PTSD symptom severity.

The PTSD Checklist–Civilian Version (PCL-C; Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item self-report measure of the severity of PTSD symptoms experienced in response to a stressful life event among civilians, as outlined by DSM-IV (APA, 1994) criteria for PTSD. Using a 5-point Likert-type scale anchored from 1 = not at all to 5 = extremely, participants rate the extent to which each symptom has bothered them in the past month. The PCL-C has excellent internal consistency and test–retest reliability in college students (Ruggiero, Del Ben, Scotti, & Rabalais, 2003). Internal consistency in this sample was excellent (ω = .94).

Data Analysis

A series of multi-level models were tested using R version 3.4.1 software (R Core Team, 2017) to evaluate daily bi-directional associations of negative affect and avoidant coping during the 30-day period. Daily reports (n = 33,513) comprised of level-1 variables nested within person at level-2 (n = 1,188). Multi-level modeling allows us to estimate within-person relations among negative affect and avoidant coping on a daily level while considering how these effects vary by individual and accounting for the autocorrelation structure of repeated assessments within an individual. All models included level-1 covariates of study day (time). Results are presented from unadjusted models and models adjusted for the level-2 covariates of gender and stress, which are differentially related to PTSD (Kilpatrick et al., 2013; Moser, Hajcak, Simons, & Foa, 2007), negative affect (Kring & Gordon, 1998; Moser et al., 2007), and avoidant coping (Matud, 2004; Roth & Cohen, 1986).

PTSD symptom severity was centered around the grand mean and evaluated using generalized mixed effects models for main effects of PTSD symptom severity on avoidant coping. To obtain unbiased estimates of the pooled within-person slopes, the level-1 predictor (negative affect) was person-mean centered and the person means were entered at level-2 to examine between-person variability. All models were initially set with random intercepts and random effects to vary across individuals. Models were run using full information maximum likelihood estimation, robust to missing data. Results are presented from population-averaging models with robust standard errors. To test the moderating effect of PTSD symptom severity on the bi-directional association of negative affect and avoidant coping, cross-level interactions were tested where PTSD symptom severity was added as a level-2 predictor of the level-1 coefficient. Significant interaction effects were examined through analysis of simple-slopes (Aiken & West, 1991).

Results

See Table 1 for prevalence rates of traumatic events assessed with the TESI. PTSD symptom severity on the PCL-C in the current study ranged from 17 to 81, with an average score of 30.53 (SD = 12.30). Using a recommended cut-off score of 44 or above (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; see Ruggerio et al. [2003] for evidence supporting this cut-off score in college student samples), 16.0% of the sample met criteria for a probable PTSD diagnosis.

Table 1.

Prevalence of lifetime traumatic events

Item	%
Bad accident/fall/fire for self	30.3
Bad accident/fall/fire for someone else	45.6
Life threatening storm/earthquake/flood	19.9
Close loved one died unexpectedly	36.9
Life threatening illness/permanent injury	13.2
Separated from close adults as a child	13.7
Your children taken away from you	0.2
Someone tried to kill or hurt you really badly	7.2
Someone threatened to kill or hurt you badly	11.3
Witnessed family violence	12.7
In close relationship feared for life/felt trapped	9.8
Emotionally shamed/humiliated by someone close	33.3
Had an abortion or miscarriage	1.5
Witnessed violence outside of family	18.6
Been in a war or the military	0.7
Lost or left home due to disaster/war/homelessness	2.5
Made to do something sexual	13.5
Other events where self or other could be killed/died/hurt	8.3

In basic models, daytime negative affect was significantly associated with evening avoidant coping (see Table 2), and evening avoidant coping was significantly associated with next-day daytime negative affect (see Table 3), at the person- and daily-level of analysis and unadjusted and adjusted for gender and stressfulness.

Table 2.

Daytime negative affect in relation to evening avoidant coping

			Avoidant Coping
	B	SE	t	p	R2
Unadjusted Models
Level-Two Negative Affect	0.295	0.012	24.18	<.001	0.311
Level-One Negative Affect	0.266	0.004	59.69	<.001	0.133
Adjusted Models
Level-Two Negative Affect	0.269	0.012	22.12	<.001	0.327
Level-One Negative Affect	0.296	0.004	69.74	<.001	0.145

Note. Estimates are adjusted for all variables in the table. Level-two=person level. Level-one=daily level. Adjusted model includes gender and daily stressfulness.

Table 3.

Evening avoidant coping in relation to next-day daytime negative affect

			Negative Affect
	B	SE	t	p	R2
Unadjusted Models
Level-Two Avoidant Coping	0.073	0.004	20.73	<.001	0.301
Level-One Avoidant Coping	0.058	0.003	22.76	<.001	0.127
Adjusted Models
Level-Two Avoidant Coping	0.044	0.003	17.33	<.001	0.313
Level-One Avoidant Coping	0.040	0.002	−16.15	<.001	0.136

Note. Estimates are adjusted for all variables in the table. Level-two=person level. Level-one=daily level. Adjusted model includes gender and evening stressfulness.

Next, moderation models explored the role of PTSD symptom severity in the reciprocal relations between avoidant coping and negative affect, at the person- and daily-level of analysis and unadjusted and adjusted for gender. Significant relations were found for the moderating role of PTSD symptom severity in daytime negative affect relating to later evening avoidant coping, (see Table 4), and evening avoidant coping relating to next-day daytime negative affect (see Table 5).^{1, 2} Analysis of simple slopes revealed that the strength of the relation of daytime negative affect to evening avoidant coping was weaker for trauma-exposed individuals with higher versus lower PTSD symptom severity, at the person- and daily-level of analysis and unadjusted and adjusted for gender (see Table 6 and Figure 1). Conversely, the strength of the relation of evening avoidant coping to next-day daytime negative affect was stronger for trauma-exposed individuals with higher versus lower PTSD symptom severity, at the person- and daily-level of analysis and unadjusted and adjusted for gender (see Table 7 and Figure 2).

Table 4.

PTSD symptom severity moderating the relation of daytime negative affect to evening avoidant coping

			Avoidant Coping
Unadjusted Models	B	SE	t	p	R2
Level-Two Negative Affect by PTSD Severity	−0.135	0.052	−2.61	.009	0.413
Level-One Negative Affect by PTSD Severity	−0.150	0.019	−7.73	<.001	0.195
Adjusted Models
Level-Two Negative Affect by PTSD Severity	−0.122	0.051	−2.38	.018	0.431
Level-One Negative Affect by PTSD Severity	−0.133	0.019	−6.86	<.001	0.208

Note. Estimates are adjusted for all variables in the table. Level-two=person level. Level-one=daily level. PTSD = post-traumatic stress disorder. Adjusted model includes gender and daytime stressfulness.

Table 5.

PTSD symptom severity moderating the relation of evening avoidant coping to next-day daytime negative affect

	Negative Affect
Unadjusted Models	B	SE	t	p	R2
Level-Two Avoidant Coping by PTSD Severity	0.032	0.016	2.46	.025	0.421
Level-One Avoidant Coping by PTSD Severity	0.028	0.012	2.34	.020	0.122
Adjusted Models
Level-Two Avoidant Coping by PTSD Severity	0.026	0.012	2.26	.024	0.441
Level-One Avoidant Coping by PTSD Severity	0.025	0.011	2.19	.029	0.132

Note. Estimates are adjusted for all variables in the table. Level-two=person level. Level-one=daily level. PTSD = post-traumatic stress disorder. Adjusted model includes gender and evening stressfulness.

Table 6.

Simple slope tests for daytime negative affect in relation to evening avoidant coping

	Avoidant Coping
	B	SE	t	p
Low PTSD symptom severity
Unadjusted Model
Level-Two Negative Affect	0.265	0.025	10.47	< .001
Level-One Negative Affect	0.275	0.009	29.5	< .001
Adjusted Model
Level-Two Negative Affect	0.248	0.025	9.746	< .001
Level-One Negative Affect	0.256	0.01	26.43	< .001
High PTSD Symptom Severity
Unadjusted Model
Level-Two Negative Affect	0.298	0.031	9.678	< .001
Level-One Negative Affect	0.299	0.012	25.889	< .001
Adjusted Model
Level-Two Negative Affect	0.263	0.031	8.577	< .001
Level-One Negative Affect	0.262	0.012	21.626	< .001

Note. Estimates are adjusted for all variables in the table. Level-two=person level. Level-one=daily level. PTSD = post-traumatic stress disorder. Adjusted model includes gender and evening stressfulness.

Figure 1.

Moderating role of PTSD symptom severity in the daily relation between afternoon negative affect and evening avoidant coping

Note. Estimates are adjusted for all variables in the table. PTSD = post-traumatic stress disorder. Adjusted model includes gender and evening stressfulness.

Table 7.

Simple slope tests for evening avoidant coping in relation to next-day afternoon negative affect

	Avoidant Coping
	B	SE	t	p
Low PTSD symptom severity
Unadjusted Model
Level-Two Negative Affect	0.063	0.013	5.05	< .001
Level-One Negative Affect	0.045	0.007	5.95	< .001
Adjusted Model
Level-Two Negative Affect	0.042	0.013	3.373	< .001
Level-One Negative Affect	0.032	0.007	4.426	< .001
High PTSD Symptom Severity
Unadjusted Model
Level-Two Negative Affect	0.081	0.011	7.679	< .001
Level-One Negative Affect	0.073	0.007	10.195	< .001
Adjusted Model
Level-Two Negative Affect	0.068	0.011	5.958	< .001
Level-One Negative Affect	0.053	0.007	7.703	< .001

Note. Estimates are adjusted for all variables in the table. Level-two=person level. Level-one=daily level. PTSD = post-traumatic stress disorder. Adjusted model includes gender and evening stressfulness.

Figure 2.

Moderating role of PTSD symptom severity in the daily relation between evening avoidant coping and next-day afternoon negative affect

Note. Estimates are adjusted for all variables in the table. PTSD = post-traumatic stress disorder. Adjusted model includes gender and evening stressfulness.

Discussion

The goal of the present study was to examine the daily, bi-directional relations between negative affect and avoidant coping, as well as the potential moderating role of PTSD symptom severity in these associations among trauma-exposed individuals. As hypothesized, negative affect and avoidant coping were found to demonstrate reciprocal associations at the daily level, such that levels of daytime negative affect were associated with use of evening avoidant coping, and use of evening avoidant coping were associated with levels of next-day daytime negative affect. Partially consistent with expectations, the strength of the daily association from negative affect to avoidant coping was stronger for individuals with less severe PTSD symptoms, whereas the strength of the daily association from avoidant coping to negative affect was stronger for individuals with more severe PTSD symptoms. These findings highlight dynamic, bi-directional relations among negative affect and avoidant coping, as well as provide support for the role of PTSD symptom severity in the strength of these relations.

The finding that the daily association from negative affect to avoidant coping was significant (and strong) among individuals with severe PTSD symptoms aligns with literature in this area. In the immediate aftermath of trauma, most individuals exhibit some PTSD symptoms. However, many of these individuals will experience a significant reduction or complete remittance of PTSD symptoms within several months (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). Avoidant coping has been theorized to play a central role in maintenance of PTSD symptoms (Foa & Kozak, 1986; Foa & Rothbaum, 1998; Keane & Barlow, 2002). For instance, avoidant coping has been posited to interfere with emotional processing of traumatic memories, such as by increasing attentional bias towards threat and trauma-related stimuli (Buckley, Blanchard, & Neill, 2000). Further, avoidant coping has been hypothesized to impede habituation of anxiety-related autonomic responses associated with traumatic memories, including the activation of the traumatic memory (also referred to as the fear memory) and introduction of new information that is incompatible with the existing memory (Foa & Kozak, 1986). Finally, avoidant coping is thought to interfere with the extinction of conditioned fear responses, including behavioral sensitization to stress (McLaughlin, Conron, Koenen, & Gilman, 2010), overgeneralization of the conditioned stimulus-unconditioned stimulus response (Pole et al., 2009), impaired extinction of conditioned stimulus-unconditioned stimulus pairings (Blechert, Michael, Vriends, Margraf, & Wilhelm, 2007), and impaired fear inhibitory learning (Jovanovic et al., 2009). Consistent with this theory, greater use of avoidant coping among trauma-exposed individuals has been shown to predict later PTSD symptoms (e.g., Dempsey et al., 2000; Krause et al., 2008; Pineles et al., 2011).

However, contrary to expectations, the association from negative affect to avoidant coping was slightly stronger among individuals with less (vs. more) severe PTSD symptoms. Future research is needed to better understand this finding. For instance, it is possible that trauma-exposed individuals with more severe PTSD symptoms exhibit heightened use of a wide range of coping strategies following negative affect, resulting in lower overall use of avoidant coping following negative affect when compared to trauma-exposed individuals with less severe PTSD symptoms. This hypothesis is consistent with Dixon-Gordon, Aldao, and De Los Reyes (2015), who found that individuals with more severe psychopathology (i.e., mood, anxiety, and borderline personality symptoms) reported high use of a greater number of coping strategies. Such an explanation is consistent with the notion that trauma-exposed individuals with more severe PTSD symptoms experience more negative affect, and thus require greater coping efforts. Future investigations that explore the relation between negative affect and multiple coping strategies are needed to test this hypothesis. It is also possible that traumatic exposure plays a more pivotal role in the negative affect-avoidant coping link than PTSD symptom severity. Indeed, our findings suggest that negative affect is strongly associated with later avoidant coping for trauma-exposed individuals, with relatively limited influence by PTSD symptoms. Research that examines these relations among individuals with (vs. without) traumatic exposure is warranted.

Extending existing research, and consistent with study hypotheses, our findings provided support for a reciprocal association of avoidant coping to negative affect at the daily level of analysis among trauma-exposed individuals. Moreover, they indicated that the strength of this association from avoidant coping to negative affect was stronger among trauma-exposed individuals in our sample who reported greater (vs. lower) PTSD symptom severity. Said otherwise, trauma-exposed individuals with greater PTSD symptom severity were more likely to experience negative affect following use of avoidant coping than those with less severe PTSD symptoms. This may suggest that avoidant coping is less effective at diminishing negative affect among trauma-exposed individuals with more (vs. less) severe PTSD symptoms. Alternatively, avoidant coping may be more likely to result in a rebound in distress among trauma-exposed individuals with more (vs. less) severe PTSD symptoms, leading to greater persistence of negative affect over time. Future research is warranted to explore these possible explanations.

Nonetheless, our findings provide further support for the utility of targeting the negative affect-avoidant coping link in the treatment of trauma-exposed individuals. Following traumatic exposure, individuals may benefit from being taught approach coping strategies for managing negative affect (e.g., getting in touch with negative emotions, allowing oneself to experience negative emotions, paying attention to the information being provided by negative emotions) to replace avoidant coping strategies (Emotion Regulation Group Therapy; Gratz, Tull, & Levy, 2014). Indeed, among trauma-exposed military veterans, greater use of approach coping to modulate distress has been found to be associated with fewer trauma-related negative outcomes (e.g., PTSD and depression severity; Hassija, Luterek, Naragon-Gainey, Moore, & Simpson, 2012). Additionally, evidence for a reciprocal relation of negative affect to avoidant coping indicates that strategies aimed at reducing negative affect may be valuable in reducing the negative affect-avoidant coping link, and subsequent PTSD symptom severity. For instance, the dialectical behavior therapy skill ACT PLEASE (Linehan, 2014) is used to decrease vulnerability to negative emotions, and involves accumulating positive emotions (A), building mastery (B), coping ahead (C), treating physical illness (PL), balanced eating (E), avoiding mind-altering drugs (A), balanced sleep (S), and exercise (E); dialectical behavior therapy has shown promise in reducing PTSD symptom severity (Harned, Korslund, & Linehan, 2014).

The direct targeting of the negative affect-avoidant coping link also has shown promise in reducing negative trauma-related outcomes. Prolonged exposure, a first-line treatment for PTSD (Rauch, Eftekhari, & Ruzek, 2012), is purported to facilitate recovery from PTSD through habituation (Foa, Hembree, & Rothbaum, 2007). Specifically, imaginal and in vivo exposures are thought to modify fear structures that maintain PTSD by providing corrective information (Rauch & Foa, 2006). Through engagement with traumatic memories – the antithesis of trauma-related avoidance – habituation of anxiety-related autonomic responses associated with traumatic memories (i.e., negative affect) is promoted. Regarding the relation of negative affect to avoidant coping, research suggests that, in some instances, a reduction in intense, overwhelming negative affect, such as through techniques aimed at promoting grounding, a present-focus, or cognitive change, may facilitate approach of traumatic memories in prolonged exposure (Jaycox & Foa, 1996). Finally, our results suggest the value of assessing negative affect and avoidant coping among individuals identified by traumatic exposure (e.g., within the emergency department following a physical injury) or PTSD (e.g., within an outpatient mental health clinic) to identify individuals who would benefit from prevention and intervention efforts, respectively.

Of note, supplemental analyses found that the pattern of findings for moderation analyses remained the same in strength and direction for PTSD re-experiencing and avoidance (but not numbing and hyperarousal) symptom severity. It will be important for future studies to clarify the potentially differential impact of PTSD symptom clusters on the association between negative affect and avoidant coping, ideally using the PTSD symptom clusters outlined in the DSM-5 (i.e., intrusions, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity; APA, 2013).

Although findings of the present study improve our understanding of the directionality of the negative affect-avoidant coping relation among trauma-exposed individuals with varying levels of PTSD symptom severity, several limitations are noteworthy. First, the correlational nature of the data precludes causal determination of the relations examined. Future research is needed using experimental paradigms in the laboratory (e.g., emotion induction) to clarify the relation of negative affect to avoidant coping among individuals with varying levels of PTSD symptom severity. Second, avoidant coping was assessed daily with a single-item measure, which has the disadvantage of having low content validity, sensitivity, and reliability. Nonetheless, single-item measures are practical when measurements are taken at frequent intervals, such as within daily diary studies, to reduce participant burden. Further, they have been shown to demonstrate adequate psychometric properties in daily diary studies where a limited number of items can be included (Cappelleri et al., 2009; Van Hooff, Geurts, Kompier, & Taris, 2007). Future research should consider including more comprehensive measures of daily coping, such as those assessing perceived efficacy of avoidant coping.

Second, evaluation of the context in which avoidant coping has occurred may provide further evidence regarding the adaptive vs. maladaptive nature of such efforts (Aldao, 2013). Indeed, although generally associated with deleterious outcomes (Aldao, Nolen-Hoeksema, & Schweizer, 2010), avoidant coping may be adaptive in some contexts (e.g., when employed flexibly to meet situational demands; Bonanno, Papa, Lalande, Westphal, & Coifman, 2004). For instance, avoidant coping may confer short-term benefits when presented with physical threat (Lewis et al., 2006) or in contexts perceived as uncontrollable (Vitaliano, DeWolfe, Maiuro, Russo, & Katon, 1990). A more comprehensive assessment of contextual factors would also be valuable to understanding the factors that both drive and constrain the association between negative affect and avoidant coping. For example, it is likely that daily experiences promote or impede both negative affect (e.g., stressful vs. pleasurable events) and avoidant coping (e.g., work vs. home environment).

Third, avoidant coping was only assessed in the evening, precluding assessment of the impact of evening negative affect on next-day daytime avoidant coping. This is an important avenue for future research as daytime and evening experiences (e.g., interpersonal interactions) and physiological functioning (e.g., cortisol secretion) may differ in important ways. Further, research using daily survey methods suggests that there is some stability in behavior from day to day, often because the underlying stressors/problems are still be salient. However, there are many things that could happen from one day to the next that could alter affect and coping. For example, someone might have been in a bad mood at mid-day assessment, then had a fun night, which in turn negated any effect of negative affect on next day avoidant coping. Alternatively, sleep may ameliorate stress, and thus reports of prior-evening avoidant coping may not be systematic. Thus, our models do suffer from misspecification in that do not account for all experiences that could have happened between reporting periods. That said, it is possible that omission of these variables actually weakens our findings. Future studies should test this hypothesis. Fourth, given that avoidance is characteristic of PTSD, it is possible that the link between PTSD symptom severity and avoidant coping reflects a measurement confound. Although our analyses that exclude PTSD avoidance items suggest a similar pattern of findings, future research would benefit from further examining this overlap.

Finally, our findings may not generalize to other samples (e.g., with regard to age, race/ethnicity, education). For instance, given the aims of the larger study, our study was comprised of alcohol-using college students. The relation of PTSD to the negative affect-avoidant coping link may be stronger among alcohol-users given evidence that alcohol use is one strategy that individuals with PTSD may use to module trauma symptoms and distress (Weiss, Tull, Viana, Anestis, & Gratz, 2012). Further, while trauma is highly prevalent among college students (Frazier et al., 2009) and associated with deleterious outcomes (Anders, Frazier, & Shallcross, 2012), including PTSD symptom severity (Read et al., 2012), replication across other samples of trauma-exposed individuals (e.g., clinical) is needed. Nonetheless, analogue samples have important strengths, such as identifying vulnerabilities to the initial development of clinical phenomena (Tull et al., 2008), highlighting the importance of research with college students to the research process.

Despite these limitations, findings of the present study underscore reciprocal relations among negative affect and avoidant coping at the daily level. Further, our results provide support for the moderating role of PTSD symptom severity in bi-directional relations between negative affect and avoidant coping, such that for individuals with more (vs. less) severe PTSD symptoms, the association of negative affect to avoidant coping was weaker and the association of avoidant coping to negative affect was stronger. These findings suggest the utility of treatments targeting negative affect to reduce avoidant coping among trauma-exposed individuals broadly, and avoidant coping to reduce negative affect among trauma-exposed individuals with greater PTSD symptom severity in particular.

Highlights.

• Daytime negative affect related to evening avoidant coping

• Evening avoidant coping related to next-day daytime negative affect

• Daily relation of negative affect to avoidant coping was stronger among individuals with less severe PTSD symptoms

• Daily relation of avoidant coping to negative affect was stronger among individuals with more severe PTSD symptoms

• Findings advance our understanding of the negative affect-avoidant coping association