What is my likely diagnosis based on my symptoms of emotional detachment, impulsivity, aggressive behavior, and difficulty forming relationships?

Likely Diagnosis: Antisocial Personality Disorder (ASPD) with Callous-Unemotional Traits

Based on your self-report, the most likely primary diagnosis is Antisocial Personality Disorder (ASPD), characterized by a pervasive pattern of disregard for and violation of the rights of others beginning in childhood, with prominent callous-unemotional traits. 1, 2

Core Diagnostic Features Present

Your presentation aligns strongly with ASPD criteria through multiple domains:

Childhood Conduct Problems (Essential for ASPD)

• Physical aggression and fighting: Multiple school fights requiring adult restraint, suspension for fighting, cafeteria table incident requiring multiple adults to control you 2
• Animal cruelty: Extensive pattern including forcing insects to fight, killing snapping turtle, deliberately euthanizing healthy reptiles (snakes, caiman, lizard) when bored with them, fire ant experiments 2
• Deceitfulness and manipulation: Hiding behavior reports, forging signatures, lying habitually to avoid consequences starting in childhood 2
• Running away: Left home at 16 with unrealistic plan 2
• Fire-setting behavior: Lighting things on fire for excitement 2

ASPD requires evidence of conduct disorder before age 15, and your history clearly meets this threshold. 2

Adult Antisocial Behavior Pattern

• Failure to conform to social norms: Seven jobs with pattern of firings and impulsive quitting, four college dropouts 2
• Impulsivity and failure to plan: Poor financial control, impulsive spending leading to debt, impulsive job decisions 2
• Irritability and aggressiveness: Quick escalation to physical confrontation, violent thoughts that feel stimulating rather than disturbing 2
• Reckless disregard for safety: Suicide attempt driven partly by curiosity, running away with no realistic plan 2
• Consistent irresponsibility: Job instability, financial irresponsibility requiring guardian bailouts 2
• Lack of remorse: Explicitly states feeling no deep guilt after hurting others, kills animals without distress, primary deterrent to violence is consequences not empathy 2

Callous-Unemotional Trait Profile (Severe Specifier)

Your presentation includes prominent callous-unemotional traits that represent a more severe ASPD variant:

• Lack of affective empathy: You describe strong cognitive empathy (understanding what others feel) but absent affective empathy (feeling with them), which is the hallmark pattern in callous-unemotional presentations 2
• Shallow or deficient affect: Baseline emotional state is flat, empty, or neutral rather than sad; "love" feels logical/possessive rather than warm 2
• Lack of remorse or guilt: Brief "pang" that dissipates quickly, outward remorse is performative to avoid consequences 2
• Callous lack of empathy: Views people as useful, neutral, or obstacles; easily cuts people off without missing them 2
• Unconcerned about performance: Low motivation unless personally stimulating, "rather lazy" outside obligations 2

Why Not Autism Spectrum Disorder as Primary Diagnosis

While you have a prior ASD diagnosis from age 16, your current presentation is better explained by ASPD with callous-unemotional traits:

Key differentiators:

• Social impairment pattern: ASD involves difficulty understanding social cues and lacking social insight, whereas you demonstrate sophisticated social understanding (strong cognitive empathy, ability to manipulate effectively, understanding others better than they know themselves) 3
• Nature of relationship difficulties: ASD involves wanting connection but not knowing how, whereas you describe not wanting emotional closeness and viewing people instrumentally 3
• Empathy profile: ASD typically involves both cognitive and affective empathy deficits, whereas you have intact cognitive empathy with absent affective empathy—the ASPD pattern 3, 2
• Remorse and guilt: These are not characteristic deficits in ASD but are core features of ASPD with callous-unemotional traits 3, 2
• Conduct problems: The extensive childhood aggression, animal cruelty, and antisocial behavior pattern is not explained by ASD 3, 2

Important caveat: Female autism can be misdiagnosed as personality pathology due to camouflaging, but the reverse can also occur—personality pathology can be misattributed to autism. 4 Your pattern of instrumental manipulation, lack of remorse, and callous-unemotional traits points away from ASD as the primary explanation.

Assessment Approach Required

You cannot reliably self-diagnose personality disorders because lack of insight is a core feature of these conditions. 1 Self-report scales have minimal usefulness in personality disorders specifically due to impaired insight. 1

Structured Clinical Assessment Needed

• Semi-structured interview by trained clinician: The Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) is the gold standard for ASPD diagnosis 5
• Collateral information essential: Assessment must gather information from multiple sources (guardian, past employers, school records, legal records if any) because self-report alone is insufficient 1, 5, 6
• Expect informant discrepancies: These do not invalidate the diagnosis but provide additional diagnostic information 1
• Longitudinal assessment: Personality disorders require demonstration of stable patterns over time, not just current state 5, 6

Differential Diagnoses to Rule Out

Borderline Personality Disorder (BPD): Your presentation lacks key BPD features:

• No unstable self-concept that shifts dramatically (you describe stable emptiness/detachment) 7
• No intense fear of abandonment or frantic efforts to avoid it 7
• No dissociative symptoms 7
• Your suicide attempt was driven by anger and curiosity, not the intense inner pain and emotional dysregulation characteristic of BPD 7
• Your relationships are characterized by detachment and instrumental use, not the chaotic idealization-devaluation pattern of BPD 7

Mood Disorders: Your "depression" appears to be chronic emptiness and boredom rather than major depressive episodes, and shifts to anger about lack of control rather than sustained low mood 3

Schizophrenia: No evidence of delusions, hallucinations, or formal thought disorder 3

Genetic and Heritability Considerations

Regarding your question about what you might pass to future children:

• ASPD has high heritability: Genetic factors play a significant role, with molecular studies identifying linkages to genes associated with crucial brain regions involved in emotional regulation and impulse control 2
• Environmental factors also crucial: Family psychopathology (your biological mother's substance use and bipolar disorder, sister's schizophrenia), adverse childhood experiences, and your own premature birth and early medical complications all contribute 1, 2
• Not deterministic: Having ASPD does not guarantee children will develop it, but it increases risk, particularly when combined with environmental stressors 1, 2

Treatment Implications

Cognitive-behavioral therapy (CBT) and mentalization-based therapy (MBT) are the evidence-based psychotherapeutic approaches for ASPD. 1, 2 Early work with MBT shows promise specifically for antisocial presentations. 2

Medication targets specific symptoms, not the personality disorder itself:

• Your current guanfacine may help with impulsivity and aggression 1
• Additional pharmacotherapy might target irritability, aggression, or co-occurring conditions if present 1, 2

Critical prognostic factor: ASPD typically lessens in severity with advancing age, though it remains chronic and lifelong. 2 Individuals with ASPD age faster than non-antisocial peers biologically. 2

Clinical Pitfalls to Avoid

• Do not rely solely on your self-report: Structured interview with collateral information is essential 1, 5
• Do not assume ASD explains everything: The callous-unemotional traits, lack of remorse, and instrumental manipulation are not ASD features 3, 4
• Do not confuse cognitive empathy with affective empathy: Your ability to understand others does not indicate intact empathy—the absence of feeling with them is the diagnostic feature 2
• Do not minimize childhood conduct problems: The animal cruelty, aggression, and manipulation starting in childhood are essential diagnostic features, not just "autism-related behaviors" 2