https://doi.org/10.35845/kmuj.2025.23323                                  ORIGINAL ARTICLE

Development and psychometric validation of the Urdu-language Avoidant personality disorder scale for adults: a reliable and culturally relevant measure

Samia Rashid  ^{1, 2}, Zaqia Bano  ^{2, 3}  

1: Department of Psychology, University of Gujrat, Gujrat, Pakistan 2: Department of Psychology, National University of Medical Sciences, Rawalpindi, Pakistan 3: Department of Clinical Psychology, NUR International University,  Lahore, Pakistan Email : zakibatool@gmail.com Contact #: +92-347- 6681017 Date Submitted: February 07, 2023 Date Revised: February 20, 202 Date Accepted: March 09, 2024

THIS ARTICLE MAY BE CITED AS: Rashid S, Bano Z. Development and validation of self-report screening measure of Avoidant personality disorder. Khyber Med Univ J 2025;17(Suppl 1):S64-S73. https://doi.org/10.35845/kmuj.2025.23323

ABSTRACT

Objective: To develop and validate an Urdu version of the Avoidant Personality Disorder (AvPD) scale, tailored to the Pakistani population, addressing a gap in culturally relevant psychological assessments.

Methods: A cross-sectional, analytical design was used with data collected from 234 adults (107 males, 127 females) including 100 clinical and 134 non-clinical participants recruited from government and private institutions in Gujrat, Pakistan. The scale development involved generating an initial pool of 104 items, refining it to 91 through expert evaluation, and further reducing it to 62 items after a tryout phase with 104 participants, followed by pilot testing and expert review. Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were employed to determine the scale’s factor structure. Reliability was assessed using Cronbach's alpha, and convergent validity was tested by correlating the scale with the Social Anxiety Scale for Adolescents (SAS).

Results: The final AvPD scale comprised 37 items across nine subscales and demonstrated strong psychometric properties. EFA revealed the scale explained 68.79% of the variance, while CFA confirmed the factor structure with an excellent model fit (CFI = 0.924, RMSEA = 0.055). The overall reliability of the scale was high (Cronbach's α = 0.964), with subscale reliabilities ranging from 0.764 to 0.931. The scale exhibited moderate convergent validity (r = 0.644) with the SAS.

Conclusion: The Urdu AvPD scale is a reliable, valid tool for assessing AvPD in Pakistan, with potential for clinical and research application. Future studies should explore its applicability across diverse populations to further establish its generalizability.

Keywords: Personality Assessment (MeSH); Personality Disorders (MeSH); Avoidant personality disorder (Non-MeSH); Factor Analysis (MeSH); Psychometric properties (Non-MeSH).

INTRODUCTION

Human beings are inherently social creatures, relying on emotional connections and social interactions for a fulfilling and healthy existence. Many tasks require collaboration and collective effort to achieve goals and maintain systemic efficiency. This raises a fundamental question: how can an individual succeed while living in isolation? Individuals who struggle with social engagement, forming connections, or confronting certain situations often do so due to their personal fears and life experiences. These fears and doubts shape their behaviors, leading to avoidance. However, total avoidance is rarely feasible. Such individuals may withdraw from challenging or intimidating situations, such as leaving social events prematurely, seeking solitude in crowded spaces, or finding it difficult to express their thoughts and feelings.

Avoidant Personality Disorder (AvPD) is characterized by a persistent pattern of avoiding social interactions, including friendships, due to a fear of criticism or disapproval. Individuals with AvPD often hesitate to take risks or engage in new activities, struggle to maintain intimate relationships due to vulnerability concerns, and harbor an overwhelming sense of inferiority and fear of rejection. Their behaviors reflect extreme cautiousness, shyness, and timidity. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), seven diagnostic criteria exist for AvPD, and meeting four or more of these is sufficient for diagnosis. Shyness, a core feature of AvPD, often manifests in early childhood. While shyness is common among children, an intensification over time may indicate the onset of avoidant behaviors.¹

A significant debate surrounds the distinction between Avoidant Personality Disorder and Generalized Social Anxiety Disorder (SAD), as both share overlapping symptoms, etiology, progression, and treatment.² Despite this, key differences set these disorders apart. Firstly, AvPD represents a more severe condition, characterized by greater levels of depression beyond social phobia symptoms.³ Secondly, while AvPD is marked by a pronounced aversion to intimacy in relationships, social phobia involves a fear of social situations.⁴

The global prevalence of AvPD is estimated to range between 1.5% and 2.5%,⁵ with lower rates reported at 0.8% and 1.2%,⁶ and higher rates between 6.6% and 9.3% in some studies.⁷ Among psychiatric outpatients, the prevalence has been reported to be as high as 14.7%.⁸ Research suggests that women may be at a higher risk for AvPD,⁹ though the American Psychiatric Association (APA, 2013) indicates that the disorder occurs with equal frequency among males and females.¹

Personality has been a focal point for psychologists, clinicians, psychoanalysts, and researchers for decades. However, in Pakistan and many other countries, the majority of psychological instruments are available only in the English language, overlooking the critical role of cultural differences. These cultural disparities may influence responses and affect the validity of psychological assessments. Cross-cultural evaluation has become an increasingly sensitive issue due to concerns regarding the applicability of standardized tests across different cultural contexts. Culture significantly impacts the measurement of psychological constructs, as it shapes various aspects of an individual’s life.¹⁰

The present study aimed to develop and validate an Avoidant Personality Disorder Scale for adults in the Urdu language, catering to the need for culturally relevant psychological assessment tools in Pakistan.

METHODS

Study design and ethical considerations: This study utilized a cross-sectional, analytical design and was conducted between February 15, 2019, and June 20, 2019. Approval was obtained from the Departmental Research Review Committee (DRRC) of the Department of Psychology, University of Gujrat, Pakistan. Ethical guidelines were strictly adhered to, including ensuring participant anonymity and confidentiality. Oral and written consent was obtained from participants, and only those willing to participate were included in the study.

Participants and sampling: Participants were recruited from government and private colleges, universities, hospitals, and community settings in Gujrat, Pakistan. The inclusion criteria focused on adults aged 19 years or older, regardless of gender. Individuals below the age of 19 and psychiatric patients were excluded from the study. A purposive sampling technique was employed due to time constraints.

Data collection procedure: Rapport was established with participants through an introduction that included research affiliation and the purpose of the study. Detailed instructions were provided on how to complete the self-report questionnaire. Respondents were guided to carefully read each item and select the most appropriate response, with their answers recorded directly on the provided forms.

Instrument development: The scale development followed a standardized procedure, progressing from item pool generation to finalization:

1. Item pool generation
• An initial pool of 104 items was developed based on a comprehensive review of avoidant personality disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), available literature, and interviews using both inductive and deductive approaches.
2. Expert evaluation
• The items were reviewed by a panel of five Ph.D.-level bilingual clinical psychology experts to assess their essentiality, appropriateness for adults, and relevance to the construct of avoidant personality disorder.
• After a thorough review, 91 items were finalized for the initial tryout phase.
3. Tryout phase and pilot testing
• The initial 91-item scale was tested with 104 participants using a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree, with reverse scoring for negatively worded items).
• Participants provided feedback on problematic, unclear, or vague questions, which were refined by a panel of three Ph.D.-level clinical psychologists.
• Items with correlation values below 0.40 were discarded. After further analysis and expert review, 62 items were retained for pilot testing.
4. Final administration
• The 62-item scale was administered to a sample of 234 adults (107 males and 127 females), including 100 clinical and 134 non-clinical participants aged 19 years and above.

Data analysis: Data were analyzed using the Statistical Package for Social Sciences (SPSS-21) and Analysis of a Moment Structures (AMOS-21). Key statistical methods included:

• Correlation analysis: Items with correlation coefficients below 0.40 were excluded during the pilot phase.
• Exploratory factor analysis (EFA): Conducted to identify the underlying factor structure and reduce the number of items.
• Confirmatory factor analysis (CFA): Performed to validate the factor structure and evaluate model fit.
• Reliability testing: Internal consistency was assessed using Cronbach's alpha.

RESULTS

The initial item pool of 104 was reduced to 91 after content validity. After a pilot study, 62-item scale was used in the final administration of the study and 234 participants responded to the questionnaire. In table I, the factor loading value was suppressed to 0.40 and literature suggests a value of 0.40 or above is considered as appropriate.¹³ Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) was applied on the same sample and the item numbers 16, 18, 19, 22, 27, 28, 62, 63, 64 and 68 were found to be reliable for the factor I. Further, 35, 36, 39, and 40 items were considered to be reliable for Factor II. Item numbers 4, 6, 7 and 8 were found reliable for factor III. The item numbers 66 and 67 were confirmed to be reliable for factor IV. Additionally, at factor V the item numbers 11, 25, 53, 58 and 59 were found reliable. The item numbers 12, 14, 15 were confirmed to be reliable for Factor VI and item number 4,7,8,9 were included in factor VII. Moreover, item number 2 and 3 fit for factor VIII and item numbers 32, 33, 54, 55 were the best fit for factor IX. Figure 1 shows the confirmatory factor analysis of avoidant personality disorder scale.

Table II shows the Kaiser-Meyer-Olkin measure of sampling adequacy i.e., .944 and significant (p<.001) Bartlett’s test of sphericity. Exploratory factor analysis initially expressed 10 factors which describe 68.79% variance.  Items with factor stuffing lower than .4 were eliminated, and ranging from .40 to .83 were retained.

The CFA was administered after running EFA to confirm the factor structure determined by EFA. Covariance was drawn to improve the points also and re-calculated until the good CFI value establishment.

Item number 1, 2, 3, 5, 9, 10, 13, 17, 20, 21, 23, 24, 26, 29, 30, 31, 34, 37, 38, 41, 42, 46, 57, 48, 49, 50, 51, 52, 56, 57, 60, 61, 65, 66, and 67 were removed to achieve the desired values.

There must be seven subscales according to diagnostic criteria but it explored nine by expanding the subscale into more than one factor. Classification indicated that two criteria; certainty essentiality and intimacy restraints, fused into a single category. Conversely, two categories explained inhibition in social situation and social ineptness also scattered to two factors. The largest factor with ten items, inadequate feelings to contact others. It depicts that the feeling of inefficiency is much more common in avoidant or cautious personality, in a current situation.

Hence, 37-items questionnaire was finalized. The value of Comparative Fit Index (CFI) was .924 which suggesting that model of goodness of fit is absolute fit and significant <0.001 (Table III). The value of CFA above 0.90 is considered as appropriate. Results confirmed the model fit of the scale for avoidant personality disorder.¹⁴

The reliability of the full scale was .964 whereas the appropriate reliability limit is 0.70 and above. The reliability of the scale was above the stated limit (Table IV). The reliability of the sub-scales was also above the prescribed limit (Table V).¹⁵ The convergent validity of the scale with the well-developed Social Anxiety Scale for Adolescents was conducted and resultant value is .644 (Table VI). The final scale is attached in Annexure.

Table I: Correlation coefficient of 68 items of Avoidant personality disorder (n=104)

Sr. No.	Item No.	R	Sr. No.	Item No.	R
1	1	.628**	35	42	.513**
2	2	.531**	36	44	.528**
3	3	.583**	37	48	.511**
4	4	.672**	38	49	.684**
5	5	.690**	39	50	.553**
6	6	.680**	40	52	.645**
7	7	.538**	41	53	.519**
8	8	.700**	42	55	.530**
9	9	.589**	43	56	.645**
10	10	.592**	44	57	.633**
11	11	.529**	45	58	.619**
12	13	.590**	46	60	.594**
13	15	.644**	47	61	.548**
14	18	.509**	48	62	.503**
15	19	.515**	49	63	.530**
16	20	.640**	50	65	.574**
17	21	.705**	51	67	.470**
18	22	.575**	52	68	.670**
19	23	.676**	53	69	.617**
20	24	.602**	54	70	.551**
21	27	.582**	55	71	.640**
22	28	.572**	56	72	.602**
23	29	.572**	57	73	.585**
24	30	.594**	58	78	.517**
25	31	.519**	59	80	.556**
26	32	.691**	60	83	.614**
27	34	.586**	61	84	.546**
28	35	.621**	62	85	.557**
29	36	.642**	63	86	.586**
30	37	.596**	64	87	.644**
31	38	.608**	65	88	.592**
32	39	.563**	66	89	.565**
33	40	.606**	67	90	.593**
34	41	.536**	68	91	.596**

**Correlation is significant at the 0.01 level (2-tailed)

The correlation coefficient of 68 items is > 0.40 and literature suggests a value of 0.40 or above is considered as appropriate.¹³

Table II: Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of sphericity (n = 234)

Variable	KMO		Bartlett’s Test
	Chi-Square		Df	Sig
Avoidant Personality Disorder Scale (APDS)	.944	13765.671	2278	.000

The Table II displays the results of Kaiser-Meyer-Olkin measure and Bartlett's test for sphericity  as .94 which is significant (p<.001) Bartlett’s test of sphericity presented in the table. The first 10 components identified using exploratory factor analysis account for 68.79% of the variance. Items with factor stuffing between.40 and.83 were eliminated if their stuffing was less than .4 values.

Table III: Factor loading of 62 item on Avoidant Personality Disorder Scale after

varimax rotation (n = 234)

Sr. No.	Item No.	1	2	3	4	5	6	7	8	9
1	16	.628
2	17	.600
3	18	.730
4	19	.726
5	20	.814
6	21	.792
7	22	.800
8	23	.834
9	24	.796
10	27	.628
11	28	.630
12	29	.633
13	30	.715
14	31	.646
15	62	.452
16	63	.493
17	64	.507
18	68	.599
19	34		.648
20	35		.603
21	36		.636
22	37		.687
23	38		.537
24	39		.705
25	40		.657
26	46		.546
27	47		.562
28	49		.458
29	50		.452
30	51		.491
31	52		.487
32	1			.500
33	4			.703
34	5			.722
35	6			.684
36	7			.482
37	8			.603
38	61				.502
39	65				.567
40	66				.730
41	67				.646
42	11					.672
43	25					.571
44	53					.441
45	57					.409
46	58					.409
47	59					.509
48	12						.465
49	13						.430
50	14						.687
51	15						.693
52	42							.639
53	43							.690
54	44							.587
55	45							.571
56	2								.715
57	3								.729
58	9								.573
59	32									.493
60	33									.575
61	54									.442
62	55									.470

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   Extraction Method: Principal Component Analysis; Rotation Method: Varimax with Kaiser Normalization. Note: (Values<.4 are suppressed)

The diagnostic criteria required seven subscales, however nine were investigated by extending the subscale into multiple factors. Classification showed that intimate constraints and certainty essentiality combined to form a single category. On the other hand, social ineptness and inhibition in social situations were likewise attributed to two types. With 10 things, the largest factor was insufficient feelings to communicate with others. It indicates that, given the existing circumstances, avoidant or cautious personalities are far more likely to feel inefficient.
Ten subscales were explored using an eigenvalue greater than one, and nine subscales with a diversity of items in consensus to quantity were confirmed (Table III).

Table IV: Model fit summary of confirmatory factor analysis (n=234)

CMIN/DF: chi-square minimum/degree of freedom; GFI: Goodness of Fit Index; CFI: Comparative Fit Index, AGFI: Adjusted Goodness of Fit Index; RMSEA: Root Mean Square of Error Approximation

In the above-mentioned table, the figures of confirmatory factor analysis of Avoidant Personality Disorder Scale for Adults are painted with nine subscales. Item number 1, 2, 3, 5, 9, 10, 13, 17, 20, 21, 23, 24, 26, 29, 30, 31, 34, 37, 38, 41, 42, 46, 57, 48, 49, 50, 51, 52, 56, 57, 60, 61, 65, 66, and 67 were removed to achieve the desired values. Fittest model appeared as .924 CFI, 1.696 CMIN/DF, .05 RMSEA and .816 GFI. The mentioned values are satisfactory as maintained by literature (Table IV).

Figure 1: Confirmatory factor analysis of Avoidant Personality Disorder Scale

Phase II: Determination of psychometric properties of avoidant personality disorder scale

a) Cronbach’s alpha reliability

Table V:  Cornbach alpha of Avoidant personality disorder scale (n=234)

Scale	Cronbach’s Alpha	Number of Items	Sig
Avoidant Personality Disorder Scale (APDS)	.964	37	.000
The reliability value of avoidant personality disorder scale is α = .964 which shows that the newly developed measure is highly reliable (Table V).   Table VI: Cronbach alpha of subscales of Avoidant personality disorder scale (n=234)

Subscales	Total items	Cronbach Alpha
.1 Feeling of inadequacy	10	.931
2. Avoid social contacts	4	.868
3. Fear of criticism	4	.849
4. Non-participation in new activities	2	.840
5. Inhibited behaviour	5	.834
6. Approval of being liked	3	.770
7. Socially inept	3	.825
8. Lack of interpersonal relation	2	.764
9. Avoid personal risks	4	.837

Note: ** P<.01

The reliability of the subscale is as follows: Feeling of inadequacy = .931, Avoid social contacts = .868, Fear of criticism = .849, Non-participation in new activities =.840, Inhibited behaviour = .834, Approval of being liked = .770, socially inept =.825, Lack of interpersonal relation = .764, and Avoid personal risks= .837. The reliability of all the subscale is significantly high which depicted that this is a consistent measure to assess the avoidant personality disorder in adults (Table VI).

b) Construct validity of Avoidant personality disorders scale: To estimate the convergent validity of Avoidant Personality Disorder Scale, Social Anxiety Scale for Adolescents¹⁶ assessment tool used that designed to estimate the avoidance to make interpersonal and social connections and links. Sample of 40 (N=40) Male=19, Female=21 recruited from colleges and university faculty and students and community population.

ii)             Results

Table VII: Validity analysis of Avoidant personality disorder scale (n=40)

Scales	1	2
1. Avoidant	-
2. SAS	.644**	-

Note: ** p<.01, SAS = social anxiety scale

Social Anxiety Scale for Adolescents (SAS-A) is an 18-item scale (plus four filler items) for assessing social anxiety. Convergent validity between Avoidant measure and Social Anxiety Scale for Adolescents (SAS) is r = .644** which is lied in moderate range (Table VII).

DISCUSSION

The current study successfully developed and validated an Avoidant Personality Disorder Scale for adults in the Urdu language, achieving the primary objective of creating a culturally sensitive tool for psychological assessment in Pakistan. The AvPD scale was developed by generating an initial pool of 104 items, refining it to 91 through expert evaluation, and further narrowing it to 62 after a tryout with 104 participants. Following pilot testing and statistical analyses, including EFA and CFA, a final 37-item scale with nine subscales was established, explaining 65.3% of the variance through a coherent factor structure. The CFA confirmed the model's goodness-of-fit, with indices such as CFI = 0.91, RMSEA = 0.05, and TLI = 0.89 supporting the scale's validity. Additionally, the reliability analysis demonstrated strong internal consistency, with a Cronbach's alpha of 0.93. These findings underscore the scale's psychometric robustness, making it a reliable and culturally appropriate tool for assessing AvPD in adults.

AvPD is characterized by an excessive desire for affiliation with others alongside intense fears of interpersonal rejection and a deep sense of personal inadequacy. The key features include heightened sensitivity to criticism and anticipated disapproval by others, which often result in social withdrawal and isolation-hallmarks of the disorder. Although AvPD shares surface similarities with disorders such as anxiety and depression, it is distinct in its presentation and chronic course, typically emerging in early life and persisting throughout adulthood. Despite its debilitating impact, AvPD remains under-documented and less extensively studied compared to Social Anxiety Disorder (SAD) .¹⁷

Globally, there is only one prominent measure for AvPD, the Five-Factor Avoidant Assessment (FFAvA).¹⁸ However, cultural variations in social norms, environmental factors, and perceptions of interpersonal problems necessitate the development of tools that align with specific cultural contexts. The misuse of standardized tests among culturally diverse populations can lead to misdiagnoses, emphasizing the importance of culturally adapted assessment tools.¹⁹ In response to this gap, the current study sought to develop and validate an AvPD scale for adults in the Urdu language, providing a culturally relevant tool for use in Pakistan.

The study’s key strength lies in developing a culturally and linguistically relevant AvPD scale in Urdu, ensuring accurate measurement for the Pakistani population. The scale demonstrated strong psychometric properties, including excellent reliability, validity, and model fit indices, establishing its credibility. The rigorous, standardized development process further reflects the study’s methodological soundness. Additionally, the scale’s broad applicability makes it a valuable tool for clinicians, researchers, and educators in diverse settings.

However, the study is not without its limitations. The scale is culturally relevant for Pakistan, but its applicability in other cultural and linguistic contexts remains untested. Additionally, the smaller clinical sample size compared to the non-clinical group may be a limitation. The reliance on self-reported data introduces potential biases, which could influence the accuracy of the results.

To address these limitations and further strengthen the scale, future studies are recommended. Recruiting larger and more diverse clinical samples across different psychiatric conditions would enhance the generalizability of the findings. Expanding the scale's validation across cultural contexts and translating it into other languages would help determine its applicability in different settings. Longitudinal studies are also suggested to assess the predictive validity and stability of the scale over time. Additionally, investigating potential gender differences in AvPD presentation could refine diagnostic criteria and treatment approaches. Extending validation efforts to other age groups, particularly adolescents and older adults, would broaden the scale’s scope. Lastly, incorporating multi-method assessment strategies, such as observational data or clinical interviews, could reduce the risk of self-report biases and provide a more comprehensive understanding of the disorder.

CONCLUSION

This study successfully developed and validated an Urdu version of the Avoidant Personality Disorder scale, addressing a significant gap in culturally relevant psychological assessments for the Pakistani population. The scale demonstrated strong psychometric properties, including high reliability, validity, and excellent model fit, making it a valuable tool for both clinical and research settings. Despite some limitations the scale offers an essential step forward in the accurate assessment of AvPD. Future studies should explore its use across diverse populations and expand clinical samples to further establish its generalizability and utility.

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AUTHORS' CONTRIBUTIONS Following authors have made substantial contributions to the manuscript as under:   SR & ZB: Conception and study design, acquisition, analysis and interpretation of data, drafting the manuscript, critical review, approval of the final version to be published Authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

CONFLICT OF INTEREST Authors declared no conflict of interest, whether financial or otherwise, that could influence the integrity, objectivity, or validity of their research work. GRANT SUPPORT AND FINANCIAL DISCLOSURE Authors declared no specific grant for this research from any funding agency in the public, commercial or non-profit sectors

DATA SHARING STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request

This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License.

KMUJ web address: www.kmuj.kmu.edu.pk Email address: kmuj@kmu.edu.pk

APPENDIX-01

Avoidant Personality Disorder Scale

Test instructions

Item Scoring Format

1 = Strongly Disagree.     2 = Disagree.    3 = To some extent.     4 = Agree.    5 = Strongly Agree.

*No reverse scoring for any item.

Subscales	Item No.	Total items
1. Feeling of inadequacy	1-10	10
2. Avoid social contacts	11-14	4
3. Fear of criticism	15-18	4
4. Non-participation in new activities	19-20	2
5. Inhibited behavior	21-25	5
6. Approval of being liked	26-28	3
7. Socially inept	29-31	3
8. Lack of interpersonal relation	32-33	2
9. Avoid personal risks	34-37	4

APPENDIX-02