It varies hugely from company to company.
In the bad case, your PTO rarely gets approved, and you never accumulate any to be paid out. Peer pressure is used to convince people to not take time off.
In the good case, leaders lead by example by taking time off frequently, and encouraging their reports to do the same. PTO is approved more often than not. If people start "abusing" the privilege, they get spoken to personally, instead of the whole team/company being punished by changing the policy.
I've worked at a place with unlimited PTO, and it was the latter case, and it was great. I never had to budget my time - I never had to worry that spending an extra day at the beach during the summer meant that I would have one less day to spend with my family in another state during the holidays. The time I took off seemed much more worthwhile than being paid out for 3 accrued days or whatever.