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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Psychol Trauma. 2021 Jul 1;14(3):446–452. doi: 10.1037/tra0001048

Posttraumatic Stress Disorder Symptom Severity Modulates Avoidance of Positive Emotions among Trauma-exposed Military Veterans in the Community

Nicole H Weiss 1, Melissa R Schick 1, Ateka A Contractor 2, Svetlana Goncharenko 1, Alexa M Raudales 1, Shannon R Forkus 1
PMCID: PMC8720112  NIHMSID: NIHMS1738430  PMID: 34197172

Abstract

Objective:

Theoretical and empirical evidence links emotional avoidance to the development and maintenance of posttraumatic stress disorder (PTSD) symptoms. However, few studies have tested whether these findings extend to positive emotional avoidance. Addressing this important gap in the literature, the current study examined the moderating role of PTSD symptom severity in the relation between positive emotional intensity and positive emotional avoidance.

Method:

Participants were 465 trauma-exposed veterans recruited from the community (Mage = 38.00, 71.6% male, 69.5% white).

Results:

The interaction between positive emotional intensity and PTSD symptom severity on positive emotional avoidance was significant. Analysis of simple slopes revealed that positive emotional intensity was significantly positively associated with positive emotional avoidance when participants endorsed high, but not low, levels of PTSD symptom severity.

Conclusions:

Veterans with more severe PTSD symptoms may utilize avoidance strategies in the context of intense positive emotions. These findings may suggest the potential need for addressing positive emotional avoidance in interventions to reduce PTSD symptom severity.

Keywords: Posttraumatic stress disorder symptom severity, Military veterans, Positive emotions, Positive emotional intensity, Positive emotional avoidance

Posttraumatic stress disorder (PTSD) symptoms are pervasive and problematic among veterans (Fulton et al., 2015). The presence of PTSD symptoms among veterans may increase reliance on emotional avoidance (attempts to alter the form, frequency, and context of emotional experiences; Chawla & Ostafin, 2007). Emotion avoidance is hypothesized to play a key role in PTSD symptoms by interfering with emotional processing of traumatic memories, habituation to aversive emotions related to trauma memories, and extinction of trauma-related fear responses (Foa & Kozak, 1986). It is a principal diagnostic feature of PTSD (APA, 2013). Moreover, it is empirically tied to PTSD symptom severity (Schick et al., 2020; Weiss et al., 2019) and predicts response to PTSD treatment (Boden et al., 2012). However, virtually all of the research in this area has focused on the avoidance of trauma-related (i.e., negative) emotions.

Through stiumulus generalization, avoidance of trauma-related emotions may extend to positive emotions among individuals with PTSD symptoms (Roemer et al., 2001). For instance, physiological arousal associated with positive emotions (e.g., excitement) may be perceived as threatening given its relation to trauma-related symptoms (APA, 2013). Additionally, positive emotions may elicit competing negative cognitions – a phenomenon known as negative affect interference (Frewen et al. 2012). Indeed, veteran’s appraisals of positive emotions – including the extent to which they view themselves as deserving of positive emotions (e.g., “I do not deserve to be happy”) or see positive emotions as predictable (e.g., “Positive emotions are always short lived”) – may elicit distress (Norman, Wilkins, Myers, & Allard, 2014). Consistent these suggestions, individuals with PTSD symptoms have been found to negatively evaluate positive emotions (Weiss et al., 2018; 2019; 2020) and subsequently engage in efforts to avoid these states (Weiss et al., 2020). Notably, positive emotional avoidance is more likely in the context of intense positive emotions (Beblo et al., 2012), with repeated avoidance of emotional cues serving to regulate intense emotional experiences (Linehan, 1993). These findings suggest that the strength of the relation between positive emotional intensity and positive emotional avoidance may be stronger among individuals with greater PTSD symptom severity.

Advancing research, this study explored the moderating role of PTSD symptom severity in the relation between positive emotional intensity and positive emotional avoidance among trauma-exposed veterans. We expected positive emotional intensity would be more strongly related to positive emotional avoidance in veterans with high (vs. low) PTSD symptom severity.

Methods

Participants and Procedure

Military veterans were recruited from Amazon’s Mechanical Turk (MTurk), an internet based crowdsourcing platform. MTurk generates reliable data (Buhrmester et al., 2011) and captures individuals with PTSD in a cost- and time-effective manner (van Stolk-Cooke et al., 2018). Inclusionary criteria were self-identified and included: (1) 18+ years old, (2) living in US, (3) English language, and (4) a veteran. Participants were warned that impersonating a veteran for financial gain is illegal and required to correctly respond to two military validity checks (Lynn & Morgan, 2016). To further improve data quality, we embedded four validity checks assessing attention and comprehension (Meade & Craig, 2012). Item-level data was missing in ≤ 6% of cases per variable and was handled using listwise deletion. Participants were compensated $2.50 for study participation. All procedures were approved by the University of Rhode Island IRB. The final sample included 465 participants. See Figure 1 for a flowchart and Table 1 for demographic information.

Figure 1.

Figure 1.

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Flow chart for sample selection

Table 1.

Sample demographics (N = 465)

M (SD) n (%) Range
Age 38.00 (11.45) 18 – 76
Gender
 Woman 131 (28.2%)
 Man 332 (71.6%)
 Transgender 1 (0.2%)
Race
 White 323 (69.5%)
 Black 108 (23.2%)
 Asian 26 (5.6%)
 American Indian/Alaska Native 19 (4.1%)
 Native Hawaiian/Other Pacific Islander 5 (1.1%)
Ethnicity
 Hispanic or Latino/a 112 (24.6%)
 Not Hispanic or Latino/a 344 (75.4%)
Employment Status
 Employed Full-Time 394 (85.7%)
 Employed Part-Time 40 (8.7%)
 Not in Labor Force (student, homemaker) 14 (3.0%)
 Unemployed 12 (2.6%)
Index Traumatic Event
 Natural disaster 47 (10.9%)
 Fire or explosion 32 (7.4%)
 Transportation accident 38 (8.8%)
 Serious accident at work/home/recreational activity 8 (1.9%)
 Exposure to toxic substance 3 (0.7%)
 Physical assault 46 (10.6%)
 Assault with a weapon 17 (3.9%)
 Sexual assault 49 (11.3%)
 Other unwanted or uncomfortable sexual 2 (0.5%)
 experience
 Combat or exposure to a war-zone 67 (15.5%)
 Captivity 1 (0.2%)
 Life-threatening illness or injury 18 (4.2%)
 Severe human suffering 13 (3.0%)
 Sudden violent death 29 (6.7%)
 Sudden accidental death 21 (4.9%)
 Serious injury, harm, or death you caused to someone else 11 (2.5%)
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Note. All reported percentages are valid percentages to account for missing data. PTSD = posttraumatic stress disorder. Participants could endorse more than one racial category.

Measures

Short Affect Intensity Scale (SAIS; Geuens & De Pelsmacker, 2002).

The SAIS-P is a 20-item self-report scale assessing positive and negative emotional intensity. Items are rated on a 7-point scale (1 = strongly disagree, 6 = strongly agree). The SAIS shows good psychometrics (Geuens & De Pelsmacker, 2002), including here (positive [α=.93] and negative [α=.94]).

Emotional Avoidance Questionnaire (EAQ; Taylor et al., 2004).

The EAQ is a 10-item self-report scale assessing positive and negative emotional avoidance. Items are rated on a 5-point scale (1 = not true of me, 5 = very true of me). The EAQ-Positive shows good psychometrics (Taylor et al., 2004), including here (positive [α = .91] and negative [.86]).

Life Events Checklist for DSM-5 (LEC-5; Weathers et al., 2013).

The LEC-5 is a 17-item self-report scale assessing lifetime traumas. Items are rated on a 6-point scale: happened to me, witnessed it, learned about it, part of my job, not sure, and does not apply. Endorsement of any of the first four responses is considered a positive endorsement of a trauma (APA, 2013).

PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013).

The PCL-5 is a 20-item self-report scale assessing DSM-5 PTSD symptoms. Participants completed the PCL-5 in response to the LEC-5 index trauma. Items are rated on a 5-point scale (0 = not at all, 4 = extremely). A score of 31 indicates probable PTSD (Blevins et al., 2015). The PCL-5 has excellent psychometrics, including among veterans (Blevins et al., 2015) and in this sample (α = .98).

Data Analysis

Correlations were computed among study variables and trauma/demographic factors. Moderation analyses were conducted with the PROCESS SPSS macro (Hayes, 2018). Negative emotional intensity, negative emotional avoidance, and trauma/demographic factors significantly related to positive emotional avoidance were included as covariates. Significant interactions were followed with simple slope analyses.

Results

Table 1 indicates prevalence rates of index traumas. Forty-nine percent of participants (n = 227) reported PTSD symptom severity consistent with a probable PTSD diagnosis. Primary study variables were significantly positively correlated (Table 2). The moderation model predicting positive emotional avoidance including the interaction of positive emotional intensity and PTSD symptom severity was significant, F (9, 420) = 39.23, p < .001, R2 = .46. Physical assault and identifying as non-White or Hispanic positively related to positive emotional avoidance, while age and non-interpersonal trauma negatively related to positive emotional avoidance; thus, these variables, as well as negative emotional intensity and negative emotional avoidance, were included as covariates (Table 3). This model revealed significant main effects for positive emotional intensity (b = .06, p = .01) and PTSD symptom severity (b = .09, p < .001) on positive emotional avoidance. Further, the interaction between positive emotional intensity and PTSD symptom severity on positive emotional avoidance was significant (b = .003, p = .004). Simple slope analyses (Figure 2) revealed that positive emotional intensity positively related to positive emotional avoidance when participants endorsed high (1 SD above the mean; b = .12, SE = .03, t = 3.67, p < .001, 95% CI [.06, .19]) but not low (1 SD below the mean; b = −.001, SE = .03, t = −0.04, p = .97, 95% CI [−.06, .06]) levels of PTSD symptom severity.

Table 2.

Intercorrelations and descriptive details regarding study variables of interest

1 2 3 M (SD) Range
1. Positive Emotional Intensity - 30.03 (9.25) 6 – 48
2. Positive Emotional Avoidance .25** - 11.83 (5.98) 3 – 25
3. PTSD Symptom Severity .17** .61** - 29.62 (23.32) 0 – 80
4. Negative Emotional Intensity .29** .43** .50** 21.85 (7.05) 6 – 36
5. Negative Emotional Avoidance .22** .59** .54** 44.39 (14.62) 3 – 70
6. Sexual Trauma −.06 .07 .16* - -
7. Physical Trauma .03 .15* .13* - -
8. Military Trauma −.04 −.03 −.05 - -
9. Other Non-Interpersonal Trauma .04 −.16* −.13* - -
10. Age .01 −.14* −.05 - -
11. Woman Gender −.01 −.05 .05 - -
12. White Racial Background −.22** −.26** −.21** - -
13. Hispanic Ethnicity .15* .38** .26** - -
14. Employed Full-Time −.01 .09 .07 - -
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Note. PTSD = posttraumatic stress disorder. Ranges reflect observed scores rather than possible scores.

*

p < .01.

**

p<.001.

Table 3.

Summary of moderation analyses

b SE t p 95% CI
Positive Emotional Intensity .06 .02 2.54 .01 [.01, .11]
PTSD Symptom Severity .09 .01 8.14 <.001 [.07, .11]
Positive Emotional Intensity X PTSD Symptom Severity .003 .001 2.88 .004 [.001, .004]
Negative Emotional Intensity −.03 .04 −0.82 .41 [−.11, .04]
Negative Emotional Avoidance .14 .02 7.56 <.001 [.10, .18]
Physical Trauma .86 .72 1.19 .24 [−.56, 2.27]
Other Non-Interpersonal Trauma −.31 .44 −0.70 .48 [−1.18, .56]
Age −.04 .02 −2.18 .03 [−.07, −.004]
White Race −.50 .50 −1.00 .32 [−1.48, .48]
Hispanic 2.45 .53 4.26 <.001 [1.21, 3.28]
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Note. PTSD = posttraumatic stress disorder, bolded typeface indicates statistical significance at the level p < .05

Figure 2. Positive emotional intensity by PTSD symptom severity interaction for positive emotional avoidance.

Figure 2.

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Note. PTSD = posttraumatic stress disorder. Values at one standard deviation above and below the mean score of PTSD symptoms, respectively, were used for plotting the figure.

Discussion

In support of the study hypothesis, the strength of the relation between positive emotional intensity and positive emotional avoidance varied as a function of PTSD symptom severity. In particular, our results showed that positive emotional intensity was significantly and positively associated with positive emotional avoidance at high (vs. low) levels of PTSD symptom severity. This finding suggests that veterans may be more likely to engage in efforts to avoid intense positive emotions when they experience greater PTSD symptom severity. Weiss et al. (2018) theorized that the distress associated with physiological, cognitive, and affective features originally paired with trauma cues might expand to positive emotions over time through stimulus generalization. Consistent with this assertion, empirical work has found trauma-exposed individuals with greater PTSD symptom severity to be less accepting of positive emotions (Weiss et al., 2018; 2019) and more likely to use avoidance strategies in the context of intense positive emotions (Weiss et al., 2020). More research is needed to test this hypothesis.

If replicated, current study findings can advance theory, research, and practice in the areas of positive emotions and PTSD. Broadly, literature underscores the protective nature of positive emotions (Fredrickson, 1998) and suggests the utility of focusing on increasing positive emotions in mental health treatment (Bolier et al., 2013). Regarding trauma recovery specifically, Folkman (1997) identified positive emotions as an integral component of the coping process following trauma, for instance counteracting negative emotions (Tugade & Fredrickson, 2004). Our findings extend this theory by indicating that individuals may have maladaptive responses to positive emotions (i.e., avoidance) following trauma, such as in the context of greater PTSD symptom severity. However, positive emotional avoidance is rarely addressed in empirically-supported PTSD treatments (Contractor et al., 2020). Instead, in line with evidence that positive emotions restore psychological resources post-trauma (Fredrickson et al., 2003), PTSD treatment for veterans often aims to increase positive emotions (Foa et al., 2007; Resick et al., 2014). If replicated, our results may suggest the need for targeting maladaptive responses to positive emotions in PTSD treatment, including physiological arousal to positive emotions (e.g., Prolonged Exposure; Foa et al., 2007) and maladaptive cognitions stemming from positive emotions (e.g., Cognitive Processing Therapy; Resick et al., 2014). Indeed, consistent with negative affect interference (Frewen et al., 2012), negative and positive emotional avoidance were significantly and positively correlated in the current study. Research indicates that trauma-exposed clients are willing/interested in discussing positive emotions (Caldas et al., 2020).

Finally, current study results highlight important avenues for future research. Investigations would benefit from examining contextual factors influencing positive emotional avoidance. While generally deleterious, there is evidence to suggest that avoidance may – at times – confer positive outcomes (Aldao, 2013), including short-term reductions in stress and anxiety (Roth & Cohen, 1986) and physical threat (Lewis et al., 2006). Yet, when applied too frequently, avoidance may result in paradoxical long-term effects, intensifying emotions (Hayes et al., 1996). Overall, this research suggests that avoidance may be functional when applied flexibly to meet individual goals or situational demands. Research is also needed to identify specific strategies utilized to avoid positive emotions. Some strategies (e.g., substance use) may be associated with greater risk for negative outcomes, and thus – when present – may highlight the more urgent need for clinical intervention that targets positive emotional avoidance.

Results need to be considered in the context of study limitations. First, the cross-sectional and correlational nature of the data precludes causal determination and temporal ordering of examined associations. Future research is needed to investigate the nature and direction of these relations through longitudinal investigations. Use of ecological momentary assessments, in particular, may minimize recall bias, maximize ecological validity, and facilitate examination of micro-processes. Second, the current study relied exclusively on self-report measures. Trauma-exposed individuals are more likely to lack emotional awareness and clarity (Weiss et al., 2013), thus studies may benefit from objective measurement of emotional responding (Gratz et al., 2006; Vasilev et al., 2009). Relatedly, PTSD diagnosis cannot be established through self-report, therefore the extent to which findings generalize to this specific PTSD outcome is unknown. Investigations in this area that integrate structured diagnostic assessment of PTSD are necessary. Third, collecting data via the internet has disadvantages that may limit generalizability of results, such as sample biases and lack of control over the research environment (Kraut et al., 2004). While our sample closely resembled veteran samples that are nationally representative (Meffert et al., 2019) and recruited from VA healthcare systems (Bovin et al., 2016), it was younger, more racially diverse, and had a greater number of women; this may have contributed to the higher rate of probable PTSD in this study. The higher rate of probable PTSD may also be due to greater comfort disclosing symptoms via MTurk due to visual anonymity (Joinson, 2001). Research should replicate findings across diverse military samples and recruitment platforms. Lastly, while examination in a community sample of veterans is a strength, replication among other veteran (e.g., clinical) or trauma-exposed (e.g., civilian) populations is warranted, and will speak to generalizability of findings. Despite these limitations, the results of the current study extend existing knowledge on the associations among positive emotional intensity, positive emotional avoidance, and PTSD symptom severity, underscoring the potential need for addressing positive emotional avoidance in interventions for PTSD symptoms.

Clinical Impact Statement.

Maladaptive responses to positive emotions (e.g., avoidance) may lead to or exacerbate mental health problems. The current study examined the role of posttraumatic stress disorder (PTSD) symptom severity in the avoidance of positive emotions. We found that more intense positive emotions were associated with greater positive emotional avoidance among veterans with high (but not low) PTSD symptom severity. These findings suggest the potential need for addressing positive emotional avoidance in interventions to reduce PTSD symptom severity.

Acknowledgments

Work on this paper by the first author (NHW) was supported by Nationals Institute of Health grants K23DA039327 and P20GM125507.

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