What the Evaluating Clinician Will Likely Say
The clinician will likely tell you that while your childhood ASD diagnosis may explain some features (sensory differences, intense interests, social differences), the pattern you describe—particularly the lifelong emotional detachment, lack of guilt or remorse, instrumental use of people, animal cruelty, violent fantasies experienced as stimulating, and manipulative behavior—raises significant concern for antisocial personality disorder (ASPD) or prominent callous-unemotional traits that extend well beyond what ASD alone would explain.
Primary Diagnostic Considerations
Antisocial Personality Disorder vs. ASD
Your presentation includes multiple DSM-5 criteria for ASPD that are not explained by autism: failure to conform to social norms (lying, manipulation), deceitfulness, impulsivity (job instability, financial problems, running away), irritability and aggressiveness (multiple physical fights), reckless disregard for safety of others (violent thoughts, animal killing), consistent irresponsibility (job/financial instability), and lack of remorse (shrugging off harm to others, killing animals without guilt). 1
The animal cruelty pattern is particularly significant: your history of deliberately killing healthy reptiles, the snapping turtle incident, and the recent possum killing "just to do it" because it was "fun" are serious markers of callous-unemotional traits and conduct problems that predict antisocial outcomes. 1
Your cognitive empathy is intact (you read people extremely well), but your affective empathy is severely limited—this pattern is more consistent with ASPD than ASD, where individuals typically struggle with understanding what others feel, not with caring about it once understood. 1, 2
What Does NOT Fit Classic ASD
You explicitly report strong ability to read emotions, motives, and weaknesses, and you use this understanding instrumentally to manipulate—this is fundamentally inconsistent with the social-cognitive deficits that define ASD. 2, 3
Your main issue is not understanding emotions but not caring about them unless they affect you directly—this is a hallmark of antisocial traits, not autism. 1
Your social difficulties appear to be more about lack of interest in emotional closeness and viewing people as objects/obstacles rather than difficulty understanding social cues. 2, 3
What She Will Assess
Structured Diagnostic Evaluation
She will likely use standardized measures for ASD (such as ADOS-2 or Autism Diagnostic Interview) to reassess whether your childhood diagnosis remains accurate or whether your presentation is better explained by personality pathology. 3, 4
She will conduct a thorough assessment for personality disorders, particularly ASPD and traits from Cluster B (antisocial, narcissistic, borderline features), using structured clinical interviews. 1, 4
She will assess for comorbid conditions that occur in approximately 75% of individuals with ASD, including depression, ADHD, anxiety, and impulse control disorders—though your presentation suggests personality pathology may be primary. 5, 6
Risk Assessment
Your violent thoughts experienced as "stimulating" rather than distressing, combined with your statement that consequences (not empathy) prevent you from acting, will trigger a careful risk assessment. 1
She will evaluate whether your risk is primarily impulsive (reactive aggression when frustrated) versus predatory (planned, instrumental violence)—your history suggests both patterns. 1
The fact that you killed the possum "just to do it" and found it "fun" despite knowing you shouldn't, combined with your history of animal cruelty, represents a significant risk marker that she cannot ignore. 1
Genetic and Medical Workup
Reassessing the ASD Diagnosis
She may recommend genetic testing if not previously done comprehensively: chromosomal microarray (10% yield), Fragile X testing (1-5% yield), and high-resolution karyotype (3% yield) to identify any underlying genetic etiology for neurodevelopmental features. 1, 3
Given your premature birth, cerebral palsy history, and family psychiatric history (mother with bipolar, sister with schizophrenia), she will want to understand whether there are identifiable genetic or perinatal factors contributing to your presentation. 1
However, she will likely emphasize that even if genetic factors are identified, this does not explain or excuse the antisocial behaviors and would not change the personality disorder diagnosis if criteria are met. 1, 3
Family History Implications
Your family history of bipolar disorder, schizophrenia, and substance use suggests genetic loading for psychiatric illness that could be passed to children. 1
The recurrence risk for ASD in siblings is 3-10% (higher if the affected child is female, 7% vs. 4% for males), but your children would also be at elevated risk for the broader range of psychiatric conditions in your family history. 1, 3
Treatment Recommendations
What Will NOT Be Offered
There is no FDA-approved medication for core ASD symptoms or for antisocial personality traits—medications only target specific symptoms like irritability, aggression, or comorbid conditions. 2, 6
Traditional psychotherapy focused on developing empathy or emotional warmth is unlikely to be effective if you have stable antisocial traits, as these are among the most treatment-resistant conditions in psychiatry. 6, 7
What MAY Be Offered
Cognitive-behavioral approaches focused on consequence-based decision making (since you acknowledge consequences, not guilt, drive your behavior) and impulse control strategies may be the most realistic intervention. 6, 7
Dialectical Behavior Therapy (DBT) skills training for emotion regulation and distress tolerance could help with impulsive reactions and anger escalation, though the evidence is limited for antisocial traits. 6
Medication for comorbid depression or impulsivity (if ADHD features are present) might be considered, but would not address the core personality features. 2, 6
She will likely be frank that your goal of "understanding, not necessarily trying to become soft" is realistic—personality traits are relatively stable, and the focus would be on harm reduction and functional improvement rather than fundamental personality change. 6, 7
Parenting and Relationship Implications
Genetic and Behavioral Transmission
She will tell you honestly that both genetic factors (family psychiatric history, possible ASD) and learned behaviors (modeling of manipulation, emotional detachment, aggression) could be transmitted to children. 1
Children of parents with antisocial traits are at elevated risk for conduct problems, callous-unemotional traits, and later antisocial behavior through both genetic and environmental pathways. 1
Your adverse childhood experiences (premature birth, medical complications, possible attachment disruptions) combined with your current traits create risk for intergenerational transmission of trauma and maladaptive patterns. 1
Relationship Capacity
She will likely address directly that your pattern of viewing people as useful/neutral/obstacles, inability to sustain emotional bonds, and tendency to discard people when bored or frustrated will significantly impair your ability to provide consistent, emotionally attuned parenting. 1
Your possessiveness without emotional warmth and tendency to manipulate to get what you want (sex, attention, compliance) are concerning patterns for intimate relationships and would model unhealthy relationship dynamics for children. 1
Critical Warnings She Will Give
Legal and Safety Concerns
She will document your violent thoughts and history of animal cruelty, and will likely discuss limits of confidentiality if she assesses imminent risk to others. 1
She will emphasize that your pattern of escalating from thoughts to action (possum killing) when opportunity arises, combined with your acknowledgment that only fear of consequences stops you, represents ongoing risk that requires monitoring. 1
She may recommend against certain occupations or situations that provide access to vulnerable populations or opportunities for harm without oversight. 1
Prognosis and Limitations
She will be honest that antisocial personality traits are among the most stable and treatment-resistant conditions, with limited evidence for interventions that produce meaningful change in core features like lack of empathy and remorse. 6, 7
She will clarify that while some functional improvements are possible (better impulse control, consequence-based decision making), fundamental changes in how you experience emotions and relate to others are unlikely. 6, 7
She will emphasize that your self-awareness and intellectual understanding of your patterns is valuable but does not substitute for the emotional capacity needed for healthy relationships and parenting. 1, 4
Common Pitfalls She Will Avoid
She will not accept the ASD diagnosis as a complete explanation for your presentation without reassessing it, as your pattern of intact cognitive empathy used manipulatively is inconsistent with autism. 2, 3, 4
She will not minimize the animal cruelty or violent thoughts as "just thoughts" given your history of acting on impulses when opportunity arises. 1
She will not provide false reassurance about treatment outcomes or your capacity for change, as this would be clinically and ethically inappropriate given the evidence on personality disorder prognosis. 6, 7
She will not fail to address the implications for future parenting directly, as this is a central concern you raised and has significant child welfare implications. 1