PTSD, PLAY, AND RELATIONSHIP SATISFACTION IN OEF/OIF...

PTSD, PLAY, AND RELATIONSHIP SATISFACTION IN OEF/OIF VETERANS

by

LISA MARIE BETTHAUSER

B.A., University of Colorado, Boulder, 2003

M.B.A., University of Colorado at Denver, Denver, 2006

M.A., University of Colorado at Denver, Denver, 2012

A thesis submitted to the

Faculty of the Graduate School of the

University of Colorado in partial fulfillment

of the requirements for the degree of

Doctor of Philosophy

Clinical Health Psychology Program

2016

ii

This thesis for the Doctor of Philosophy degree by

Lisa Marie Betthauser

has been approved for the

Clinical Health Psychology Program

by

Krista Ranby, Chair

Elizabeth Allen, Advisor

Lisa A. Brenner

Jim Grigsby

April 16, 2016

iii

Betthauser, Lisa, Marie (Ph.D., Clinical Health Psychology)

PTSD, PLAY and Relationship Satisfaction in OEF/OIF Veterans

Thesis directed by Associate Professor Elizabeth Allen

ABSTRACT

Veterans returning from service in Afghanistan (OEF) and Iraq (OIF) may have experienced

intense warfare, which can contribute to negative mental health issues, such as posttraumatic

stress disorder (PTSD). PTSD has been repeatedly linked with poorer relationship functioning.

Past research on PTSD and relationship functioning has focused primarily on negative outcomes

with limited research on positive influences that function within the relationship for increasing

relationship satisfaction. One positive strategy to promote relationship functioning is through

shared leisure activities. However, PTSD may interfere with Veterans’ ability to either

participate or enjoy such activities. To my knowledge, no studies have examined these topics in

OEF/OIF Veterans. To address this gap, this study explored Veteran’s appraisal of shared leisure

with their intimate partners with increased specificity regarding frequency and affect during

various types of such activities. I hypothesized that less frequent shared leisure, greater negative

affect during leisure, and/or less positive affect during leisure would mediate associations

between PTSD and relationship satisfaction in this sample. A sample of 68 OEF/OIF Veterans

provided self-report data on these constructs. A unique contribution of this study was the

development and initial testing of psychometric properties of the Positive Leisure Activities with

You (PLAY). In general, the results of this study demonstrate that the pilot measure tested in this

sample is a reliable and valid measure of shared leisure activity. The evidence as a whole

iv

supports the basic validity of the PLAY subscales. When proceeding to hypothesis testing, there

were unexpected findings regarding the interrelationships between PTSD, PLAY and

relationship satisfaction. One significant correlation was found between PTSD avoidance

symptoms and relationship satisfaction; no other PTSD and relationship satisfaction associations

were significant. Also, PTSD was not associated with frequency of PLAY. There were

interesting patterns regarding significant associations between PTSD and negative affect during

PLAY. Finally, results confirmed prior literature regarding the associations between shared

leisure and relationship satisfaction. Overall, these results provides some support for promoting

shared leisure activities, with consideration of the affective experience and the potential impact

of PTSD symptoms, to increase relationship satisfaction.

The form and content of this abstract are approved. I recommend its publication.

Approved: Elizabeth Allen

v

DEDICATION

I dedicate this work to my curious, resilient, and playful son, Trystan Roarke Betthauser Hayes. I

look forward to many years of play with you. I also dedicate this work to my family and mentors

that supported and encouraged me through all the trials and tribulations on this fantastic journey.

vi

ACKNOWLEDGMENTS

I would like to thank Dr. Lisa Brenner, Dr. Elizabeth Allen, Dr. Jim Grigsby, and Dr. Krista

Ranby for their invaluable input and guidance. I would like to thank the research team at the

Rocky Mountain Mental Illness, Research, Education and Clinical Center at the Denver Veterans

Affairs Medical Center for the assistance and support of this project. I extend my greatest

appreciation for all the brave men and women who have dedicated their lives and loyalty to

ensuring our freedom in this beautiful country.

This publication is based on work supported by the Department of Veterans Affairs, but does not

necessarily represent the views of the Department of Veterans Affairs or the United States

Government.

vii

TABLE OF CONTENTS

CHAPTER

I. INTRODUCTION………………………………………………………………........1

II. REVIEW OF THE LITERATURE…………………………………………………..3

PTSD in OEF/OIF Veterans………………………………………………………….3

PTSD………………………………………………………………………………….3

PTSD, Veterans & Interpersonal Relationships………………………………………4

Positive Relationship Factors…………………………………………………………6

PTSD Symptoms & Shared Activities………………………………………………..9

Current Study………………………………………………………………………...10

Specific Aims……………………………………………………………….……..…12

Aim 1…………………………………………………………………………….12

Aim 2…………………………………………………………………………….12

Hypotheses……………………………………………………………….12

Aim 3…………………………………………………………………………….13

Hypothesis……………………………………………………………….13

III. METHOD……………………………………………………………………………14

Procedure………………………………………………………………………….....14

Consent & HIPAA Authorization Procedure………………………………………..14

Participants…………………………………………………………………………..15

Demographics……………………………………………………………………15

Relationship Status………………………………………………………18

viii

Measures……………………………………………………………………………..19

Posttraumatic Stress Disorder Checklist – Civilian (PCL-C)……………………19

Kansas Marital Satisfaction Scale (KMSS)……………………………………...20

Positive Leisure Activities with You (PLAY)…………………………………...20

Measures for Validation of the PLAY Scales………………………………………..21

Marital Activities Profile (MAP)………………………………………………...22

Aron’s items of excitement in relationships……………………………………..23

Additional Measures of Relationship Satisfaction…………………………………...23

Couples Satisfaction Index (CSI-4)……………………………………………...23

Satisfaction with Marital Life Scale (SWMLS)………………………………….24

Data Analysis………………………………………………………………………...24

Power Analysis………………………………………………………………………24

Data Assumptions & Corrections……………………………………………………24

IV. RESULTS……………………………………………………………………............25

Posttraumatic Stress Disorder Checklist (PCL-C)……………………………………….25

Relationship Satisfaction………………………………………………………………...26

Marital Activities Profile (MAP) Scale & Aron Item……………………………………27

Aim 1…………………………………………………………………………………….28

PLAY Psychometrics…………………………………………………………….28

ix

PLAY Frequency Scales…………………………………………………28

PLAY Affect Scales……………………………………………………...30

Construct Validity of PLAY……………………………………………..30

Validation of PLAY Affect………………………………………………………33

Construct Validity of PLAY Continued: Extension to Additional

Measures…………………………………………………………………39

Aim 2…………………………………………………………………………………….43

PTSD & Relationship Satisfaction……………………………………………….46

PTSD & PLAY…………………………………………………………………..47

PLAY & Relationship Satisfaction………………………………………………50

PLAY Affect & Relationship Satisfaction……………………………………….51

Aim 3…………………………………………………………………………………….52

V. DISCUSSION…………………………………………………………......................53

PLAY Psychometric Properties………………………………………………………….53

Interrelationships between PTSD, PLAY & Relationship Satisfaction………………….55

VI. LIMITATIONS………………………………………………………………………60

VII. CONCLUSIONS & IMPLICATIONS………………………………………………62

REFERENCES…………………………………………………………………………………..63

x

APPENDIX….…………………………………………………………………………………...72

A: PLAY Measure……………………………………………………………………….73

B: PLAY Scales………………………………………………………………………….81

C: Predicted Correlation Matrix………………………………………………………….84

D: Mediation Figure……………………………………………………………………...86

xi

LIST OF ABBREVIATIONS

CSI-4 Couples Satisfaction Index - 4 DSM-IV-TR Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition Text Revision ECHCS Eastern Colorado Healthcare System KMSS Kansas Marital Satisfaction Scale MAP Marital Activities Profile OEF Operation Enduring Freedom OIF Operation Iraqi Freedom PCL-C Posttraumatic Stress Disorder Checklist - Civilian PLAY Positive Leisure Activities with You PTSD Posttraumatic Stress Disorder SWMLS Satisfaction with Marital Life Scale VA Veterans Affairs

1

CHAPTER I

INTRODUCTION

United States (U.S.) military troops deployed since 2001 provided the most sustained

ground combat military operations since the Vietnam conflict (Friedman, 2005). Significant

numbers of troops deployed to Iraq and Afghanistan have been exposed to intense guerilla

warfare, chronic threats of improvised explosive devices (IEDs), and roadside bombs over

multiple and extended deployments (Hoge et al., 2004). Exposure to prolonged, violent combat

situations has been shown to be correlated with negative physical and mental health outcomes

(Prigerson et al., 2002, Tanelian & Jaycox, 2008). Post-traumatic stress disorder (PTSD) is one

of the most common and prevalent mental health disorders associated with stressful combat

experiences (Hoge et al., 2004; Hoge et al., 2006; Tanelian & Jaycox, 2008). Not only does

PTSD and subclinical PTSD have a negative impact on a Veteran’s ability to function post-

deployment, but it also detrimentally affects his or her significant others, as well as his or her

families. In fact, Veteran endorsement of PTSD symptoms is reliably associated with decreased

relationship satisfaction (Lambert, Engh, Hasbun, & Holzer, 2012; Nelson Goff, Crow, Reisbig,

& Hamilton, 2007; Newby, McCarroll, Ursano, Fan, Shigemura, & Tucker-Harris, 2005; Riggs,

Byrne, Weathers, & Litz, 1998; Taft, Stafford, Watkins, Street & Monson, 2011). Although

research has suggested that increasing social support and reducing negative social interactions

may mitigate the development of chronic PTSD (Sautter, Armelie, Glynn, & Wielt, 2011),

relatively fewer studies have examined strategies to mitigate decreases in relationship

satisfaction when symptoms of PTSD are present. One strategy that might mitigate decreases in

relationship satisfaction when symptoms of PTSD are present is increasing the amount of time

couples spend together engaging in pleasurable activities. For couples in general, spending time

2

together and engaging in pleasurable activities are important strategies for enduring relationship

quality and satisfaction (Dindia & Baxter, 1987; Holman & Epperson, 1989; Orthner & Mancini,

1991). One way PTSD may be related to decreased relationship satisfaction is by reduced shared

leisure activities, for example, due to PTSD related numbing or avoidance symptoms which may

lead to avoiding even leisure activities with the partner. If this is the case, increasing shared

leisure activities for couples with PTSD could help to improve relationship functioning.

However, to my knowledge, no literature has explored whether couple engagement in shared

leisure activities mediates the associations between PTSD and relationship satisfaction.

Therefore, the goals of this study were to thoroughly explore the associations between PTSD,

relationship satisfaction, and shared leisure activities with the partner in OEF/OIF Veterans, and

to test whether such shared activities mediate the association between PTSD and relationship

satisfaction for the Veteran.

3

CHAPTER II

REVIEW OF THE LITERATURE

PTSD in OEF/OIF Veterans

Over 2.3 million individuals have been deployed in support of the Global War on Terror,

including deployments to Iraq and Afghanistan (Environmental Health Strategic Healthcare

Group, 2011). For Veterans serving in Operation Enduring Freedom (OEF; Afghanistan) and

Operation Iraqi Freedom (OIF; Iraq) prolonged exposure to combat-related stress has been linked

to an increase in psychological disorders such as PTSD (Tanielian & Jaycox, 2008). Estimates of

PTSD prevalence in the OEF/OIF Veteran population spans a wide range, with recent findings

noting a range of 11-22% (Finley, Baker, Pugh, & Peterson, 2010), and previous estimates

finding 10-44% of OEF and/or OIF Soldiers surveyed report clinically significant PTSD

symptoms (Erbes et al., 2007; Hoge et al., 2004; Lapierre, Schwegler, & Labauve, 2007; Seal et

al., 2007). Seal and colleagues (2007) looked at OEF/OIF Veterans seeking services at the

Department of Veterans Affairs and found a 13% prevalence of PTSD based on the ICD-9-CM

diagnosis. Furthermore, Seal et al. (2007) found a significant increased risk of PTSD and mental

health diagnoses in the youngest OEF/OIF age group (ages 18-24) as compared to Veterans 40

years and older. As more of the Soldiers serving in the Iraq and Afghanistan wars return home

and transition out of active duty to civilian life, the psychological impact of combat exposure is

an increasing public concern.

PTSD

PTSD is an anxiety disorder that can develop from exposure to a traumatic event which

involves threat, or occurrence, of severe injury or death to oneself or to others. Traumatic events

that may cause PTSD include accidents, natural disasters, violent assaults, and military combat.

4

Diagnostic criteria of PTSD include three symptom clusters: 1) re-experiencing the event, 2)

persistent avoidance of things associated with the event/numbing of emotions, and 3)

hyperarousal (DSM-IV-TR, American Psychological Association, 2000). Individuals may re-

experience the traumatic event in various ways, such as through recurrent, intrusive memories,

dreams, or flashbacks. These recollections are frequently associated with distress and heightened

arousal (APA, 2000). Persistent and deliberate avoidance of thoughts, feelings, activities,

situations or people comprise the avoidance cluster of PTSD symptoms. Also included in this

symptom cluster is “emotional numbing.” Emotional numbing often is expressed as diminished

interest or participation in previously enjoyed activities; feelings of detachment from

interpersonal relationships; and a reduced ability to feel emotions, specifically emotions

associated with physical and emotional intimacy. Hyperarousal symptoms are frequently

described as persistent symptoms of anxiety or arousal, such as hypervigilance, exaggerated

startle response, and increased irritability or outbursts of anger.

Many negative outcomes also are associated with PTSD symptoms, including decreased

physical functioning and emotional well-being (Erbes et al, 2007; Zatzick et al. 1997), decreased

quality of life and mortality (Pietrzak et al., 2010; Tanielian & Jaycox, 2008), and greater

problems in interpersonal functioning (Pietrzak et al., 2010).

PTSD, Veterans & Interpersonal Relationships

Research has found that Veterans with PTSD report greater frequency and severity of

relationship problems and poor family adjustment. Such issues may lead to higher divorce rates

for combat Veterans with PTSD as compared to combat Veterans without PTSD (Cook, Riggs,

Thompson, Coyne, & Sheikh, 2004; Jordan et al., 1992). Two recent meta-analyses (Lambert,

Engh, Hasbun, & Holzer, 2012; Taft, Stafford, Watkins, Street, & Monson, 2011) have

5

supported prior findings regarding the association between PTSD and family relationships,

specifically noting significant associations between military-related PTSD and intimate

relationship issues. Negative impacts of PTSD on Veterans’ relationships include poorer

communication, greater relationship instability, and problems with relationship adjustment,

positive bonding, commitment, and communication (Allen, Rhoades, Stanley, & Markman,

2010; Meis, Erbes, Polusny, & Comptom, 2010; Monson, Taft, & Fredman, 2009; Nelson Goff,

Crow, Reisbig, & Hamilton, 2007; Ray & Vanstone, 2009; Riggs et al., 1998).

Riggs and colleagues (1998) proposed reasons on why PTSD may affect intimate

relationships. For example, these authors suggest that hyperarousal symptoms of PTSD, such as

hypervigilance, increased irritability, and impaired concentration skills may serve to increase

conflict and distress within the relationship (Riggs et al., 1998). Moreover, emotional exchange

is thought to be inhibited by PTSD-specific symptoms of emotional numbing, such as restricted

affect, detachment, loss of interest in activities, and an inability to communicate intimacy and

love (Feeney, Zoellner, Fitzgibbons, & Foa, 2000; Riggs et al, 1998). In fact, Riggs and

colleagues (1998) found that the avoidance symptom cluster including emotional numbing and

effortful avoidance symptoms were significantly correlated to lower relationship satisfaction.

Emotional numbing symptoms also may lead to decreases in self-disclosure with loved ones,

which has been found in male Veterans with chronic PTSD (Carroll, Rueger, Foy, & Donahoe,

1985). Self-disclosure has been found to partially mediate the relationship between avoidance

symptoms and marital intimacy (Solomon, Dekel, & Zerach, 2008). These consequences are

especially concerning as increased difficulties in relationships in turn often contribute to the

persistence of PTSD symptoms (Barrett & Mizes, 1988).

6

Positive Relationship Factors

Past research on PTSD and relationship functioning has focused primarily on negative

outcomes such as increases in conflict, distress, domestic violence, and divorce, with limited

research on potential distinct positive influences that function within the relationship for

increasing and/or maintaining relationship satisfaction. This mirrors the general literature in

clinical psychology on couple functioning, which has sought to closely examine more negative

aspects of relationship functioning such as distress and conflict. However, there is a call in this

general literature to increase exploration of more positive psychological factors in relationship

functioning (Fincham & Beach, 2010; Freeman, Moore, & Freeman, 2009), such as fun,

friendship, positive bonding, shared activities, and leisure time (Aron, Norman, Aron, McKenna,

& Heyman, 2000; Johnson, Zabriskie, & Hill, 2006). Prior literature has shown that spending

time together and engaging in pleasurable activities as a couple is an important strategy for

enduring quality and satisfaction within a relationship (Dindia & Baxter, 1987; Holman &

Epperson, 1989; Orthner & Mancini, 1991). Aron et al. (2000) suggests that maintenance of

relationship satisfaction occurs through self-expansion in the relationship via continuous

engagement in shared activities that are novel and exciting. This suggestion originates from Aron

and Aron’s (1986) self-expansion model which proposes that the individual is motivated to

expand the self through acquired knowledge, experience, identities and other resources (Aron &

Aron, 1986). As the early honeymoon phase of the relationship passes and self-expansion slows,

the exhilaration and novelty of the relationship declines. Couples who continue to seek joint

activities that are new and challenging may experience positive effects and subsequently attribute

these effects to the relationship quality (Aron et al., 2000). The process of sharing in new and

exciting activities has been associated with feelings of pleasure, arousal, and excitement (Aron,

7

Aron, & Norman, 2001). As long as self-expansion and associated positive feelings occur, it is

hypothesized that relationship satisfaction and quality increase (Strong & Aron, 2006). Aron and

colleagues (2000) have explored this theory and found that couples who engaged in shared

activities that are novel and challenging show increases in relationship satisfaction.

The importance of both new and “expansive” activities for couples, as well as sharing of

more common activities, are delineated in Johnson and colleagues’ (2006) Core and Balance

Model of shared leisure patterns in couples. The Core and Balance Model subsumes two patterns

of leisure: Core (common, everyday activities), and Balance (novel, less frequent activities). The

process of engaging in such activities assists the couple in meeting their needs of stability and

change (Zabriskie & McCormick, 2001). Core activities consist of common, every day,

accessible, low-cost, and often home-based activities that the couples may do frequently.

Watching movies/television, cooking dinner together, gardening, or playing board games are

examples of Core activities. On the other hand, Balance activities consist of engaging in

interactions that are less common and less frequent and typically provide a relatively novel

experience. Balance activities are usually not considered home-based, and may require more

resources. Outdoor recreation, attending amusement parks or music concerts, and vacations are

examples of these types of activities. Furthermore, Balance activities are unpredictable and

necessitate adaptation to new experiences and challenges (Zabriskie & McCormick, 2001).

While the Core and Balance Model is rooted in family systems theory and has been applied to

family leisure patterns (Zabriskie & McCormick, 2001), more recent research has begun to

investigate the use of this model in examining couples’ relationship satisfaction (Johnson et al.,

2006).

8

As noted, the positive affect experienced in shared leisure is important to healthy

relationship functioning. As described above in the self-expansion model, Aron and colleagues

(2000) have demonstrated that positive emotions, such as pleasure and excitement during novel

and exciting activities, are a primary factor in concomitant increases in relationship satisfaction

and feelings of closeness. Fredrickson’s broaden-and-build theory of positive emotion (1998;

2001) furthers the importance of positive emotion in relationship functioning. This theory posits

that when individuals feel positive emotions they experience a greater sense of “oneness” with

other people. Fredrickson (1998) highlights positive emotions including joy, interest,

contentment, and love, all of which may serve as factors that generate and expand romantic

relationships. In the broaden-and-build theory, joy is conceptualized as a relative high-arousal

positive emotion, interest is presented as interchangeable with excitement, and is associated with

challenge, and contentment as a low-arousal positive emotion that arises in contexts perceived as

“safe” and with a high degree of certainty. Love is defined by Fredrickson (1998) as an

amalgamation of positive emotions with the emphasis that love experiences must be felt towards

specific individuals. Love, combined with joy, interest, and contentment, experienced within the

intimate relationship contributes to the “broadening” and “building” of the individual’s physical,

psychological, intellectual and social resources. This is consistent with Aron & Aron’s (1986)

self-expansion model with an emphasis on increasing positive emotions to spark growth in

personal resources and interpersonal relationships.

Taking all this into account, if partners are able to engage each other in positive emotion

during leisure, this may serve to improve relationship satisfaction and functioning. This may be

an especially important area of intervention for Veterans who are experiencing PTSD and their

partners, as PTSD may itself inhibit this area of connection for couples.

9

PTSD Symptoms & Shared Activities

As discussed above, PTSD symptoms have shown negative impacts on relationship

quality and satisfaction (Galovski & Lyons, 2004; Monson et al., 2009). Related to the issue of

shared leisure, Riggs et al. (1998) suggests that emotional numbing and avoidance may decrease

participation in leisure activities and positive affect (as noted above, an important element in the

bonding process of shared leisure). PTSD symptoms such as hypervigilance, the need for control,

high startle response, and constant alertness may cause the Veteran to become irritable, angry,

and on guard, also while interfering with chances to enjoy a new experience and share positive

emotions with their partner. PTSD symptoms may also lead the individual to avoid crowds, loud

noises, or other stimuli associated with a shared activity that mimics or triggers memories of the

traumatic event may inhibit the individual from engaging in new and/or exciting activities with

his or her partner (e.g. amusement parks, movies, concerts). Thus, considering the symptoms of

PTSD and how these symptoms may manifest in the relationship, there may be a number of ways

that the frequency and/or enjoyment of shared leisure with a romantic partner may be affected.

That is, PTSD may decrease shared leisure, through hypervigilance or emotional numbing,

limiting emotional expression and shared intimacy, which in turn may decrease relationship

satisfaction. In fact, these interactions between PTSD symptoms and shared leisure can be

cyclical, as the loss of shared activities subsequently may affect the individual’s ability to be

emotionally expressive and share intimacy with his or her partner, decreasing relationship

satisfaction.

In support of this overall conceptualization of the links between PTSD, shared leisure,

and marital adjustment, Allen et al. (2010) found that a measure of “positive bonding”, which

included questions about fun and friendship, partially mediated the relationship between PTSD

10

symptoms and marital satisfaction for Active Duty soldiers and their spouses. However, this

measure only included three broad and nonspecific items regarding fun and friendship (e.g. “We

have a lot of fun together”, “We regularly make time for fun activities together as a couple,” and

“We have conversations where we just talk as good friends.”); only one of those referring to

activities specifically. Thus, there is a lack of data exploring the links between PTSD, shared

leisure, and marital adjustment in a more detailed manner.

Current Study

To address this gap in knowledge, I will explore the Veteran’s appraisal of shared leisure

with their intimate partners with increased specificity regarding various types of shared leisure

and the affect experienced during shared leisure activities. That is, I will explore types of leisure

that encompass both Core and Balance activities, and Aron’s delineation of activities that are

novel, and I will also explore the associated emotional experience during the activity type (i.e.,

reflecting Fredrickson’s broaden-and-build theory of emotion). I will then examine how the

frequency and emotional aspects of shared leisure may mediate the relationship between PTSD

symptoms and marital quality. If the hypothesized relationships are found, it may support the

inclusion of maximizing couple play in current interventions such as cognitive-behavioral

conjoint therapy for PTSD (Monson & Fredman, 2012).

A unique contribution of this study was the creation of a pilot measure to assess

frequency of, and affect regarding, various shared activities. Goals for this study include (1) an

examination of the psychometric properties of the pilot measure, and (2) to use psychometrically

adequate scales from this measure to assess the relationships among the variables of interest and

test the hypotheses. The pilot measure is called the Positive Leisure Activities with You (PLAY)

measure. This measure was informed by reviewing existing research by Aron and colleagues

11

(2000), by the Core and Balance model of leisure activities (Johnson et al., 2006; Zabriskie &

McCormick, 2001), and by the broaden-and-build theory of emotion (Fredrickson, 1998; 2001).

First, the measure was designed to assess frequency of participation in various types of PLAY,

that is, shared activities that are normal/routine (Routine), new/different (Novel), and

exciting/thrilling (Exciting). This was done by asking a single item frequency and scale

frequency (i.e., responding to a set of adjectives) designed to respectively assess Routine, Novel,

and Exciting activities, using a Likert rating scale. In addition to the various types of PLAY

assessed in this manner, overall frequency of PLAY can be assessed by combining all these

frequency items into a combined scale of Overall PLAY frequency.

Second, the measure assesses the emotions associated with the various types of PLAY.

Aron and colleagues (2000), and Fredrickson (1998; 2001) assert that the emotional aspect of

shared activities is integral to the maintenance and/or expansion of relationship satisfaction.

Many reactions to various types of PLAY are possible, including theoretically plausible reactions

of distress, anxiety, or numbness as would be posited in the case of PTSD. For example, going to

a concert may be very stressful, rather than fun, for a person with the hypervigilance symptoms

of PTSD. Therefore, the measure provides a list of emotion words informed by the broaden-and-

build theory of positive emotion (Fredrickson, 1998; 2001), the Positive and Negative Affect

Schedule (PANAS; Watson, Clark & Tellegan, 1988), as well as PTSD literature. Respondents

are asked to rate the frequency of each emotion associated with each type of activity. That is, a

list of emotion words is presented three times, per category of activity (1) Routine; 2) Novel; and

3) Exciting), and respondents indicate how often they experience that emotion during that type of

activity. Please see Appendix A for the PLAY measure.

12

Specific Aims

Under each Aim, a priori hypotheses have been considered and are presented below.

Aim 1

To establish basic psychometric adequacy of the PLAY measure. The first aim of the

current study focused on psychometric evaluation of the PLAY measure. Scales have been

rationally-derived for this proposal and are described in the Data Analysis section below. The

scales are included in Appendix B. Tests of Cronbach’s alpha will be run iteratively, deleting

items as needed, until a final set of items with good internal consistency have been established

per scale. Each scale will then be evaluated with a series of criterion validity tests. This

sequencing of rational development of a scale combined with statistical tests of psychometric

adequacy is a content, or rational-empirical, approach to scale construction. This approach was

adopted for a number of reasons, including limited power to conduct procedures such as factor

analysis and the fact that these scales were derived a priori based on theory. Please see Results

for further elaboration of the tests of reliability and validity for this measure. After the PLAY

scales are finalized per Aim 1, they will be used for Aims 2 and 3.

Aim 2

To better understand interrelationships among the variables. Interrelationships among

core variables of interest (PTSD, PLAY, relationship satisfaction), as well as the various

components of these variables (i.e., PTSD symptom clusters, types of PLAY, emotional aspects

of PLAY) will be analyzed using a correlation matrix. Please see Appendix C for the proposed

correlation matrix.

Hypotheses

13

Overall, I predicted that PTSD symptom severity would be negatively correlated with

PLAY frequency and relationship satisfaction. Furthermore, the various components of these

variables (PTSD symptom clusters, types of PLAY frequency, emotional aspects of PLAY,

relationship satisfaction) are hypothesized to be significantly correlated in the directions noted

(e.g., high PTSD would be associated with low PLAY).

Aim 3

To test whether PLAY is a mediator between PTSD and marital satisfaction. I

hypothesized that the relationship between PTSD symptoms and relationship satisfaction for the

Veteran will be significantly mediated by the Veteran’s engagement in shared leisure activities

with the partner. Please see Appendix D for the proposed mediational model.

Hypothesis

Greater PTSD symptom severity will predict decreased frequency of PLAY, which in

turn will predict decreased relationship satisfaction. This general hypothesis will be evaluated

with various scales/clusters of the constructs.

14

CHAPTER III

METHOD

Procedure

Participants were recruited at the Denver Veterans Affairs Medical Center (DVAMC,

part of the ECHCS) in the following ways: 1) approved flyers were posted around the DVAMC

and given to staff, 2) Veterans who completed informed consent for a research repository

database were referred to the study; and 3) I attended primary health and mental health care staff

meetings to inform DVAMC staff of the study. Inclusion criteria specified that participants were

OEF/OIF Veterans who had received services at the DVAMC, were between the ages of 18 and

50, and reported having a current, intimate relationship that was at least one year in duration. A

waiver of HIPAA authorization was obtained at COMIRB initial approval to allow members of

the research team to record personal information needed for screening via telephone. Eligible

participants were screened in-person or via telephone and were invited to the DVAMC for an

approximate two-hour appointment to complete consent and study procedures.

Consent & HIPAA Authorization Procedure

Approved study team members conducted all procedures regarding consent to participate

in the study and authorization to collect protected health information (PHI). All research team

members were trained in COMIRB procedures. All approved study team members reported to

me. All study regulatory procedures were conducted by me under the supervision of Dr. Brenner

at the VA and Dr. Allen at the University of Colorado at Denver (UCD). Informed consent was

obtained from participants by reading the consent and by explaining the nature of the study and

potential risks and benefits in a calm environment at the DVAMC. Participants were given ample

time to ask questions and, if they agreed to participate, they were given a copy of his or her

15

signed and dated consent. The participants were then asked to complete the following five

questions to ensure comprehension: 1) What are you being asked to do? 2) Finish this sentence -

The purpose of this study is to find out… 3) True or False: After beginning this study, you can

decide not to continue at any time, without penalty. 4) What should you do if you have questions

about this study? 5) Who should you call if you feel you have been harmed in the study?

(Janofsky, McCarthy, & Folstein, 1992). All participants answered these items adequately.

Separate from constructs used in the current study, measures regarding suicide risk were

included (see Appendix E for the complete set of measures included in the study). Participants

were informed that Dr. Brenner or her designee might review their responses to questions

regarding burdensomeness and belongingness and self-directed violence, and if necessary, would

discuss these responses with them and their treating clinician to ensure their safety. No

participant exceeded the safety monitoring criteria.

Participants

Participants’ were recruited from the population of OEF and/or OIF Veterans seeking or

eligible to receive healthcare within the Veterans’ Affairs (VA) Eastern Colorado Health Care

System (ECHCS). Approval for the study was obtained from the Colorado Multiple Institutional

Review Board (COMIRB) prior to any procedures. Sixty-eight Veterans completed all study

procedures.

Demographics

Please see Table 1. The majority of the sample were male (86%). Most participants were

Caucasian (78%), 10% identified as African American, 9% as Hispanic ethnicity, and the rest

self-identified their ethnicity as “Other”. The average age of Veterans was 34 years (SD = 7

years; range 23-50).

16

The average years of education completed was 14.71 (SD = 2.14). Income was reported

as household income, which could have included personal salary, benefits, and/or partner salary

or benefits. Approximately 17% reported income of less than $24,999, 18% reported an income

of $25,000 - $34,999, 19% reported an income of $35,000 - $49,999, 20% reported an income of

$50,000 - $74,999, and 22% reported an income equal to or greater than $75,000. Half of the

sample reported unemployment, 29% employed full-time, 10% employed part-time, and 10%

retired. Forty-four percent of the Veterans also reported being a student.

Most Veterans reported Active Duty service in the Army (57.4%), followed by Marine

Corp (19.1%), Navy (13.2%) and Air Force (7.4%). Veterans also reported National Guard and

Reserves military service. Please see Table 1 for complete details. Veterans served an average of

5.33 years (SD = 11.3 months) in the military prior to separation from the service.

17

Table 1 Demographic Characteristics

Characteristics

(n=68) Male 58 (86%) Age 34 (7.0) Median & Range 33 (23, 50) Race/Ethnicity Caucasian 53 (78%) African American 7 (10%) Hispanic 6 (9%) Other 2 (3%) Years of Education 14.71 (2.14) Employment Full Time 20 (29.4%) Part Time 7 (10.3%) Retired 7 (10.3%) Unemployed 34 (50.0%) Student Household Income < $24,999 $25,000 - $34,999 $35,000 - $49,999

> $75,000

30 (44.1%)

14 (17.3%) 12 (17.7%) 27 (57.4%) 15 (22.1%)

Branch of Service* Army Army National Guard Army Reserves

39 (57.4%) 6 (8.8%)

8 (11.8%) Air Force Air Force Reserves

5 (7.4%) 2 (3%)

Navy Navy Reserves

9 (13.2%) 3 (4.4%)

Marines Marine Reserves Coast Guard

13 (19.1%) 2 (30%) 1 (1.5%)

Length of Military Service 5.33 (11.3 months)

Numbers represent N (%) or Mean (SD) *Numbers do not equal 100% as Veterans may have served in multiple Military Services.

18

Relationship Status

Sixty percent of the participants were married. Of the married participants, 58% were in

their first marriage, 37% were in their second marriage, and 5% were in their third marriage. The

current average dating duration prior to marriage was 1.7 years (SD = 1.42 years), and the

current average marital relationship was 7.55 years (SD = 6.48 years). Over three-quarters of the

married participants (78%) reported having children.

Forty percent of the sample were in a dating relationship, and 37% of those reporting a

dating relationship had a prior divorce. The current average dating relationship was 2.75 years

(SD = 1.42 years). Forty-eight percent of those in a dating relationship reported having children.

Complete relationship status characteristics are presented in Table 2.

Table 2 Relationship Status Characteristics

Relationship Status Married 41 (60%)

First Marriage 24 (58%) Second Marriage 15 (37%) Third Marriage 2 (5%) Length of Relationship Prior to Marriage Length of Marriage Have Children No. of Children

1.7 years (1.42)

7.55 years (6.48) 32 (78%)

2.38 (1.18) Dating 27 (40%) Prior Divorce Length of Relationship Have Children No. of Children

10 (37%) 2.75 years (1.42)

13 (48%) .85 (1.1)

Numbers represent N (%) or Mean (SD)

19

Measures

Core measures for testing the hypotheses specified in the aims are presented below in

Table 3 and described below

Table 3

Core Measures for Hypothesis Testing

Posttraumatic Stress Disorder Checklist—Civilian (PCL-C)

The PCL-C (Weathers, Litz, Herman, Huska, & Keane, 1993) is a 17-item self-report

measure that assesses respondents’ endorsement of the level of distress that co-occurred with

each PTSD symptom in the last 30 days. Items on the PCL-C parallel diagnostic criteria for

PTSD in the DSM-IV. A five-point scale is used to rate each item (1 = not at all, 5 =

extremely).The PCL-C can be used as a continuous measure of symptom severity by summing

all 17 items, or items can be summed and interpreted based on the DSM-IV PTSD criteria and

core symptoms (avoidance, hyperarousal, emotional numbing). The National Center for PTSD

has suggested cut-off scores on the PCL for assisting in the diagnosis of PTSD, depending on the

target setting (U.S. Department of Veterans Affairs, 2014). In the general population settings, the

cut-off score suggested is 30-35, but it is 36-44 in specialized medical clinics/VA primary care,

and 45-50 in VA and/or civilian mental health clinics. The PCL-C has demonstrated excellent

reliability (α = .97, test-retest r = .96) in prior samples of Vietnam Veterans, and had good

Measure Domain

Assessed

Application of

Variable PTSD Checklist-Civilian (PCL-C) PTSD symptoms

IV

Kansas Marital Satisfaction Scale (KMSS) Relationship Satisfaction

DV

Positive Leisure Activities With You Leisure Mediator

20

sensitivity (.82) and specificity (.83) for a SCID diagnosis of PTSD (Weathers, et al., 1993). For

this study, the total PTSD score was summed, and each symptom sub-cluster was summed.

Kansas Marital Satisfaction Scale (KMSS)

The KMSS (Schumm et al, 1986) is a brief measure of relationship satisfaction. It has 3-

items that assess for satisfaction with the marriage, marital relationship, and the character of

one’s spouse. For this study, this has been modified to fit a sample that includes non-marital

relationships by modifying the following terms: (question 1) term “marriage” to “relationship,

(question 2) term “husband/wife” to “partner”, (question 3) “husband/wife” to “significant other”

and “spouse” to “partner”. Items are rated on a 7-point Likert scale (1 = extremely dissatisfied, 7

= extremely satisfied). The KMSS has high internal consistency, concurrent validity with other

measures of marital quality, and criterion validity with marital instability measurements (for a

review see McLeland, Sutton, & Schumm, 2008). The KMSS score was averaged for use in

analyses.

Positive Leisure Activities with You (PLAY)

As discussed earlier, the PLAY measure is designed to more specifically assess

frequency of types of shared leisure activities with the partner, and the degree of actual pleasure

experienced during various types of activities. The first three items on the PLAY assessed for

frequency of activities that were Routine, Novel, and Exciting. These three items were each rated

on a scale of 1 to 5 (1 = once a month, 5 = five or more times a month). These three single-item

frequency questions were each used respectively as a frequency of that type of PLAY, and also

averaged for an Overall Frequency score of PLAY.

Next, participants were presented with 46 adjectives designed to assess the concepts of

“routine”, “novel”, and “exciting” leisure as well as additional words not predicted to

21

conceptually fall onto the three scales (i.e., Routine, Novel, Exciting). Participants were asked to

rate how often they engaged activities that fit each adjective with their partner on a 5-point Likert

scale (1 = Not at all; 5 = Very often).

Finally, individuals were presented with emotion words that were a priori believed to

represent positive, negative, and neutral affect. There were 50 positive (N = 22), negative (N =

25) and neutral (N = 3) emotion words. Respondents were asked to rate the frequency of the

specific emotion when they engaged in (a) Novel, (b) Routine, and (c) Exciting leisure activities

with their partner. The frequency of these affect words during the respective activities was rated

on a 5-point Likert scale (1 = Not at all; 5 = Very often). Whereas there exist measures that

assess frequency and type of leisure activities, to my knowledge, no measure assesses affect

experienced during shared leisure. This is an important construct to measure, as Fredrickson

(1998) posits the “broadening” and “building” of intimate relationships through the experience of

shared positive emotion. This measure is included in Appendix A and E. Psychometric properties

of this measure are presented in the Results.

Measures for Validation of the PLAY Scales

The Marital Activities Profile and Aron’s items were used in data collection for the

purpose of validation of the PLAY measure. These measures are presented in Table 4 and

described further below.

22

Table 4

Measures to validate the PLAY scales

Marital Activity Profile (MAP)

The MAP is a 15-item questionnaire measuring couples’ leisure involvement and leisure

satisfaction. Zabriskie and McCormick (2001) modified the MAP from the Family Leisure

Activity Profile (FLAP) based on the Core and Balance Model of Family Leisure Functioning,

replacing the phrase “with your family” to “with your spouse” and adapting some activity

questions to better reflect couple (as opposed to family) interactions and communication.

Participants are asked if they participate in 15 types of activities. If the participant positively

endorses the activity, additional questions ask about the frequency (at least: daily, weekly

monthly, annually), duration (< 1 hour to >1 day for Core activities; < 1 hour to 3 or more weeks

for Balance activities), and satisfaction with level of participation with spouse for each activity.

Although there are no existing psychometric properties for the MAP, the original FLAP has

demonstrated good construct validity, content validity, and test-retest reliability for core and

balance activities (Zabriskie, 2001). For the purpose of this study, additional modifications

replaced the phrase “spouse” to “significant other” to be more inclusive of relationship status. In

order to calculate a translatable score of frequency of Core and Balance activities, the overall

Core and Balance scales were computed using the frequency item only. That is, participants’

responses to frequency of each activity (e.g., daily, weekly, monthly, annually) were used to

Measure Domain

Assessed

Application of

Variable

Marital Activities Profile (MAP) Shared Leisure Validation

Aron’s items of excitement and degree of exciting activities in current relationship

Excitement in relationships

Validation

23

determine the average score and scale reliabilities. I did not include the duration part of the

coding as I needed a scale that represented simple frequency of the activity.

Aron’s Items of Excitement in Relationships

A three-item questionnaire developed by Aron, Norman, Aron, McKenna, & Heyman

(2000) assessed the degree of excitement: 1) within the relationship, and 2) of activities shared in

the relationship. Specifically, the questions are: “How bored are you with your current

relationship?”, “How exciting is your current relationship” and, “How exciting are the things you

do together with your partner?”. The questions are answered on a 5-point scale ranging from 1

(not at all) to 5 (extremely). This exciting activities question has demonstrated a strong positive

association with experienced relationship quality (r = .51, p < .001) (Aron et al., 2000). For

PLAY validation and subsequent correlation and regression analyses, only the third item “How

exciting are the things you do with your partner?” was used. This item was used as it best

represented another measure of participation in frequency of exciting activities with the partner.

Additional Measures of Relationship Satisfaction

To help explore the impact of PTSD and PLAY on relationship satisfaction, additional

measures of relationship satisfaction were included.

Couples Satisfaction Index (CSI-4)

The CSI is a measure of relationship satisfaction with 32, 16 or 4 item forms. The CSI

was constructed using item response theory using the Marital Adjustment Test, the Dyadic

Adjustment Scale, and 75 additional satisfaction items. The four-item version was used in this

study. The first item is rated on a 7-point Likert scale (1 = extremely unhappy, 7 = extremely

happy) and the following three items rated on a 6-point Likert scale (1 = not at all true, 7 =

completely true). The CSI scales have demonstrated adequate convergent validity and excellent

24

construct validity with previous relationship satisfaction scales (Funk & Rogge, 2007). The four

items were summed to generate a total score and used in analyses.

Satisfaction with Marital Life Scale (SWMLS)

This five-item measure is included at the end of the Marital Activities Profile, and was

modified by Ward and colleagues (2009) from the Satisfaction with Life Scale (Diener,

Emmons, Larson, & Griffin, 1985) as a measure of global marital satisfaction. The items are

rated on a Likert scale from 1 (strongly disagree) to 7 (strongly agree). Ward and colleagues

(2009) found excellent internal consistency of this measure (α = .94), as well as face, criterion

and construct validity. The mean score for each participant was used for analyses.

Data Analysis

All analyses, except for power analyses, were conducted using the Statistical Package for

the Social Sciences (SPSS) version 22. Each Aim and associated statistical analyses are

presented below.

Power Analysis

Power analyses were conducted using G*Power to determine the sample size needed in

order to conduct the proposed analyses. To detect medium effects in the most complex analysis

to be used (i.e., a regression with two predictors) a sample size of 68 was needed and was met as

the recruitment goal for this study.

Data Assumptions & Corrections

The proposed study includes several analyses, which increases the likelihood for Type I

error. Rather than apply Bonferroni corrections, which would require very large effect sizes to

achieve significance, I proposed to take a pattern approach to evaluating the randomness of the

findings.

25

CHAPTER IV

RESULTS

Prior to use in analyses, all measures integral to hypothesis testing were assessed for

internal consistency and descriptive properties. Reliabilities and scale details for this sample are

presented below.

Posttraumatic Stress Disorder Checklist – Civilian (PCL-C)

Please see Table 5 for the PCL-C scale statistics. The PCL-C total symptom severity and

Re-experiencing symptom cluster score demonstrated excellent reliability (α > .90). PCL-C

Avoidance and Hyperarousal symptom cluster scores demonstrated good reliability (α = .88,

respectively). The convention for the PCL is to present summed values. The average total PCL

score in this sample was 43.2. According to cut off suggestions by the National Center for PTSD

delineated above, the average level in this sample exceeds some of the cutoffs used for

diagnostic purposes for PTSD. On a cluster level, the average sum of 12.41 on the “re-

experiencing” scale and the average sum of 16.58 on the “avoidance” score would both represent

an average item rating of 2.4 on the items on that scale, which lands between “a little bit” and

“moderately” bothered by those symptoms. The average sum of 14.82 on the “hyperarousal”

cluster score would represent an average rating of 3.0 on those items, indicating “moderately”

bothered by those symptoms.

26

Table 5

PCL-C scale statistics

No. Items

M SD α

PTSD Total 17 43.2 16.6 .94

PTSD Re-experiencing 5 12.41 5.59 .90

PTSD Avoidance 7 16.58 7.08 .88

PTSD Hyperarousal 5 14.82 5.84 .88

Note: Means represent averages of the summed items on that scale.

Relationship Satisfaction

Please see Table 6 for relationship satisfaction scale statistics. All three measures of

relationship satisfaction demonstrated excellent reliability (α > .90). Higher mean scores indicate

greater relationship satisfaction. Both the KMSS and SWMLS are rated on a 7-point Likert scale.

On average, the participants are reporting a qualitative description of being “somewhat satisfied”

relationship satisfaction based on the KMSS. Crane, Middleton, and Bean (2000) have

recommended a cut-off score of 5.67, such that individuals whom endorse lower scores are more

dissatisfied in their relationship and individuals whom endorse higher scores are more satisfied

in their relationship. The average score for participants on the SWMLS indicate relationship

satisfaction at slightly above “neither agree nor disagree”. Compared to a community sample that

found participants had an average score of 5.7 (Ward et al., 2009), the Veteran participants in the

current study endorsed relatively less relationship satisfaction on the SWMLS with an average

score of 4.53. On the CSI-4, the lowest score possible is a 4 and the highest score possible is 25.

The average total score for this sample was 17.3. Luebcke and colleagues (2014) recommend a

distress cutoff score of 13 on the CSI-4, with higher scores indicating greater relationship

satisfaction. Thus, in two of the relationship satisfaction measures (KMSS and SWMLS), the

27

current sample is, on average, either in the distressed range or relatively more distressed than a

community sample, but they do not fall in the distressed range based on the CSI-4.

Table 6

Relationship Satisfaction Scale Statistics

No. Items M SD α

KMSS 3 5.18 1.40 .97

CSI-4 4 17.30* 5.57* .98

SWMLS 5 4.53 1.82 .95

Note: Means represent averages of the items on that scale except for CSI-4. *CSI-4 mean represents the total score and standard deviation.

Marital Activities Profile (MAP) Scale & Aron Item

Please see Table 7 for additional validation measure scale statistics. The MAP Core

activity scale demonstrated low reliability (α = .60). Subsequent analyses using the MAP Core

scale should be cautiously interpreted. Participants reported, on average, weekly engagement in

activities that are common, every day, accessible, and frequently home-based. The MAP Balance

activity scale demonstrated adequate reliability (α > .70). Participants reported less frequency

engaging in Balance activities. Specifically, they reported approximately monthly engagement in

activities that typically provide a relatively novel experience, are not home-based, and that may

require more resources. This relative frequency is consistent with predicted patterns of such

leisure.

Although only one item from Aron’s scale (“How exciting are the things you do with

your partner?”) was used in subsequent analyses, as it was the only item out of the three items on

this scale that provided another assessment of frequency of exciting activities in the relationship,

28

the full Aron’s scale demonstrated good reliability (α = .80). Veterans reported approximately

“moderate” engagement in activities that were exciting with their partner.

Table 7

Additional Measure Scale Statistics

No. Items M SD α

MAP Core 7 3.02 .46 .60

MAP Balance 6 1.90 .44 .71

Aron 1 2.90 .93 ---

Note: Means represent averages of the items on that scale.

Aim 1

PLAY Psychometrics

PLAY Frequency Scales

Please see Table 8 for the PLAY frequency scale statistics. All of the frequency scales on

the PLAY measure demonstrated at least adequate internal consistency. Excellent reliability (i.e.,

α > .90) was found for the Novel and Exciting frequency PLAY scales. Adequate reliability (i.e.,

α > .70) was demonstrated for the overall frequency of PLAY scale. The Routine PLAY scale

initially had six items (routine, normal, unexciting, ordinary, mundane, predictable). Although

these items had adequate internal consistency (α = .77), I noted that two of the items (mundane

and unexciting) had relatively lower item-total correlations than the other items. Removing these

items actually improved the reliability (i.e., α = .81), even in the context of fewer items. I also

observed that these two items seemed more negatively valenced than the remaining words, which

appeared more neutral. I removed these items to compute a four item version of the scale. In

subsequent correlational analyses with both the six item and four item, I found the correlation

with the PLAY one item rating of monthly frequency of Routine PLAY stronger with the four

29

item measure. Thus, I felt that these two words may have detracted from the intent of the scale to

be a basic overview of frequency of the behavior, and incorporated more of the affective ratings

element into this scale. The four item measure seemed to be a better representation of the

intended construct and I used it for all remaining analyses.

Veterans in this sample are reporting an Overall Frequency of engaging in shared leisure

approximately two to three times a month. Veterans reported their average frequency of

engaging in Routine PLAY as “often”, Novel and Exciting PLAY “a little”. Paired samples t-

tests were conducted to compare frequency of routine, novel and exciting PLAY. There was a

significant difference for all comparisons. Specifically the results suggest that Veterans in this

sample more frequently participate in Routine PLAY as compared to Novel PLAY (t(67) =

11.30, p = .000). There was also a significant difference between frequency of Routine PLAY

and Exciting PLAY (t(67) = 10.26, p = .000). In addition, Veterans in this sample participate in

more Novel PLAY as compared to Exciting PLAY (t(67) = 4.36, p = .000).

Table 8

PLAY Frequency Scale Statistics

No. Items M SD α

PLAY

Overall Frequency

3

2.85

.94

.78

Routine Scale 4 3.87 .83 .81

Novel Scale 8 2.28 .82 .91

Exciting Scale 14 2.04 .82 .95


30

PLAY Affect Scales

Excellent reliability (α > .94) was found for each of the positive and negative affect

scales for all three types of PLAY (Routine, Novel, Exciting). Please see Table 9 for the PLAY

Affect scale statistics.

In general, the participants reported feeling “some” positive affect during Routine PLAY,

and positive affect increased towards being rated as “often” during shared leisure that was Novel

and/or Exciting. On average, negative affect was reported as being experienced “a little” of the

time across all three types of PLAY (Routine, Novel, Exciting).

Table 9

PLAY Affect Scale Statistics

No. Items Mean SD α

PLAY Routine

Positive Affect

22

2.98

.96

.98

Negative Affect 25 1.99 .75 .95

PLAY Novel

Positive Affect

22

3.48

.97

.98


PLAY Exciting

Positive Affect

22

3.70

1.03

.99



Construct Validity of PLAY

Construct validity of the PLAY measure was tested using a series of correlational

analyses. Each correlation served as an index of criterion validity. Please see Table 10 for an

31

overall table presenting these correlations. Each step in construct validity will be delineated in

detail below, in both narrative and table form.

Table 10

PLAY Frequency Correlations

Routine Item

Novel Item

Exciting Item Routine Scale

Novel Scale

Exciting Scale

Overall Frequency .76** .89** .84** .29* .64** .66**

Routine Item .50** .42** .46** .29* .31*

Novel Item .69** .22 .64** .59**

Exciting Item .06 .66** .76**

Routine Scale .02 -.07

Novel Scale .84**

*p < .05; **p < .001

Note: “Item” refers to the one item of frequency, whereas “Scale” refers to the scale of frequency.

Initially, most central to confirming validity of my PLAY measure is the degree to which

different measures of the “same” construct converge. Overall these measures converged. As an

initial test of criterion validity, the single items assessing frequency of types of PLAY were

shown to converge appropriately with their respective scale frequency of PLAY. For example,

the single-item assessment of monthly frequency of Routine PLAY correlated .46 (p < .001) with

the Routine scale of frequency. These single item assessments correlated with their respective

scales from .46 to .76 (see boldface values in Table 11).

32

Table 11

Correlations of Single Item and Scale PLAY Frequency

Routine Scale

Novel Scale

Exciting Scale

Routine Item .46** -- --

Novel Item -- .64** --

Exciting Item -- -- .76**

*p < .05; **p < .001


Although not central to confirming construct validity of my measure, it would also be

expected that greater frequency of “novel” PLAY should relate to greater frequency of

“exciting” PLAY given their theoretical overlap (per “Balance” activities in Johnson and

colleagues’ (2006) theory of Core and Balance). In fact, these do correlate significantly

regardless of whether they were asked in the scale or single item approach, with correlations

ranging from .59 to .84 (see boldface values in Table 12).

Table 12

Novel and Exciting PLAY Frequency Correlations

Exciting Item

Novel Scale

Exciting Scale

Novel Item .69** .64** .59**

Exciting Item .66** .76**

Novel Scale .84**

*p < .05; **p < .001


Similarly, whereas not a part of validation of the measure, it is also interesting that other

aspects of PLAY frequency sometimes converged. For example, correlations also indicate that

33

the Routine Frequency Item (but not the Routine scale) was positively correlated with the

frequency of Novel and Exciting PLAY (both single item and scale; see boldface values in Table

13). Although this pattern was not consistent, there was some indication that more shared leisure

of one type is usually associated with more shared leisure of other types (as already evidenced by

the adequate internal consistency of the overall frequency PLAY scale). The only exception to

this were the correlations of the Routine scale with Novel or Exciting play (measured as a scale

or one item; see italicized values in Table 13).

Table 13

Correlations of PLAY Frequency

Routine Item

Novel Item

Exciting Item

Routine Scale

Novel Scale

Exciting Scale

Routine Item .50** .42** .46** .29* .31*

Novel Item .69** .22 .64** .59**

Exciting Item .06 .66** .76**

Routine Scale .02 -.07

*p < .05; **p < .001


Validation of PLAY Affect

Returning to the process of validation, in addition to the posited basic associations within

the PLAY measures of frequency, there are theoretically related patterns regarding affect during

PLAY. For example, one might posit that more positive affect regarding a specific type of play

will correlate with increased frequency of that specific type of PLAY. In general, this was

supported across all measurements of frequency of PLAY (i.e., Overall Frequency, single item,

and scale frequency), with one exception (see this exception in italicized font in Table 14)

34

wherein the Novel frequency single item did not significantly correlate with the Novel positive

affect scale).

Table 14

Positive Affect and Frequency of Same Type of PLAY

Routine

Positive Affect

Novel

Positive Affect

Exciting

Positive Affect

Routine Item .29* -- --

Routine Scale .25* -- --

Novel Item -- .19 --

Novel Scale -- .53** --

Exciting Item -- -- .38**

Exciting Scale -- -- .60**

*p < .05; **p < .01


As a side note, it could be that positive affect during Routine PLAY (thus enjoying the

basic Core activities with a partner) would also be associated with higher levels of one’s

participation in PLAY that is either Novel or Exciting with the partner (i.e., perhaps having fun

with the basic types of activities with the partner encourages more of the novel and exciting

activities with the partner). These associations were significant (see Table 15). In fact, positive

affect during novel and exciting play also predicted greater frequency of other types of play

(with the exception of the one item frequency of routine leisure).

35

Table 15

Positive Affect and Frequency of Different Types of PLAY

Routine

Positive Affect

Novel

Positive Affect

Exciting

Positive Affect

Routine Item -- .10 .18

Routine Scale -- .28* .34**

Novel Item .46** -- .28*

Novel Scale .66** -- .56**

Exciting Item .49** .35** --

Exciting Scale .63** .55** --

*p < .05; **p < .01


Similarly, just as positive affect regarding a specific type of activity should (and

generally did) predict greater reported frequency of that specific type of activity, one might

assume that more negative affect regarding a specific type of activity would correlate with less

frequency of that specific type of activity. However, there were no significant associations

between negative affect during specific types of PLAY and frequency of that respective type of

PLAY (see Table 16).

36

Table 16

Negative Affect and Frequency of Same Type of PLAY

Routine

Negative Affect

Novel

Negative Affect

Exciting

Negative Affect

Routine Item -.12 -- --

Routine Scale -.04 -- --

Novel Item -- .14 --

Novel Scale -- .01 --

Exciting Item -- -- -.11

Exciting Scale -- -- -.13

*p < .05; **p < .01


Likewise, one could assume that negative affect during any type of PLAY would

suppress frequency of participation in other types of PLAY. Interestingly, in general, this was

not supported. Only negative affect during Routine PLAY correlated with less frequency in both

Novel (r = -.26) and Exciting (r = -.29) type of PLAY (both p < .05; please refer to items in

boldface in Table 17).

37

Table 17

Negative Affect and Frequency of Different Types of PLAY

Routine

Negative Affect

Novel

Negative Affect

Exciting

Negative Affect

Routine Item -- -.01 -.04

Routine Scale -- -.08 -.03

Novel Item -.11 -- .02

Novel Scale -.26* -- -.05

Exciting Item -.24 -.02 --

Exciting Scale -.29* .01 --

*p < .05; **p < .01


Thus, whereas the expected associations were found with positive affect predicting

frequency of PLAY, they were typically not found with negative affect predicting frequency of

PLAY.

An additional aspect of criterion validity is the level to which affective ratings are

associated with one another. We tested correlations among positive affect regarding different

types of PLAY (assumed to be positively correlated), correlations among negative affect

regarding different types of PLAY (assumed to be positively correlated), and correlations

between positive affect and negative affect regarding different types of PLAY (assumed to be

negatively correlated). In Table 18 it is shown that all instances of positive affect during PLAY

were positively correlated with each other, as would be expected. That is, one would predict that

positive emotional experience in one type of PLAY would be associated with positive emotional

experiences across all types of PLAY. This would also be expected of negative affect during

PLAY, and this was also found. Please see Table 19.

38

Table 18

Positive Affect Correlations

Novel Positive Affect

Exciting Positive Affect

Routine Positive Affect

.71** .67**

Novel Positive Affect

-- .87**

*p < .05; **p < .01

Table 19

Negative Affect Correlations

Novel Negative

Affect

Exciting Negative

Affect

Routine Negative Affect .75** .64**

Novel Negative Affect -- .75**

*p < .05; **p < .01

Furthermore, one would expect that correlations between positive affect during each type

of PLAY and negative affect during each type of PLAY would be inversely correlated with one

another, respectively. In fact, this was found and is shown by boldface values in Table 20 below.

Similarly, one could extend this prediction such that positive affect during any type of PLAY

would be negatively correlated with negative affect across other types of PLAY. In general, this

was found with two exceptions when looking at positive affect during Routine PLAY and

negative affect in Novel and Exciting PLAY. However, the association between positive affect

during Routine PLAY and negative affect during Novel PLAY demonstrated a trend (p = .075),

thus with a larger sample size it is likely this would become significant.

39

Table 20

Positive and Negative Affect Correlations

Routine Negative

Affect

Novel Negative

Affect

Exciting Negative

Affect

Routine Positive Affect -.52** -.22+ -.13

Novel Positive Affect -.43** -.43** -.29**

Exciting Positive Affect -.47** -.39** -.45**

**p < .01; +p is a trend (p = .075)

Taken together, the results from the correlations of positive and negative affect during all

types of PLAY provide more evidence regarding the validity of the affect measures.

Construct Validity of PLAY Continued: Extension to Additional Measures

Additional correlational analyses were conducted assessing the relationship of PLAY

frequency items and scales with existing measures of theoretically similar constructs, specifically

the MAP and Aron’s question regarding engagement in exciting activities with the partner. It

was expected that frequency of Routine activities measured on the PLAY would correlate with

Core activities on the MAP. Similarly, it was predicted that frequency of both Novel and

Exciting PLAY would be correlated with Balance Activities on the MAP. Finally, it was

predicted that the frequency of Exciting PLAY would correlate with Aron’s question. These

associations are bolded in Table 21 and 22. As seen in those tables, there is support for these

hypothesized relationships, with 5 of the 6 being significant in the predicted direction, and the

sixth showing a trend (p = .06). That is, the PLAY Routine single-item frequency was not

associated with the MAP Core scale, as predicted, though it trended towards significance. As

noted in the Measure Reliabilities and Scale Statistics section above, the MAP Core scale

demonstrated lower internal consistency than all other scales, and thus may have limited the

40

validity of the scale as an overall measure of frequency of Core activities. Given the fact that the

PLAY Routine frequency item performed well in the most fundamental tests of criterion validity

noted above, this trend association with a measure of limited reliability is not seen as an

indication that the PLAY Routine frequency item is invalid.

Table 21

Frequency of PLAY and MAP Activities

MAP Core

MAP Balance

Routine Item .23± --

Novel Item -- .50**

Exciting Item -- .50**

*p < .05; **p < .01; ±p is a trend (p = .059).

Note: “Item” refers to the one item assessment of frequency.

On the other hand, Routine PLAY scale was significantly correlated with the MAP Core

scale. The MAP Balance scale was significantly correlated with the Novel and Exciting PLAY

scales, as expected. See Table 19 for PLAY frequency scales and MAP Activity correlations.

Table 22

PLAY Scales and MAP Activities Correlations

MAP Core

MAP Balance

Routine Scale .25* --

Novel Scale -- .42**

Exciting Scale -- .51**

*p < .05; **p < .01

41

In regards to validating the PLAY measure against Aron’s question, results were found

that supported prior hypothesis. That is, the Exciting PLAY scale was correlated with Aron’s

single-item assessment of “how exciting are the things you do with your partner” (r = .25, p <

.05).

Whereas not central to the validation process of the PLAY measure, additional

correlational analyses with MAP Core and Balance and the PLAY frequency scales also

provided some interesting results. The Overall Frequency of PLAY was correlated with both

MAP Core and Balance. Moreover, frequency of MAP Core activities were not significantly

associated with Novel and Exciting PLAY frequency, with one exception where the MAP Core

activity frequency did correlate with single-item Novel frequency of PLAY (r = .31**, p < .001;

see boldface value in Table 23). In regards to the MAP Balance activity frequency, there was a

significant association with the single item Routine frequency of PLAY, but not the Routine

scale frequency of PLAY (see Table 23).

Table 23

PLAY Frequency and MAP Activities

MAP Core

MAP Balance

Overall Frequency .30* .52**

Routine Item -- .27*

Routine Scale -- -.06

Novel Item .31** --

Novel Scale .23 --

Exciting Item .20 --

Exciting Scale .09 --

*p < .05; **p < .01

In general, the results of Aim 1 suggest that the PLAY measure demonstrates

psychometric adequacy as a valid measure of frequency of and affect during shared leisure with

42

the partner, with the possible exception of the measurement of negative affect during PLAY.

First, validity assumptions seem to have been met for the frequency of specific types of activities

with other measures of the same type of activities, both as assessed within the PLAY measure

and with external measures of frequency of shared leisure (e.g., MAP Core and Balance, Aron’s

item).

Next, assessment of positive affect appeared to be valid in that there were generally

significant associations between positive affect during each type of PLAY (Routine, Novel,

Exciting) and increased frequency of the same types of PLAY (Routine, Novel, Exciting,

respectively). The one exception was between positive affect during Novel PLAY and the single-

item frequency of Novel PLAY. Positive affect during specific types of PLAY was also

consistently negatively correlated with negative affect during those specific types of PLAY.

Lastly, the findings with negative affect during PLAY were interesting. Contrary to

expectations, I did not find that negative affect during PLAY was associated with less frequent

PLAY (this will be deliberated further in the Discussion section of this document). However,

scales of negative affect during types of PLAY were strongly positively associated with each

other, and, as noted above, negative affect during specific types of PLAY was consistently

negatively correlated with positive affect during those specific types of PLAY. Thus, I consider

these results to provide tentative initial validation support for the negative affect scales.

Additional data will be presented later in the convergence and divergence of these scales with

measures of PTSD and relationship satisfaction, which will also inform the evaluation of validity

of the negative affect and other PLAY scales.

Thus, the PLAY measure appeared to have adequate reliability and validity to proceed

with the next aims.

43

Aim 2

Two correlation matrices are presented, Figure 1 is the predicted correlation matrix and

Figure 2 is the actual correlation matrix. Although some findings were as predicted, there were

no significant associations between PTSD and PLAY. There were also no significant

associations between PTSD and relationship satisfaction, with one exception, the PTSD

Avoidance symptom sub-cluster and relationship satisfaction as measured by the KMSS.

Associations between PTSD and relationship satisfaction, PTSD and PLAY, and PLAY and

relationship satisfaction are further described below.

44

Figure 1. Predicted Correlation Matrix.

Note: Shading indicates the direction and magnitude of the correlation. Red shading indicates a negative correlation and blue shading indicates a positive correlation.

PT

SD

Sy

mp

tom

Sev

erit

y

PT

SD

: R

e-E

xper

ien

cing

Clu

ster

PT

SD

: E

mo

tional

Nu

mb

ing

Clu

ster

PT

SD

: H

yp

erar

ou

sal

Clu

ster

PL

AY

: O

ver

all

Fre

qu

ency

PL

AY

: N

orm

al/R

outi

ne

Fre

quen

cy

PL

AY

: N

ew/D

iffe

rent

Fre

qu

ency

PL

AY

: E

xci

ting

/Th

rill

ing

Fre

quen

cy

PL

AY

: P

osi

tive

Aff

ect

Du

rin

g

No

rmal

/Rou

tine

Act

ivit

ies

PL

AY

: P

osi

tive

Aff

ect

Du

rin

g

New

/Dif

fere

nt

Act

ivit

ies

PL

AY

: P

osi

tive

Aff

ect

Du

rin

g

Ex

citi

ng/T

hri

llin

g A

ctiv

itie

s

PL

AY

: N

egat

ive

Aff

ect

Du

ring

No

rmal

/Rou

tine

Act

ivit

ies

PL

AY

: N

egat

ive

Aff

ect

Du

ring

N

ew/D

iffe

ren

t A

ctiv

itie

s

PL

AY

: N

egat

ive

Aff

ect

Du

ring

Ex

citi

ng/T

hri

llin

g A

ctiv

itie

s

Rel

atio

nsh

ip S

atis

fact

ion

PTSD Symptom Severity 1.00

PTSD: Re-Experiencing Cluster 1.00

PTSD: Emotional Numbing Cluster 1.00

PTSD: Hyperarousal Cluster 1.00

PLAY: Overall Frequency 1.00

PLAY: Normal/Routine Frequency 1.00

PLAY: New/Different Frequency 1.00

PLAY: Exciting/Thrilling Frequency 1.00

PLAY: Positive Affect During Normal/Routine Activities 1.00

PLAY: Positive Affect During New/Different Activities 1.00

PLAY: Positive Affect During Exciting/Thrilling Activities 1.00

PLAY: Negative Affect During Normal/Routine Activities 1.00

PLAY: Negative Affect During New/Different Activities 1.00

PLAY: Negative Affect During Exciting/Thrilling Activities 1.00

Relationship Satisfaction 1.00

-1.00 0 1.00

45

.

Figure 2. Actual Correlation Matrix

PT

SD

Sy

mp

tom

Sev

erit

y

PT

SD

: R

e-E

xper

ien

cing

Clu

ster

PT

SD

: E

mo

tional

Nu

mb

ing

Clu

ster

PT

SD

: H

yp

erar

ou

sal

Clu

ster

PL

AY

: O

ver

all

Fre

qu

ency

PL

AY

: N

orm

al/R

outi

ne

Fre

quen

cy

PL

AY

: N

ew/D

iffe

rent

Fre

quen

cy

PL

AY

: E

xci

ting

/Th

rill

ing

Fre

quen

cy

PL

AY

: P

osi

tive

Aff

ect

Du

ring

No

rmal

/Routi

ne

Act

ivit

ies

PL

AY

: P

osi

tive

Aff

ect

Du

ring

New

/Dif

fere

nt

Act

ivit

ies

PL

AY

: P

osi

tive

Aff

ect

Du

ring

Exci

ting

/Th

rill

ing

Act

ivit

ies

PL

AY

: N

egat

ive

Aff

ect

Du

ring

No

rmal

/Routi

ne

Act

ivit

ies

PL

AY

: N

egat

ive

Aff

ect

Du

ring

New

/Dif

fere

nt

Act

ivit

ies

PL

AY

: N

egat

ive

Aff

ect

Du

ring

Exci

ting

/Th

rill

ing

Act

ivit

ies

Rel

atio

nsh

ip S

atis

fact

ion

PTSD Symptom Severity 1.00 .90** .89** .89** .08 .05 .10 .05 -.05 -.15 -.15 .18 .22 .32** -.20

PTSD: Re-Experiencing Cluster 1.00 .69** .77** .13 .09 .14 .08 .02 -.12 -.09 .10 .20 .32** -.08

PTSD: Emotional Numbing Cluster 1.00 .65** .04 .04 .01 .05 -.02 -.05 -.11 .15 .09 .25* -.30*

PTSD: Hyperarousal Cluster 1.00 .06 .03 .13 -.01 -.15 -.24 -.20 .25* .31* .32** -.13

PLAY: Overall Frequency 1.00 .76** .89** .84** .49** .26* .34** -.18 .05 -.05 .32**

PLAY: Normal/Routine Frequency 1.00 .50** .42** .29* .10 .18 -.12 -.01 -.04 .18

PLAY: New/Different Frequency 1.00 .69** .44** .19 .28* -.11 .14 .02 .27*

PLAY: Exciting/Thrilling Frequency 1.00 .49** .35** .38** -.24 -.02 -.11 .35**

PLAY: Positive Affect During Normal/Routine Activities 1.00 .71** .67** -.52** -.23 -.13 .41**

PLAY: Positive Affect During New/Different Activities 1.00 .87** -.43** -.43** -.29** .32**

PLAY: Positive Affect During Exciting/Thrilling Activities 1.00 -.47** -.39** -.45** .40**

PLAY: Negative Affect During Normal/Routine Activities 1.00 .75** .64** -.31**

PLAY: Negative Affect During New/Different Activities 1.00 .75** -.16

PLAY: Negative Affect During Exciting/Thrilling Activities 1.00 -.22


**Correlation sig at 0.01 *Correlation sig at 0.05 -1.00 0 1.00

-1.00 0 1.00

.

46

PTSD & Relationship Satisfaction

Surprisingly, in this sample, there were no significant associations between total PTSD

symptom severity and relationship satisfaction as measured by three distinct indices (KMSS,

CSI-4, SWMLS). Please see Table 24 for PTSD and Relationship Satisfaction correlations. This

was not an expected finding, as this relationship has been found repeatedly in prior literature. A

significant limitation of this study is the sample size. Two of the correlations with the Total score

were in the moderate range (e.g., -.20) but were not significant in this sample. Therefore, I may

have not had enough power to detect smaller effects. In other studies evaluating links between

PTSD and marital satisfaction, there has been variability in the magnitude of this association. For

example, Taft et al.’s (2011) meta-analysis reported that PTSD was related to intimate

relationship discord, but that the range of correlations in various studies was .11 to .73, with a

medium true score correlation (ρ) of .38. This is similar to other studies not included in the meta-

analysis by Taft and colleagues (2011), that have found modest to moderate associations between

PTSD and marital satisfaction, including correlations from -.31 (Miller, Schaefer, Renshaw, &

Blais, 2013), to -.39 (Meis et al., 2010), and -.48 (Renshaw, Rodrigues, & Jones, 2009). This

will be considered in more detail in the Discussion. When looking at sub-clusters, the only

significant correlation was found between the PTSD Avoidance symptom cluster and the KMSS

(r = -.30, p = .01; see boldface value in Table 24).

47

Table 24

PTSD & Relationship Satisfaction Correlations

KMSS CSI-4 SWMLS

PCL-C

Total Symptom Severity -.20

-.10

-.20

Re-Experiencing -.08 -.05 -.13

Avoidance -.30* -.10 -.18

Hyperarousal -.13 -.12 -.23+

*p < .05; +p is a trend (p = .06)

PTSD & PLAY

Contrary to hypotheses, there were no significant findings between total PTSD symptom

severity and/or sub-clusters of PTSD symptoms and (1) single-item frequency of PLAY (that is,

Routine, Novel, or Exciting) or (2) PLAY frequency scales. See Table 25 for PTSD and PLAY

frequency correlations.

Table 25

PTSD & PLAY Frequency Correlations

PLAY

Overall Frequency

Routine Item

Routine Scale

Novel Item

Novel Scale

Exciting Item

Exciting Scale

PCL-C

Total Symptom Severity

.08

.05

.

01

.10

-.06

.05

-.04

Re- Experiencing

.13 .09 -.03 .14 .00 .08 .04

Avoidance .04 .04 .01 .01 -.09 .05 -.09

Hyperarousal .06 .03 .04 .13 -.07 -.01 -.05


48

Non-significant findings also occurred between the PTSD variables and types of leisure

activities as assessed by the MAP. That is, Core and Balance activities were not significantly

correlated with PTSD symptoms.

In examining PTSD and the emotion scales of PLAY, the direction of correlations were

generally consistent with predictions (i.e., PTSD symptoms associated with less positive affect

and more negative affect during play), but the magnitude and significance of these associations

varied considerably. Negative affect during Exciting PLAY was significantly correlated with all

aspects of PTSD. The Hyperarousal cluster of PTSD symptoms was also significantly positively

correlated with negative affect during Routine and Novel types of PLAY. See Table 26 for PTSD

and PLAY Affect correlations, where significant correlations are shown in boldface.

49

Table 26

PTSD and PLAY Affect Correlations

PLAY Routine PLAY Novel PLAY Exciting

Positive Affect

Negative Affect

Positive Affect

Negative Affect

Positive Affect

Negative Affect

PCL-C

Total Symptom Severity

-.05

.18

-.15

.22^

-.15

.32**

Re-Experiencing Cluster .02 .10 -.12 .20 -.09 .32**

Avoidance Cluster -.02 .15 -.05 .09 -.11 .25*

Hyperarousal Cluster -.15 .25* -.24+ .31* -.20 .32**

*p = .01; **p < .001; +p is a trend (p = .055); ^p is a trend (p = .080).

50

PLAY & Relationship Satisfaction

Overall, the majority of the PLAY frequency variables were significantly correlated with

all measures of relationship satisfaction (Table 27). There were only non-significant findings

between the single-item frequency and scale frequency of Routine PLAY and the KMSS (see

italicized values in Table 27).

Table 27

PLAY Frequency & Relationship Satisfaction Correlations

KMSS CSI-4 SWMLS

PLAY

Overall Frequency

.32**

.60**

.54**

Routine Item .18 .40** .42**

Routine Scale .16 .30* .32**

Novel Item .27* .54** .45**

Novel Scale .38** .66** .57**

Exciting Item .35** .56** .48**

Exciting Scale .41** .59** .47**

*p = .01; **p < .001.


51

PLAY Affect & Relationship Satisfaction

Positive affect across all types of PLAY were significantly correlated with all measures

of relationship satisfaction (Table 28). Negative affect showed a less consistent pattern with

relationship satisfaction. Negative affect during Routine PLAY was significantly associated with

all measures of relationship satisfaction, and in the correct direction. That is, as negative affect

during Routine PLAY increased, relationship satisfaction decreased. However, negative affect

during Novel and Exciting PLAY was not significantly correlated with relationship satisfaction

with one exception (negative affect during Novel PLAY was negatively correlated with the

SWMLS, r = -.32, p < .001).

Table 28

PLAY Affect and Relationship Satisfaction Correlations

KMSS CSI-4 SWMLS

PLAY

Routine

Positive Affect

.41**

.74**

.70**

Negative Affect -.31** -.51** -.51**

Novel

Positive Affect

.32**

.53**

.53**

Negative Affect -.16 -.20 -.32**

Exciting

Positive Affect

.40**

.59**

.57**

Negative Affect -.22+ -.19 -.24

*p = .01; **p < .001; +p is a trend (.08)

52

Aim 3

Due to the lack of significant correlations found between PTSD variables and relationship

satisfaction, I was unable to test the mediation models as previously planned. Although there

exists one significant association between PTSD Avoidance symptom sub-cluster and

relationship satisfaction as measured by the KMSS, given the isolated nature of this finding, it

may be Type I error in this sample. That is, it was not consistent with the general pattern of

findings in the sample. Thus, no tests of mediation were conducted.

53

CHAPTER V

DISCUSSION

The purpose of this study was to thoroughly explore the associations between PTSD,

relationship satisfaction, and shared leisure activities with the partner in OEF/OIF Veterans. In

addition, this study uniquely contributed to the design and validation of a measure to assess both

frequency and affective experience of different types of shared leisure activities. To my

knowledge, this is the first study to explore these constructs with detailed specificity.

PLAY Psychometric Properties

In general, the results of this study demonstrate that the pilot measure tested in this

sample is a reliable and valid measure of shared leisure activity. Specifically, internal

consistency ranged from adequate to excellent reliability for both frequency and affective

experience of PLAY. Construct validity of the frequency of shared leisure items was

demonstrated by significant correlations both within and across specific types of leisure that

were defined as Routine, Novel and Exciting as assessed by both single-item frequency and scale

frequency. Not only did frequency of these types of leisure demonstrate validity within the same

measure of PLAY, it was also correlated in the predicted manner with external measures of

leisure (e.g., Core and Balance). The fact that the reported frequency of Routine PLAY was

significantly less than Novel and Exciting PLAY also supports the validity of these scales, as this

was the expected pattern.

Interesting findings occurred during validation of the affective experience during types of

PLAY scales. Positive affect during all three types of PLAY generally demonstrated the

predicted associations thought to support validity for these scales; that is, positive affect during

PLAY was correlated with increased frequency of that type of PLAY (with one exception

54

between positive affect during Novel PLAY and Novel PLAY assessed by the single-item

frequency), positive affect during a specific type of play was inversely related with negative

affect during that type of play, and positive affect during PLAY was consistently positively

associated with relationship satisfaction. There were some unexpected findings (e.g., positive

affect did not relate to PTSD), but the overall pattern suggests that the positive affect scales were

valid.

Whereas the positive affect during PLAY scales appear valid, I found relatively more

unpredicted results regarding negative affect experienced during PLAY. That is, none of the

negative affect scales during all three types of PLAY correlated with less frequency of that

respective type of PLAY. It is unclear as to why there were no significant associations between

negative affect and reduced frequency of PLAY. However, negative affect during specific types

of PLAY was consistently negatively correlated with positive affect during those specific types

of PLAY. Moreover, I found that PTSD and all the PTSD symptom sub-clusters were correlated

with negative affect during Exciting PLAY. Negative affect during Routine and Novel PLAY

was also correlated in the right direction with the PTSD Hyperarousal symptom sub-cluster. One

would expect that negative affect would increase during PLAY as PTSD symptoms increase,

thus my findings show a pattern here that provides some confirmation that the negative affect

scale may be a valid scale. In addition, negative affect during Routine PLAY was inversely

associated with relationship satisfaction. This would be expected, such that if an individual is

experiencing negative emotions during the typical shared leisure, they are less likely to enjoy

their relationship. Here again is an interesting finding in that this was only significant for Routine

PLAY. Negative affect during Novel and Exciting PLAY did not demonstrate associations with

the primary measure of relationship satisfaction, although negative affect during Exciting PLAY

55

may be demonstrating a trend toward significance with relationship satisfaction. It could be that

with a larger sample size, negative affect would demonstrate significant inverse associations.

Due to these additional analyses, I tentatively consider the negative affect scales on the

PLAY measure to be valid. It would be beneficial for future studies to administer the PLAY

measure and assess validation of the negative affect scale in larger samples, either to explore

additional patterns and/or to have the power to conduct a factor analysis. It could be that negative

affect is more nuanced than was previously theorized, particularly in a population with

symptoms of PTSD. For instance, there could be multiple categories of “negative” affect, such as

differentiating between “sad” and “angry” or “hypervigiliant”. Moreover, certain adjectives

thought to be “positive” such as exciting, may actually be negative for a population with

symptoms such as hypervigilance. Administering the PLAY measure to a larger sample would

provide the necessary power to conduct a factor analysis and determine if these differences in

negative affect exist.

Interrelationships between PTSD, PLAY & Relationship Satisfaction

Interesting findings emerged from conducting analyses on the interrelationships among

PTSD, PLAY and relationship satisfaction as well as examining specific components of these

variables (i.e., PTSD symptom clusters, frequency of PLAY, affect during PLAY). Some

unexpected findings emerged, such as a general lack of association between PTSD and the

measures of relationship satisfaction or leisure. When considering these findings, an

understanding of this sample’s demographic characteristic may be beneficial. On average, this

sample is reporting high levels of PTSD, including total symptom severity and at the symptom

cluster level. Veterans also are endorsing some dissatisfaction with their relationship, in fact,

with the average of 5.18 on the KMSS, this sample fell below the cutoff criteria of a score of

56

5.67 on the KMSS as recommended by Crane and colleagues (2000), where below 5.67 would be

considered distressed. This sample did report participating in shared leisure with their partner,

and on somewhat expected levels of more frequency of shared leisure that was routine, normal

and home-based day-to-day activities compared to less frequency of shared leisure that was

considered exciting, new, and not home-based. As there are no norms for these shared leisure

measures, it is unknown whether the observed frequency of shared leisure represents typical or

divergent levels compared to other samples.

Given these general levels of PTSD and relationship satisfaction, it is unclear why PTSD

did not generally correlate with relationship satisfaction; that is, there did appear to be adequate

variability on the constructs such that an association would not be constrained by issues such as

uniformly high satisfaction or low PTSD. One possibility is that, due to the fact that the Veterans

in this study were recruited and included into the study because they were all receiving mental

and/or physical health care at a VA setting, perhaps these Veterans have learned strategies to

cope with the impact of PTSD on their relationship functioning. Of course, one issue affecting

the fact that PTSD and relationship satisfaction did not significantly correlate is limited power.

The magnitude of correlations was, at times, moderate, which is consistent with prior literature

that has found correlations from .11 to .73 (Taft et al., 2011), though is lower than more recent

magnitude of correlations reported between -.31 (Miller et al., 2013) and -.48 (Renshaw et al.,

2009). One significant inverse correlation was found between PTSD Avoidance symptom cluster

and one of the measures of relationship satisfaction (the KMSS). Avoidance has prior research

support as one of the more potent predictors of relationship distress (Riggs et al., 1998). A more

recent study reported that the avoidance symptoms showed the strongest association with general

57

functional impairment, an intermediate association with hyper-arousal symptoms, and the lowest

association with re-experiencing symptoms (Rona et al., 2009), which is similar to my results.

In addition to the unexpected results for PTSD and relationship satisfaction, I also did not

find any significant correlations between PTSD and PLAY frequency. This was contradictory to

my hypotheses that as PTSD symptoms increase, one would engage in less frequency of shared

leisure with their partner. In examining the values of the correlations, it does not appear that this

is a limitation of a small sample size, as the magnitude of all the correlations was nil to small. It

could be that these Veterans, who are engaged with the VA and able to participate in research,

are not significantly impacted by their PTSD such that it does not interfere with their day-to-day

functioning or engagement in activities with the partner. Another possible explanation that may

warrant future investigation is looking at categorizing these Veterans into “subtypes”. For

example, there may be Veterans with PTSD who are seeking more PLAY, in order to escape

negative affect or a need to re-create the “combat rush” experience (Grigsby, 1991) and pursue

more dangerous, thrilling activities. In addition, these Veterans that pursue more “exciting”

activities that may include elements of danger may engage in these activities by themselves or

with military and/or civilian buddies as compared to their romantic partners. There may be a

category of Veterans that are more avoidant of play, perhaps because engaging in activities

because participation in activities amplifies their symptoms of PTSD (e.g., startle response,

anger, detachment) or they feel depression and anhedonia which suppresses their desire to

engage in leisure. Although these subtypes have not been verified, they do correspond with

qualitative analyses I conducted with a subset of the participants in this sample (Betthauser,

Allen, Grigsby & Brenner, under review). Thus, the overall lack of findings may obscure two

underlying subtypes where some Veterans show positive associations between PTSD and PLAY

58

with the partner, and others show negative associations between PTSD and PLAY with the

partner. It should be noted that in these qualitative analyses, thrilling play was usually either

engaged in as an individual pursuit or with their military and civilian buddies, with less

participation of this type of play shared with their partner. Thus, it is likely that the frequency of

play reported in this study is not an accurate representation of the actual frequency of these

Veterans leisure, as I asked them only to report on shared leisure with the partner. In any case,

future research may better identify such subtypes of differential associations between PTSD and

play.

When examining the relationship between PTSD and affect during PLAY, there emerged

more, and interesting, significant patterns. First, as PTSD symptoms (measured by total symptom

severity and each symptom sub-cluster) increased, the experience of negative affect during

Exciting PLAY increased. Second, as PTSD Hyperarousal symptoms increased, so did negative

affect during all three types of PLAY. Although frequency of PLAY is not inhibited by PTSD

symptoms in this sample, assessing the association between negative affect and PLAY is

important. This makes sense, considering the manifestation of PTSD symptoms such as

numbing, anger, and irritability may increase when exposed to situations that activate their

behavioral response or negative cognitions that remind them of a traumatic event. Considering

that the question asked was about leisure that is “exciting” or “thrilling” this may have brought to

mind activities such as dangerous activities or activities that include crowds or loud noises,

which in turn would exacerbate PTSD symptoms of avoidance and hyperarousal. Clinically, this

information is relevant, as a focus of therapy may be on collaborating with the Veteran on coping

techniques for the specific symptoms and/or on coping techniques during activities that may be

considered too “exciting”. Educating the partner about potential increases in negative affect

59

during PLAY and PTSD symptoms may help the couple to explore activities in a safe manner

and promote problem-solving or coping techniques when faced with such situations that may

increase PTSD symptoms or negative affect.

Results from this study did show that participation in shared leisure is associated with

greater relationship satisfaction. This is consistent with Aron and colleagues (2001) “self-

expansion” theory as applied to couples and Johnson and colleagues’ (2006) theory of Core and

Balance leisure in couples. These findings of significant associations between Novel and

Exciting PLAY and relationship satisfaction should be carefully considered with the findings that

negative affect during Exciting PLAY is more likely to be reported when PTSD symptoms are

higher, and that Hyperarousal predicts negative affect during all types of PLAY. Specifically, if

recommending increased leisure for populations that may have experienced trauma, one should

prepare the couple with coping and/or problem-solving techniques for managing negative affect

during leisure that may exacerbate PTSD symptoms. In this way, the couple may further benefit

from engaging in safe, shared leisure in a manner that can promote relationship functioning

while mitigating negative outcomes.

We know from cognitive behavioral therapy and couples therapy techniques that

behavioral activation is a key component of addressing dysfunctional symptoms. Thus, carefully

considering types of PLAY, promoting frequency, and providing strategies around the affective

experience of PLAY may assist the Veteran and their partners in employing more constructive

activation and connection strategies in naturalistic settings that could help with PTSD symptoms

and relationship adjustment.

60

CHAPTER VI

LIMITATIONS

The most significant limitation of this study was the small sample size. As such, I was

limited in conducting additional scale development techniques, such as factor analysis.

Administration of the PLAY measure to a diverse and larger sample size would likely assist in

more sophisticated scale development. This may also address the validation concern regarding

the negative affect scales and provide greater understanding of how negative affect correlated

with shared leisure in romantic relationships.

Because the PLAY measure was developed with the idea to assess PTSD, PLAY and

relationship satisfaction in the OEF/OIF Veteran population, there are limitations to generalizing

these findings to other cohorts of Veterans and/or the general population. Additional

psychometric testing of this measure in diverse populations would provide greater external

validity of this measure.

The limitation of sample size also inhibited my power to detect significant associations

between PTSD and relationship satisfaction that may emerge in a larger sample. At the same

time, I considered the sample demographics and responses on measures and analyses showed

that there was good variability around responses on PTSD and relationship measures.

Another limitation of this study was that all the data were collected at one-time point.

This precluded my ability to assess the temporal sequencing of PTSD, shared leisure activity,

and relationship satisfaction. It is likely that the association between shared leisure activities,

PTSD, and relationship satisfaction are cyclical, with these variables influencing each other.

61

Since only the OEF/OIF Veteran completed the study procedures, I am lacking data from

the Veteran’s significant other; thus limiting my ability to interpret the findings as a

representation of the couple.

62

CHAPTER VII

CONCLUSIONS & IMPLICATIONS

This study provided an in-depth examination of the associations between clinically

relevant issues (i.e., PTSD, relationship satisfaction) and shared leisure, for Veterans returning

home from Afghanistan and Iraq. Research has demonstrated that reintegration into close

interpersonal relationships for these combat Veterans is difficult (McNulty, 2005). Veterans have

reported that these reintegration issues are as important or even more important that resolving

psychiatric symptoms (Johnson, Rosenheck, Fontana, et al., 1996; Zatzick, Russo, Rajotte, et al.,

2007). Thus, family therapy or couple conjoint therapy techniques addressing reintegration

should be useful. The current study provides some support for the notion that including elements

of promoting shared leisure activities within such interventions may serve to increase the

Veterans’ relationship adjustment with the caveats noted above regarding affect during such

activities. Future studies may expand upon our understanding of the interrelationships PTSD,

PLAY and relationship satisfaction by including larger and more diverse samples, qualitative

elements, possible moderators of associations, partner data, and additional measures of

psychosocial functioning.

63

REFERENCES

Allen, E.S., Rhoades, G.K., Stanley, S.M., & Markman, H.J. (2010). Hitting home: Relationships

between recent deployment, posttraumatic stress symptoms, and marital functioning for

Army couples. Journal of Family Psychology, 24, 280-288.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders

(4th ed., text revised). Washington, DC: Author.

Aron, A., & Aron, N.E. (1986). Love as the expansion of self: Understanding attraction and

satisfaction. New York: Hemisphere.

Aron, A., Norman, C.C., Aron, N.E., McKenna, C., & Heyman, R.E. (2000). Couples’ shared

participation in novel and arousing activities and experience relationship quality. Journal

of Personality and Social Psychology, 78, 273-284.

Aron, A., Aron, E.N., & Norman, C. (2001). Combating boredom in close relationships by

participating in self-expanding activities. In J.H. Harvey & A.E. Wenzel (Eds.), Close

romantic relationship maintenance and enhancement. Mahwah, NJ: Lawrence Erlbaum.

Barrett, T.W., & Mizes, J.S. (1988). Combat level and social support in the development of

posttraumatic stress disorder in Vietnam veterans. Behavior Modification, 12, 100-115.

Betthauser, L.M., Allen, E., Grigsby, J., & Brenner, L.A. (2014). A qualitative analysis of

adventurous activities among OEF/OIF Veterans. Manuscript submitted for publication.

Carroll, E.M., Rueger, D.B., Foy, D.W. & Donahoe, C.P. (1985). Vietnam combat veterans with

posttraumatic stress disorder: Analysis of marital and cohabiting adjustment. Journal of

Abnormal Psychology, 94, 329-337.

64

Cook, J.M., Riggs, D.S., Thompson, R., Coyne, J.C., & Sheikh, J. (2004). Post-traumatic stress

disorder and current relationship functioning of WWII ex-prisoners of war. Journal of

Family Psychology, 18, 36-45.

Crane, D., Middleton, K., & Bean, R. (2000). Establishing criterion scores for the Kansas Marital

Satisfaction Scale and the Revised Dyadic Adjustment Scale. American Journal of

Family Therapy: 28(1), 53-60.

Diener, E., Emmons, R.A., Larson, R.J., & Griffin, S. (1985). The Satisfaction with Life Scale.

Journal of Personality Assessment, 49, 71-75.

Dindia, K., & Baxter, L.A. (1987). Strategies for maintaining and repairing marital relationships.

Journal of Social and Personal Relationships, 4, 143-158.

Environmental Health Strategic Healthcare Group. (2011). Analysis of VA health care utilization

among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and

Operation New Dawn (OND) veterans. PowerPoint presentation. Veterans Health

Administration Department of Veterans Affairs.

Erbes, C., Westermeyer, J., Engdahl, B., & Johnson, E. (2007). Post-traumatic stress disorder

and service utilization in a sample of service members from Iraq and Afghanistan.

Military Medicine, 172, 359-363.

Feeney, N.C., Zoellner, L.A., Fitzgivvons, L.A., & Foa, E.B. (2000). Journal of Traumatic

Stress, 13, 489-498.

Fincham, F.D., & Beach, S.R.H. (2010). Of memes and marriage: Toward a positive relationship

science. Journal of Family Theory & Review, 2, 4-24.

65

Finley, E.P., Baker, M., Pugh, M.J., & Peterson, A.L. (2010). Patterns and perceptions of

intimate partner violence committed by returning veterans with post-traumatic stress

disorder. Journal of Family Violence, 25(8), 737-743. doi: 10:1007/s10896-010-9331-7.

Fredrickson, B.L. (1998). What good are positive emotions? Review of General Psychology,

2(3), 300-319. doi: 10.1037/1089-2680.2.3.300.

Fredrickson, B.L. (2001). The role of positive emotions in positive psychology: The broaden-

and-build theory of positive emotions. American Psychologist, 56(3), 218-226. Doi:

10.1037/0003-066X.56.3.218.

Freeman, S.M., Moore, B.A., & Freeman, A. (Eds.) (2009). Living and surviving in harm’s way.

New York, NY: Routledge.

Friedman, G. (2005). America's secret war: inside the hidden worldwide struggle between the

United States and its enemies. Random House Digital, Inc.

Funk, J.L., & Rogge, R.D. (2007). Testing the ruler with item response theory: Increasing

precision of measurement for relationship satisfaction with the Couples Satisfaction

Index. Journal of Family Psychology, 21, 572-583.

Galovski, T., & Lyons, J.A. (2004). Psychological sequelae of combat violence: A review of the

impact of PTSD on the veteran’s family and possible interventions. Aggression and

Violent Behavior, 9, 477-501.

Grigsby, J. (1991). Combat rush: Phenomenology of central and autonomic arousal among war

veterans with PTSD. Psychotherapy: Theory, Research, Practice, Training, 28(2), 354-

363.

66

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.L., & Koffman, R.L. (2004).

Combat duty in Iraq and Afghanistan mental health problems, and barriers to care. New

England Journal of Medicine, 351, 13-22.

Hoge, C.W., Auchterlonie, J.L., & Milliken, C.S. (2006). Mental health problems, use of mental

health services, and attrition from military service after returning from deployment to

Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023-1032.

Holman, T.B., & Epperson, A. (1989). Family and leisure: A review of the literature with

research recommendations. Journal of Leisure Research, 16, 277-294.

Janofsky, J. S., McCarthy, R. A., & Folstein, M. F. (1992). The Hopkins Competency

Assessment Test: A brief method for evaluating patients' capacity to give informed

consent. Hospital and Community Psychiatry, 43, 132-136.

Johnson, D.R., Rosenheck, R., Fontana, A., Lubin, H., Charney, D., & Southwick, S. (1996).

Outcome of intensive inpatient treatment for combat-related posttraumatic stress disorder.

American Journal of Psychiatry: 153(6), 771-777.

Johnson, H.A., Zabriskie, R.B., & Hill, B. (2006). The contribution of couple leisure

involvement, leisure time, and leisure satisfaction to marital satisfaction. Marriage and

Family Review, 40, 69-91.

Jordan, B.K., Marmar, C.R., Fairbank, J.A., Schlenger, W.E., Kulka, R.A., Hough, R.L., &

Weiss, D.S. (1992). Problems in families of male Vietnam veterans with posttraumatic

stress disorder. Journal of Consulting and Clinical Psychology, 60, 916-926.

Lambert, J.E., Engh, R., Hasbun, A. & Holzer, J. (2012). Impact of posttraumatic stress disorder

on the relationship quality and psychological distress of intimate partners: A meta-

analytic review. Journal of Family Psychology, 26(5), 729-737. doi: 10.1037/a0029341

67

Lapierre, C.B., Schwegler, A.F., & Labauve, B.J. (2007). Posttraumatic stress and depression

symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal

of Traumatic Stress, 20, 933-943.

Luebecke, B., Owen, J., Keller, B., Shuck, B., Knopp, K, & Rhoades, G.K. (2014). Therapy

interventions for couples: A commitment uncertainty comparison. Couple and Family

Psychology, 3(4), 239-254. doi: 10.1037/cfp0000031

McLeland, K.C., Sutton, G.W., & Schumm, W. (2008). Marital satisfaction before and after the

deployments associated with the global war on terror. Psychological Reports, 103, 836-

844.

McNulty, P.A.F. (2005). Reported stressors and health care needs of active duty Navy personnel

during three phases of deployment in support of the war in Iraq. Military Medicine, 170,

530-535.

Meis, L.A., Erbes, C.R., Polusny, M.A., & Compton, J.S. (2010). Intimate relationships among

returning soldiers: The mediating and moderating roles of negative emotionality, PTSD

symptoms, and alcohol problems. Journal of Traumatic Stress, 23(5), 564-572.

Miller, A.B., Schaefer, K.E., Renshaw, K.D., & Blais, R.K. (2013). PTSD and marital

satisfaction in military service members: Examining the simultaneous role of childhood

sexual abuse and combat exposure. Child Abuse & Neglect, 37(11), 979-985.

doi:10.1016/j.chiabu.2013.05.006

Monson, C.M., Taft, C.T., & Fredman, S.J. (2009). Military-related PTSD and intimate

relationships: From description to theory-driven research and intervention development.

Clinical Psychology Review, 29, 707-714.

68

Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for

posttraumatic stress disorder: Harnessing the healing power of relationships. New York,

NY: Guilford Press.

Nelson Goff, B.S., Crow, J.R., Reisbig, A.M.J., & Hamilton, S. (2007). The impact of individual

trauma symptoms of deployed soldiers on relationship satisfaction. Journal of Family

Psychology, 21, 334-353.

Newby, J.H., McCarroll, J.E., Ursano, R.J., Fan, Z., Shigemura, J., & Tucker-Harris, Y., (2005).

Positive and negative consequences of a military deployment. Military Medicine, 170,

815-819.

Orthner, D.K., & Mancini, J.A. (1990). Leisure impacts on family interaction and cohesion.

Journal of Leisure Research, 22, 125-137.

Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rivers, A.J., Johnson, D.C., & Southwick, S.M.

(2010). Risk and protective factors associated with suicidal ideation in veterans of

Operations Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 123,

102-107.

Prigerson, H.G., Maciejewski, P.K., & Rosenheck, R.A. (2002). Population attributable fractions

of psychiatric disorders and behavioral outcomes associated with combat exposure

among US men. American Journal of Public Health, 92(1), 59-63.

Ray, S.L., & Vanstone, M. (2009). The impact of PTSD on veterans’ family relationships: An

interpretive phenomenological inquiry. International Journal of Nursing Studies, 46(6),

838-847.

69

Renshaw, K.D., Rodrigues, C.S., & jones, D.M. (2009). Combat exposure, psychological

symptoms and marital satisfaction in National Guard soldiers who served in Operation

Iraqi Freedom from 2005 to 2006. Anxiety, Stress & Coping, 22, 101-115.

Riggs, D.S., Byrne, C.A., Weathers, F.W., & Litz, B.T. (1998). The quality of the intimate

relationships of male Vietnam veterans: Problems associated with posttraumatic stress

disorder. Journal of Traumatic Stress, 11, 87-99.

Rona, R.J., Jones, M., Iversen, A., Hull, L., Greenberg, N., Fear, N.T.,…Wessely, S. (2009). The

impact of posttraumatic stress disorder on impairment in the UK military at the time of

the Iraq war. Journal of Psychiatric Research, 43, 649-655.

Sautter, F.J., Armelie, A.P, Glynn, S.M., & Wielt, D.B. (2011). The development of a couple-

based treatment for PTSD in returning veterans. Professional Psychology: Research and

Practice, 42(1), 63-69.

Schumm, W.R., Paff-Bergen, L.A., Hatch, R.C., Obiorah, F.C., Copeland, J.M., Meens, L.D.,

Bugaighis, M.A. (1986). Concurrent and discriminant validity of the Kansas Marital

Satisfaction Scale. Journal of the Marriage and the Family, 48, 381-387.

Seal, K.H., Bertenthal, D., Miner, C.R., Sen, S., & Marmar, C. (2007). Bringing the war back

home: Mental health disorders among 103,788 US veterans returning from Iraq and

Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal

Medicine, 167, 476-482.

Solomon, Z., Dekel, R., & Zerach, G. (2008). The relationships between posttraumatic stress

symptom clusters and marital intimacy among war veterans. Journal of Family

Psychology, 22, 659-666.

70

Strong, G., & Aron, A. (2006). The effect of shared participation in novel and challenging

activities on experienced relationship quality: Is it mediated by high positive affect? In K.

Vohs & E. Finkel (Eds.), Self and relationships: Connecting intrapersonal and

interpersonal processes (pp. 342-359). New York: Guilford.

Taft, C.T., Watkins, L.E., Stafford, J., Street, A.E., & Monson, C.M. (2011). Posttraumatic stress

disorder and intimate relationship problems: A meta-analysis. Journal of Consulting and

Clinical Psychology, 79(1), 22-33. doi: 10.1037/a0022196

Tanielian, T., & Jaycox, L.H. (2008). Invisible wounds of war: Psychological and cognitive

injuries, their consequences, and services to assist recovery. California: RAND

Corporation.

U.S. Department of Veterans Affairs. National Center for PTSD. (2014). Using the PTSD

checklist for DSM-IV (PCL). Retrieved from:

http://www.ptsd.va.gov/professional/pages/assessments/assessment-pdf/PCL-

handout.pdf.)

Ward, P., Lundberg, N., Zabriskie, R., & Barret, K. (2009). Measuring marital satisfaction: A

comparison of the Revised Dyadic Adjustment Scale and the Satisfaction with Married

Life Scale. Marriage and Family Review: 45(4), 412 – 429.

Watson, D., Clark, L.A., & Tellegan, A. (1988). Development and validation of brief measures

of positive and negative affect: The PANAS scales. Journal of Personality and Social

Psychology, 54(6), 1063-1070.

Weathers, F.W., Litz, B., Herman, D., Huska, J.A., & Keane, T.M. (1993). The PTSD checklist

(PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual

Convention of the International Society for Traumatic Stress Studies, San Antonio, TX.

71

Zabriskie, R.B. (2000). An examination of family and leisure behavior among families with

middle school aged children. (Unpublished doctoral dissertation). Indiana University,

Bloomington, Indiana.

Zabriskie, R.B., & McCormick, B.P. (2001). The influences of leisure patterns on perceptions of

family functioning. Family Relations, 50, 281-289.

Zatzick, D.F., Marmar, C.R., Weiss, D.S., Browner, W.S., Metzler, T.J., Golding, J.M., …

Wells, K.B. (1997). Posttraumatic stress disorder and functioning and quality of life

outcomes in a nationally representative sample of male Vietnam Veterans. American

Journal of Psychiatry, 154, 1690-1695.

Zatzick, D.F., Russo, J., Rajotte, E., Uehara, E., Roy-Byrne, P, Ghesquiere, A, … Rivara, F.

(2007). Strengthening the patient-provider relationship in the aftermath of physical

trauma through an understanding of the nature and severity of posttraumatic concerns.

Psychiatry, 70, 260 – 273. doi:10.1521/psyc.2007.70.3.260

72

APPENDIX

73

APPENDIX A

PLAY MEASURE

74

1. How often do you do

activities with your partner?

Response: Not at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

FUN

EXCITING

DIFFERENT

NEW

EXTREME

OUT OF THE ORDINARY

ROUTINE

TEDIOUS

STIMULATING

CHALLENGING

ADVENTUROUS

NORMAL

UNFAMILIAR

ARTISTIC

UNEXCITING

AMUSING

FRESH/ORIGINAL

SUBDUED

UNUSUAL

ENJOYABLE

CAREFREE

PEACEFUL

Response: Not at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

ADRENALINE PUMPING

HEART RACING

BORING

RISKY

AROUSING

PLEASURABLE

NOVEL

PLAYFUL

INTERESTING

EXPLORATORY

CREATIVE

BOLD

ORDINARY

ACTIVATING

MUNDANE

EXHILARATING

SILLY

PREDICTABLE

SHOCKING

DARING

RELAXING

UNPLEASURABLE

REWARDING

MISCHIEVOUS

75

2.

When you do new, different activities with your partner, how often do you feel:

Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

JOY

HAPPINESS

LOVE

SADNESS

ANGER

FRUSTRATION

EXCITED

STIMULATED

SCARED

ANNOYED

PLEASURE

CONTENTMENT

ANXIOUS

OPTIMISTIC

PESSIMISTIC

FEAR

DISGUST

MOTIVATED

THE NEED TO ESCAPE

AMUSEMENT

NOTHING

Response:

Not

at all (1)

A

little (2)

Some

(3)

Often

(4)

Very often (5)

GIDDY

BORED

STRESSED

NEUTRAL

UNCOMFORTABLE

COMFORTABLE

INTERESTED

HOPE

DISINTERESTED

GOOD

BAD

CONFIDENT

INDIFFERENCE

DETACHED

RESTRICTED

MISERABLE

SATISFIED

DISSATISFIED

ALIVE

WONDERFUL

THE NEED TO LAUGH

76

LIKE YOU WANT TO SMILE

JITTERY

NUMB

2.

When you do new, different activities with your partner, how often do you feel:

Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

JUMPY

IN HIGH SPIRITS

ON EDGE

CHEERFUL

PANICKY

EMPTY

77

3. When you participate in normal, routine leisure activities

with your partner, how often do you feel:

Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

JOY

HAPPINESS

LOVE

SADNESS

ANGER

FRUSTRATION

EXCITED

STIMULATED

SCARED

ANNOYED

PLEASURE

CONTENTMENT

ANXIOUS

OPTIMISTIC

PESSIMISTIC

FEAR

DISGUST

MOTIVATED

THE NEED TO ESCAPE

Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

AMUSEMENT

NOTHING

GIDDY

BORED

STRESSED

NEUTRAL

UNCOMFORTABLE

COMFORTABLE

INTERESTED

HOPE

DISINTERESTED

GOOD

BAD

CONFIDENT

INDIFFERENCE

DETACHED

RESTRICTED

MISERABLE

SATISFIED

DISSATISFIED

ALIVE

WONDERFUL

78

THE NEED TO LAUGH


3. When you participate in normal, routine leisure activities


Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

JITTERY

NUMB

JUMPY

IN HIGH SPIRITS

ON EDGE

CHEERFUL

PANICKY

EMPTY

79

4. When you participate in exciting or thrilling activities


Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

JOY

HAPPINESS

LOVE

SADNESS

ANGER

FRUSTRATION

EXCITED

STIMULATED

SCARED

ANNOYED

PLEASURE

CONTENTMENT

ANXIOUS

OPTIMISTIC

PESSIMISTIC

FEAR

DISGUST

MOTIVATED

THE NEED TO ESCAPE

AMUSEMENT

NOTHING

Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

GIDDY

BORED

STRESSED

NEUTRAL

UNCOMFORTABLE

COMFORTABLE

INTERESTED

HOPE

DISINTERESTED

GOOD

BAD

CONFIDENT

INDIFFERENCE

DETACHED

RESTRICTED

MISERABLE

SATISFIED

DISSATISFIED

ALIVE

WONDERFUL

THE NEED TO LAUGH


80

JITTERY

NUMB

4. When you participate in exciting or thrilling activities


Response: Not

at all (1)

A little (2)

Some (3)

Often (4)

Very often (5)

JUMPY

IN HIGH SPIRITS

ON EDGE

CHEERFUL

PANICKY

EMPTY

81

APPENDIX B

PLAY SCALES

Positive Leisure Activities with You Measure Scales

Activities Scales (Item 1: How often do you do ________ activities with your partner?)

NORMAL/ROUTINE NEW/DIFFERENT EXCITING/THRILLING

Routine Different Exciting

Normal New Extreme

Unexciting Out of the Ordinary Stimulating

Ordinary Unfamiliar Adventurous

Mundane Fresh/Original Adrenaline-Pumping

Predictable Unusual Heart-racing

Novel Risky

Exploratory Arousing

Bold

Activating

Exhilarating

Shocking

Daring

Mischievous

82

ADDITIONAL WORDS (do not predict loading on scales above)

Fun Tedious

Challenging Artistic

Amusing Subdued

Enjoyable Carefree

Peaceful Boring

Pleasurable Playful

Interesting Creative

Silly Relaxing

Unpleasurable Rewarding

Affect Scales (Items 2-4: When you do [new/different; normal/routine; exciting/thrilling

activities] with your partner, how often do you feel)

POSITIVE EMOTION NEGATIVE EMOTION

Joy Sadness

Happiness Anger

Love Frustration

Excited Scared

Stimulated Annoyed

Pleasure Anxious

Contentment Pessimistic

Optimistic Fear

Motivated Disgust

Amusement Need to escape

83

Giddy Bored

Interested Stressed

Hope Uncomfortable

Good Disinterested

Confident Bad

Satisfied Detached

Alive Restricted

Wonderful Miserable

Need to laugh Dissatisfied

Like you want to smile Jittery

In high spirits On edge

Cheerful Jumpy

Numb

Panicky

Empty

ADDITIONAL WORDS

Nothing

Neutral

Indifference

84

APPENDIX C

PREDICTED CORRELATION MATRIX

85

PT

SD

Sym

pto

m S

ever

ity

PT

SD

: R

e-E

xper

ienci

ng C

lust

er

PT

SD

: E

moti

onal

Nu

mbin

g C

lust

er

PT

SD

: H

yper

arousa

l C

lust

er

PL

AY

: O

ver

all

Fre

quen

cy

PL

AY

: N

orm

al/R

outi

ne

Fre

quen

cy

PL

AY

: N

ew/D

iffe

rent

Fre

quen

cy

PL

AY

: E

xci

ting/T

hri

llin

g F

requen

cy

PL

AY

: P

osi

tive

Aff

ect

Duri

ng

Norm

al/R

outi

ne

Act

ivit

ies

PL

AY

: P

osi

tive

Aff

ect

Duri

ng

New

/Dif

fere

nt

Act

ivit

ies

PL

AY

: P

osi

tive

Aff

ect

Duri

ng

Exci

tin

g/T

hri

llin

g A

ctiv

itie

s

PL

AY

: N

egat

ive

Aff

ect

Du

ring

Norm

al/R

outi

ne

Act

ivit

ies

PL

AY

: N

egat

ive

Aff

ect

Du

ring

New

/Dif

fere

nt

Act

ivit

ies

PL

AY

: N

egat

ive

Aff

ect

Du

ring

Exci

tin

g/T

hri

llin

g A

ctiv

itie

s

Rel

atio

nsh

ip S

atis

fact

ion

PTSD Symptom Severity 1.00

PTSD: Re-Experiencing Cluster 1.00

PTSD: Emotional Numbing Cluster 1.00

PTSD: Hyperarousal Cluster 1.00

PLAY: Overall Frequency 1.00

PLAY: Normal/Routine Frequency 1.00

PLAY: New/Different Frequency 1.00

PLAY: Exciting/Thrilling Frequency 1.00

PLAY: Positive Affect During Normal/Routine Activities 1.00

PLAY: Positive Affect During New/Different Activities 1.00

PLAY: Positive Affect During Exciting/Thrilling Activities 1.00

PLAY: Negative Affect During Normal/Routine Activities 1.00

PLAY: Negative Affect During New/Different Activities 1.00

PLAY: Negative Affect During Exciting/Thrilling Activities 1.00


-1.00 0 1.00

86

APPENDIX D

MEDIATION FIGURE

Step 1: Conduct a correlation to establish a significant association between PTSD symptom

severity and Relationship Satisfaction.

PTSD Symptom Severity Relationship Satisfaction

c

Step 2: Conduct a correlation to establish a significant association between PTSD symptom

severity and PLAY.

PLAY*

a


Step 3: Conduct a regression using PTSD symptom severity and PLAY simultaneously to

establish PLAY as a significant predictor variable to the outcome variable of Relationship

Satisfaction (controlling for PTSD).

PLAY*

b


87

Step 4: Based on Step 3 regression equation, assess the effect of PTSD symptom severity on

Relationship Satisfaction, controlling for PLAY (path c’). Degree of change from c to c’ will be

described. The indirect effects accounted for by PLAY will be estimated using Kenny (2009).

PLAY*

a b


c′

*PLAY variables will change for each mediation analyses. See below:

Mediation 1: PLAY = Overall frequency of PLAY

Mediation 2: PLAY = Normal/routine frequency of PLAY

Mediation 3: PLAY = New/different frequency of PLAY

Mediation 4: PLAY = Exciting/thrilling frequency of PLAY

Mediation 5: PLAY = Positive affect during Normal/routine PLAY

Mediation 6: PLAY = Positive affect during New/different PLAY

Mediation 7: PLAY = Positive Affect during Exciting/thrilling PLAY

Mediation 8: PLAY = Negative affect during Normal/routine PLAY

Mediation 9: PLAY = Negative affect during New/different PLAY

Mediation 10: PLAY = Negative Affect during Exciting/thrilling PLAY

Date post:	09-Oct-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

PTSD, PLAY, AND RELATIONSHIP SATISFACTION IN OEF/OIF...

Documents