socialization and responsibility, impulsivity, sensation-seeking (in some cases), and aggression. otto kernberg, from a particular psychoanalytic perspective, believed psychopathy should be considered as part of a spectrum of pathological narcissism, that would range from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end. psychopathy, narcissism and machiavellianism, three personality traits that are together referred to as the dark triad, share certain characteristics, such as a callous-manipulative interpersonal style. the dark tetrad refers to these traits with the addition of sadism. criticism of current conceptions the current conceptions of psychopathy have been criticized for being poorly conceptualized, highly subjective, and encompassing a wide variety of underlying disorders. dorothy otnow lewis has written: the concept and subsequent reification of the diagnosis "psychopathy" has, to this author's mind, hampered the understanding of criminality and violence. according to hare, in many cases one need not even meet the patient. just rummage through his records to determine what items seemed to fit. nonsense. to this writer's mind, psychopathy and its synonyms (e.g., sociopathy and antisocial personality) are lazy diagnoses. over the years the authors' team has seen scores of offenders who, prior to evaluation by the authors, were dismissed as psychopaths or the like. detailed, comprehensive psychiatric, neurological, and neuropsychological evaluations have uncovered a multitude of signs, symptoms, and behaviors indicative of such disorders as bipolar mood disorder, schizophrenia spectrum disorders, complex partial seizures, dissociative identity disorder, parasomnia, and, of course, brain damage/dysfunction. half of the hare psychopathy checklist consists of symptoms of mania, hypomania, and frontal-lobe dysfunction, which frequently results in underlying disorders being dismissed. hare's conception of psychopathy has also been criticized for being reductionist, dismissive, tautological, and ignorant of context as well as the dynamic nature of human behavior. some have called for rejection of the concept altogether, due to its vague, subjective and judgmental nature that makes it prone to misuse. psychopathic individuals do not show regret or remorse. this was thought to be due to an inability to generate this emotion in response to negative outcomes. however, in 2016, people with antisocial personality disorder and dissocial personality disorder were found to experience regret, but did not use the regret to guide their choice in behavior. there was no lack of regret but a problem to think through a range of potential actions and estimating the outcome values. in an experiment published in march 2007 at the university of southern california neuroscientist antonio r. damasio and his colleagues showed that subjects with damage to the ventromedial prefrontal cortex lack the ability to empathically feel their way to moral answers, and that when confronted with moral dilemmas, these brain-damaged patients coldly came up with "end-justifies-the-means" answers, leading damasio to conclude that the point was not that they reached immoral conclusions, but that when they were confronted by a difficult issue – in this case as whether to shoot down a passenger plane hijacked by terrorists before it hits a major city – these patients appear to reach decisions without the anguish that afflicts those with typically functioning brains. according to adrian raine, a clinical neuroscientist also at the university of southern california, one of this study's implications is that society may have to rethink how it judges immoral people: "psychopaths often feel no empathy or remorse. without that awareness, people relying exclusively on reasoning seem to find it harder to sort their way through moral thickets. does that mean they should be held to different standards of accountability?" signs and symptoms socially, psychopathy typically involves extensive callous and manipulative self-serving behaviors with no regard for others, and often is associated with repeated delinquency, crime and violence. mentally, impairments in processes related to affect and cognition, particularly socially related mental processes, have also been found. developmentally, symptoms of psychopathy have been identified in young children with conduct disorder, and suggests at least a partial constitutional factor that influences its development. primary features disagreement exists over which features should be considered as part of psychopathy, with researchers identifying around 40 traits supposedly indicative of the construct, though the following characteristics are almost universally considered central. core traits cooke and michie (2001) proposed a three-factor model of the psychopathy checklist-revised which has seen widespread application in other measures (e.g. youth psychopathic traits inventory, antisocial process screening device). arrogant and deceitful interpersonal style: impression management or superficial charm, inflated and grandiose sense of self-worth, pathological lying/deceit, and manipulation for personal gain. deficient affective experience: lack of remorse or guilt, shallow affect (coldness and unemotionality), callousness and lack of empathy, and failure to accept responsibility for own actions. impulsive and irresponsible lifestyle: impulsivity, sensation-seeking and risk-taking, irresponsible and unreliable behavior, financially parasitic lifestyle and lack of realistic, long-term goals. low anxiety and fearlessness cleckley's (1941) original description of psychopathy included the absence of nervousness and neurotic disorders, and later theorists referred to psychopaths as fearless or thick-skinned. while it is often claimed that the pcl-r does not include low anxiety or fearlessness, such features do contribute to the scoring of the facet 1 (interpersonal) items, mainly through self-assurance, unrealistic optimism, brazenness and imperturbability. indeed, while self-report studies have been inconsistent using the two-factor model of the pcl-r, studies which separate factor 1 into interpersonal and affective facets, more regularly show modest associations between facet 1 and low anxiety, boldness and fearless dominance (especially items assessing glibness/charm and grandiosity). when both psychopathy and low anxiety/boldness are measured using interviews, both interpersonal and affective facets are both associated with fearlessness and lack of internalizing disorders. the importance of low anxiety/fearlessness to psychopathy has historically been underscored through behavioral and physiological studies showing diminished responses to threatening stimuli (interpersonal and affective facets both contributing). however, it is not known whether this is reflected in reduced experience of state fear or where it reflects impaired detection and response to threat-related stimuli. moreover, such deficits in threat responding are known to be reduced or even abolished when attention is focused on the threatening stimuli. criminality psychopathy is strongly correlated with crime, violence, and antisocial behavior. in terms of simple correlations, the pcl-r manual states an average score of 22.1 has been found in north american prisoner samples, and that 20.5% scored 30 or higher. an analysis of prisoner samples from outside north america found a somewhat lower average value of 17.5. studies have found that psychopathy scores correlated with repeated imprisonment, detention in higher security, disciplinary infractions, and substance misuse. psychopathy, as measured with the pcl-r in institutional settings, shows in meta-analyses small to moderate effect sizes with institutional misbehavior, postrelease crime, or postrelease violent crime with similar effects for the three outcomes. individual studies give similar results for adult offenders, forensic psychiatric samples, community samples, and youth. the pcl-r is poorer at predicting sexual re-offending. this small to moderate effect appears to be due largely to the scale items that assess impulsive behaviors and past criminal history, which are well-established but very general risk factors. the aspects of core personality often held to be distinctively psychopathic generally show little or no predictive link to crime by themselves. for example, factor 1 of the pcl-r and fearless dominance of the ppi-r have smaller or no relationship to crime, including violent crime. in contrast, factor 2 and impulsive antisociality of the ppi-r are associated more strongly with criminality. factor 2 has a relationship of similar strength to that of the pcl-r as a whole. the antisocial facet of the pcl-r is still predictive of future violence after controlling for past criminal behavior which, together with results regarding the ppi-r which by design does not include past criminal behavior, suggests that impulsive behaviors is an independent risk factor. thus, the concept of psychopathy may perform poorly when attempted to be used as a general theory of crime. violence studies have suggested a strong correlation between psychopathy scores and violence, and the pcl-r emphasizes features that are somewhat predictive of violent behavior. researchers, however, have noted that psychopathy is dissociable from and not synonymous with violence. it has been suggested that psychopathy is associated with "instrumental aggression", also known as predatory, proactive, or "cold blooded" aggression, a form of aggression characterized by reduced emotion and conducted with a goal differing from but facilitated by the commission of harm. one conclusion in this regard was made by a 2002 study of homicide offenders, which reported that the homicides committed by homicidal offenders with psychopathy were almost always (93.3%) primarily instrumental, significantly more than the proportion (48.4%) of those committed by non-psychopathic homicidal offenders, with the instrumentality of the homicide also correlated with the total pcl-r score of the offender as well as their scores on the factor 1 "interpersonal-affective" dimension. however, contrary to the equating of this to mean exclusively "in cold blood", more than a third of the homicides committed by psychopathic offenders involved some component of emotional reactivity as well. in any case, fbi profilers indicate that serious victim injury is generally an emotional offense, and some research supports this, at least with regard to sexual offending. one study has found more serious offending by non-psychopathic offenders on average than by offenders with psychopathy (e.g. more homicides versus more armed robbery and property offenses) and another that the affective facet of the pcl-r predicted reduced offense seriousness. studies on perpetrators of domestic violence find that abusers have high rates of psychopathy, with the prevalence estimated to be at around 15-30%. furthermore, the commission of domestic violence is correlated with factor 1 of the pcl-r, which describes the emotional deficits and the callous and exploitative interpersonal style found in psychopathy. the prevalence of psychopathy among domestic abusers indicate that the core characteristics of psychopathy, such as callousness, remorselessness, and a lack of close interpersonal bonds, predispose those with psychopathy to committing domestic abuse, and suggest that the domestic abuses committed by these individuals are callously perpetrated (i.e. instrumentally aggressive) rather than a case of emotional aggression and therefore may not be amenable to the types of psychosocial interventions commonly given to domestic abuse perpetrators. some clinicians suggest that assessment of the construct of psychopathy does not necessarily add value to violence risk assessment. a large systematic review and meta-regression found that the pcl performed the poorest out of nine tools for predicting violence. in addition, studies conducted by the authors or translators of violence prediction measures, including the pcl, show on average more positive results than those conducted by more independent investigators. there are several other risk assessment instruments which can predict further crime with an accuracy similar to the pcl-r and some of these are considerably easier, quicker, and less expensive to administer. this may even be done automatically by a computer simply based on data such as age, gender, number of previous convictions and age of first conviction. some of these assessments may also identify treatment change and goals, identify quick changes that may help short-term management, identify more specific kinds of violence that may be at risk, and may have established specific probabilities of offending for specific scores. nonetheless, the pcl-r may continue to be popular for risk assessment because of its pioneering role and the large amount of research done using it. the federal bureau of investigation reports that psychopathic behavior is consistent with traits common to some serial killers, including sensation seeking, a lack of remorse or guilt, impulsivity, the need for control, and predatory behavior. it has also been found that the homicide victims of psychopathic offenders were disproportionately female in comparison to the more equitable gender distribution of victims of non-psychopathic offenders. sexual offending psychopathy has been associated with commission of sexual crime, with some researchers arguing that it is correlated with a preference for violent sexual behavior. a 2011 study of conditional releases for canadian male federal offenders found that psychopathy was related to more violent and non-violent offences but not more sexual offences. for child molesters, psychopathy was associated with more offences. a study on the relationship between psychopathy scores and types of aggression in a sample of sexual murderers, in which 84.2% of the sample had pcl-r scores above 20 and 47.4% above 30, found that 82.4% of those with scores above 30 had engaged in sadistic violence (defined as enjoyment indicated by self-report or