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Received: 2 May 2021 Revised: 17 January 2022 Accepted: 18 January 2022

DOI: 10.1002/jts.22820

RESEARCH ARTICLE

The associations between posttraumatic stress disorder and

delay discounting, future orientation, and reward
availability: A behavioral economic model
Cecilia C. Olin1 Meghan E. McDevitt-Murphy1 James G. Murphy1
Rebecca J. Zakarian1 John D. Roache2,3 Stacey Young-McCaughan2,3
Brett T. Litz4,5,6 Terence M. Keane5,7 Alan L. Peterson2,3,8 for the
Consortium to Alleviate PTSD
1 Department of Psychology, The University of Memphis, Memphis, Tennessee, USA
2 Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
3 Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
4 Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA
5 Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
6 Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts, USA
7 Behavioral Science Division, National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts, USA
8 Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA

Correspondence
Meghan E. McDevitt-Murphy,
Department of Psychology, The University
of Memphis, 400 Innovation Drive,
Memphis, TN 38152.
Email: mmcdvttm@memphis.edu
Funding information
This research was supported by
Consortium to Alleviate PTSD (CAP)
awards from the U.S. Department of
Defense, Defense Health Program,
Psychological Health and Traumatic Brain
Injury Research Program (PH/TBI RP;
W81XWH-13-2-0065), and from the U.S.
Department of Veterans Affairs, Office of
Research & Development, Clinical
Science Research & Development Service
(I01CX001136-01).
Abstract
The theoretical framework of behavioral economics, a metatheory that integrates
operant learning and economic theory, has only recently been applied to post-
traumatic stress disorder (PTSD). A behavioral economic theory of PTSD reflects
an expansion of prior behavioral conceptualization of PTSD, which described
PTSD in terms of respondent and operant conditioning. In the behavioral eco-
nomic framework of PTSD, negatively reinforced avoidance behavior is overval-
ued, in part due to deficits in environmental reward, and may be conceptualized
as a form of reinforcer pathology (i.e., excessive preference for and valuation of
an immediate reinforcer). We investigated cross-sectional relationships between
PTSD severity and several constructs rooted in this behavioral economic frame-
work, including future orientation, reward availability, and delay discounting in
a sample of 110 military personnel/veterans (87.2% male) who had served com-
bat deployments following September 11, 2001. Total PTSD severity was inversely
related to environmental reward availability, β = −.49, ΔR2 = 0.24, p < .001; hedo-
nic reward availability, β = −.32, ΔR2 = 0.10, p = .001; and future orientation,
β = −.20, ΔR2 = 0.04, p = .032, but not delay discounting, r = −.05, p = .633.
An examination of individual symptom clusters did not suggest that avoidance
symptoms were uniquely associated with these behavioral economic constructs.
The findings offer support for a behavioral economic model of PTSD in which
there is a lack of positive reinforcement as well as a myopic focus on the present.

1252 © 2022 International Society for Traumatic Stress Studies. wileyonlinelibrary.com/journal/jts J. Trauma. Stress. 2022;35:1252–1262.

A BEHAVIORAL ECONOMIC MODEL
Posttraumatic stress disorder (PTSD) affects approximately
7% of the U.S. population (Kessler et al., 2005), resulting
in impairment that is often chronic and pervasive across
many life domains (Kessler, 2000). Although each of the
four PTSD symptom clusters has been associated with sig-
nificant distress, avoidance symptoms may be uniquely
pernicious, as they may contribute to or exacerbate other
symptoms (Ehlers & Clark, 2000; Keane et al., 1985).
Empirical evidence suggests that although avoidance may
reduce distress initially, it ultimately leads to worsening
severity over time (Boden et al., 2012).
Historically, Mowrer’s two-factor theory (Mowrer, 1960)
has provided a behavioral model to explain the acqui-
sition of PTSD as a trauma reaction that occurs as the
result of two interacting processes: classical and oper-
ant conditioning (Keane & Kaloupek, 1982; Keane et al.,
1985). Classical conditioning describes the acquisition of
emotional responses, typically fear or anxiety, to trauma-
related stimuli, and operant conditioning refers to the
development of behavioral patterns reinforced by their
consequences. Avoidance behaviors are negatively rein-
forced by the immediate reduction of aversive internal
experience (e.g., anxiety).
Through the behavioral process of generalization, the
avoidance response may be elicited by stimuli that share
properties with trauma-related stimuli, even when there
appears to be no apparent connection to the traumatic
event (e.g., a car backfiring causing the same response
as a gunshot). Additionally, higher-order conditioning
describes a process whereby stimuli that occurs in the envi-
ronment when a conditioned response is elicited become
conditioned stimuli as well (Keane et al., 1985). Over
time, the dual processes of ongoing associative and oper-
ant conditioning lead to an expanding web of associa-
tions among formerly neutral stimuli that become cues
for avoidance. As the network of avoided stimuli expands,
engagement in one’s environment is reduced, and this lim-
its exposure to previously pleasurable or enjoyed stim-
uli. Thus, negative reinforcement patterns strengthen, and
opportunities for positive reinforcement become more lim-
ited. This parsimonious behavioral model provides a com-
pelling description of the acquisition and maintenance of
PTSD, and it is also consistent with the metatheory of
behavioral economics.
Behavioral economics incorporates operant learning
theory and microeconomic constructs to describe decision-
making and behavior (Kahneman, 2003). Applying behav-
ioral economic theory to psychopathology (initially addic-
tive behavior) led to the concept of “reinforcer pathol-
ogy” (Bickel et al., 2014), which describes a maladaptive
behavior pattern characterized by the persistently inflated
valuation of a reinforcer and a preference for immediate
reinforcement regardless of long-term consequences. In
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1253
economic terms, the inflated valuation of the reinforcer
reflects a high level of demand, resulting in an excessive
allocation of resources, such as time and effort, in the pur-
suit of that reinforcer. The preference for the immediate
reinforcer instead of alternative or preferable reinforcers
that would only be available after a delay reflects a “dis-
counting” of the value of later reinforcers due to their
temporal distance (i.e., delay discounting; Mazur, 1987;
Rachlin et al., 1991). This model has been widely applied
to hazardous alcohol use and other substance use (Acuff
et al., 2017; Beenstock et al., 2014). In the context of PTSD,
the reduction in negative affect that results from avoid-
ance is overvalued and pursued at the expense of other
important life domains. There have been a few investiga-
tions of behavioral economic indices of substance misuse
among individuals with PTSD (Acuff et al., 2018; Luciano
et al., 2019; Murphy et al., 2013); however, to our knowl-
edge, no prior published work has conceptualized PTSD-
related avoidance as a form of reinforcer pathology.
Delay discounting has been assessed using behavioral
choice tasks that present respondents with a series of
choices between two monetary sums that differ in magni-
tude and delay until their receipt (e.g., “Would you pre-
fer to have $50 now or $100 in one month?”). The liter-
ature on delay discounting and psychopathology broadly
has shown that substance use disorders, major depressive
disorder, schizophrenia, borderline personality disorder,
bipolar disorder, bulimia nervosa, and binge-eating disor-
der are all related to steeper discounting of delayed rewards
(Amlung et al., 2017, 2019). There is limited literature inves-
tigating this phenomenon among individuals with PTSD,
although the process of avoidance in PTSD suggests a
pattern of discounting delayed rewards in favor of the
immediate negative reinforcement associated with distress
reduction. Some research, though, indicates that trauma
exposure itself is associated with subsequent preference for
immediate rewards over delayed rewards at steeper rates
than controls (Simmen-Janevska et al., 2015; van den Berk-
Clark et al., 2018), suggesting that this is likely a relevant
construct for understanding the pathology of PTSD.
Future orientation is a conceptually related but empir-
ically distinct construct that reflects the degree to which
individuals organize their behavior around anticipated
future events (Daugherty & Brase, 2010). Typically
assessed through self-report, future orientation refers
to the extent to which individuals consider the future
consequences of their current behavior and how much
they allow this to influence their behavior (Strathman
et al., 1994). The behavior pattern associated with PTSD
(i.e., favoring the short-term effects of avoidance) suggests
that limited future orientation may be characteristic of
the syndrome. Of note, the symptom criteria for PTSD
included an item referring to the “sense of a foreshortened

1254
future” in prior editions of the Diagnostic and Statistical
Manual of Mental Disorders (DSM; American Psychiatric
Association [APA], 1980, 1994). Some research suggests
that restricted future orientation may play a role in linking
acute PTSD symptoms to a more chronic course of the
disorder (Haag et al., 2017). Further, one study found
that a sense of foreshortened future contributed to other
emotional numbing symptoms, such as social withdrawal
(Bryant, et al., 2017). Thus, limited future orientation has
been associated with PTSD and may be relevant to under-
standing the persistent avoidance that is characteristic of
PTSD.
The third construct that is relevant to considering PTSD
in the framework of behavioral economics is reward avail-
ability and accessibility. Environmental reward availabil-
ity refers to the density of reinforcing activities in one’s
environment, and hedonic reward availability is the capac-
ity to seek out and enjoy positive stimuli. Based on the
tendency for individuals with PTSD to develop negatively
reinforced patterns of avoidance that are pervasive and per-
sistent, contact with potential positive reinforcers becomes
limited. Thus, avoidance may functionally reduce the envi-
ronmental availability of reinforcing stimuli. It is unclear,
however, whether avoidance affects hedonic reward avail-
ability (i.e., the internal experience of positive stimuli)
in the same way. For instance, as an individual’s range
of avoided stimuli widens and previously enjoyed activi-
ties may trigger anxiety, they may no longer derive plea-
sure from those activities. Broader examinations of anhe-
donia (i.e., the loss of hedonic pleasure or motivation to
access pleasure) among individuals with PTSD compared
to healthy controls have suggested that PTSD is related to
deficits in the experience of pleasure (Nawijn et al., 2015),
but examinations of the relation to avoidance specifically
have yet to be conducted. The findings from a previous
study suggest that PTSD may be inversely associated with
environmental, but not hedonic, reward availability (Acuff
et al., 2018). As such, PTSD is likely to be inversely related
to overall reward availability and environmental reward
availability, but the association with hedonic reward avail-
ability remains unclear.
To examine this behavioral economic conceptualization
of PTSD, the present study investigated the associations
between PTSD severity and three behavioral economic
constructs that are implicated in this model (i.e., delay dis-
counting, future orientation, and reward availability) in a
sample of veterans and military personnel. We predicted
that PTSD severity would be related to an increased prefer-
ence for immediate rewards (i.e., high delay discounting),
less regard for future consequences (i.e., low future ori-
entation), and lower availability of positive reinforcement
(i.e., low environmental reward availability).
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OLIN et al
METHOD
Participants
Participants (N = 110) were veterans (n = 89, 80.9%),
reservists (n = 17, 15.5%), and active duty military per-
sonnel (n = 4, 3.6%) who had served at least one combat
deployment as part of the U.S. military following the
September 11, 2001, terrorist attacks. In total, 87.2% (n
= 96) of participants identified as male. Regarding race,
63.6% (n = 70) of participants identified as White or
Caucasian, 30.0% (n = 33) as Black or African American,
1.8% (n = 2) as Asian or Asian American, and 4.5%
(n = 5) as “other”; for ethnicity, 4.5% of (n = 5) participants
identified as Hispanic or Latinx. A total of 70.9% of partic-
ipants (n = 78) met the criteria for a PTSD diagnosis based
on a structured clinical interview. In addition, 34.5% (n =
38) reported behavior suggesting the risk of an alcohol use
disorder, as assessed using the Alcohol Use Disorder Iden-
tification Test (Babor et al., 2001); 23.6% (n = 26) reported
illicit drug use, as assessed using the Drug Use Disorder
Identification Test (Berman et al., 2005); 27.3% (n = 30)
report smoking cigarettes as assessed using the Fagerström
Test for Nicotine Dependence (Heatherton et al., 1991);
and 11.8% (n = 13) report using smokeless tobacco (Fager-
ström Test for Nicotine Dependence–Smokeless Tobacco;
Ebbert et al., 2006). Based on the Mini International
Neuropsychiatric Interview (M.I.N.I.; Sheehan et al.,
1998), 41.8% (n = 46) of the sample met the criteria for
current major depressive disorder, 22.7% (n = 25) for gen-
eralized anxiety disorder, 11.8% (n = 13) for panic disorder,
and 14.7% (n = 16) for social anxiety disorder. Addi-
tional descriptive data about the sample can be found in
Table 1.
Procedure
All procedures were approved by the University of
Memphis Institutional Review Board as well as the U.S.
Army Medical Research and Materiel Command Human
Research Protection Office. Data for this investigation
came from the baseline assessment session of a longer
study. Participants were recruited via social media adver-
tisements, flyers posted in the community, and in-person
recruitment at community events. Screening was com-
pleted over the phone, online, or in person to confirm
military history; DSM-5 Criterion A event exposure; and
the presence of PTSD symptoms, as assessed using the
PTSD Checklist for the DSM-5 (PCL-5; Weathers, Litz,
et al., 2013). Individuals were invited to participate if
they scored above 25 on the PCL-5; those who screened
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A BEHAVIORAL ECONOMIC MODEL 1255

TA B L E 1 Descriptive statistics for all variables Measures

Variable n % M SD
Gender PTSD
Male 96 87.3
Female 14 12.7 PTSD was assessed using the 20-item Clinician-
Race
Administered PTSD Scale for the DSM-5 (CAPS-5;
Weathers, Blake, et al., 2013). The CAPS-5 is a structured
Asian/Asian American 2 1.8
diagnostic interview based on the diagnostic criteria
African American/Black 33 30.0
outlined in the DSM-5 (APA, 2013). Items assess each of
White/Caucasian 70 63.6
the four PTSD symptom clusters of intrusions (Cluster B),
Hispanic/Latinx 5 4.5 avoidance (Cluster D), negative alterations in cognition
Other 5 4.5 and mood (Cluster D), and alterations to arousal and
Education reactivity (Cluster E). All items include an initial probe for
GED 1 0.9 that symptom followed by questions regarding symptom
High school diploma 7 6.4 onset, duration, subjective distress, and functional impair-
Some college 46 41.8 ment. Interviewers use these prompts to rate the item’s
Associate degree 23 20.9 severity on a 5-point scale ranging from 0 (absent) to 4
4-year college degree 20 18.2 (extreme/incapacitating). For the present study, interviews
Master’s degree 11 10.0 were conducted by advanced clinical psychology doctoral
Doctoral degree 2 1.8
students who were trained to administer the CAPS by
the National Center for PTSD. The measure can be used
Income (USD)
to derive a diagnosis of PTSD by applying the DSM-5
< $10,000 11 11.3
algorithm (i.e., at least: one intrusion symptom, one
$10,000–$20,000 11 11.3
avoidance symptom, two negative alterations in cognition
$20,000–$35,000 14 14.4 and mood symptoms, and two alterations to arousal and
$35,000–$50,000 22 22.7 reactivity symptoms) and can also be scored as a contin-
$50,000–$100,000 29 29.9 uous measure by summing the scores for each symptom.
> $100,000 10 10.3 Scores can also be derived for each symptom cluster.
Age (years) 37.11 7.76 The CAPS-5 has been psychometrically evaluated among
CAPS-5 total score 29.27 10.38 veteran samples and found to demonstrate high interrater
RPI total score 49.49 6.67 reliability and good test–retest reliability (Weathers et al.,
RPI Hedonic Reward 29.42 4.56 2017). Internal consistency for the present study was
Availability adequate, Cronbach’s α = .82.
RPI Environmental Reward 20.16 3.68
Availability
Consideration of Future 40.86 7.89
Delay discounting
Consequences
Delayed reward discounting was assessed using an eight-
Delay discounting score 0.58 0.23
item measure (Gray et al., 2014) based on the Monetary
Note: CAPS-5 = Clinician-Administered PTSD Scale for DSM-5; RPI = Reward
Choice Questionnaire (MCQ; Kirby et al., 1999). The mea-
Probability Index.
sure was intended to assess the degree to which the respon-
dent values hypothetical monetary rewards as a function
positive were invited to participate in a comprehensive of the delay before their receipt. Participants were asked to
assessment session to determine their study eligibility. choose between a hypothetical smaller amount of money
During this assessment session, deployment history was (e.g., $30, $50, $70) available immediately and a larger
confirmed via DD-214 review, and participants com- amount of money (i.e., $100) available in varying amounts
pleted a battery of self-report measures and structured of time in the future (e.g., 1 month, 6 months, 1 year). Pref-
interviews (e.g., the Clinician-Administered PTSD Scale erence for the immediate reward (e.g., $50 today) is coded
for DSM-5 [CAPS-5]; Weathers, Blake, et al., 2013). as “1,” and preference for the delayed reward (e.g., $100
During the interview process, eligible participants were in 1 month) is coded as “0.” Scores are then added and
required to report having experienced a DSM-5 Criterion divided by 8 to create a ratio ranging from 0 to 1, with larger
A traumatic event (APA, 2013) that occurred during their values indicating an increased preference for the immedi-
deployment. ate reward. The eight items included in the measure were

1256
selected using an item-based analysis of a larger sample
of items by Gray and colleagues (2014). Using exploratory
and confirmatory analyses in an undergraduate sample,
they found that the selected eight items predicted most of
the variance in several delay discounting indices (e.g., area
under the curve, k, points of indifference).
Future orientation
Future orientation was assessed using the Consideration
of Future Consequences Scale (CFC; Strathman et al.,
1994), which includes twelve items that query the extent
to which one’s decisions about current behavior are influ-
enced by the future consequences (e.g., “I consider how
things might be in the future and try to influence those
things with my day to day behavior”). Participants rated the
extent to which each item was characteristic of them on a 5-
point scale ranging from 1 (extremely uncharacteristic) to 5
(extremely characteristic). Psychometric evaluations in col-
lege samples have shown adequate test–retest reliability,
convergent validity with alternative measures of future ori-
entation and delayed gratification, and incremental valid-
ity over and above alternative measures (Stratham et al.,
1994). In the present sample, Cronbach’s alpha was .82.
Reward availability
Hedonic and environmental reward availability were
assessed using the 20-item Reward Probability Index (RPI;
Carvalho et al., 2011), which consists of two subscales.
The Reward Probability subscale includes 11 items that
are used to assess respondents’ hedonic experience of
rewards in their environment (e.g., “I have the abilities
to obtain pleasures in my life”), and the Environmental
Suppressors subscale includes nine items used to examine
the barriers that participants experience when it comes to
accessing reward (e.g., “My behaviors often have negative
consequences”). Herein, we refer to the constructs of
“hedonic reward availability” and “environmental reward
availability” to reference the Reward Probability and Envi-
ronmental Suppressors subscales, respectively, for clarity
in the present manuscript. Participants were asked to rate
their agreement with each item on a 4-point scale ranging
from 1 (strongly disagree) to 4 (strongly agree). Both sub-
scales are scored such that higher scores indicate higher
levels of reward obtained. Psychometric evaluations of the
RPI have been conducted with emerging adult samples
and have demonstrated evidence of reliability for both
subscales as well as convergent validity with measures
of activity and avoidance, environmental reward, and
depression (Carvalho et al., 2011; Voss et al., 2021). In the
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OLIN et al
present sample, Cronbach’s alpha values for the Reward
Probability and Environmental Suppressors subscales
were .78 and .68, respectively.
Data analysis
Analyses were conducted using IBM SPSS Statistics (Ver-
sion 27). Data were evaluated for appropriateness of anal-
yses using recommendations by Tabachnik and Fidell
(2013). Evaluations of skew and kurtosis were within nor-
mal limits. No cases were identified as univariate or multi-
variate outliers, as assessed using Mahalanobis and Cook’s
distances. Estimates of collinearity were within normal
limits for all three regressions: r values were less than .70
for all independent variables, the Condition Index did not
exceed 30 for any variable, and no two variables showed
a variance proportion greater than .50. Missing data were
minimal (n = 4) and addressed using pairwise deletion,
resulting in a final sample size of 106 participants for
the present analyses. We conducted correlational analy-
ses to understand the associations among PTSD severity,
reward availability, future orientation, delay discounting,
and potential covariates (i.e., age, race, income, and edu-
cation). We then conducted a series of hierarchical regres-
sions to control for relevant covariates (i.e., participant
characteristics that demonstrated an association with a
dependent variable). First, we conducted separate regres-
sion analyses with CAPS-5 total score as the independent
variable and each of the significantly correlated behav-
ioral economic variables, environmental reward availabil-
ity, hedonic reward availability, and future orientation as
dependent variables. When CAPS-5 total severity was a sig-
nificant predictor of unique variance for a given depen-
dent variable, we followed up with regression analyses that
simultaneously entered the CAPS-5 symptom clusters that
were significantly correlated with each outcome, control-
ling for relevant covariates, to understand the specific con-
tribution of each symptom dimension.
RESULTS
Correlational analyses showed that CAPS-5 total symp-
tom severity scores were significantly inversely correlated
Reward Probability Index (RPI) total scores, scores on both
RPI subscales, and CFC scores. RPI was correlated with
all four PTSD symptom clusters; hedonic reward avail-
ability was significantly inversely correlated with Clus-
ters D (negative alterations in cognition and mood) and
E (alterations in arousal and reactivity); and CFC was
significantly inversely correlated with Cluster E (alter-
ations in arousal and reactivity). Delay discounting was not
 15736598, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jts.22820 by Thüringer Universitäts- Und, Wiley Online Library on [12/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
A BEHAVIORAL ECONOMIC MODEL 1257

TA B L E 2 Correlations among all variables

RPI RPI Delay
Variable RPI Total Environmental Hedonic CFC discounting Age Racea Income Educationb
CAPS-5 total −.48*** −.50*** −.32** −.20* −.05 −.09 .04 −.06 .01
Cluster B–Intrusion −.26 **
−.34 ***
−.12 −.12 −.04 −.02 .14 .01 −.06
Cluster C–Avoidance −.24* −.28** −.15 −.09 −.05 .08 −.02 .18 < .01
Cluster D–NACM −.46*** −.46*** −.32** −.16 −.07 −.14 −.05 −.12 .03
Cluster E– Alterations −.41*** −.38*** −.30** −.23* .02 −.11 .08 −.12 .05
in Arousal and
Reactivity
RPI total − .75*** .86*** .35*** <−.01 .13 .08 .21* .03
RPI Environmental − .32**
.27 **
−.04 .16 .06 .23* .05
RPI Hedonic − .29** .02 .05 .07 .10 .02
CFC − −.16 .16 −.09 .09 .07
Delay discounting − .07 .01 < −.01 .02
Note: CAPS-5 = Clinician-Administered PTSD Scale for DSM-5; NACM = negative alterations in cognition and mood; RPI = Reward Probability Index; RPI
Environmental = RPI Environmental Reward Availability subscale; RPI = Hedonic = RPI Hedonic Reward Availability subscale; CFC = Consideration of Future
Consequences Scale.
a
White versus non-White.b Dichotomized to include college degree versus no college degree.
***p < .001; ** p < .01; *p < .05.

significantly correlated with CAPS total or cluster-specific
severity scores. Correlations for all variables are presented
in Table 2.
A series of hierarchical regressions were conducted to
investigate the extent to which CAPS-5 severity scores
explained unique variance in both RPI subscales (i.e.,
hedonic and environmental reward availability), as well
as CFC score, after controlling for covariates. After con-
trolling for income, CAPS-5 total severity was a significant
predictor of RPI environmental reward availability,
accounting for an additional 23.5% of variance, F(2, 94)
= 19.16, p < .001, R2 = .29. When each symptom cluster
score was entered simultaneously in a follow-up analysis,
the overall model was significant, F(5, 91) = 7.73, p < .001,
R2 = .30, but only Cluster D (i.e., negative alterations in
cognition and mood) emerged as a significant predictor
(see Table 3). No demographic characteristics were signif-
icantly correlated with RPI hedonic reward availability,
so no covariates were entered for this dependent variable.
Thus, the magnitude of the beta coefficient for CAPS-5
total severity score was of the same magnitude as the
zero-order correlation coefficient. The overall model was
significant, with CAPS-5 total severity accounting for 9.9%
of variance in RPI hedonic reward availability, F(1, 108)
= 11.92, p = .001, R2 = .01. When Clusters D (negative
alterations in cognition and mood) and E (alterations
in arousal and reactivity) were entered into a regression
simultaneously as predictors, the overall model was
significant, F(2, 107) = 8.23, p < .001, R2 = .13, as was
the coefficient for each cluster (see Table 4). There were
no significant correlations between CFC score and any
demographic characteristics; thus, CAPS-5 total severity
score was entered without covariates, and the overall
model was significant, F(1, 108) = 4.70, p = .032, R2 = .04.
In the regression analysis with Cluster D and E scores
entered simultaneously, the overall model was significant,
F(2, 107) = 3.23, p = .043, R2 = .06, but neither cluster was
a significant predictor (see Table 5).
Given the high frequency of anxiety and depression
present in the sample, we also reran the regressions with
CAPS-5 total severity predicting each behavioral economic
variable and included dichotomous M.I.N.I. Major Depres-
sive Disorder and M.I.N.I Anxiety (i.e., generalized anxiety
disorder, panic disorder, social anxiety disorder) in a prior
step. Due to the focus of the present paper on PTSD specif-
ically, the results are not presented herein but are included
in the Supplemental Materials.
DISCUSSION
The present study explored the associations among aspects
of PTSD and a set of behavioral economic constructs
reflecting future orientation, delay discounting, and access
to reinforcement/reward in a sample of combat veter-
ans. Consistent with the reinforcer pathology model, we
posited that PTSD symptoms would be associated with
a focus on the present timeframe, a pattern of discount-
ing future rewards, and a reduced experience of pos-
itive reinforcement. Our correlational analyses showed
that PTSD severity was significantly inversely related
to future orientation, suggesting that PTSD may be
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1258 OLIN et al

T A B L E 3 Regressions evaluating variance in Reward Probability Index (RPI) Environmental Reward Availability explained by
Clinician-Administered Posttraumatic Stress Disorder Scale for DSM-5 (CAPS-5) total severity and symptom cluster severity scores
Independent variable B SE 95% CI β p ΔR2
Predicting RPI-Environmental Reward Availability with CAPS-5 total severity score
Step 1
Income 0.50 0.21 [0.08, 0.92] .21 .020 .06*
Step 2
CAPS-5 total −0.17 0.03 [−0.23, −0.11] −.49 < .001 .24*
Predicting RPI- Environmental Reward Availability with CAPS-5 symptom cluster score
Step 1
Income 0.50 0.22 [0.06, 0.94] .21 .026 .06*
Step 2
CAPS-5 Cluster B–Intrusions −0.10 0.13 [−0.35, 0.16] −.09 .441 .24*
CAPS-5 Cluster C–Avoidance −0.25 0.21 [−0.67, 0.16] −.13 .231
CAPS-5 Cluster D–NACM −0.23 0.08 [−0.38, −0.08] −.31 .003
CAPS-5 Cluster E– Alterations in Arousal and Reactivity −0.12 0.13 [−0.37, 0.13] −.11 .337
Note: n = 97; n = 13 participants in the full sample did not complete income variable due to survey administration error. Bolding indicates statistical significance.
NACM = negative alterations in cognition and mood.
*p < .05; ** p < .01; ***p < .001.

accompanied by a myopic focus on the present. Correla-
tions also showed that PTSD was significantly inversely
related to both environmental and hedonic reward avail-
ability, suggesting that higher levels of PTSD severity were
associated with lower positive reinforcement in this sam-
ple due to both blunted reward functioning (i.e., anhedo-
nia) and reduced access to positive reinforcement in the
environment. Regression findings supported both these
associations even after controlling for income in the model
predicting environmental reward availability. Contrary to
our prediction, PTSD severity was not associated with
delay discounting.
Although the findings were largely consistent with
our hypotheses, when we examined the role of each
symptom cluster, the results did not point to avoidance as a
specific mechanism across the board. Whereas avoidance
was correlated with environmental reward availability, it
was not a significant predictor when entered simultane-
ously with the other PTSD symptom clusters in a regres-
sion model. Only the negative alterations in cognition and
mood cluster was a significant predictor when all symp-
tom clusters were examined simultaneously. This cluster
was also a significant predictor of hedonic reward avail-
ability. The fact that this symptom dimension predicted
both aspects of reward availability is consistent with the
fact that it includes criteria regarding diminished interest
or participation in activities, reduced ability to experience
positive emotions, and detachment or estrangement from
others, all of which have been conceptualized as reflecting
deficits in reward functioning. Diminished reward func-
tioning has been observed previously in PTSD (see Naw-
ijn et al., 2015, for a review). Importantly, these symptoms
also overlap with the experience of and diagnostic criteria
for depressive disorders (APA, 2013). Given the relevance
of deficits in reward functioning to depression, a condition
that is frequently comorbid with PTSD, this may reflect
an important transdiagnostic factor. In PTSD specifically,
experimental research on the phenomenon of approach–
avoidance conflict suggests that when a rewarding stimu-
lus is associated with a trauma-related cue, the tendency to

T A B L E 4 Regressions Evaluating Variance in Reward Probability Index (RPI) Hedonic Reward Availability Explained by
Clinician-Administered Posttraumatic Stress Disorder Scale for DSM-5 (CAPS-5) total severity and significant symptom cluster severity scores
Independent variable B SE CI β p ΔR2
Predicting RPI-Hedonic Reward Availability with CAPS-5 total severity score
CAPS-5 total −0.14 0.04 [−0.22, −0.06] −.32 .001 .10*
Predicting RPI-Hedonic Reward Availability with CAPS-5 symptom cluster score
CAPS-5 Cluster D–NACM −0.22 0.94 [−0.41, −0.03] −.24 .021 .133*
CAPS Cluster E –Alterations in Arousal and Reactivity −0.26 0.14 [−0.54, 0.01] −.19 .061
Note: Bolding indicates statistical significance. NACM = negative alterations in cognition and mood.
*p < .05; ** p < .01; ***p < .001.

A BEHAVIORAL ECONOMIC MODEL
T A B L E 5 Regressions evaluating variance in Consideration of Future Consequences (CFC) scores explained by Clinician-Administered
Posttraumatic Stress Disorder Scale for DSM-5 (CAPS-5) total severity and significant symptom cluster severity scores
Independent variable
Predicting CFC with CAPS-5 total severity score
CAPS-5 total score
Predicting CFC with CAPS-5 cluster scores
CAPS-5 Cluster D–NACM
CAPS-5 Cluster E–Alterations in Arousal and Reactivity
Note: Bolding indicates statistical significance. NACM = negative alterations in cognition and mood.
*p < .05; ** p < .01; ***p < .001.
avoid will undermine the rewarding value of the stimulus,
a dynamic that has been described as “sacrifice of reward”
(Weaver et al., 2020). In light of this work, the present find-
ings support the idea that anhedonia, particularly the moti-
vational aspect, may play a significant role in maintain-
ing PTSD symptoms. This approach–avoidance conflict is
also consistent with a focus on the present timeframe and
a diminished capacity to conceptualize the future.
As an alternative to the approach–avoidance conflict
model, it is possible that low hedonic experience of reward
is a premorbid trait that increases the risk of PTSD; thus,
individuals who lack the drive to seek positive reinforce-
ment could be most vulnerable to developing a myopic
focus on avoiding aversive experiences. Although the
present findings highlight the role of Cluster D (i.e., neg-
ative alterations in cognitions and mood) symptoms, it
remains possible that avoidance plays a role, alongside
anhedonia, among individuals with PTSD. To fully under-
stand the dynamic between avoidance and reward func-
tioning/anhedonia among individuals with PTSD, how-
ever, more granular examinations of avoidance may be
necessary. We used a gold-standard, interview-based mea-
sure of PTSD, which is a strength of the study; however, this
includes only two items that assess avoidance, which cor-
responds with the DSM-5 criteria. Avoidance did not show
a salient pattern of unique associations with the behavioral
economic variables, despite the centrality of avoidance as
a maintaining factor in PTSD. It is possible that our assess-
ment of avoidance was inadequate for this purpose, with
only two items and a total possible score range of 0–8. A
more detailed method of measuring avoidance could help
to fully explore this theoretical model.
Hedonic reward availability was also significantly
related to altered arousal, suggesting that a state of high
alert may be incompatible with the subjective experience
of pleasure. Past literature has found that emotional numb-
ing, which includes anhedonia, is more strongly related to
hyperarousal symptoms than intrusion or avoidance symp-
toms (Flack et al., 2000; Tull & Roemer, 2003). It is also
possible that the overvaluation of avoidance indirectly con-
tributes to this association. Avoidance may reduce much
15736598, 2022, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jts.22820 by Thüringer Universitäts- Und, Wiley Online Library on [12/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1259
B SE CI β p ΔR2
−0.16 0.07 [−0.30, −0.01] −.20 .032 .04*
−0.11 0.17 [−0.45, 0.22] −.07 .506 .06*
−0.47 0.25 [−0.97, 0.03] −.20 .062
of the acute distress caused by altered arousal in the short
term but lead to worsening symptoms in the long term
(Boden et al., 2012; Tull et al., 2004; Tull & Roemer, 2003).
As such, this association may suggest that the overvalua-
tion of avoidance negatively impacts hedonic reward avail-
ability by increasing arousal. Future research may eluci-
date this possibility.
As noted, total PTSD severity scores were significantly
inversely related to future orientation, suggesting that
PTSD is related to the extent to which individuals incor-
porate future consequences into their decision-making.
Interestingly, though, when investigated simultaneously
in a regression, not even the significantly correlated clus-
ters were significant predictors of future orientation. PTSD
severity was not related to delay discounting, which was
unexpected considering that past literature has found a
significant association between discounting and trauma
exposure (Simmen-Janevska et al., 2015; van den Berk-
Clark et al., 2018). Additionally, given that delay discount-
ing and future orientation are conceptually similar, it is
surprising that they showed different patterns of asso-
ciation with PTSD and were not significantly correlated
with each other. Taken together, these findings suggest
that PTSD may not be associated with undervaluing future
rewards but rather with a diminished ability to envision the
future and organize one’s behavior in accordance with the
anticipated consequences.
It is possible that the absence of a significant association
between PTSD and discounting could be due to our use of a
brief (i.e., eight-item) measure of delay discounting. Meta-
analytic evaluations have found that measures using fewer
items produce smaller effect sizes (MacKillop et al., 2011).
Additionally, the brevity of this measure does not allow
for calculation of specific metrics offered by longer mea-
sures of discounting (e.g., discounting rate or area under
the curve), limiting our ability to examine the extent to
which participants were making systematic discounting
choices. Relatedly, this measure was also validated in a pri-
marily female sample of undergraduates (Gray et al., 2014),
and, thus, may not have been appropriate for the present
predominately male, older sample. Future studies may

1260
benefit from investigating these associations using a longer
measure, such as the MCQ (Kirby et al., 1999). Behavioral
measures like the MCQ offer alternative insight to tradi-
tional self-report measurement. Future studies of behav-
ioral economic models of PTSD may benefit from addi-
tional behavioral measurement as well, such as hypotheti-
cal purchase tasks, which evaluate the demand for a partic-
ular reinforcer (e.g., the Alcohol Purchase Task; Murphy &
Mackillop, 2006).
Although the present study offers encouragement for
the further exploration of a behavioral economic model of
PTSD, we must acknowledge some important limitations.
Our analyses were cross-sectional, and, thus, we cannot
establish the direction or causality of any of these asso-
ciations. Additionally, the small sample and very small
proportion of women (12.8%) limited our power to detect
effects and precluded the exploration of gender differ-
ences. Although this disparity is common in samples of
military veterans, it is regrettable given that past literature
has found gender differences in some of the constructs we
examined (Silverman, 2003). Further, internal consistency
for the RPI Environmental Suppressors subscale was
questionable in the present sample (Cronbach’s α = .68);
thus, analyses with this subscale should be interpreted
with caution. Finally, reinforcer pathology was originally
conceptualized and explored in the context of substance
use and misuse, but we did not incorporate substance
use into the present analyses given that our interest in
the present investigation was to explore relations among
these behavioral economic variables and PTSD more
broadly, not limited to the intersection of PTSD and
substance misuse. It would be an important direction for
future studies, however, to explore any role behavioral
economic variables may play in the comorbidity of PTSD
and substance misuse.
The present study offers some initial support for a behav-
ioral economic conceptualization of PTSD and for the rel-
evance of the constructs of future orientation and positive
reinforcement and reward to this diagnosis. The signifi-
cant associations between PTSD severity and both of these
behavioral economic constructs suggest that the concept
of PTSD as a form of reinforcer pathology may be worth
further investigation. Although avoidance symptoms did
not appear to drive these connections in the present sam-
ple, it is possible that avoidance is a contributing factor,
particularly in the presence of motivational anhedonia.
The present findings suggest that individuals with PTSD
experience a dearth of positive reinforcement and show a
diminished ability to consider the future in their decision-
making. Given the relevance of deficits in reward function-
ing to depression, a diagnosis that is frequently comorbid
with PTSD, this may reflect an important transdiagnostic
factor.
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OLIN et al
O P E N P R AC T I C E S S TAT E M E N T
The study reported in this article was not formally prereg-
istered. The data are not available on a permanent third-
party archive but are maintained in the STRONG STAR
Repository. Requests for access to the data as well as for
materials and the analysis code also can be emailed to
repository@strongstar.org.
AU T H O R N OT E
The authors have no conflicts of interest to report. The
views expressed in this article are solely those of the
authors and do not reflect an endorsement by or the offi-
cial policy of the Department of Defense, the Department
of Veterans Affairs, or the U.S. Government.
ORCID
Cecilia C. Olin https://orcid.org/0000-0002-5132-2005
Meghan E. McDevitt-Murphy https://orcid.org/0000-
0002-3880-7083
James G. Murphy https://orcid.org/0000-0001-9378-
8754
John D. Roache https://orcid.org/0000-0002-7010-8119
Stacey Young-McCaughan https://orcid.org/0000-0002-
3327-5233
Brett T. Litz https://orcid.org/0000-0002-0479-8887
Terence M. Keane https://orcid.org/0000-0002-0482-
3149
Alan L. Peterson https://orcid.org/0000-0003-2947-2936
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S U P P O RT I N G I N F O R M AT I O N
Additional supporting information may be found in the
online version of the article at the publisher’s website.
How to cite this article: Olin, C. C.,
McDevitt-Murphy, M. E., Murphy, J. G., Zakarian,
R. J., Roache, J. D., Young-McCaughan, S., Litz, B.
T., Keane, T. M., & Peterson, A. L., for the
Consortium to Alleviate PTSD. (2022). The
associations between posttraumatic stress disorder
and delay discounting, future orientation, and
reward availability: A behavioral economic model.
Journal of Traumatic Stress, 35, 1252–1262.
https://doi.org/10.1002/jts.22820