A
Reza Rahimi; Ali khodaei
Abstract
Objective: Avoidance, understood as an attempt to escape internal experiences such as emotions, thoughts, and memories, is generally adaptive but becomes maladaptive when excessive, contributing to the maintenance of anxiety and depression. Within the Third Wave of psychological therapies, growing attention ...
Read More
Objective: Avoidance, understood as an attempt to escape internal experiences such as emotions, thoughts, and memories, is generally adaptive but becomes maladaptive when excessive, contributing to the maintenance of anxiety and depression. Within the Third Wave of psychological therapies, growing attention has been directed to emotional, behavioral, and particularly cognitive avoidance (Panjwani et al., 2024). Cognitive avoidance includes strategies such as distraction, thought suppression, and worry, which aim to prevent engagement with unwanted thoughts (Hearn et al., 2018). Evidence shows that thought control strategies are strongly linked to anxiety disorders, where worry is seen as a verbal, problem‑focused chain of negative thoughts. According to the avoidance theory of worry, worry functions to block threatening mental imagery and related autonomic arousal, reducing immediate anxiety but maintaining long‑term vulnerability (Mihailova & Jobson, 2020). To assess this construct, Gosselin et al. (2002) introduced the French Cognitive Avoidance Questionnaire, followed by the English 25‑item, five‑factor version developed by Sexton & Dugas (2008), which demonstrated strong psychometric validity. In individuals with multiple sclerosis, fluctuating disease progression increases intolerance of uncertainty, chronic pain, and anxiety through mechanisms such as cognitive avoidance, negative problem orientation, and positive beliefs to worry (Kusec et al., 2024; Chang, 2024). Given the high uncertainty associated with MS, patients frequently anticipate further functional decline, often relying on avoidance‑oriented coping strategies (Lleraa & Newman, 2023).Because coping resources influence MS outcomes and cognitive avoidance plays a central role in anxiety processes, evaluating the psychometric properties of the Persian Cognitive Avoidance Questionnaire among individuals with MS is essential. This study was
therefore conducted to examine its validity and reliability in this population. Method: This descriptive survey study examined the psychometric characteristics of the Persian version of the Cognitive Avoidance Questionnaire (CAQ) among patients with Multiple Sclerosis (MS). A sample of 350 patients (175 women and 175 men) was recruited through convenience sampling from the Iranian MS Society in Tehran. Sample size estimation followed Klein’s (2023) guideline for factor analysis based on the 25‑item CAQ. Several validated psychological instruments were administered. The Intolerance of Uncertainty Scale by Freeston et al. assesses responses to ambiguous situations; prior findings by Buhr & Dugas supported its strong reliability, which was replicated in this study (α=.96). The Metacognition Beliefs Questionnaire by Wells & Cartwright‑Hatton was used, specifically the Positive Beliefs about Worry subscale (α=.95). The Negative Problem Orientation Questionnaire by Robichaud & Dugas showed similarly high reliability (α=.94). The primary instrument, the Cognitive Avoidance Questionnaire, measures five dimensions of cognitive avoidance: thought substitution, converting images into thoughts, distraction, avoidance of threat, and thought suppression. The CAQ was translated and adapted into Persian using a rigorous back‑translation protocol to ensure conceptual and linguistic equivalence. Data analysis employed Classical Test Theory principles, and confirmatory factor analysis using maximum likelihood estimation was conducted. Model fit was evaluated using standard indices (χ², χ²/df, CFI, GFI, AGFI, RMSEA). In alignment with earlier studies by Sexton & Dugas, Gosselin et al., and Latari et al., the five‑factor structure showed satisfactory fit and was retained as the preferred model. Overall, the findings provide strong psychometric support for the Persian CAQ and its associated constructs, highlighting its applicability for MS populations. Results: In this study, data were analyzed using SPSS-26 and AMOS-24. Prior to confirmatory factor analysis, normality and multicollinearity assumptions were tested. Results showed no outliers, acceptable skewness (<|3|) and kurtosis (<|8|) values, and no multicollinearity issues (tolerance >0.1, VIF <3).
Three competing models were compared: the independence model, single-factor model, and five-factor model. Results indicated that the five-factor model showed good fit (χ²=1185.96, df=2.69, CFI=0.95, GFI=0.94, AGFI=0.91, RMSEA=0.063), while the single-factor model showed poor fit. Factor loadings ranged from 0.65 to 0.90, all statistically significant (p<0.001). Cronbach's alpha for subscales ranged from 0.86 to 0.92. For criterion validity, significant positive correlations were found between the Cognitive Avoidance Questionnaire dimensions and Intolerance of Uncertainty (r=0.60-0.70), Negative Problem Orientation (r=0.59-0.70), and Positive Worry Orientation (r=0.60-0.67). Conclusion: This study aimed to evaluate the psychometric properties of the Persian version of the Cognitive Avoidance Questionnaire (CAQ) in patients with Multiple Sclerosis (MS). Using confirmatory factor analysis, the findings replicated the original questionnaire’s five‑factor structure, comprising thought suppression, thought substitution, distraction, avoidance of threatening stimuli, and converting images into thoughts. These factors were empirically supported in the MS patient population, indicating that cognitive avoidance in this group is a multidimensional construct. Evidence for criterion validity was demonstrated through significant associations between CAQ subscales and related psychological variables, including intolerance of uncertainty, negative problem orientation, and positive beliefs about worry. These correlations align with cognitive models of psychopathology, suggesting that MS patients’ reliance on maladaptive avoidance strategies may be linked to heightened uncertainty, negative cognitive appraisals, and perceived benefits of worry. The unpredictable and stressful nature of MS symptoms may erode coping resources, thereby increasing dependence on avoidant cognitive responses. Reliability was confirmed through item‑level analyses and internal consistency indices, supporting the Persian CAQ as a stable and coherent measure. The results parallel earlier research validating the multidimensional structure of cognitive avoidance, further reinforcing the theoretical foundation underlying the construct. Despite the positive findings, the study noted limitations, including non‑random sampling from an MS association in Tehran, restricted psychometric assessment methods, and the absence of gender invariance testing. These limitations suggest the need for further research with broader samples and additional methodological approaches. In conclusion, the study provides strong support for the validity and reliability of the Persian CAQ and recommends its use for assessing cognitive avoidance strategies among individuals with Multiple Sclerosis.
