The Barroom Blitz: Competing Neural Underliers of Impulsive Aggressive Phenotype Have Different Implications in Antisocial Personality Disorder

The DSM-V diagnostic criteria for antisocial personality disorder (ASPD) focus on indicators of impulsive aggressive phenotype (IAP), such as reckless, aggressive, or law-breaking behavior (American Psychiatric Association, 2013). However, concentrating primarily on behavioral data casts a wide diagnostic net, enabling criteria to describe various individuals with little in common aside from a history of rule-breaking (Hare, Hart, & Harpur, 1991). Other diagnoses, including borderline personality disorder (BPD) and intermittent explosive disorder (IED), and clinical constructs, such as psychopathy, are associated with and often comorbid with ASPD, due to some shared symptoms of IAP, although the three clinical constructs differ in many ways (APA, 2013; Lenzenweger, Lane, Loranger, & Kessler, 2007). Due to the poor discriminant validity of ASPD criteria, these clinical populations are at risk of conflation under the ASPD umbrella due to shared IAP, with little consideration that underlying factors and other symptoms may differ and thus have different clinical implications. This review describes distinguishing structural and functional neural traits of psychopathy, BPD, and IED and discusses how these differences produce distinct subjective experiences contributing to IAP. The article additionally discusses potential harmful consequences of failure to differentiate these clinical populations, including heterogenous research populations that yield nongeneralizable results, limited or inappropriate treatment of some psychiatric patients, and general mischaracterization of the disorders (Hare, 1996; Hare et al., 1991). To illustrate these differences, the paper includes an entertaining thought exercise involving a dispute amongst three very different, but equally aggressive, characters at their local pub.