The conceptual analysis of DSM criteria required a complex methodological approach, which involved the following steps:

1.

Defining the specific words that would indicate a criterion as socially relevant, such as “social”, “interpersonal”, and “peers”.

2.

Identifying the textual domains to be examined, which included the criteria themselves and the introductory text, while excluding additional text related to epidemiology, comorbidity, etc. Specific categories of the DSM were also selected for investigation, excluding those deemed irrelevant for the analysis, such as substance-induced mental disorders.

3.

Selecting specific domains of sociality for mapping the criteria, utilizing RDoC constructs, such as affiliation and attachment, social communication, and other relevant constructs like culture.

4.

Conducting the coding process criterion by criterion, which involved reading the entire DSM from beginning to end.

Selecting socially relevant words: a textual grid

To ensure our investigation aligns with the DSM's epistemology, we adopted a descriptive approach. In this approach, we considered only those aspects explicitly described as social to be classified as such.

We considered specific words that are indicative of social aspects: social*,Footnote 1interpersonal*, relation*, attach*, care, caregiver*, parent*, peer*, friend*, playmate*, relatives, partner*, other* (when used as a noun to indicate “other people”), people, person, bereavement, rejection, sexual violence,Footnote 2sexual encounters, intercourse, alone (when implying a conscious avoidance of others), opposit*, defian*, hostil*, aggress*, assault*, paranoid, persuas*, cultur*. This list was sorted out after a first read of all DSM criteria.

A qualitative semantic analysis was conducted to distinguish the inherently social meaning of words from their other uses within the textual context. For instance, in sub-criterion 5 of criterion A of Specific Learning Disorder, the words "relationship" and "peers" are mentioned, but without social relevance. The passage states, “(…) has poor understanding of numbers, their magnitude, and relationships; counts on fingers to add single-digit numbers instead of recalling the math fact as peers do…” [4], p. 66, our emphasis]. In this context, the term "relationship" is used in a logical sense and refers to numbers, while the comparison with “peers” is based solely on differences in cognition rather than social interaction.

Focusing on relevant DSM categories and text

In line with [77], we excluded disorders due to other medical conditions or substance-medication-induced disorders from our analysis. Similarly, we did not include specifiers and subtypes, medication-induced movement disorders, other adverse effects of medication, categories in the research appendix, and Z-V codes (conditions not officially considered as mental disorders). However, contrary to Wakefield and First [77], we did consider former-NOS (not otherwise specified) categories, which are now noted in DSM-5 as Other Specified disorders and Unspecified disorders. This decision was based on their widespread usage in the clinical setting [30, 60].

Our analysis specifically concentrated on the text within the “Diagnostic Criteria” section of each disorder, encompassing the introductory text (when present), the main criteria, sub-criteria, and notes. We intentionally excluded any additional text that is not essential for the diagnosis, such as the introduction preceding the “Diagnostic Criteria” section and text following it, including information on epidemiology and differential diagnosis. The total number of mental disorder categories considered in our analysis was 192.

Selecting specific aspects of sociality

Content validity plays a critical role in our analysis of the concept of sociality. Merely identifying DSM criteria that may relate to sociality without examining the various facets of this construct can lead to misleading interpretations. To assess these differences accurately, we adopted an approach that incorporates several factors. These include the Social Processes categories outlined in the Research Domain Criteria (RDoC) (i.e., Affiliation and Attachment, Social Communication, Perception, and understanding of others), a broader non-specific social category, cultural aspects, and the Clinical Significance Criterion.

The RDoC social processes constructs selected are:

Affiliation and Attachment (AA) [“Affiliation is engagement in positive social interactions with other individuals. Attachment is selective affiliation as a consequence of the development of a social bond.”] [52]

Social Communication (SC) [“A dynamic process that includes both receptive and productive aspects used for exchange of socially relevant information”] [53].

Perception and Understanding of Others (PUO) [“the processes and/or representations involved in being aware of, accessing knowledge about, reasoning about, and/or making judgments about other animate entities, including information about cognitive or emotional states, traits or abilities”] [54].

Our decision to focus on the RDoC categories was motivated by three key reasons. First, the RDoC framework represents the forefront of integrating various research perspectives. Second, it offers a manageable number of categories that are practical for our analysis. Finally, the RDoC framework is not tightly linked to any specific meta-theoretical assumptions about the human psyche, aligning with the “a-theoreticity” of the DSM [55]. The RDoC has been indeed already used in conceptual analyses of DSM criteria [37]. Given these considerations, we excluded the RDoC construct concerning Perception and Understanding of Self.Footnote 3 To ensure clarity, we also excluded RDoC sub-constructs following a similar approach as [37].

Culturally relevant criteria, such as the requirement that “the disturbance is not a normal part of a broadly accepted cultural or religious practice” [4], p. 292], have been recognized and categorized separately under “Culture.”

A significant emphasis has been placed on the Clinical Significance Criterion (CSC). The CSC holds significant theoretical importance in nosology [7, 14, 17, 25, 32, 50, 59, 62, 65, 66, 69, 72, 73, 78, 88], and due to its specific nature, it is considered a distinct and separate category. The CSC serves as an indicator of the "harm" criterion, implying that the alleged mental dysfunction must cause impairment in the patient's everyday life to be considered a disorder [25]. The commonly used formula for the CSC is as follows: "the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” [4], p. 12]. Different expressions may be used to define the same distress or impairment within the DSM. For example, in children, the CSC often requires references to impairments in "academic achievement" and "communication." Our analysis acknowledges that the CSC can manifest in slightly different forms (see the Method section for more details).

In instances where no clear association between constructs could be established or when the mention of sociality was too broad to be attributed to specific categories, a "No specific Construct" (NSC) category was employed.

Coding

We utilized a qualitative-conceptual coding approach, which seem to be the major means of investigation in DSM categories [37, 77]. The coding procedure was conducted by the first author, under the supervision of the second author. This supervision entailed collaboratively establishing the conceptual grid and coding the initial class of the DSM, namely neurodevelopmental disorders. Following this initial training phase, the first author independently proceeded with reading all the DSM and coding the remaining sections of the DSM and sought consultation from the second author when uncertainties arose. Notably, the category of personality disorders was examined collectively due to its inherent conceptual intricacies.

When sociality was mentioned in the main criterion, we indicated its presence by assigning the corresponding letter to the criterion (e.g., A, B, or C) and marking it in the appropriate box (e.g., Social Communication, Perception and Understanding of Others). For example, in Autism Spectrum Disorder (ASD), criterion A states: "Persistent deficits in social communication and social interaction across multiple contexts" [4], p. 50]. We marked the letter "A" in the social communication (SC) box of ASD.

When sociality was noted in a sub-criterion only, we highlighted it using the acronym "SUB" followed by the sub-criterion number, and the corresponding main criterion in square brackets. For example, in Alcohol Use Disorder, sub-criterion 6 of criterion A states: "Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol" [4], p. 491]. In this case, we noted "SUB 6 [A]" in the box labeled "NSC" (No Specific Construct) for Alcohol Use Disorder. Mentions about sociality in sub-criteria were not specifically annotated if their corresponding main criterion was already labeled as social.Footnote 4

If sociality was mentioned in the introductory text to the criteria, we used the acronym "INT" (intro) to indicate its presence. Additionally, we used the acronym "NT" (note) + [main criterion in square brackets] when sociality was mentioned in the notes following the criteria. For example, the second note following criterion C of Major Depressive Episode includes references to "bereavement" and "cultural norms" [4], p. 125–126]. In Major Depressive Disorder, we marked the affected areas (AA) and culture boxes with the acronym "NT [C]” to denote the presence of sociality. Mentions of sociality given in “differential diagnosis” criteria have been noticed as well. For instance, criterion D of Panic Disorder states: “The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder (…)” [4], p. 209].

Multiple attributions have been allowed. For example, criterion A of ASD [6], p. 50] encompasses three attributions: AA, SC, and PUO. We have also allowed for a single social category to be marked with more than one criterion. For instance, in the case of Intellectual Disability, both the introductory text (INT) and criterion B can be classified as "No specific construct." In such cases, they are indicated in the same box using a semicolon (;) to separate them, like "INT; B".

In the case of Other Specified and Unspecified Disorders, where separate criteria are not provided, the text of these disorders is represented by a single criterion labeled "A" for simplicity. Regarding the Clinical Significance Criterion (CSC), if it is not mentioned in its usual form, a notation of "MF: Modified Version" is used. This notation is accompanied by the specific text, which is displayed below the table. For example, in criterion B of Stereotypic Movement Disorder, the text states: "The repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury." This modified version of the CSC is indicated in the box of CSC using the mark "B MF (6)." This notation signifies that a modified version of the CSC is explained at criterion B, and further details can be found in note 6 for the corresponding text.