the supportive therapy for our myeloma patients, is this working? There we go, thank you. Alright, so we know that myeloma is a highly treatable disease, but at this point in time is considered incurable. Hopefully that will change in our lifetime, right? And so the overall serates have significantly improved due to the recent advancements and newly approved novel agents, but with its survival improvements can lead to more comorbidities for our patients. So the goal of treatment is to control the disease to prolong overall survival, but we also need to preserve quality of life. So understanding what these side effects could be and prompt management of these side effects can really improve quality life for our patients. So we know that the effects of myeloma itself can affect the bone marrow, can cause myelosuppression, those plasma cells are overcrowding the bone marrow, it can cause renal dysfunction, you know those free light chains, those monoclonal antibodies can be really toxic to the kidneys and also bone damage. So for our bones we know that about 85% of our patients have bone disease and this is really because these myeloma proteins can up-regulate the activity of osteoclasts and kind of suppress osteoblast maturation, you know those two systems working together to maintain the bone health. And we can see weakened bone holes in the bones from this exact mechanism of action. So the widespread bone destruction can lead to hypercalcemia, it can cause fractures because the bones are really brittle, we can see sometimes spinal cord compression, we can see these kind of lytic lesions and sometimes we can see really weakened bones such as osteoporosis and osteopenia. So the main state of treatment for bone disease is actually using bisphosphonates for myeloma and how they work is they inhibit the osteoclast activity and cause osteoclast apoptosis. So it slows down bone destruction, it doesn't really build bone it just kind of works on those osteoclasts and it can decrease pain and can also reduce skeletal related events meaning reduce risks of fractures that can happen with myeloma. And there's also an anti-myeloma benefit to these drugs that we don't entirely understand because there was a study that was published in 2013 that looked at the usage of bisphosphonates particularly zometa for patients who had myeloma and the patients who were on zometa versus not on zometa actually live longer. So there is a survival advantage and an anti-myeloma effect to these drugs. So we typically give these the two drugs that are approved from myeloma zoologonic acid and pomegranate are given as IV infusions once a month for usually the first year and then we'll spread it out thereafter to maybe every three months and there are pretty rare side effects but important to note they can affect kidney function so it's important to know what your patients create and every time you dose these drugs. There's a risk of fractures of the long bones of the femur and it can be usually bilaterally and it can be it can happen with little to no trauma to the area so it's really important if your patients reporting groin pain or thigh pain to investigate to see if they have this fracture if they've been on bisphosphonates for a long period of time. It can cause flu-like symptoms maybe within the first three days of getting the drug typically with your first dose and not really with subsequent dosing happens in about 10 to 20 percent of patients manifesting as kind of a low-grade fever or chills or body aches can be mitigated with taking something like Tylenol and then we do see this very rare side effect called osteonecrosis of the jar ONJ and so the risk is increased with more exposure to these drugs and also having a recent invasive dental procedure so we always tell our patients that if they have to have any sort of major dental work to make sure they get that done before they start bisphosphonate therapy and make sure their dentists know that they're on bisphosphonates because when they are dentists tend to be a little bit more conservative with the type of treatments that they do because the risk increase if there's exposed bone in the jaw so maybe tooth extractions or even implants can increase the risk. There was a study that showed that patients who were on Zometa for more than two years and had a dental procedure they had about a 2% risk of developing ONJ so it's rare but it is something that's important to note. How else we manage bone disease? Well you know treat the underlying problem the myeloma but we can also do surgical procedures like vertebroplasty or kyphoplasty and they're minimally invasive so vertebroplasty they're basically kind of reinforcing the collapsed vertebrae and then kyphoplasty is they're inserting a balloon inflating it in the collapsed vertebrae and filling it with a bone like cement and this is minimally invasive patients can get pretty quick relief with this pain relief maybe within the first month of getting the procedure and it really isn't a hospitalization of all with this so it's a nice option for our patients who have really painful compression fractures. We can do radiotherapy it's really only for a select patient population because we know that radiotherapy can affect bone marrow function but if patients have painful plasma cytomas that could benefit from this will sometimes offer this and also if we see on imaging that patients have maybe an impending fracture we'll send them to our orthopedic colleagues to see if they need reinforcement. So the kidneys we always hammer to our patients that they really have to protect their kidneys not allow themselves to become dehydrated and that's because there's several factors at play so the myeloma can cause cast nephropathy the hypercalcemia we talked about can affect your renal function hyperviscocity and light chain deposition disease and amyloidosis can all call cause renal dysfunction and so other causes to such as other comorbidities such as hypertension or diabetes can affect your kidney function dehydration and certain medications so the nonsteroidal anti-inflammatory drugs we always tell our patients to stay away from make sure they're not getting IV contrast and there's certain drugs that we give them that can affect their renal function too such as the bisphosphonates and also some drugs we know we have to might we might have to dose reduced due to impaired renal function such as some of the immunomodulatory agents like Len Linamide. So how do we treat this? We make sure our patients are well hydrated I always tell my patients that they should be coming into clinic with a bottle of water because they should not allow themselves to get dehydrated make sure you correct that hypercalcemia because that can really influence the renal function and teach your patients not to take nonsteroidal anti-inflammatory drugs and make sure they understand what the brand names are and the generic names are because they might not know what they're taking is a nonsteroidal anti-inflammatory drug and if they ever see another physicians who's ordering a CAT scan make sure they tell the physician that it should be without contrast sometimes plasma freezes can help if they have really a lot of monoclonal antibody burden so you're just kind of getting rid of the excess monoclonal antibodies but doing plasma freezes but really treating the underlying myeloma as the way to go and then also dialysis if kidney function is really impaired. So here is a list of the approved agents for the treatment in months of myeloma it's not an exhaustive list because I don't have the alkylating drugs that we use such as bendomostine and cyclophosphamide and mouthland and the good old steroids that patients can never get away from but we have our immunomodulatory agents we have our proteasome inhibitors we have our monoclonal antibodies and we have our HDAC inhibitor. So you can see that these drugs they're break down by class and drug itself they can cause a slew of side effects for our patients so cytopenias increase risk for infection some gi distress we can even see issues with you know their blood sugars from the dexamethasone or prednisone we're giving our patients we can see even some cardiopulmonary effects so it's really important to understand all the risks of using these drugs and help prevent some of these side effects that can occur. So peripheral neuropathy we know that this can happen either from the disease itself or some of the drugs that we give our patients and it can range from sensory defects to actual neuropathic pain you know patients can just notice some intermittent numbness to constant numbness that can manifest to kind of electric shooting pain or pinpricks or a burning sensation that they have in their hands or feet and so it can happen like i said from disease or treatment itself amyloid deposition can do it hyper viscosity can do it and we know that the incidence of high-grade peripheral neuropathy can be mitigated with certain changes in some of the drugs that you use so bortesimib we know the risk is decreased if you give bortesimib once a week versus twice a week and we know it's also decreased if you give it subcutaneously I can tell you here at Hackensack we pretty much never give bortesimib intravenously and we really only give it as a sub-q injection because the efficacy is the same but it's much more better tolerated thalidomide we know that this is dose dependent meaning kind of the longer you're on it the more likely you're able to develop neuropathy and it's less it's a little bit harder to reverse neuropathy associated with thalidomide with bortesimib we know about one-third of patients can have irreversible peripheral neuropathy so we can help two-thirds of patients if we recognize it early and give them a break so how do we manage it if we know it's related to the drug we might have to modify the dose or the schedule of the drug meaning if it's from bortesimib we might want to change from going twice a week to once a week or you may need to give the patient a break to see if the neuropathy gets much better we can also try oral medications such as deloxatine or progabalin gabapentin some of the tricyclic antidepressants can be really helpful like nortriptyline or amitriptyline and even opiates can sometimes be helpful but those neuropathic medications seem to be a little bit more beneficial there's compounded creams that you can use we don't use them very often some patients find them to be a little bit more painful than anything else it usually has a mixture of stuff in there like a muscle relaxant or a high dose opiate like ketamine and then just teaching your patients about really how to protect themselves so make sure they don't have clutter in the house if they have trouble walking so they're not tripping over anything make sure they're using safety features maybe installing stuff in their bathroom make sure they're using canes and walkers as needed and if they're having a lot of trouble with their balance maybe physical therapy can be beneficial and even calling our neurology colleagues because we know they can do sometimes some EEG testing to figure out the origin of the neuropathy and see if they have any other better ideas than we do. So clots is a huge issue for cancer patients we know that cancer patients are inherently hypercoagulable myeloma is no different and we can see our patients can get either DVTs or PEs sometimes just from the drugs that we're giving them or just inherently at risk so we know that these clots can result from kind of an unregulated activation of both the coagulation that occurs with endothelial damage or reduced blood flow and just inherent hypercoagulability it's important to recognize the signs and symptoms of a clot it can be very insidious sometimes patients can have very minimal swelling in their legs not pain not heaviness not redness and you send them for you know adopter study and they can have bilateral DVTs so how do we prevent clots we have to understand what our patients risk factors are so obesity a previous history of a clot can tell us that they're already inherently hypercoagulable having a central venous catheter certain comorbidities and even certain medications like the erythropoiesis stimulating agents that we give can increase your risk of developing clots we have certain myeloma related risk factors too such as hyperviscosity or even certain drugs that we use and it's important to recognize the risk factor where they lie on the scale because doing something like aspirin can be sufficient but if they have more risk factors doing therapeutic anticoagulation is the best way to go so the best way to manage it is to recognize the risk and prevent it i can tell you we pretty much use a low dose aspirin for our patients who are low risk but if our patients are at high risk we'll use therapeutic anticoagulation and we tend to ad-hack and sac to lean a little bit more to the oral agents a little bit easier for our patients to avoid taking another shot every day and also watching how much corticosteroids we use because there was a trial that showed reducing the dose of dexamethasone there was a trial showing high dose dex with rev or low dose dex with rev and the patients who had a lower dose of dexamethasone with revlimid had less clots and actually less infections we can do Doppler studies or a vq scan and also if patients develop a clot while they're on therapy switch them over to therapeutic anticoagulation so myelosuppression we know is a problem for our patients because the plasma cells are overcrowding the bone marrow and causing these low blood counts and the drugs that we give them itself can be myelosuppressive so it's important to recognize the risk and when patients naters are going to be and anticipate that and make sure they understand what the signs and symptoms of myelosuppression can be so check those blood counts frequently particularly during that nadir period if your patient has poor bone marrow reserve maybe you need to check it more frequently while they're on therapy make sure they're not on any other medications that can lower their blood counts besides their myeloma therapy if they're really symptomatic from their anemia maybe giving them a transfusion to improve their oxygen carrying capacity can be helpful trying those erythropoiesa stimulating agents may be useful too you can try prokrid or aeronasp and maybe look for other underlying issues that can cause anemia such as deficiency in iron or B12 or folate we've had a couple of patients develop this kind of coombs negative hemolytic anemia on some of the treatments that we're giving them so make sure you look for that and correct it if you're seeing a lot of surrogate markers such as hyperbilarubinemia or the anemia is becoming more pronounced and long-term usage of some of the drugs like the immunomodulator drugs can cause hypothyroidism which can in turn cause anemia so make sure you're checking for that too so for our neutropenic patients we can offer them growth factor support more importantly teach them about infection precautions you know i had a patient yesterday who was very neutropenic and was very sad that i told him he couldn't have a huge birthday party this weekend because he could develop a life-threatening infection with all his grandchildren were playing to be at the party so it's really important to explain to your patients that it's they really need to avoid large crowds wash their hands really well it's so easy for someone to cough sneeze into their hand touch a surface your patient touches that surface rubs their eyes rubs their nose make sure they have a thermometer at home it's so easy to ask your patients if they're experiencing fevers they'll tell you no but your second question should be do you have a thermometer at home because sometimes the answer will be no so how do you know you have a fever if you don't have a thermometer at home and so make sure patients know that if they do have a fever it's a medical emergency so for febrile neutropenics we have to basically panculture these people give them empiric IV antibiotics Tylenol to bring the fever down and also for thrombocytopenia make sure for patients are really at high risk for spontaneous bleeds with a low platelet count give them a platelet transfusion and also make sure we're holding anti coagulation if their platelet count really low so infection we know our patients are really at risk so the immune deficiency of myeloma patients is caused by many things so the myelosuppression they have suppression of their normal immunoglobulin because of that excessive monoclonal antibody that they're producing they have deficiency in their normal antibody response because that monoclonal antibody that they're producing it's kind of non-functional not helpful for their immune system there can be a shift in their microbial flora so they're really at high risk for developing bacterial and viral infections myeloma patients have an inherent problem with their humeral immunity so they're at high risk for encapsulated bacteria infections such as homophilus infections and streptococcus so they're also at risk for zoster and that's from the myeloma itself the treatment they get we give them such as proteasome inhibitors daratumab and even stem cell transplant so it's important to recognize this and prevent it make sure they're on antiviral prophylaxis if they develop zoster recognize it quickly and treat it so because the risk is always developing post-herpetic neuralgia which is really terrible for our patients and we do not recommend the shingles vaccine for our patients it's a live vaccine and our patients should not be getting it but we can also make sure that we are finding a source of infection if we do suspect one so sometimes we'll do a respiratory pathogen panel to check for the most common viruses a lot of my colleagues joke in the office that i order this way too much but you know when you have a patient who develops the flu in the middle of the summer and has a develops a flu in april i had a patient who developed the flu twice this year um in the summertime and just in the non flu season so it's important to see that these people can be at risk for these kind of opportunistic infections when the general population is fine chest x-ray looking for pneumonia they're really at risk for that empiric antibiotics if you think they do have an infection vaccines are important so getting their seasonal flu vaccine and their pneumonia vaccines very very important they may may not be able to mount the response to these vaccines at a patient who doesn't have myeloma but there's still a protective benefit there and if your patients have really they have chronic infections chronic sinus infections respiratory infections and really low levels of igg you may want to offer them intravenous igg to see if it can help them if your patients are having a lot of trouble with diarrhea may want to do a stool culture to see if they have C. diff or an o.m.p. urinalysis and urine culture if they're having urinary symptoms blood cultures antifungals growth factors but i just want to remind you that sometimes patients may not really mount the same kind of immune response to an infection because the corticosteroids can really mask the typical signs and symptoms of an infection so you really have to be careful and look for insidious things and make sure your patient is not infected so fatigue so this is one of the most serious complications of myeloma because it really really reduces quality of life and it usually starts with diagnosis and just gets worse over time and it's not the type of fatigue that you and i know after working a long day at work it's more the type of fatigue that's really not relieved with rest you know you and i may be able to take a nap and then get going and feel refreshed a lot of the times our patients don't feel that way and they're not really sure but they think it's due to increase inflammatory cytokines so it's important to kind of recognize what the risk factors are so you know anemia nutritional deficiencies if they're not sleeping well from the steroids we keep hammering into them even depression a lot of the time patients say they don't feel depressed but it's really manifesting as difficulty sleeping and having little interest in no energy and things that they love to do pain medication can do it just being sedentary can do it it's just like with babies right sleep but get sleep so the more you sit the more tired you're going to be and even some hormonal changes can do it too in the myeloma treatment so we have to tackle it from various standpoints correct anemia if we think that's the cause if it's drugs doing it maybe they just need a little bit of a break you know these patients are going to be on treatment probably indefinitely so maybe they just need a little bit of break just to kind of refill their tank um sleep disruption disruption can be a big problem so educate your patients on proper sleep hygiene make sure they're not drinking a ton of caffeinated beverages before they go to bed and try and tell them you know if you are trouble having trouble sleeping please don't turn on the lights and start vacuuming your house because your body's going to get confused and think it's time to stay awake and and be productive for the day so just try and rest and close your eyes if it's because their mind's racing a lot at night maybe giving them a benzodiazepine but maybe a sleep aid is really where they need to go such as ambien or even lunesta sometimes our patients don't have energy because they're just not eating well so it's really important to lean on our nutrition colleagues our nutritionist is fantastic she can really come up with an individualized treatment plan for our patients and sometimes patients are dehydrated they just see an IV hydration to help them get going depression is a huge problem can cause fatigue we have a monthly support group here for our patients or myeloma patients it meets the third Thursday of every month we also have social workers that can help our patients sometimes they need more advanced help such as seeing a psychiatrist or even having psychotherapy and the demands of cancer care itself are very fatiguing you know a lot of our regimens that we give patients make them come twice a week sometimes two days in a row three weeks on and one week break so we're coming to the clinic sometimes six times a month maybe more than that if you have to check them more frequently because you're worried about their counts so patients can be just really exhausted with the cancer care itself so i always tell my patients make sure you're leaning on your caregivers to help you with other things that you don't need to do run into the grocery store run to the laundry mat let them do those things so you can conserve your energy to do more important things such as that holiday dinner or their birthday that you really wanted to have and make sure they're exercising so basically exercise is the only thing that's been proven to help with cancer related fatigue and a lot of patients just say you know i don't have enough energy to exercise but once you get those natural endorphins pumping they actually do feel better proper pain management as well and of course check for hormonal imbalances so gi distress we see a lot of this with our patients most of the time not related to the myeloma itself but more the treatment that we give them and there's tons of risk factors here so for nausea the hypercalcemia being constipated being anxious we know our female even our younger female patients are really at risk for nausea pain medicine can do it constipation there's lots of risk factors there too such as uncontrolled diabetes we forget about that sometimes just not eating well can cause constipation and diarrhea you know recent exposure to antibiotics can do it and sometimes people have pre-existing issues like lactose intolerance or irritable bowel syndrome so how do we manage nausea so if it's due to drug we'll try and modify the dose but we really lean on our supportive medications for this so and sometimes it requires drugs from all of these classes so our five ht3 receptor antagonists our neuro one receptor our neuro kind in one receptor antagonists our dopamine receptor antagonists and sometimes even using the cannabinoids can be helpful for our patients using marinol particular for patient has trouble sleeping and they have a low appetite and trouble with nausea sometimes marinol can be really helpful maybe the benzodiazepines are a way to go to to add on top of this alternative therapies like acupuncture bands or acupressure can be really helpful and teaching your patient about small frequent meals a lot of the times patients say you know I had my large pasta dinner and I felt really nauseous well maybe you shouldn't have your large pasta dinner how about small frequent meals just to get that nutrition in and make sure you tolerate it well and a lot of our patients have trouble with reflux in fact one of my patients just stopped me in the hall and said Amy I just want you to know I've been having reflux all day today so I said well what are you eating she was drinking you know coca-cola and eating a chocolate cookie so we talked a little bit about sometimes food can exacerbate it such as caffeine and chocolate but you know a lot of the steroids we give our patients can really cause a lot of gastritis so making sure they might need to be on a ppi or even on the h2 and even she said she's been chewing tums all day so talked about how to best manage that constipation we forget that almost all of our patients are on opiates and so they can cause a lot of constipation make sure their diet is appropriate relaster can be helpful for opiate induced constipation make sure they're not taking their 5HT3s very often and diarrhea make sure your dose reducing are delaying if you think it's related to drug make sure patients are slow down slow down slow slow down on laxatives make sure they're hydrating well they can use supportive medications like ammonium or lomodal even cholecystiramine can be helpful make sure it's not related to gvhd because sometimes I can really cause excessive diarrhea make sure they're eating appropriately and treat infections if you think that's the cause so now we have infusion related reactions as a problem for a myeloma patients we're lucky to have this usually our lymphoma colleagues had to deal with this now we do too so we don't really understand what the mechanism is but we think it's some sort of cytokine release and if usually occurs it's usually really quickly and usually with the first infusion and the symptoms can range so I always tell my patients if they feel strange in any way during the infusion let your nurse know so how do we manage it the best ways to prevent it so make sure your patients adequately pre-medicated start low and slow and there's some parameters for certain monoclonal antibodies so there's a risk of having a delayed reaction with deratumab up to 48 hours after getting the drug so patients need to take prednisone for two days after ilotuzumab they need to take it before they come and see you and how we manage it stop the infusion of course give them more supportive medications if you're worried about airway obstruction make sure you have epinephrine and make sure they're getting fluids we do see some skin reactions from time to time make sure they're taking antihistamines topical corticosteroids we can see injection site reactions with portesimib it's important to use the air sandwich technique to help reduce this make sure you're rotating the site of injection to help minimize this dyspnea can happen sometimes from drugs or underlying issues we have a ton of risk factors that can cause this make sure you're asking your patient if they're smoking and make sure they're not smoking they can sneak by us with that a lot of the time and so we manage this by basically correcting issues that can cause it so if it's heart failure doing it make sure we're getting a repeat echocardiogram if we think it's a clot do a vq scan and sometimes patients need supplemental medications to get them through so just in summary we basically have a lot of survival improvements with our new novel agents but it can also lead to comorbidity so it's and the adverse effects that can happen can happen really to pre-existing risk factors the disease state and the treatment regimen that we're giving them and a lot of this can really be potentiated by understanding what the risk factors are because we know a lot of these adverse effects can be managed more properly if we prevent it and harder to control once they happen and we know that if we can control this well and recognize it well we can improve our patient's quality of life that's it thank you i tried to wrap it up thanks sweetie so she only has like three minutes because she has to go speak next door who's got pressing questions for amy please you said with the hypercalcemia i was wondering if you probably don't recommend vitamin D actually vitamin D is really important but um the hypercalcemia usually is from the underlying myeloma itself not not mostly because a patient has taken a lot of calcium or tons although that does happen it's really from the underlying myeloma itself so treating the myeloma and also um supporting them with like calcitonin or bisphosphonates and fluids to correct the hypercalcemia but it's really important for patients to stay on vitamin D particularly living in the northeast we're all very vitamin D deficient here no i don't think it's going to make the matters worse but of course watch for patients calcium levels so that one of the issues with vitamin D and calcium supplementation because especially because you're dealing with an older population particularly the women they're on calcium and vitamin D because that's what their doctors tell them to take all the time we those are actually very important to make the bisphosphonates work better but we don't usually recommend them to their myelomas under control so they need to take a holiday from their vitamin D calcium until we get their disease under control and then they actually can go back on it because it does make you know it makes the the bisphosphonates work better so they need to take a holiday make sure they're not hypercalcemic because they're taking exogenous calcium control their disease put them back on it because it helps their bones other questions yes we can use exjiva we can all use exjiva in refractory hypercalcemia it is approved for that so if they want to bisphosphonate they become hypercalcemic you can give them exjiva do you have any that do you have any idea when the news may have no i know i've been waiting the trial has been done in myeloma they didn't approve it no if you look at the original exjiva trial there was only there was a handful there was like 200 or something like that out of the 1800 patients and they didn't feel the FDA didn't think that was a large enough subpopulation to approve it so a couple years later the company finally decided to do an exjiva versus zoonodronic acid study it's been done the results are not available so we can't answer that question


Welcome to All Hands Update, I'm Petty Officer Andrew Johnson with your headlines from around the fleet. Vice Admiral Eugene Wilkinson, commanding officer of the first nuclear-powered submarine USS Nautilus and cruiser USS Long Beach, died July 11th. Wilkinson is remembered as a pioneer of nuclear power. His leadership of the Navy's first nuclear-powered vessels fundamentally changed the way we fight from the sea. Effective immediately, anyone sending mail to Navy mobile units must use a nine-digit zip code to ensure delivery. The United States Postal Service is implementing new automated mail sorting to increase efficiency as it downsizes from two coastal locations to one central location in Chicago. Refer to allNAB 047-13 for more details about the change. You can read more about these stories at navy.mil. From All Hands Update, thanks for watching.


When you fast, you're weakening the flesh again. Yeah, you may repent of that sin. Yeah, you may receive the forgiveness of God, but it's also a good idea to not only receive the forgiveness of God, to not only turn from that sin, but to get the flesh back in a weakened state so that habit doesn't return. So think about how it takes months, weeks, days to fall into the ways of the flesh. Well, when you fast, it brings you back to the spiritual state so that you're not in the fleshly state that caused the problem in the first place.


Hello everyone, I am Sachin Duttwood working as an assistant professor in mechanical engineering department from Walton Stop Technology, Swalapur. Today we will see the part 3 of the CAM and FOLLOWER. In the previous lecture, we have seen the part 1 and part 2 in which we had covered the basic classifications of CAM and FOLLOWER also we have seen the terminology used in the CAM. So, in this lectures, we will see at the end of this session, learner will able to understand the displacement velocity and acceleration diagram when the follower moves with uniform velocity. So, in that we will see the motion of the follower. So, we can pause this video and you can think about that whether the follower moves with any different motion means what the CAM is rotated with uniform velocity with uniform angular velocity. So, whether is it required to move the follower with certain different motion you have to think about this. The follower during its travels may have one of the following motion. First one, the displacement velocity and acceleration diagrams when the follower moves with the uniform velocity. Second, the displacement velocity and acceleration diagram when the follower moves with simple harmonic motion. Third one, displacement velocity and acceleration diagram when the follower moves with uniform acceleration and retardation and the last one is displacement velocity and acceleration diagram when the follower moves with cycloidal motion. So, these are the four types of motion of the follower. First one, the follower moves with uniform velocity, second one the follower moves with the simple harmonic motion, third one the follower moves with the uniform acceleration and retardation and the fourth one the follower moves with the cycloidal motion. So, from these four types of the motion of the followers we will see the first that is a follower moves with uniform velocity. So, for finding the motion of the followers that is moving with the uniform velocity firstly you have to able to understand how to draw the displacement velocity and acceleration diagram when the follower moves with the uniform velocity. So, firstly we will see how to draw the displacement velocity and acceleration diagram when the follower moves with uniform velocity. So, firstly we will draw the displacement diagram. This vertical line indicates the motion of the follower or the displacement of the follower that is also called as stroke length or lift of the follower. So, this will give you the displacement y axis this is a x axis indicating the angular displacement of the cam. So, if we rotate the cam then we are observing that the follower will get rise for certain angular rotation of the cam then the followers will dwell or it remains at constant position for certain period of the time that is called as a dwell. So, like this we are getting the displacement of the follower for certain angular displacement of the cam then the follower will fall for certain angular displacement of the follower that is called as return stroke like this and again the followers remains at lowest position for certain angular displacement that is called as dwell. So, these diagrams is highlighting the motion of the follower when the cam will rotate with a certain angular displacement. This is called as displacement diagram when the follower moves with uniform velocity then you should know how to draw the velocity diagram. So, this is a horizontal line this lines we have projected from the initial point when the cam is just at rotating the y axis indicating the velocity just we have projected the line in which the rising of the followers occurs then dwell then return and again the dwell. So, like this we have projected the lines so as the displacement moves with the uniform velocity we are getting the velocity for the rising period is like this for the dwell period the velocity is 0 again for the return the velocity we are getting like this velocity. So, the velocity is maximum at the rising period and the velocity minimum velocity for the return strokes we can get by this diagram again for the dwell period the velocity is 0. So, like this we are getting the velocity diagram this portion indicating the velocity at the rising of the cam this portion indicating the velocity is 0 during this dwell period because the follower will not move up and down for the dwell period it remains at the constant position and for the return stroke we are getting the velocity that is a vr velocity for the return stroke this again for the dwell period the followers remains at constant position. So, the velocity is 0 so we are getting like this diagram so this is called as a velocity diagram. Now, we will see the acceleration diagram so the vertical line indicating the acceleration so if you observe that within 0 time the velocity we are getting at infinite at finite value as the velocity within 0 times we are getting at the finite value it means that the acceleration at that point is at infinity similarly at this point we are getting the acceleration at infinity because within 0 times we are getting the infinite value of acceleration because of the velocity the time required for the velocity is 0 so we are getting the infinite value of the acceleration so like this we are getting the value of the acceleration is at infinite in the actual practice the infinite accelerations we are not getting so we have done some modifications in the displacement velocity and acceleration diagram so this is a modified displacement velocity acceleration diagram when the follower moves with the uniform velocity just in the velocity diagrams we had given us the uniform velocity so we are getting the acceleration at finite level so like this we are getting the acceleration diagram. So here for getting the uniform velocity we had done some parabolic natures of the displacement diagram then and then only we are getting the acceleration in the finite level so this is the displacement velocity acceleration diagrams when the follower moves with the uniform velocity so in this diagrams we are getting that how to draw the displacement diagram so if you observe this displacement diagram so in which the followers will get rise then it will get dwell then it will get return strokes against it will get dwell stroke so this is a motion of the follower when the cam will get rotate with angular velocity means the cam will rotates with the constant angular velocity at that time when we require the motion of the followers will be in the uniform velocity at that time we have to draw the displacement diagram like this and we have to transmit the motion or the transmit the displacement in the cam profile so like that we are generating the cam profile if we generate the cam profile by referring this displacement diagram then and then only we will get the follower motions will be in the uniform velocity. So by this lectures we will understand how to draw the displacement velocity and acceleration diagrams when we required the follower moves with uniform velocity so for this lecture I have taken the references so these are my references thank you.


Hello and welcome to the session. My name is Mansi and I'm going to help you with the following question. The question says, find the derivative of x square minus 2 at x equal to 10. Before starting with the solution, let us see the key idea behind the question. That is, the theorem 7 of your book that says that let fx be equal to an x raise to power n plus an minus 1 x raise to power n minus 1 and so on till a1x plus a0 be a polynomial function where ais are all real numbers and an is not equal to 0. Then derivative function is given by dfx by dx is equal to n into an x raise to power n minus 1 plus n minus 1 into an minus 1 x raise to power n minus 2 and so on till 2a2x plus a1. Now, if we clearly see what we have done in this question is, we have found the derivatives of all the terms and we have added them. For example, in the first term we see that an is a constant path so it remains as it is. Derivative of x raise to power n with respect to x is n into x raise to power n minus 1 and so on for the second term. Now, the last term we see that this is a constant derivative of a constant is 0. So, in the last term we have 0. So, this is how we get this theorem. Using this theorem we find the derivative of x square minus 2. So, let us start with the solution to this question. First of all, let fx be equal to x square minus 2. We have to find derivative of fx happens because we see that derivative raise to power n minus 1 here n is 2. So, 2 minus 1 is 1 which is same as is equal to 2x. Now, we have to find the derivative at the point x equal to 10. So, dfx by dx 10 will be and that is equal to 20. So, our answer to this question is 20. I hope that you understood the question and enjoyed the session. Have a good day.


Dear hostages and prisoners everywhere, I drink to you.  And the night is young, who knows what may transpire between us. Which leads me to the topic of today's extremely long presentation. The presentation will deal with various aspects of the same issue and if you're interested in the topic, I recommend that you listen to the variant or suffer to the variant. And the topic is promiscuity. My name is Sam Baknin and I'm the author of Malignant Self-Love, Narcissism Revisited. Cheating and promiscuity are now common reactions to neglect, abuse, rejection, monotony or indifference in ostensibly intimate relationships. I'm saying ostensibly because all these things are of course the exact antithesis, the exact opposite of intimacy. Promiscuity and cheating are so widespread because sex has been reduced to a mere mechanical, pneumatic exercise, a kind of an emotionless act of masturbation with near anonymous and objectified partners. Sex is very reminiscent today as practiced to pornography. Devoid of its function as an expression of intimacy, expression of love, men and women alike no longer feel guilty or ashamed to engage in this largely meaningless, purely physical activity. Add to these the ease of finding sexual partners online, the veritable supernova of growing abuse of all manner of substances, the tsunami of broken and abusive relationships, the virulent collapse of inter-gender communication, the dysfunctioning of social institutions, social atomization, isolation and anatomy, especially in our days, and the evaporation of inhibitory social and religious mores. Put all these together and you get the perfect storm of everyone copulating with everyone recklessly and with utter disregard for consequences, medical consequences, moral, social, psychological, and what about the traumatic effects on loved ones, the hurt, the pain, intolerable pain sometimes. No one cares. But let's study the topic a bit more academically. There are numerous myths about promiscuity.  They say about women that they are promiscuous. It's very rare to hear about a promiscuous man. In the 19th century they called them nymphomaniacs, but of course there are many promiscuous men as well. Promiscuity has little to do with the intensity and frequency of one's sexual urges. The potency or strength of the sex drive is actually poorly correlated with promiscuity, especially when it is associated with personality and mood disorders. Studies have repeatedly demonstrated that histrionic women, seductive, flirtatious, well-dressed, provocative, ostentatious, histrionic women, be epitome of the femme fatale. They regard actual sex as a bit of a chore. Take borderlines. Borderlines are prone to promiscuity as a form of reckless behavior, or when they act out they decompensate, they disintegrate. Poor impulse control is a part of the equation and one of the criteria of borderline personality disorder to this very day, or for example somatic noses. They are more calculated than borderlines. Their promiscuity is goal-oriented. They seek narcissistic supply by polar patients or promiscuous in the manic phase, etc. etc. So promiscuity is correlated with mental health disorders much more than it's correlated with a sex drive or its strength. Promiscuity is intimately connected to teasing in women and in men, driving a potential partner insane or driving him to destruction with desire, tantalizing potential partner with verbal, visual and tactile implied promises and hints of sex, teasing, we all know what it is. And then we're drawing a broccoli and frustrating the unfortunate target. Promiscuity is a dysfunctional way to regulate a labile, fluctuating sense of self-worth and to restore one's self-esteem in the wake of a narcissistic injury, rejection, humiliation, being cheated and so on. It is exactly like rape. Promiscuity is about power, not about sex. It is about reassuring oneself that one is still considered irresistibly desirable and as there were widows to frustrate, rage and hurt other people by withdrawing oneself. So in a way promiscuity is an approach avoidance repetition compulsion. Promiscuity is also about thrills and risk in adrenaline junkies, the encyclopaths will deal with that at length a bit later. Promiscuity is therefore in a way situational. It's reactive. It is not a personality trait but a learned coping strategy in the repertoire of one's behaviors. It is compulsive but has to be triggered by external events. Promiscuous people go through long periods of strict monogamy or even abstinence, celibacy. As long as they get their fix from their source of narcissistic supply from an intimate partner spouse, they are tranquil. They are not promiscuous. There are three types of promiscuity. There is frequency promiscuity, conditional, contextual promiscuity and standards related promiscuity. Let's start with the first one. In frequency promiscuity, the quantity of partners and sexual encounters is statistically abnormal, very high. But some criteria, some standards are maintained throughout with regards to mate selection, with regards to what little time is spent together. There are some minimal emotions, for example, liking the partner, affection, feeling good in the partner's company and there are behavioral choices. So it's a much more controlled behavior, frequency promiscuity. In standards promiscuity, the numbers of sexual liaisons and disparate partners, these numbers are not always high. But on the other hand, there are no thresholds or benchmarks as to the type of partner chosen or which behaviors are deemed unacceptable. In other words, in standards promiscuity, anyone and anything go. And finally, in conditional or contextual promiscuity, usually women reward with sex, anyone, even a bad guy, who is nice to them. And when women say nice, they mean three things, in combination. He's attentive, he pays attention to them. He's protective. And he is possessive, he reacts to implied or explicit triangulation. And so such a man who would be nice to them and finds them irresistibly desirable, they find irresistible. It is a meaningless transactional exchange, actually. Emotionless sex on the part of the woman is swapped for worn out pickup lines on the part of the man. But when women are asked, why do this, they say, better have the wrong kind of attention than no attention at all. So these are women who are addicted to attention, or more colloquially attention boards. The first type of promiscuity is not really casual sex. Frequency promiscuity involves getting to know the prospective sex partner, however superficially and cursorily. The second type, standards promiscuity, is compulsive. It is intended to ameliorate anxiety and depression. And then it is ego dystonic. Later, it creates shame and guilt. It could also be, instead of compulsive, it could also be impulsive, reckless, emotionless, novelty seeking. And then it is ego-syntonic. Actually, the person feels good afterwards. So let's take case examples. A heterosexual man who is frequency promiscuous, trolls' bars, or swipes' dating apps, to pick up partners for casual sex. But he would be selective as to the physical type of the partner, her psychology and background. He would also not do drugs or get drunk senseless. He would not visit a brother. He would spend some time with a potential partner, getting to know her better, and making up his mind whether he wants to copulate with her or not. That is an example of frequency promiscuity. And now, standards promiscuity. A heterosexual woman who is standards promiscuous will rarely have a one night stand. But when she does have it, she will do it with anyone, anywhere, at any time. She would also get drunk senseless, do drugs, go to street clubs, let herself be grogged in public or by multiple men, and even in extreme cases, make herself available to gangbanks and to video shoots and so on. In short, in standards promiscuity, there are no standards. There are no inhibitions. Let's regress a bit. In clinical practice, we are likely to come across a cluster of issues very frequently. These patients present with problems in psychosexuality, body image issues in extreme cases, somatophore or body dysmorphic disorders, grandiose narcissism with obvi-associated alloplastic defense mechanisms. It's not my fault, it's your fault that I misbehaved. Antisocial behaviors and ineffective dysfunctional and self-destructive strategies to cope with negative emotions, such as boredom, frustration, narcissistic injuries, anger, envy, and so on. And these strategies, which, as I said, are ineffective and dysfunctional and self-destructive, they include substance abuse, but there are many more. We will discuss substance abuse with an emphasis on alcoholism a bit later in this presentation. But all these issues are interconnected. For example, boredom and frustration are emotions that trigger antisocial behaviors in a certain way. Addictions are ultimately or intimately related to grandiosity. Grandiosity compensates for inferiority and alloplastic defenses get rid of egodystonic emotions, like shame and guilt. I shouldn't be ashamed. I shouldn't feel guilty. It was not my fault. Inferiority manifests also via body image issues and rigid self-control, for example, of a latent promiscuity. And rigid self-control generates boundary issues and leads time and again to decompensation, being overwhelmed by emotions and to acting out. So you see, there are numerous intricate connections within this complex. Another thing that many promiscuous people have is paranoid ideation. It is common among people with pronounced fantastic grandiosity, which is a defense against a dysregulated labile sense of self-worth and vanishingly low self-esteem. Yet counter-intuitively, such people are much more prone to reckless behaviors involving strangers in dangerous situations. So never mind how paranoid they are, they end up placing themselves in danger. How can we reconcile this apparent conflict between psychodynamic paranoia and behavior risk-seeking? Well, in such patients, paranoid ideation is provoked by socially stressful situations, by emotional intimacy, by self-imputed inferiority, a challenge to grandiosity, or by risk of loss, a perceived disadvantage or weakness. Paradoxically, therefore, such people, paranoid, would feel most threatened in the presence of their intimate partners and their nearest and dearest. But they would trust total strangers as safe, even in the most precarious, dangerous and reckless situations. For example, when they are totally drunk, or in a hotel room, together, alone. So there is a kind of shifting attachment, a kind of wrong attachment or attachment dysfunction, or intimate partners are perceived as potential threats because they can cause pain. And strangers, because they are meaningless and passing and transient, they don't have power over the paranoid person, so he or she is not paranoid. The threat perception of these people is not affected even when the stranger makes his nefarious intentions known, because there is no risk of intimacy or attachment involved. They are far more likely to end up having sex with a total unknown person than with someone they love, for instance. And the sex would often be unprotected and in compromising circumstances. These people are bound to shun and avoid all forms of intimacy with potential mates, and they would have a kind of sex aversion, and they would compensate with instant fall closeness or affection and promiscuity with strangers. Similarly, people with these psychological defences would trust even known criminals, bums, junkies, over their friends and loved ones, because they can feel equal or superior to these losers, and thus their grandiosity is upheld and their self-esteem is restored by comparison. Let's see how complex the background of promiscuity is. Promiscuity is just the tip of an iceberg. The iceberg is submerged and includes literally every known dysfunction. People with paranoid ideation tend to suspect and fear anyone who has the perceived power to deny them something that they crave and depend on, or to take it away from them, because they are focused on highly specific potential losses.  Such misjudgment and misperception of risk is enhanced by alcohol or drug abuse, and this is what we call alcohol myopia. We will discuss alcohol a bit later, but before we get to alcohol, let's talk about the body. The instrument of promiscuity is of course the human body. Promiscuous people use their body to communicate something, and most of these people have a kind of body dysmorphia, body kind of misperception of their own bodies. I call it labile body dysmorphia, or labile body dysmorphic disorder. It's a phenomenon I come across in my practice more and more often. Women and far less often men misjudge the shape of their bodies or parts of their anatomy. They see their bodies sometimes as flawed or defective, and at other times as irresistibly perfect. They pendulate, they swing between these, they shift between these two misperceptions. A client with labile body dysmorphia will point at herself and say, I could get any men I want, but minutes later she would complain bitterly about how repulsive and deformed her body is, or had become in how, for example, how obese she is, or fat. And this fluctuation between ego-dystonic self-loathing and ego-syntonic histrionic grandiosity, these are both facets of a severely impaired reality test. The problem is that such pervasive ubiquitous delusionality often yields reckless and self-destructive behavior, disinhibition, substance abuse, eating disorders, and a severe impairment of impulse control. The person afflicted with labile body dysmorphic disorder, such a person seeks to affirm her fantastically grandiose view of her body, and how best to do that by proving how irresistible she is to herself, and how best to accomplish this by sleeping around. These risky choices often lend her in hot water, endanger her, and profoundly affect her relationships with nearest dearest intimate partners and loved ones. And of course, how can promiscuity be adequately described or tackled without mentioning narcissism? Let's regress on it. I attribute the rise of narcissism to urban overcrowding, the population bomb over population, our innate desire to be noticed by others to be seen at any cost to us and even at the expense of others. Narcissism is therefore the human equivalent of the behavioral sink in rats and mice. What is the behavioral sink in rats and mice? You ask, which gives me an opportunity to take another seat. Ethology is the study of animal behavior. So the ethologist John B. Calhoun conducted experiments in the 1960s and 1970s on rats in what he called rat utopias. These were rat pens with optimal conditions for unfettered reproduction. He reproduced his alarming results with mice later in his career. As the number of rodents, rats, mice, as the number of rodents rose in their enclosures, he observed an explosion of social pathologies. First and foremost among these pathologies was promiscuity, but also spontaneous miscarriages, cannibalism, maternal dysfunctions, schizoid withdrawal or its opposite gregariousness, compulsive and frenetic fraternizing. And so everything went haywire and awry. The very fabric of social organization was frayed by overpopulation and overcrowding. The rodents, rats and mice, developed what today would be called personality disorders within an anomic society. In his fantasies, the narcissist or psychopath is always in unmitigated control of the environment. The assemblages of bodies and limbs which populate his daydreams, his body included, are minutely choreographed to yield maximum titillation. The narcissist or the psychopath is like an exhibitionistic and very realistic porn director with an endless supply of well-undoubbed actors and actresses, either cowed into compliance or craving it.  Such imaginarium invariably leads to acts of self-stimulation, the ultimate manifestations of autoeroticism. Even when the narcissist incorporates his real-life partners in his fantasies, he is bound to treat her as a mere prop, a body to masturbate with, in or on, an object to be defiled, contaminated in acts such as group sex, swinging, wife-sharing or swapping or outright sexual deviance, examples urophilia or coprophilia, water sports, golden showers, etc.  It is the kind of woman with whom he can have lustful, emotion-free sex. He reserves love, involvement, catechesis, emotional investment and intimacy to sexless, Madonna types. These are women who are sexually inaccessible or unattainable, kind of renditions of his own mother. The somatic narcissist and psychopath's sexual promiscuity emerges from underlying problems in gender identity. Many of these people are actually closer to bisexuals, cross-dresses and prone to parapherias such as pedophilia, fetishism, sexual sadism and masochism. Some of these people try to act out their fantasies and to get their partners to assume roles commensurate with their propensities and predilections or shall I say proclivities however outlandish, illegal or extreme.  If the answer is yes then in all likelihood we are dealing with the narcissist or a psychopath and yet these glimpses into the thwarted and the demented rarely go down well with their significant others. The narcissist's self-exposure often elicits reactions of horror, repulsion and estrangement and so no wonder that most narcissists don't even bother to share their fantasies with their loved ones.  The somatic narcissist compulsively hunts for new feminine prey to sacrifice on the insatiable altar of his own self and this leads of course to promiscuity. Another mental background for promiscuity involves dissociation. We know today that about 1.5% of the global population suffer from extreme dissociative conditions. Some of them even suffer from dissociative identity disorder, the new name or new label for multiple personality disorder. Many narcissistic and psychopathic behaviors may actually reflect this lack of inner cohesion, this failed integration of identity and self, this discontinuity. Let's take an even simple behavior like triangulation. When people with dissociation are romantically rejected and abused, their dysregulated negative emotions overwhelm them. They begin to prepare the ground for switching to a protective altar to another self-state. That other self-state is supposed to shield them from the pain of rejection and the humiliation of abuse and so it has to be a bit psychopathic and a bit slottish, a bit antisocial and a bit of a bully has to be a strong person. Such spurned parties with dissociation scan for an alternative to the rejecting party and that is the hypervigilant phase. They're looking for another person who would act as rescuer, savior in the case of a man or a motherly, maternal, solving mother fear. So let's repeat, when the person has dissociation and is rejected, another state of the self comes out, another if you wish alternative personality and that self-state is highly psychopathic and the first thing it does is look for an alternative, a rescuer, savior if it's a woman looking for a man or a motherly figure if it's a man looking for another one. Having spotted the candidate, the host, the core personality signals its readiness for intimacy including sex by flirting, seduction. Once the signal is reciprocated the host makes way for the protective altar to emerge and the inevitable sex act usually involves dissociative amnesia as the promiscuity averse core, the host personality defends itself against dissonance. The whole episode is sliced off and is later denied vehemently. The alter, the alternative personality, the psychopath that comes out remains out for as long as the triggers that cause the switching are on for as long as the perceived humiliation, perceived abandonment, perceived abuse, perceived rejection are ongoing. So you see promiscuity can be the outcome of numerous psychopathological conditions. I mentioned narcissism, I mentioned psychopathy. I even mentioned emergent psychopathy in people with dissociation, a psychopathy that is kind of a self-state that is protective. But promiscuity can also be acquired or situational. For instance we know that people are much more promiscuous when they're traveling alone in a foreign place. People resort to either of two default behaviors or to both of them alternatively. One of them I call the McDonald effect, finding themselves in unfamiliar territory. People default to old, well-established, true and tested patterns of behavior, choices and brands. This is exactly the allure of the likes of McDonald's or KFC. It's home away from home. So if there's a person who at home pub crawls, bar hops, visits museums, samples gourmet food, that person is likely to end up doing exactly the same when he's traveling abroad. That's the McDonald effect. But there's another effect and that is the effect I call Roman holiday. Being away from home also means freedom from prying eyes, prurient neighbors, pure pressure and social control. It legitimizes the sight of you that is inhibited or suppressed. So it's very common when people travel abroad, when they are far away from home, they suddenly begin to drink. They become promiscuous. They have a fling. They cheat. They have one-eyed stents. They become anti-social. They even display petty criminal behavior, aggression, racism, misogyny, misery, xenophobia, adventurousness, shoppavolism, recklessness, gambling or any number of behaviors that at home would be frowned upon and would carry a social cost that would be social sanctions. It's an example of how a situation can induce promiscuity. The environmental cues can induce promiscuity. But of course, the ultimate in promiscuity is alcoholism or substance abuse. Substance abuse is intimately linked with promiscuous behaviors over decades. We have decades of so. Let's study especially alcoholism because for some reason, psychoactive substances, for example, wheat, cocaine, don't really lead to promiscuity. But alcoholism almost always does. Alcoholism serves several psychological purposes effectively. This is why alcoholism is so intractable, so untreatable, difficult to get rid of. It's why recidivism relapse is as high as 60% within the first year after rehab. It's because alcohol works fulfills and caters to numerous psychological needs. It's palliative. It helps the alcoholic to cope with dissonance, frustration, anxiety, anger, stress, sadness, panic and other negative emotions or mood disorders. It's restorative. It helps the alcoholic to restore his or her self-confidence and self-esteem also as a man or a woman, especially when coupled with a body image issue. After rejection, after abuse, alcohol helps to restore the person. Alcohol is disinhibitory. It lowers inhibitions. It legitimizes narcissistic traits and behaviors like lack of empathy, extreme selfishness, a sense of entitlement. It allows the alcoholic to express his or her repressed promiscuity and aggression. Traits that she or he find ego dystonic. Traits that she dislikes or finds denigrating or unacceptable in herself are legitimized by alcohol because alcohol removes the inhibitions that society and its agents inculcated in us. Alcohol renders the alcoholic much more sociable, grandiose and sociopathic. She or he becomes volubly defined, hates authority figures, feels in control or in charge of others and of the situation, capable of anything she sets her mind to. Irresistibly attractive, charming or charismatic and unfettered by rules or social mores.  It's a result of these cognitive and emotional changes.  So alcohol is in a way instrumental because it allows the alcoholic to accomplish goals, to become goal oriented and these were goals that she or he would never even try when sober. It allows the alcoholic to reach over and to reach out to exceeds his or her own self-perceived limitations, gives the alcoholic confidence. Promiscuity and alcohol abuse are often linked and they are both now veritable pandemics excuse the pun, among women of all ages. The rates of cheating are now almost equal between men and women. Casual sex, hookups and one-night stands is fast becoming the exclusive sexual practice among socially isolated females addicted to social media. The picture is still much worse among men, don't misunderstand me, men invented all these, but the gap is closing fast or reversing with some behaviors and lifestyle choices becoming more prevalent among women actually. The drunk person during an alcohol-induced episode, even if there is a blackout and blackouts are very rare, much more rare than most alcoholics would ever believe, the drunk person is fully aware of what she's doing or what he's doing, who she's doing it with, whether what he is doing is wrong and if she is hurting loved ones with her or his promiscuity, immoral or anti-social or even criminal acts. So it is not true to say that the alcoholic doesn't know what he or she is doing, fully, fully aware. During the entire episode, she makes multiple choices and decisions based on rational analysis and emotional states. He or she is 100% in control and should be held and is held legally accountable for the misbehavior. Throughout the alcohol-induced episode of blackout, orientation, reasoning, a moral sense, short-term memory and decision-making are never impaired, they're all intact. The only thing affected rarely is long-term memory. The next morning, some recovering alcoholics have little or zero recall of what has happened during, for example, a brownout or a blackout. This is why it is very difficult to tell a drunk in a blackout state from a merely inebriated person or a social drinker.  Motor functions are affected. There is a tendency to repeat the same sentences over and over again, but essentially, that's it. Everything else is in perfect functioning order. Like narcissists, people wasted to the point of a blackout just don't care about anything or anyone but themselves. Behavioral inhibitions are down. Remember, alcohol disinhibits. Empathy towards one nearest and dearests is turned off, or mysteriously redirected at strangers. A sense of invulnerability, invincibility, omnipotence and impunity sets in. The drunkard experiences attraction or even infatuation with all and sundry. There's less discrimination. Standards collapse, and the high and the buzz of the drink compensate for any frustration, depression, stress or anxiety with a heightened sense of well-being and with aggression. Of course, alcohol also affects the perceived attractiveness of other people.  People, especially women, get that drunk in order to feel better about themselves and their lives, legitimize their promiscuity and cheating, and trash themselves in a bout of self-destruction and self-punishment. They say, the drink did it to me and I cannot remember a single thing. This is alcohol. What about other transient states? Victims of complex post-traumatic stress disorder, CPTSD induced by interpersonal and relational abuse are also prone to promiscuity, especially if they are sensitive to rejection. Prolonged abuse in an intimate relationship changes some women and more rarely men, and so profoundly alters their psychology and behavior. Prolonged abuse renders these men and women unrecognizable even to themselves, and this is called estrangement. Having emerged from the black hole of a dysfunctional liaison, these broken, vulnerable people are transformed into the dark mirror images of their former selves. Some would say that they are emulating their abuses. Having been faithful before, now they become sexually promiscuous. They avoid intimacy, they trust no one, they develop addictions, abuse, alcohol, or drugs engage in a monopoly of reckless behaviors, generally self-destruct. But why is that? Why this sudden shift? Well, let's take a woman with a pre-existing mental health condition. She would tend to internalize the abuser's rejection of her, and the sentence that she pronounces upon her.  She would kind of confirm the abuser's verdict. Such congruence is intended to avoid dissonance and inner conflict. Abuses control their victims by rendering their lives meaningless and inconsequential. The prey adopts the abuser's point of view. You're nothing without me.  You're bad. You're sad. You're mad. This kind of perpetual rejection and hurt often renders the abuser's judgment a self-fulfilling prophecy. CPCs, these survivors, are typically indistinguishable from patients with borderline personalities. They become impulsive, reckless. They abuse substances. They have modulability. They have emotional dysregulation. And so inevitably, they deteriorate, and they begin to be promiscuous. Exposed to the abuser's grinding and relentless devaluation, his so-called intimate partners and insignificant others resort to vengeful and demonstrative self-trashing. It is intended to hurt the perpetrator by debasing his property, often in humiliating public displays of infidelity and drunkenness, or by committing antisocial, even criminal acts. With these self-destructive actions, the victim is protesting. She's saying, you, my abuser, you say that my life is meaningless?  You will never forget me.  It's another facet of abuse. These people were molded in their formative years to associate pleasure and intimacy with risk, with deception, with adrenaline. These people are aroused by their own immorality or immorality, by their porridge promiscuity, by the chase, the mind games, the power plays, and the compass. So this is the abuser's promiscuity. We have just described the victim's promiscuity, which is reactive, which tends to uphold the abuser's view of the victim. But the abuser himself is very likely to engage in promiscuity as well, most psychopaths do, and many narcissists. The less socially acceptable the act, the more illicit, the higher the degree of betrayal and self-debasement, the deeper the decadence and deviance perversion and shock value, the greater the resulting carnal titillation. And this type of compulsive behavior is a variety of roleplay. Such people need a narrative, a story, a confabulation, a script, in order to get sexually aroused, to enjoy the encounter. The role they assume is that of a promiscuous and treacherous prostitute, or hormonger. But the very fact that they take on this personality is in a cinematic rendition. This fact makes them feel removed and distant from their own misconduct, absorbed in a way. It's like it was not me who did it, I was not myself. I felt unautopilot, dissociated, like an observer. When these people are asked why they behave the way they did, they typically shrug it off. I don't know, I don't remember. Ironically, it is exactly this kind of cheaters who are inordinately attached and bonded to their emotionally thwarted, masochistic, codependent, financially generous and enabling spouses. To fully enjoy sex, they need to remain married. They need someone to cheat on and torment, someone to lie to, to betray repeatedly, and to blame for their misbehavior. They need what we call a persecutory object.  Some women, single and married, use male attention to regulate their sense of self-worth, self-confidence, self-esteem. When these are low, these attention whores become flirtatious, seductive, they tease, they trade sex for even the most inconsequential, inconsequential signs of attention. A chat, a compliment, small gifts, flowers, a meal. Even if the attention they get is vulgar, demeaning, being grove, being fondled in public, or the targets of lewd, loud, explicit, so-called compliments, they still prefer this to being ignored. As I said, bad or wrong kind of attention is better than no attention. Male attention in these women serves a few functions. It reassures the woman of her irresistibility and attractiveness. A woman who is rejected, neglected, abandoned, and ignored by her intimate partner feels compelled to restore her badly eroded self-image, so she conducts Paul, among other men, offering her body in exchange for an erectile affirmation, a vote of fluids that she still desire. The second function is to reassert control and power of a man via her sex. When she does this, such a woman assuages her anxiety over their misogynistic hostility and aggression. She tames men with her body to feel safe, she wins the competition with them. This is one upmanship and pregnancy. Some women are adrenaline junkies. Elicit affairs, cheating, deception, risky and reckless behaviors or situations are all perceived as thrilling and breathless adventures which alleviate the tedium of daily life. And many of these women sexualize frustration. They act out. Their impulse control is impaired.  And then there's the unsated hunger for intimacy and a semblance of emotion. And that is overpowering. A woman who lacks both intimacy and emotion will sometimes provide access to her body in return for even the fake versions of what she craves. Some women break all boundaries in a feast of unbridled promiscuity. This is a form of masochistic self-punishment, self-annihilation and affirmations of the woman's deeply ingrained sadistic interjects. Her inner critic, the voices, the super ego, which informed her mercilessly that she is a whore, a bad object and unworthy of anything better than being pumped and dumped by multiple men. And so there are two ways to regulate intimate relationships via intimacy or with romantic jealousy. Mature partners achieve a workable balance between togetherness and personal autonomy. They engender intimacy via both communication and actions. Intimacy feels so good that no one in his right mind will exit such a boat. Thus, both abandonment or separation anxiety and romantic jealousy are absent in healthy relationships. There is object permanence, object constancy. When one of the partners is a codependent, however, or a borderline, and the other one is a narcissist or a psychopath or a histrionic, these are common combinations. When such couples, when both partners suffer from mood disorders, they cannot achieve, they cannot maintain even minimal intimacy. They don't have object permanence or constancy. What they do instead, they mesh, they merge, they fuse, and this fusion fosters intolerable abandonment or separation anxiety.  The only way to regulate this anxiety is to make sure that the partner doesn't jump ship, and this is done by provoking the partner's romantic jealousy, reaction to anticipated loss. Indiscreet extramarital affairs, flagrant purposeful promiscuity, ostentatious flirtatious or seductive behaviors with strangers, provocative speech address, and hints of impending breakup, these are all ways to provoke the partner into sitting up and paying attention, to raise the partner's value in her eyes, to say to the partner, look, I'm desirable, look, I'm irresistible to other men or women. The instigator of such triangulation wants her counterpart to set boundaries and to put his foot down, as proofs that he cares. Alas, such behaviors precipitate exactly what they have been meant to prevent, and have the exact opposite effect to the one intended. These behaviors are because the partner anticipates loss, because the partner is averse to pain, but they combine to drive the injured party away. They actually guarantee loss and abandonment, separation, they guarantee pain. And what about the psychopathic female? A psychopathic female into a lesser extent narcissists of both genders.  She abuses relationally, she smears, she cheats with your best friends or colleagues or with spouses or such. She manipulates by flirting or by begging for pity and sympathy, casting men in rescuer roles. The psychopathic female charms and beguiles, always the long-salt soulmate, a perfect resonance in feet. The other long-loss half.  She is demure and shy or extroverted and histrionic. She somehow introduces even the most reluctant into her chaos, without and within. The role of the crazy making space is to provide an optimal environment for the expression of the psychopath's grandiosity and sadism, as well as for the attainment of her goals, power in all its forms. The disenvironment is a theater set, stage upon which she enacts her antisocial immorality place with everyone in her life as props. Without remorse, with not a hint of empathy, she mercilessly and relentlessly meets out just desserts, rewards and punishments. She acts mechanically, fearlessly, impulsively and with determination, like an inexorable automaton, force of nature. In a way, culturally conditioned as we are to regard all women as weak and ineffectual, well-meaning and maternal, the female psychopath is far more nefarious, pernicious, subterranean and dangerous than her male brother. She is subtle, passive-aggressive and surreptitious. She stealthily undermines the foundations, rather than overtly bombard the citadel. The male psychopath's thespian capacity is hampered by his narcissism. He feels humiliated by the very need to pretend, to act, to manipulate, to supplicate. But the female of the species doesn't have these hindrances, doesn't have these inhibitions, her grandiosity is muted.   More common than you know. What happens when he wants to convert a female psychopath into his source of secondary supply, also known as intimate power? Well, the narcissist ends up being traumatized by such a woman. Why and how? The psychopath challenges and obliterates the narcissist's grandiose self-perceptions and assumptions, especially his fantasy of being unique. The psychopath's promiscuity, risk-seeking reckless behaviors and addictions to novelty and thrills, adrenaline junkie. These render the narcissist just one of her many sexual compasses. She never gets emotionally attached to the narcissist, she never misses the narcissist. To her, the narcissist is just another notch in her belt, a mere casualty over a teasing power place with men, roadkill. He is soon forgotten as she moves on, often by cheating on him, as she had done to all her previous men. He is a number, he is a statistic. But the narcissist believes in his unique ability to detect lying and he takes pride in his intelligence and resistance to be induced. Still, narcissists are very gullible. The psychopathic female uses their thirst for narcissistic supply, their addiction, to manipulate them. What she does, she feeds the narcissist with half-truths and outright lies. She tells the narcissist what the narcissist is in her life, what they want to hear. She flatters them, she writes her own history, to render them unique. And she deceives them repeatedly. She fakes everything, from emotions, to tears, to orgasms. The narcissist gets taken in, time and again, always, invariably. And when he discovers the truth, his grandiosity is shattered. And finally, the narcissist holds himself to be irresistible. But the psychopath is not interested in him. She is goal-oriented. She wants his money, his contacts, his protection, his prestige, something. She is a golden social climber. She slips her weight to the toe. When the narcissist finds out that he had merely been used as an instrument, he is wounded to the quick. And these narcissistic injuries often evolve into a form of ruminative obsession, or stalking, as the narcissist tries in vain to integrate the painful experiences into his view of himself, as Godlike, omniscient, and desirable. The psychopath gives the narcissist a taste of his own medicine via her promiscuity. And it is bitter and sometimes threatens what is left of the narcissist's sanity and his life. Promiscuity is a part of a much bigger phenomenon. Women are newly emancipated slaves. They have been mistreated as chateaune property by men since the agricultural and urban revolutions thousands of years ago. And they have been enslaved and they have been misused and abused. No one disputes this. And now they have rebelled. And not only have they rebelled, they had prevailed. But a collective psychology shaped over millennia cannot be undone or modified within a few decades. Society and its agents, parents foremost, had brainwashed girls and inculcated in them rigid stereotypical gender roles replete with coping and survival strategies in a male dominated world. And so women were conditioned to make use of the surreptitious weapons of the weak. They were conditioned to manipulate, to undermine passively, passive-aggressively, to feign weakness, clinging in codependent neediness, to extort economic benefits often by triangulating or by getting pregnant. And having acquired civil rights and economic prowess, women lacked a credible behavioural social model to interject and follow. In other words, they didn't know what to do with all these newfound powers and rights. Instead, women started to emulate and imitate male caricatures which comprised pronounced psychopathic features, disempathic machoism, promiscuity, defined reactance, recklessness, infidelity, antisocial conduct, and substance abuse. In a way, women are pathetically trying to be more men than men, among other things by being promiscuous. In such abrupt discarding of traditional gender roles, in a uni-gender universe, this has led to gender vertical, gender alienation, gender dysphoria, misogyny, misundry, and a tsunami of auto-eroticism, masturbation with porn, incest, and homosexuality, for instance. A decline in births to below the replacement rate and the collapse of intergender communication in institutions such as family and marriage led to changes in behaviours. And now we have much less dating, much more meaningless sex. These followed ineluctably on these tectonic shifts in how men and women view each other, how they relate to each other, and how they reward and, frankly, punish each other. Where are we headed from here? Is there any hope for intimacy, for meaningfulness and relationships? I am among the pessimists. I don't think these changes are either reversible or revocable. And the reason is that we are catering to the lowest, most primitive needs, to what Freud called the eat. This is very intoxicating, very rewarding, and it creates operant conditioning. It's almost impossible to break this spell. I wouldn't be surprised if we are all atomised to the point that we all live alone, totally self-sufficiently.  We have lost all incentive and motivation to be together as a cooperative species. The recent pandemic is just highlighting what has been happening for at least four decades.