Today I'm returning to my favorite topics, self-defeat, self-destruction, doom and gloom, hopelessness and demise, my natural habitat. My name is Sam Vaknin, I'm a professor of psychology, unluckily for you, and the author of Malignant Self-Love, Narcissism Revisited. Today we are going to discuss, now on a serious note, self-destructive behaviors in a variety of settings and attached to various mental illnesses and states of mind. Before I go there, I'm available for counseling. Down in the description there's a link, click on it, follow the instructions and I'm all yours at least for an hour. And so the human mind is very creative, very mutable, very shape-shifting, even the human mind of healthy people.  And many of us engage in self-destructive and self-defeating behaviors and we just don't realize it. I will mention just a few forms of self-defeat and self-destructiveness, a constricted life, self-denial, depression, emotional numbing, dissociation, masochism and insecure attachment. Actually, I'm going to deal with each and every one of these things at length in this lecture. But before we go there, people ask me, what happens to the narcissist when he switches from cerebral to somatic? Doesn't this solve the problem of deficient narcissistic supply? If the narcissist fails to obtain supply as a cerebral, why doesn't he simply switch to somatic and then obtain supply? My previous video deals with the experience of collapse. And so the cerebral can collapse, can become somatic, but there are of course situations where the narcissist fails to obtain supply both as a cerebral and as a somatic. My previous video deals with these situations. What happens to the narcissist? And the reason I'm mentioning it here is because the narcissist essentially self-detonates, self-destructs as a solution to his predicament. But watch the previous video for more details. Generally speaking, narcissists are masochists. They destroy and defeat themselves by behaving, for example, recklessly or thoughtlessly, by retarding and preventing intimacy, by sabotaging their careers and relationships and by being obstructive, passive-aggressive, negativistic. These are all narcissistic behaviors, some of them attributable to the overt narcissists and some of them to the covert narcissists. But today we're going to discuss not only narcissists, we're going to discuss self-defeating and self-destructive behaviors as I said also in healthy people. Let's start with a phenomenon of life constriction. Life constriction is about denying yourself all kinds of things, including things, activities and people you like. Self-denial, asceticism, abstinence, celibacy, avoiding sex or abstaining from sex is a private case of abstinence. But we can abstain from a variety of things. When we constrict our lives, when we narrow life, when we make it a tunnel vision, when we avoid things more than we pursue things, when we withdraw, when we become hermetically sealed in a capsule or a pod or a cocoon of our own making, that is life constriction. I want to read to you something I had written in my journal a few weeks ago. Self-loathing, self-punitive and terrified of failure, having performance anxiety, I have rejected, disowned, sabotaged and avoided all aspects of life. I have, in collect these words, rejected life, or in Seinfeld words, Jeffrey Seinfeld, the psychoanalyst. I had rejected life. I had rendered myself invulnerable by being dead within and without. As a form of rigid, proud, defiant, sadistically self-denying ideology. I continued to write in my journal, I acted entitled and contemptuous. Celebrity was an expression of my contempt. I gave up on and denied my body, my health, my home ownership, sex, romance, intimacy, all positive emotions, relationships, family of origin, having children, academic degrees, career, country, language, success, reputation, business, social life, fans and friends. Almost nothing is left.  Now, there is a confusion between being introverted and being constricted. Constriction has to do usually with clinical depression, either in the form of dysthymia, background depression, or in the form of major depressive episodes. There is a difference between introverts and the depressed. On the surface they appear to be indistinguishable, but they actually have nothing in common. I will mention just three important differences. The introvert is egocintonic. She feels comfortable in her own skin. She is at her best and happiest when she is all by herself, all alone. She prefers her own company to any others. This is the introvert. The depressive is egocintonic by definition. He is profoundly unhappy. He is disforming. He is unhedonic. He finds pleasure in nothing. That's the first difference. Number two, the introvert never willingly socializes or mingles. You will never find the introvert frequenting clubs or attending parties. She rarely, if ever, exits home, except to go to her workplace and back. By comparison, the depressive can be very sociable, even reckless and promiscuous. He uses interactions with other people as a form of self-soothing or self-medication. Another difference is the rates of substance abuse among introverts is drastically lower than among sufferers of depression or anxiety. We are beginning to see the background of self-destruction and self-defeat. A permanent, only present depression. Depression is a critical feature in self-destruction and self-defeat. Depression can come and go, as it does with healthy people, or it can be a major feature in, for example, a personality disorder or a mood disorder, major clinical feature. And so, depression is often a type of frustration. When frustrations accumulate and reach large, this leads to paralysis owing to performance anxiety or the wish to avoid hurt and pain. This paralysis is one of the first hallmarks of depression, but frustration also yields aggression, that is the Donald frustration aggression hypothesis of 1939. So ironically, encounter intuitively, frustration can, on the one hand, lead to paralyzing depression and on the other hand, it can lead to aggression and even violence. Men tend to externalize the aggression, while women tend to internalize and self-direct it. Depressed men, for example, tend to become antisocial, secluded and even violent. In contrast, depressed women typically self-trash, sexually or otherwise. Depression is a rejection of life, it's a rejection of happiness, it's embracing misery. It is commonly believed that depression has biochemical roots, even genetic roots. There is this myth that depression is out of our control, that is a form of a bodily disease or illness, and it does have, of course, these elements. There is a somatic background, a body background to depression. But depression is sometimes a choice. Some people reject happiness and embrace misery happily, and they belong to one of three groups. Number one, masochist. The masochist has been taught from an early age to hate herself, to consider herself unworthy of love and worthless as a person. And yes, you can change the pronouns. When I use herself, you can think himself, when I use she, you can think he, and when I use he, you can think she. I hope we dispense with this endless line of questioning. For convenience sake, I'm going to sometimes use one gender and sometimes another. The truth is that in reality, all mental health disorders are equally distributed among the genders. So the masochist has been taught to consider herself as lowly. So consequently, she's prone to self-destructive, punishing, and self-defeating behaviors, though capable of pleasure and possessed of social skills, the masochist avoids or undermines pleasurable experiences. The masochist does not admit to enjoying himself. The masochist seeks suffering, pain, and hurt in relationships, in situations, and he rejects help, and he resents people who offer help. The masochist actively renders futile attempts to assist or to mitigate or to ameliorate or to solve her problems and predicaments. And these self-punitive behaviors are also cathartic. They're self-purging. They intend to relieve the masochist of overwhelming pent-up anxiety. Masochist conduct is equally aimed at avoiding intimacy and its benefits, companionship and support. So this is the first group of people who seek self-destruction. The second group are the eternal victims. Victimhood can become an identity. You've all heard of victimhood movements and identity politics. So victimhood can become an identity. It can become an organizing principle, an explanatory principle that endows the world and your life with meaning and predictability. It's a pernicious poison. Surviving abuse is an accomplishment. And victims are proud of this accomplishment. They're emotionally invested in their victimhood and they are loath to relinquish the foundation of their fragile and labile self-esteem or newly acquired self-esteem. They mistakenly identify their victimhood with their worthiness or worth. They're worthy, they're good, only as long and as far as their victims, as they continue to be victims. And when they're victims, they also garner sympathy and attention. Some victims regard themselves as damsels in distress or sleeping beauties, princesses, awaiting rescue by a knight in a shining armor, or in a fabulous, mythical, morally righteous, grandiose morality play or narrative. There's nothing more dangerous than victimhood as a way of life because it leads to self-inflicted self-defeat and self-destruction. And finally, there's a third group. Those who are used to the familiar addicted to the comfort zone. For example, being a victim. Being a victim can become a profession of sorts. The abused know the ropes of abuse, the unspoken rules, the codes of conduct. And so they are adept at predicting and foreseeing forthcoming maltreatment. The victims of abuse evolve coping strategies and manipulative techniques in order to adapt to and survive in toxic environments. They feel threatened when they are not in a toxic environment. They feel that in non-abusive situations with nice people, they don't know what's going to happen. They're waiting for the other shoe to drop because they don't have a clue about this kind of good people. They are not in their comfort zone. Their comfort zone is being in pain, being hurt, feeling bad, being mistreated. There is another aspect of the narcissist, for example, his behavior, which makes the narcissist oblivious to cues, information and events in his immediate environment. His single-minded, solipsistic focus on extracting narcissistic supply from existing and potential sources blinds him to everything else and everyone else around him. It's a form of a comfort zone. The narcissist's comfort zone is the mind where the mind's narcissistic supply is underground in the mind and he believes that's the world and he doesn't want to exit the mind. He doesn't want to see the sun. He doesn't want to enjoy life. He doesn't want to pick up a flower or smell it because he's inside the mind and he knows every vein and every wall and every canary. Narcissists are so obsessed with supply that they fail to notice when people around them conspire to take advantage of them it's that bad. The pathetic narcissist drones on endlessly and self-aggrandizingly as his intimate partner aggressively flirts with another man and then departs with her new conquest on an assignation. The narcissist keeps lecturing and showing off even as his audience smirks and mocks the bumbling fool for his clownish mannerisms or when he's interlocked as a board out of their collective mind. In a desperate attempt to impress people the narcissist shares ideas, classified information, proprietary data that is then plagiarized or stolen or used against him. The narcissist is utterly unaware of anything else but the compulsive pursuit of his next fix of attention and mostly imagined and delusional adulation. And this one-track-mindedness is the undoing of the narcissist. Defenseless, driven, the narcissist opens himself up to attack, to harm, to hurt, to pain, to humiliation, to shame, to defeat the sometimes threatened and undermined, his very survival, for example, in the process of narcissistic modification but the narcissist does all this because death is his comfort zone. Narcissism is a good case because all narcissists, even high-functioning narcissists, even so-called productive narcissists, all narcissists, without any single exception and badly, all of them destroy themselves and everyone and everything around them, all of them enter the twilight of the gods, goreter, demo, and never exit. So it behooves us to delve a bit deeper into the differences between narcissism and masochism. The true self of some narcissists is masochistic, actually. The inner child is masochistic. This child, inner child, seeks to recreate the maternal abuse and rejection in the narcissist's adultery relationships, approach, avoidance, repetition, compassion, and other repetition compassions. I discussed these at length in other videos. On the face of it, the narcissist reenacts the unresolved conflicts with his primary object, typically a mother. And there is this misplaced hope of obtaining a different outcome each and every time, resolving the new conflict in an adult relationship painlessly and favorably, finally being loved and accepted unconditionally. But in reality, the masochistic narcissist chooses in a made selection process, a broken made selection process. It chooses damaged, dysregulated partners.  These partners dump him cruelly and sadistically, cheat on him, betray him. These partners deem anything and anyone preferable to the narcissist's injurious and ostentatious absence and rejection. And so, the narcissist recreates the conditions for his own for his own self-defeat and self-destruction by, for example, choosing the wrong, repeatedly choosing the wrong intimate partners or business partners. The masochistic and self-destructive narcissist uses the twin-defense mechanisms of projection and introjective identification to coerce his intimate partners to abandon him, traumatically, exactly as his mother did. Painful love is the comfort zone of the narcissist, the only kind of attachment and bonding that he recognizes. We're going to discuss it at length and we'll get to the part about insecure attachment. And so, ineluctably, the intimate partner betrays the narcissist. Somehow, cheats on him, discards him, whatever. The painful part is now out of the way. The demons of the past have been exercised. Mothers egregious maltreatment is validated yet again and legitimized. All women are like mother. All women treat me the same. She is not a monster. I am the bed and lovable object who is justly punished. Ironically, as the curtains descend on the end-play drama, the narcissist is available to settle into a long-term relationship with a very woman who had wronged and pained himself. Only to find out in most cases that she is long gone unnerved and freaked out by the creepy nature of the narcissist's nauseatingly sick mind games and asphyxiating power plates. So, the narcissist converts negative emotions such as envy into enjoyable experiences by affecting them with a conviction of his own superiority. In other words, he invests emotionally in his negative emotions because they make him feel superior. He gets used and attached to his negative emotions. He renders them pleasurably habit-forming. Negative emotions lead to conflicts with other people and sometimes to an internal dissonance.  They drive the narcissist inexorably into the corner, isolated more and more, frightened out of his mind within the absence of supply, falling apart, disintegrating, self-defeat, self-destruction, wrought by and brought on by the narcissist's own delight at his self-implosion. And within this comfort zone, the narcissist actually enjoys being envious of others, for instance.  These are all good reasons to be envious and to maintain the high moral ground. The narcissist's inner dialogue goes something like this. I'm superior to everyone, but this is exactly why I'm left behind. Society rewards mediocrity. Society dreads true genius and integrity, such as mine. This is a martyr complex. It's especially pronounced in conditions of deficient narcissistic supply. Now, I've been talking about the narcissist, in all these dynamics. We all harbor, we all shelter a small narcissist inside ourselves. We all have healthy narcissism, which can go easily malignant and awry. Many of us have an insecure attachment style. An insecure attachment style often leads to the expression of narcissistic defenses. In other words, we use narcissism to defend against the uncertainty and the pain involved in insecure attachment. Attachment disorders, attachment dysfunctions are common and prevalent in cluster B personalities, narcissists, psychopaths, border likes, histrionics, but they are also pretty common among healthy people and they elicit these behaviors because these attachment dysfunctions are very traumatic. In early childhood you may have been exposed to what Andrea Greene called a dead mother, mother who is absent, selfish, instrumentalizing, parentifying, pampering and spoiling a mother who did not allow you to fully separate an individual. Not everyone becomes a narcissist when exposed to such defective and deficient motherhood. But the traces of such bad parenting are always there lurking in the shadows, penumbrily waiting to erupt even in healthy people. Most of us don't dare to verbalize or even think about our childhood this way. Bolas called it the unthought known. Instead, what we do is we resort to emotional thinking. Many people correct emotionally invest in death and aggression, this is known as destrudo, the opposite of libido. And so many people dedicate their lives to material goods, which are essentially embodiments and ramifications of death. They are dead objects. Many people are emotionally invested in money. Money and material goods are dead. We place them over and above our relationship with live people because we are terrified of live people. They can hurt us. Owing to this hurt aversion people place a premium on self-sufficiency, independence, personal autonomy and unbridled asocial or antisocial self-efficacy. People frequently self-parentify or become sexually auto-erotic. These are all forms of constriction. These are all forms of withdrawing from life into a trine of dead objects, Netflix, cats, money, cars, smartphones, even social media which is not social and is not media. So, we as a society and as individuals in this anomic civilization we increasingly destroy ourselves by empowering ourselves actually. When you become too empowered you reject life itself. People can love only dead mothers so they try to turn other people into dead mothers killing the mother figure in order to be able to love her. So, I've discussed the processes of snapshotting, interjection, extension in other videos. People have a dead, inert non-interacting mute interject or interjects and that makes it very difficult for them to distinguish the outside from the inside external from internal objects. And this is common beginning to be common terrifyingly also among healthy people and the reason this is beginning to be common is trauma. Many, many otherwise totally functional and totally healthy people are experiencing trauma. The environment is traumatic climate change, wars, pandemics other people are traumatizing there are tens of millions if not hundreds of millions of refugees internally displaced from abusive relationships. I had to coin the phrase in 1995 because it was relatively new and so a huge number of people had been traumatized by other people or by the civilization they live in or by history or by the gender wars and so we live in a post-traumatic world. There are new directions in the study of trauma we are beginning to reconceive our personality disorders as post-traumatic conditions and we realize that externalized trauma results in acting out or in experiential avoidance while internalized PTSD leads to emotional dysregulation flashbacks, not emotional flashbacks there's no such thing, but flashbacks, real ones there's emotional numbing reduced to inappropriate effect display and emotional detachment but one of the most dangerous pernicious and destructive effects of trauma is dissociation we are beginning to live in a world where forgetting is the main escape hatch the main way to cope with reality is to forget it and forget all about it structural dissociation has to do with trauma dissociation is an integrative deficit it's not a defense it's a symptom integration and adaptive behavior depend on synthesis, on being able to associate all the components and experiences and functions into meaningful coherent mental structures both episodically and across time, schemas and integration and adaptive behavior depend on these synthesis but also on the realization of things realizing things, analysis assimilation via personification and presentification bringing past and future to bear on the presence mindfulness, reflexivity so integration is a complex process and any hitch and glitch and bug in it usually leads to dissociation dissociation has many forms amnesia, depersonalization which is a failure in personification semantic, not episodic memory trauma reduces integrative capacity in premorbid and subclinical personalities with low integrative capacity it leads to dissociation the dissociative parts because dissociation breaks us apart dissociation creates self states again the terrifying thing is that this kind of discourse used to be limited to mentally ill people but today we are using it more and more with perfectly healthy and functional people who walk into our clinics because they are desperate and despondent and unable to function dysfunctional and because they're falling apart and they're falling apart because the stress the stress, the tensions, the anxiety are beginning to overwhelm the perfectly adaptable functional people and the dissociation creates self states parts and these parts vary in degree of intrusion and avoidance of trauma related cues affect regulation, psychological defences capacity for insight, response to stimuli body movements, behaviors, cognitive schemas attention attachment styles sense of self self-destructiveness from insecurities, suicidality flexibility and adaptability in daily life structural division, autonomy, number of subjective experiences etc so dissociation affects absolutely everything and it can push us it does push us to self-defeating and self-destruction which is all pervasive dissociation leads to dissociative symptoms like amnesia, numbness, impaired thinking loss of skills, needs, wishes, fantasies loss of motor functions or skills loss of sensation and so it has a massive impact on our ability to survive in an environment especially an ever-changing environment Freud and Klein have suggested that healthy narcissism is somehow related to the self-regarding life force that they called libido together they counter and deflect the death drive the fanatic drive or instinct they redirect the death impulse at outside objects narcissism accomplishes exactly the opposite it nourishes and nurtures the death wish that is why everyone should be exceedingly terrified by the rising tide of narcissism among various population cohorts especially the young we can group self-defeating and self-destructive behaviors according to the underlying motivation one group is reckless impulsive and intermittent explosive these are rage-related behaviors impulsive people act first and consider their options and their actions later they are impaired their deficient lacking have an absent impulse control in other words they have no self-control in some mental health pathologies cluster B dramatic erratic personality disorders mood disorders other disorders in these pathologies unfulfilled or suppressed urges, drives and impulses give rise to extreme anxiety and stress if you deny yourself if you betray yourself if you don't allow yourself to manifest and to express you develop anxiety develop anxiety because you perceive unconsciously that you are becoming your own West enemy instantly catering to these pressing wishes, drives is the only way to alleviate and ameliorate this inexorably mounting inner volcanic pressure to mitigate the anxiety following impulsive acts any kind of impulsive act cheating, spending, shopping, promising, traveling, binge eating, whatever following these impulsive acts there is an overwhelming sense of guilt and shame usually unhealthy people definitely even in borderlines for example and it is followed by purging and penitent behaviors, penance like acting extra nice to a cheated spouse or force vomiting in bulimia or working hard to make up for profligacy and this leads to a restoration of inner peace and homeostasis, balance and a cathartic feeling of having attained a state of clean slate and at least until the next transgression mind you many people describe this as a pseudo or quasi quasi religious experience it has a lot in common with mystical experiences so reckless impulsive acts lead afterwards to a cathartic almost religious experience of expiation, exparigation but impulsive and this is addictive these cycles are addictive, they are very self-destructive and self-defeating but they are addictive impulsivity has another critical function the regulation of labile, self-esteem fluctuating self-confidence and one sense of self-worth regulating these via the restoration and buttressing of grandiosity the cheating spouse for example affirms his irresistibility the shopaholic, her omnipotence and wealth the kleptomania, her invincibility and luck getting away with it the forbidden, the risky, the illicit nature of most impulsive acts and behaviors only adds to this mystical aura of uniqueness, this magical elevation to a godlike status of invisibility feels like a euphoric high it's very addictive as are all the impulsive behaviors recidivism is guaranteed there's no agreement or rule of vow that can prevent the impulsive person from repeating impulsive acts, again let's consider narcissism, the narcissist impulse control is compromised by his negative emotions especially his rage aggression and his envy he feels ruled by these emotions and driven to act he has in other words external locus of control narcissists are used to being controlled from the outside starting with their abusive parents the overbearing and all pervasive and infinitely demanding false self and the addiction to narcissistic supply and the sources of supply, other people narcissists regulate themselves from the outside they outsource their internal functions especially ego boundary functions and so no wonder that the narcissist feels more at home with negative emotions and finds them way more accessible to him than positive ones ironically the narcissist who considers himself godlike and omnipotent and superior is actually a slave he's a slave to external circumstances and feedback from his human environment he derives this very sense of cohesion identity and being from his impotence and dependence another group of self-defeating and self-destructive behaviors are the self-punishing guilt purging behaviors these are intended to inflict punishment I will use the example of the narcissist again but all of you can find yourselves in what I'm saying these behaviors are common also among healthy people becoming more and more common by the day regrettably but let's again use the narcissist as a punching bag self-punishing guilt purging behaviors are intended to inflict punishment on the narcissist to instantly soothe the narcissist to relieve him of his overwhelming anxiety to restore his sense of reasserted omnipotent control over himself, his environment and his life and so by preempting society's punitive measures by self-flagellating the narcissist is actually saying if I'm to suffer unjustly it will be only by my own hand and no one else's because I am in charge and I am in control self-punishing guilt purging behaviors are very reminiscent of compulsive rituals the narcissist sometimes feel guilty though lacking self-awareness he rarely knows why and he often believes himself to be the victim of a gross miscarriage of justice his guilt is diffuse it's not the kind of guilt healthy people experience it's more like unease this dim, uneasey stirrings could be also anticipatory the narcissist foresees a retribution for his abusive misconduct towards others this is the beginning of authority so anticipatory or they could be an ancient early childhood guilt a kind of sexual guilt according to Freud or a social guilt in his infancy the narcissist had internalized and interjected the voices of meaningful and authoritative other people parents, role models, peers and convincingly judged him to be no good, bad, blame worthy deserving of punishment or retaliation corrupt, helpless the narcissist's self-destruction validates these inner voices these internal objects the narcissist is actually saying you have been right all along I am really hopeless and I am going to prove it to you the parents of the narcissist teach their offspring to expect only conditional transactional love the child is supposed to render a service or to fulfill the parent's wishes in return for affection and compassion and attention and emotion and so inevitably the child is hurt he feels that he is betraying himself and failing his parents and he reacts with rage to this unjust predicament and mistreatment with no recourse to the offending parent because the child cannot attack the parent the child cannot even think bad things about the parent the child is dependent on the parent for his or her life she can't afford to be critical so she has no recourse to the offending parent this fury that the child experiences is directed outwards at other people who stand in for the bad parents or it's directed inwards the former solution externalizing aggression yields a psychopath or a passive aggressive the latter solution internalizing aggression yields a depressive person or a masochist and similarly with an unavailable parent the child's reserve of love can be directed either inwards at himself and yield a narcissist or outward towards other people and create a codependent and all these choices all these choices of one thing in common they retard personal growth and development they are self-annihilating in the sense that the child cannot become and realize his potential he cannot self-actualize he cannot actually create a self in all four ways the adult plays the dual roles of a punitive parent and an eternal child who is unable and unwilling to grow up for fear of incurring the wrath and abandonment of the parent that emerged so thoroughly early on the battle goes on it's a civil war between parent interjects and the inner child the narcissist's life is transformed into an ongoing trial the constancy of this trial the never adjourning tribunal is the punishment it is a Kafkaesque process undecipherable, never ending it leads to no verdict even the charge sheet, even the accusations are not clear it is subject to mysterious and fluid rules and presided over by capricious shape-shifting, ever-changing set of judges so the narcissist masochistically frustrates his deepest desires and drives he procrastinates, develops perfectionism he obstructs his own efforts sets himself up for failure, alienates his friends and sponsors, provokes figures of authority to punish him, to demote him, to ignore him actively seeks and solicits disappointment, failure, maltreatment he relishes his victim status he's martyrdom, he incites anger rejection, bypasses or rejects opportunities and engages in excessive self-sacrifice in their seminal book Personality Disorders in Modern Life Theodore Millen and Roger Davies described the diagnosis of masochistic or self-defeating personality disorder found in the appendix of the DSM Edition 3 text revision of the DSM 4 While the narcissist is rarely a full-fledged masochist many narcissists exhibit some of the traits of this proposed and now abandoned personality disorder So these are the self-punishing and self-purging behaviors There's another group of self-destructive behaviors These are the depressive, fanatic, death-wish behaviors I'm loved by his labile self-centered immature and capricious parents the depressive or the fanatic narcissists comes to regard herself as unlovable in principle as unloved by one and all If she cannot be loved, especially by her own parents if she is never to experience being loved she prefers to die capable of intimacy, of mutual trust and of a mature reciprocation of love such a person seeks to destroy the very object that causes her such pervasive frustration herself habits such as substance abuse reckless behaviors these are mere manifestations of lethal self-loathing and self-directed rage mood disorders are common there the preponderance of depressive episodes and decimia outright suicide is uncommon but there are many ways to commit suicide bodily suicide is in the minority most people commit mental or psychological suicide and then another group of self-destructive and self-defeating behaviors are the extracting behaviors people with personality disorders are very afraid of real, mature intimacy intimacy is formed not only within a couple but also in the workplace, in a neighborhood with friends, community and while collaborating on a project intimacy implied weakness, vulnerability it's another word for emotional involvement it's a result of interacting with others in a constant and predictable, safe, propinquity patients with personality disorders they interpret intimacy as weakness codependence, emotional strangulation the snuffing of freedom kind of death in installments they are terrorized by intimacy they avoid it and to avoid it their self-destructive and self-defeating acts are intended to dismantle the very foundations of a successful relationship they undermine and sabotage their relationships their careers, a project or a friendship narcissists more specifically feel elated and relieved after they unshackle themselves from these chains they feel that they had broken through a siege but they are liberated free at last they dread abandonment they have abandonment anxiety and in order to pre-empt it they load the lines, they very frequently abandon first then there are the default behaviors we are all to some degree inertial, we are all afraid of new situations change, new opportunities, new challenges new circumstances, new demands, new we are afraid of the new being healthy, being successful, getting married becoming a mother, becoming someone's boss these entail abrupt breaks with the past some self-defeating behaviors are intended to preserve the past to restore the past to protect the past from the winds of change to self-deceptively skirt and avoid and shun promising opportunities while seeming to embrace them and finally, I think finally, they are the sadistic, negativistic, passive-aggressive behaviors which all lead to self-defeat self-destruction frustrating ones nearest and dearest has the dual advantage of simultaneously satisfying masochistic and sadistic urges when you frustrate people habitually when you hurt them sadistically or otherwise you're destroying your environment and all your potential, so it's masochistic but you're also being a sadist by withholding love, sex, intimacy and the fulfillment of other people's desires and needs for example, to be parents you torment these people even as you obstruct obstruct your own gratification and this enhances and buttresses fantasies of omnipotence, not only in narcissists self-subotage, self-defeat self-denial, self-destruction martyrdom and victim-stats frustrating others they serve to prevent the forming of attachment and intimacy and the potential for ultimate hurt and pain as these may dissolve it's about cowardice it's craven it's the fear of ultimate pain and hurt that dictates to you to avoid life but life is about loss and suffering and pain and hurt these are the engines of growth and personal development in the case of the narcissists such behaviors uphold this sense of superiority uniqueness and omnipotence only the strongest can overcome and vanquish desires, urges, needs and emotions that easily overwhelm lesser mortals the narcissist adheres to his idiosyncratic brand of ascetic religion in which he is both God and a worshipper self-denial is proof of superiority the narcissist in a monologue goes I reject everything that matters to other people everything that is deemed valuable worthwhile, meaningful and desirable I don't need any of these things, I'm above this I hold the weaklings who succumb to their emotions and drives in contempt nothing they have and nothing they can possess or attain is of any value to me, it is all meaningless the narcissist devalues these people they are commoners, the average Joe the pedestrian, the routine, the animalistic sex, bestial, socially conformist they are all beneath the narcissists he is above the fray, he is the next stage in evolution and so he constricts his life he denies himself, he isolates himself even when he is surrounded by thousands of people he becomes so self-sufficient that there is no self so this self-defeating self-denying and self-destructive behaviors and choices and gender narcissistic supply self-supply because they support demonstrate and prove the superhuman nature of the narcissists, his utter titanic independence of society, of nature, of others in interpersonal relationships, it's a form of reactance or defiance, that's why narcissists are on the cusp of psychopathy when narcissistic supply is in short supply embarking on the path of self-negation is an efficacious shortcut to obtaining and securing supply I have dealt with it in my previous video at the very least, denying yourself draws astounded attention to the narcissists, people either admire or decry the narcissists and is again the focus in the center of everyone's interventions and administrations the negativeistic, passive-aggressive personality disorder is not yet recognized by the DSM committee it makes its appearances in Appendix B of the Diagnostic and Statistical Manual titled criteria sets and axes provided for further study covert narcissists are definitely passive-aggressive and negativeistic some people are perennial pessimists and negative energy and negativeistic attitudes they say, good things don't last it doesn't pay to be good, the future is behind me these are automatic negative thoughts and not only do these people disparage the efforts of other people, but they make it a point to resist demands to perform in the workplace and in social settings they revel in frustrating people's expectations however reasonable and minimal they may be such people regard every requirement an assigned task as impositions they reject authority, they resent authority figures such as bosses, teachers, parent-like spouses they feel shackled and enslaved by commitment and they oppose relationships that bind them in any manner passive-aggression, passive-aggressiveness there is a multitude, myriad guises procrastination is a form of passive-aggression malingering, perfectionism, forgetfulness neglect, truancy, intentional inefficiency stubbornness, outright sabotage and this repeated an advertent misconduct has far-reaching effects not least upon the passive-aggressive person consider the negativist in the workplace he or she invests time and efforts in obstructing their own chores and in undermining relationships but these are self-destructive and self-defeating behaviors they wreak havoc throughout the workplace or the workshop or the office and then this person gets fired or demoted or not promoted or gets no raise who suffers ultimately who is paying the price for these forms of egregious misconduct people diagnosed with negativistic passive-aggressive personality disorder resemble narcissists in some important aspects despite the obstructive role they play passive-aggressives feel unappreciated underpaid, cheated misunderstood, discriminated against they are the eternal victims some paternal martyrs they chronically complain, whine, carb, criticize they blame their failures and defeats on other people, they have alloplastic defenses exactly like the narcissists, they pose martyrs and victims of a corrupt, inefficient and heartless system they're prone to conspiracy theories they have an external locus of control passive-aggressive people sulk this is a silent treatment in reaction to real or imaginary slides they suffer from ideas of reference, referential ideation they believe themselves to be the butt of derision contempt, gossip and condemnation these people are mildly paranoid the world is out to get them and this explains their constant personal misfortune in the words of the PSM these people may be silent, irritable impatient, argumentative, cynical skeptical and contrary these people are also hostile explosive, many of them lack impulse control and sometimes they're reckless bullies, many of them so inevitably, passive-aggressive people are envious of the fortunate, the successful they're superior, those in favor the happy, same goes for covert narcissists covert narcissism is a marriage between passive-aggression and narcissism these people vent this venomous jealousy envy, openly and defiantly whenever they're given the opportunity but deep at heart, deep inside passive-aggressive people are craven, they're cowards when they're reprimanded, they immediately revert to begging forgiveness, cow-towing modest protestations, turning on their charm promising to behave and perform better in the future begging for forgiveness again when the narcissist truly needs and wants something or someone it is experienced by the narcissist as a challenge to his omnipotence of sufficiency unbridled freedom of action and entitlement so the narcissist resents this challenge consequently, it is perceived as profound narcissistic injury to need anyone to want something or someone, to love love is narcissistic injury the narcissist then rejects and abuses the very things and the very people he saw craves, he frustrates himself he inevitably ends up experiencing recurrent losses frustrations and modifications he convinces himself that people are evil and envious and that the world is a hostile jungle undeserving of him, but actually he is creating the preconditions and the conditions for his own downfall the narcissist's reactions are misperceived by other people as self-destructive and self-defeating when in effect they are meant to preserve and buttress grandiosity, anarchy liberty, sadistic superiority and nihilistic cynicism, as well as the inner equilibrium that these afford the narcissist the narcissist says I need no one, I need nothing look how I willingly discard and trash everything that you, my inferior mediocre peers hold dear and essential what you hold dear and essential is my trash why? because I'm a free man and this is the beginning of transition from narcissism to psychopathy such overt humiliating disdain and contempt, these are tinged with the form of mild taunting sadism the narcissist and similar personalities dark personalities, they say easy come, easy go I'm happy go lucky, I accomplish all things effortlessly and this facility renders everyone and everything worthless dispensable, interchangeable you know, you're not worth my investment, intimacy, sex, money career, family, celebrity, they are easy come, easy go I just couldn't care less about what you care about most and burning it all to the ground to communicate to you that you are slaves to society and that I hold you in contempt because I'm the master of my life I'm my best source of self supply, you have no hold over me because I do not need you, I do not want anything you can possibly possess or wish to share with me I do it my way or the highway, of course these are all mere defensive and compensatory projections we all know that, deep inside the narcissist is hollow it's a void, it's an emptiness he knows his inferior and so it's a desperate attempt by the narcissist to pretend that he is in control of his own decline collapse and defeat, which are to a logic sent inevitable but it is also a rigid immutable ideology akin to the mores of the hereditary aristocracies in times gone by by noblemen in previous centuries they held in abiding disdain the commoners and their existence work was despicable labor thrifts, sexual exclusivity commitment to family and church leisurely hedonistic idleness slacking in a way was elevated and normative the ideal among these grandiose grandees and entitled circles was to become a childless bachelor a gentleman of leisure or gifted amateur as Eric Byrne noted in the founding text of transactional analysis human relationships are games people play, there are two types of people who adamantly and proudly refuse to partake of such ludic exchanges and refuse to participate in the games that people play the narcissist and the psychopath they would not play sex or intimacy or family you know and they declined to play business or friendship and of course the rejected parties walk away, they revert to other partners who is losing who is on the receiving side of this content you know, ultimately the narcissists and psychopaths end up in ruins this is self-inflicted loss and it warps and thwarts and stunts the minds and lives of the narcissist and the psychopath in his seminal survey of grandiose psychopathy the mask of sanity, how he collectively branded it rejection of life itself the only game the narcissist would participate in is let us all pretend that this is for real a delusional shared fantasy with limited longevity and guaranteed expiry the psychopaths only concession to human intercourse is a zero sum, let's play my game you give it all and I take everything you have and then some ultimately people wise up to the narcissist and the psychopath and they just turn the backs again as the inimitable harvick correctly had observed in 1942 psychopaths and narcissists reject life itself by refusing to participate in it and by mocking it the nihilistic acts of self-destruction are driven by a proud ideology of defiance consumatiousness and reactance it signals their profound contempt for other people for authority, for society, for everything that everyone holds dear, it's opting out it's not a cop out even, it's just opting out narcissists and psychopaths consider themselves superior, unique and therefore entitled, including entitled to not be they disdain mediocrity shipple reflexes to obey trust and follow narcissists and psychopaths are contrarians they act against all norms, subvert all expectations and reject all the attributes of civilized coexistence and collaboration, they smuggling and ostentatiously trample upon the rewards, incentives and inducements that reality has to offer what is love to them, family, career, safety, reason that's for the low bro low lives when these people do pursue anything that is deemed conformant and sublimated socially acceptable they take great care to do it their way in the most extravagant, antisocial, reckless colors ruthless, merciless and shocking manner psychopaths and narcissists consider being hated and feared a badge of honor, they strive to be an enigma to the great unwashed, teeming masses being widely misunderstood is the coveted pinnacle of their accomplishments, what others consider a wasted, abandoned, sad life narcissists and psychopaths see as poking society's collective eye with a triumphant middle finger they prevail by refusing to play the game and by aggressively upturning the social tables in everyone's temples the devastation of their own lives is a statement of how little they value the lives and toys of others but it is also a sad testament to enormously wasted potential which could have been leveraged and put to good use but wrong upbringing and wrong environment condition all of us to take it upon us to take it on ourselves, to punish ourselves one way or another no one is exempt, not even you


All right, so we're going back to Portugal. And this is Cintar. It's an area south of the capital. And this is where the old imperial castle was. And this was also, it's a hilly fortress area. And so there's a lot of Moorish castles that are there that you can wander through. But this is the old castle where the king of Portugal used to live. It's very interesting castle. It's a combination of Moorish influence and Dr. Zeus. So it's weird. It's got pastels. It's got these areas that you see in Moorish castles. But then it's got weird stuff. And it's a mishmash of different types of architectural patterns. But it is up on a hill. And this area has got about a half a dozen hills. And there's like palaces or winter homes or fortresses on all of the hills. So very interesting place. And you can see it is very much on a hillside. And so you have to go with these special buses or you can hike it if you'd like. But again, pastel colors, very weird pastel colors, domes, kind of almost minarets. Actually looking here. So very much a mishmash of conditions. And then again here, you've got kind of a coat of arms. But again, you've got this pattern. It almost looks like kind of the stuff that Gadi did in Barcelona. And he was a little bit later. He was like 100 years after this. But very much the same bizarre architecture. And again, your gargoyle protecting things. But yet you're arched Middle Eastern looking entryway. So very, very interesting mishmash of stuff. So if we're going to talk about IOLs, we have to go back to Mr. Ridley. Mr. Harold Ridley, a surgeon from London. And so this plaque is in St. Thomas' hospital. That's very interesting. Alan Crandall and I were there. This is many years ago. You see a little bit less gray hair. And Crandall looking a little younger. But St. Thomas' is right across the hospital from, right across, I'm sorry, the river from Parliament. So we went over, we said, where is the Ridley plaque? At which time the information people looked at us like we'd asked for where the moon landing was. I mean, they had no idea what we were talking about. So you didn't really need IDs in that era. So we just kind of wandered the hospital. And sure enough, in a lower hallway, away from everything, we found this plaque. The first intraocular lens for the treatment of cataract was implanted by Mr. Harold Ridley at St. Thomas' hospital. And so this is interesting. This plaque is there. We found it. We took our pictures. So Mr. Ridley, there's Mr. Ridley. He lived to be 94 before he finally passed away. But he was very interesting. He was a surgeon in the Royal Medical Corps during the Second World War. And during the Blitz in London, the British Spitfire pilots were trying to protect London from the Nazi bombers. And their cockpits would be hit by machine gun fire. The cockpits would shatter. And bits of the cockpit would go into the pilot's eyes. And what Ridley noticed is that these were inert. And just by fortuitous circumstance, it turned out that the British RAF cockpits were made of plexiglass, which is PMMA, polymethylmethacrylate. And so Ridley was smart enough to say, gee, this material is inert inside the eye. Maybe we should consider this for making materials that go inside the eye. Now, legend has it. I don't know. I didn't get this from the horse's mouth. But legend has it that he was doing surgery, showing a student in the late 1940s taking out a cataract. And the student asked an innocent question of, well, what are you going to put a lens back in? And no, of course not. We give people glasses. And so I'm not sure if that's what really spurned Ridley, but Ridley decided that he wanted to go ahead and to develop an intracutal lens that you could put in after doing cataract surgery. The second fortuitous thing is that Ridley was doing very crude extra caps at that time. Now, surgery at that time was with loops. And so you'd go into the eye with what's called a graphe knife. It was a sharp, long knife. You punctured the limbus on one side, go all the way across the eye, punctured the limbus on the other side, saw the cornea in half. Then you lift it up.   And then you would manually squirt out the hard nucleus and flush out the cortex and then Ridley designed a lens to go into the posterior chamber where the normal crystalline lens was. And what Ridley's lens was is it was round, like our normal lens. It was very thick. It had a little rim around it. And if it were placed into the capsular bag and centered well and surrounded by the bag, this is an eye that had a Ridley lens for 30 years. And this was the eye with what we call the Miyake view. You cut an eye in half coronally. You look at it from the inside. So it's like you're sitting at the optic nerve looking out. Here is the capsular bag. Here's the pupil we're looking for behind. Here's the scleric processes. And here's this Ridley lens within the back 30 years later. Well, unfortunately, with those crude extra caps, the lens didn't end up in the bag. And in fact, would end up getting captured by the optic, would scrape on the iris, would get dislocated. And these lenses really did not do well afterward. They turned that to be kind of a disaster. And one of the reasons is this is the edge of the lens. And so they didn't have sophisticated polishing techniques. You can see that's very rough, very irregular. So it's a big, rough, irregular lens. And so lots of problems with that. So I just want to give you a little bit of a background of issue with Mr. Ridley. So Mr. Ridley put these lenses in. And so he came to the United States, crossed the pond, went to the AAO, Academy of Ophthalmology and Otolaryngology meeting in Chicago, and presented this data on his intraocular lenses, at which time the president of the American Academy stood up and said, if anybody in the United States puts these disastrous lens in a patient eye, I will personally testify at the malpractice suit. So this was the response of organized ophthalmology in the United States. And I must add that response continued for 20 years. So the organized ophthalmology, especially the AAO, was vehemently opposed to intraocular lenses and FACO, I might add. So did their best to try to retard progress for at least two decades, if not three. So poor Mr. Ridley went back to the continent, continued doing his work there. One of his students, Peter Choice, said, well, you know, these extra caps are pretty crude. Most people are doing what we call intracaps.  So why don't we put an IOL in the anterior chamber? And so Choice worked on many different lenses in the anterior chamber. In his first one, this was the Choice Mark I. And so I don't know why you call it Mark, but it sounds kind of space age and sounds kind of cool. I don't know if you remember the shaving blades, the Mach 5 shaving blade. And so it sounded very, very good. And so this was his first one, and it's a solid PMMA again. This is very solid. And so Mr. Choice played around with these for a while, and eventually came out, this was the Mach 8. So this was his eighth one. So this was the one that really attained widespread use. And this was the Mach 9. He cut down the bulk a little bit. But the idea is it's a one piece PMMA lens. And so the problem with these lenses is that you have to size them perfectly. And the sizing then was very crude. You take a caliper, you'd measure the limbus, the so-called white to white, and you'd add one. And you'd say, OK, the anterior chamber is 11.5 millimeters in diameter. Therefore you put a lens in plan of this. And so the standing joke at that time was that these lenses come in two sizes, too big and too small. And so what happens is when these lenses are too big, you get them to scrape against the iris. You'll get little hythomas that are going along here. And this is an eye that is viewed now anteriorly. We've removed the cornea because it was totally clouded. But you see the basic, the cat's eye pupil. And so you can see when these are too big, you get a definite overlaying of the pupil. This particular lens happens to have one of the foot plates stuck in a peripheral aridectomy. Because you do a peripheral aridectomy to prevent pupil area blocks of lots of problems with these. And you can see if they were too big, the other thing is when you're putting them in, you tuck the iris. So this is the anterior chamber angle. Here's the cornea. Here's the trabecular mesh work. Here's the iris with the IOL haptic tucking that behind there. Now I want you to note something. Look at all the pigment in the trabecular mesh work. You guys are going to know all about this next week. About Coleman next week. So you ended up with pigment dispersion. You ended up with chronic inflammation. And so lots of problems. When these were too small, they would propel it. And so they could literally turn around inside the anterior chamber of the eye. So some issues. From scraping, literally from scraping on the iris. Now the other problem with these is they were poorly fixed. Poorly finished in addition to being poorly fixed. And so the problem is American companies started to try to rip off these lenses in the late 70s, early 80s. And this was an early American rip off. This is the edge of an IOL, believe it or not. So I wish I still had this picture one. I was a fellow with Dave Apple. We took a Coke bottle and broke it. And EDM of the edge. And the edge was no worse than that. So you can imagine what this is going to do inside the eye. I had the displeasure of being a young fellow presenting a paper on these lenses, saying how bad they were, at which point Mr. Choice was the moderator and made it very clear that these were an unlicensed rip off, not his normal lenses. So he was very perturbed that we were presenting this as a choice lens. So it was a rip off. But this lens caused so much inflammation that the term UGG was coined. And you guys may hear of that now. UVitis glaucoma hyphema. So they would cause chronic UVitis from scraping on the iris. You would get hyphemas from rubbing on the vessels and you'd get glaucoma from the pigment dispersion. So UGG syndrome really was named with these choice rip off lenses. So American companies started getting into this finally now. This, we're talking now early 80s. And so this is a long time from 1949, 1950. But American companies started to say, okay, these IOLs are gonna be something we better start making. So they started making what we call open loop IOLs. And by open it means that the optic is still PMMA, polymethylmethacrylate, the loops are made of polypropylene, proline. You know, proline's a main plastic that make Gore-Tex out of it, all kinds of other things. So proline is what these were made of. And people started designing these. And so this was the era where guys were drawing these on napkins and IOL companies were popping up left and right. And so this was the AESAR 911 Z-Lens. So AESAR was an ophthalmologist down in New Orleans designed this and it was closed loop. And the idea was, is that you didn't have to size these so well. They wouldn't cause so many problems. And indeed, these lenses looked pretty good for about a year and a half to two years before they started causing problems. And so companies jumped on the bandwagon right away. This was another lens. They squared it off a little bit. Same thing, PMMA haptics. I'm sorry, PMMA optic, proline haptics. And you can see various different kinds. But they're all the same idea. They're all closed loop lenses. This was an interesting one. This was called the stable flex. And it had literally eight of these little loops all over the place. And this was one, unfortunately, there was someone in town here who put a whole bunch of these in. And even into like the 10 years ago, Alan Crandall and Andy Olson were removing these.  And so heck of a time getting these out. But this was when, you know, again, there was a new lens coming out every week. Now what happens with these lenses? It turns out that these closed loop lenses, if you put pressure on them, if you squeeze them, the closed loops would not take that squeezing and so they'd vault the optic forward. So if people rub their eyes or you can just squeeze their eyes, that optic was bouncing up and down on the cornea. So what would happen is you would get corneal edema, what we called pseudophagic bolus carotopathy. And there was a rash of them. In fact, from 1984 to 1989, the number one reason for doing a corneal transplant worldwide was pseudophagic bolus carotopathy because of these lenses. And so you'd get edema, but the second thing that would happen is, so here's the chronic edema. You're gonna get this bolus carotopathy. This is a cornea, believe it or not, cut in half, totally opaque. These loops would go into the angle and the angle that you'd get, fibrotic bands all the way across them. This is a gonioscopic view into the angle. And you would get that. And so what you would do is you'd get chronic UGG syndrome. Also you'd get chronic glaucoma from the angle closing off. And so these closed loop lenses would look good for a while, but then they would look bad. And so you don't see these anymore. Here's one of the loops digging into the ang, digging into the Irish roots. So this is cornea up here, iris pigment thin. Look at that loop. That loop was dug in almost to the major iris circle. So these would really cause significant issues. And here you can see again an eye, the cornea has been removed. And this is one of these stable flex lenses. Totally synecd into the angle. And you've had these crudier edectomies that were made when we put them in. So these caused real problems. This was an interesting lens. It's called the Dubrov lens. We just saw one of these in the lab being the last month, which I was really surprised. You can still see these once in a while. This had three loops like propellers. And it had three loops. And the problem is, is it was the worst of all worlds in that these loops would go into the angle and totally close off the angles. If you can imagine three broad loops, you would close off half your angle. So these caused lots and lots of glaucoma. And here again is a person with chronic UG syndrome plus corneal edema. So real issues with these implants. And here, remember from the corneal lecture, here's a balei.  Anybody? To retina. What's going on with that retina? Edema. Cystoid macular edema. So you could get with chronic UVI, they should get chronic cystoid macular edema. So they call that UG plus. So it's UG plus cystoid macular edema. Okay, so with that, Charlie Kelman, the guy who invented the FAKO machine, by the way, said, well, you know what? These closed loop lenses are causing real problems. The solid one-piece lens is causing problems. Why don't we make an open loop lens? And so he played with an all PMMA lens that was shaped like a seven. And so in fact, we used to call this the pregnant seven because it looks like a seven that's pregnant. And so the pregnant seven, turned out these were pretty unyieldy. And so he thinned down the haptics real rapidly, made them a little bit more flexible and called this the tripod lens or the omni-fit lens. And so Kelman would argue at that time that three was better than four.  And the argument was that if you're in a bar, you've got a three-legged bar stool on an uneven floor. That's more stable. That was his argument. And so people barely even use these and Kelman immediately figured out, you know, three isn't better than four. So again, like a month later, he made his present lens. Now, does that look familiar? Okay, this lens came out in like 1984. So here we are 34 years later, this is still our anterior chamber lens. And so you can see it's one-piece PMMA, but it's open looped. And so the idea is if you squeeze that, you know, rub the eye, squeeze the eye, instead of vaulting that optic up and down, the haptics would take the squeezing. So almost like the leaf springs on a big truck. You see them all the time, right?  And so the leaf springs take up the slack and so these don't vault. And so this is the lens we use to this day if you use an anterior chamber lens. So one-piece PMMA, open loop, four-point fixation. And the other thing is you have these haptics instead of curving out where they block the angle they curve in. And so there's only a couple little points where this intersects the angle. So these are well, well-tolerated. So this is kind of the ultimate anterior chamber lens. So here's the old Apple Core. I don't know who the guy with the mustache is, but we didn't have a big enough office so we would take the corner of the old cafeteria and this day of Apple would dictate stuff when you had fellows and students and we'd lay, you know, EM papers out here and write chapters and all. So this is how it was done. And this is the predecessor of the ocular surgery news which you still get today. So we held that up because we were on the cover of that when they took this picture. So this is the Apple Core. Well, at the same time that all this evolution with anterior chamber lenses was going on, people in Europe were looking at iris fixated lenses. So they were saying, hey, we can't put a lens in the posterior chamber. There's no support anterior chamber IOLs are causing corneal edema. Why don't we clip an IOL to the iris? So this was the original Bincorst. Bincorst is an ophthalmologist in, I never forget, because Bincorst had worse. One was in Belgium, one was in Netherlands and in any event, one of those two countries in Europe. And so the idea is, is that two of those loops go in front of the iris to go behind it and it clips it to the iris.  And then he put two holes in here so you could suture it to the iris if you had to. And so these would cause iris atrophy, they would cause Ugg syndrome, they would cause glaucoma, they would cause all kinds of problems. The other problem is these haptics were made out of proline. If you put proline next to uveal tissue, proline degrades. So this was the so-called mud flap degradation. And again, you think you never see these last month in our lab, we saw proline haptic with degradation, so it's still to this day, you can see that. So this was the impetus to get away from proline with the haptic materials. So when proline wasn't working well, they said, why don't we make a loop out of titanium? Indestructible inert, very, very heavy. And so it didn't work, it didn't work. So this had titanium, if you think about it now, imagine someone goes in an MRI and they flip the MRI scan and that goes, yeah, probably not a good idea. So those lasted, not even a week, those lasted about two days, you know, with the titanium haptics. No, no, these are all going into humans, yeah. These are all going into humans. So here is a worst lens, beyond worst, and here is the positioning hole here and there's a suture in here that's broken. A little suture here that used to go from here to here that's broken. And there's a tab here, trying to hold it on and look at the irises all chewed up and chronic edema and chronic ugg syndrome. So these really didn't work that well. This was a haptic that was behind the iris and this is all iris and lens tissue attached to it. So these could cause some real problems and again they looked good initially and then 18 months, two years later they'd start having problems. So here's the idea, you would clip it to the iris, loops in front, loops behind. Now, what happens if you dilate the eye widely to look at the perforate now? Sometimes these would fall into the vitreous, so. And people would have to turn people over and put them face down in the operating room and operate underneath them so that that lens would come forward. So it was very interesting. So my favorite is the ads were coming out. So there's a company called Copeland that made an IOL that looked like a propeller. Two loops anteriorly, two loops posteriorly and here's the Copeland elves wishing you married Christmas and so they'd send these ads out, little elves making the IOLs. And so Copeland was an interesting one. It was shaped like a propeller. Two loops in front, two loops in back and you would get a square pupil. So here's the loops in front, the loops would be behind here. Look at the pigment on the surface of the implant. Look at the iris stuck to it. So again, chronic UG syndrome, difficulty dilating, all kinds of problems. And here is a Copeland lens looking through the cornea. That's the view you got with the severe corneal edema these would cause. So my favorite is at this point, a lot of companies were advertising, this lens has proven safe and effective, discontinued. So it was interesting, it was safe and effective but they still discontinued it anyway. All right, so finally, we get to the more modern era. And now remember, Ridley was doing a crude extra caps. It didn't work well. Most people were doing intra caps. You'd remove the whole lens, capsule bag, the whole thing. But in the late 70s, early 80s, people started to use microscopes when you did your surgery. They didn't do loops. And they started to think, gee, maybe we could try to preserve that capsule bag, started going back to doing extra caps of surgery. So Steve Shearing, who was an ophthalmologist in Las Vegas, said, well, if we're gonna put in a posterior chamber lens, why don't we put a little haptic like a J on there to support it in the back? So this was the first posterior chamber lens. So people looked at that and they said, wow, that's a great idea. But that J was very stiff and came straight out. It tend to overlives the capsule. So immediately people started looking at different ways to do this. So a guy named Simco put a broad sea loop on this implant. And then Bob Sinski put a modified J loop. He moved that loop over and he made it a little bit less severe. And so this was the kind of standard lens that we used for a decade. And you guys will use a Sinski hook in surgery. So same guy. Sinski just passed away a year ago, but this was our go-to lens in the mid-80s. So this was a Sinski lens, modified J loop. And the idea is, is you try to put them in the capsule or bag. If you couldn't put them in the bag, you put them in the ciliary sulcus. Again, we still do that if our bag is not intact. But the bag is better than the sulcus. You still get scraping of the iris. You still get other problems. So put it in the bag if you can rather than in the sulcus. Here's what happens if you put an IOL in the sulcus. Look at where the haptics have disrupted the posterior iris pigment. And then the optic can scrape on there. So you can get some pigment dispersion. And here is a haptic that was in the ciliary sulcus. You've got a Vicksum ring ring here. Iris, cornea, peripheral anterior, synechia, haptic all the way again into the ciliary body there. So you want to put them in the bag, not in the sulcus. And finally, here is a Miyake view of a modified J loop IOL in the bag. Quiet eye, tolerated for 30 years, doing well. And that's where we want to put them. So here you can see the haptic surrounded by the capsular bag, away from the pigment, not digging into the iris, not causing disruption. And so we finally started putting implants within the capsular bag. So as implants got better, as we started putting them into the capsular bag, the companies got better at polishing them. And so this was now a lens that's what we call tumble polish. So remember I showed you the one look like a broken Coke bottle. Tumble polishing is interesting. And again, they still use it to this day.  And it polishes it. So when you were kids, did you ever have a rock polisher? You know, you put the rocks in there and you grind it for seven days. You have to put it in the garage because it makes so much noise. But same idea when you polish IOLs, look at that finish on that. So when you do scanning again now of IOLs in this area, they're gorgeously polished. So you don't get any problems from that. Okay, so I just wanted to kind of show you what the previous surgeries used to look like because you guys never see these now. But this was an intra cap. So you would make an incision from stem to stern. Now, because the eye is wide open, you really worry about it. So you put some special stay sutures in here. Then you lift up the cornea. You'd go in there with a cryoprobe. You'd stick the cryoprobe to the capsular bag. You'd put in what's called alpha chymotrypsin to dissolve the zonules and you would pop the whole lens out. Now, sometimes the visions would come out, sometimes not. But this would leave a nice clear view. These guys, once you refract them would be like 2015, but you can imagine there's a high incidence of systolic macular edema. You had some real issues with the intra caps. So we started going to do extra caps. And the idea is, is now you do a capsulotomy, you'd go in there, you dislocate the nucleus, you put a lens loop behind it, you pull it out. And then you put these two little stay sutures in there.  So these are extra caps. Now, those of you who are going on some third world trips were now doing small incision extra caps. The difference is, instead of making this incision that you have to put sutures in the smiles, we now make a frown incision way back on the sclera that self seals. And so we can do extra caps in the third world without stitches. So hopefully you guys will get a chance to learn that on your international travels. And last but not least, finally, Charlie Kellman invented the FACO, which allows us to take out an IOL through a small opening so that we can put in an implant that we don't have to expand the incision. So we can make a smaller self sealing incision. Kellman was a smart guy. He was at his dentist. And the hygienist was using an ultrasound to take off the plaque. And he said, what the heck is that? And she said, well, it's an ultrasound. It grinds the plaque. And so he was trying to come up with ideas on how to take out a cataract. So he went to the company that was at that time called Cavatron and they developed the first ultrasound to grind up the cataracts. Now, the first time he did a FACO, it took like two hours to do and tremendous amounts of energy. He was doing out on an I that was functionally blind. But still it again was the basis of the FACO we use today. Incisions have also changed. And so we used to make scleral, corneal incisions. You make an incision through the sclera. You would tunnel forward into the cornea and then you enter the cornea. Howard Fine said, well, wait a minute now. You know, why do we need to go back in the sclera? Why do we need to even disturb that? Why don't we make our incision in clear cornea? And again, that's what we do today. So here's a clear corneal incision. You don't use stitches on it. You don't disturb the sclera. You don't worry about bleeding. So clear corneal incision. Now, the final step in all of this, sir.  One thing I talked about was having lower rates of endothemitis of scleral tonsils. Yeah, 12 years ago. And so again, the BCSC is put together by the Academy. Everything the Academy puts out is a decade behind the times when it comes to cataracts and IOLs. And so when people first switch from scleral incisions to clear corneal incisions, there was a bump up in endothemitis. As people got better at making clear corneal incisions that didn't leak, that bump immediately went down. And that was 10 years ago. And so, but again, it's in the BCSC books. If it's in the book, you have to put that on boards even though it's not true. So there is no increase in endothemitis right now with clear corneal incisions, but there was initially. Okay, so people said, wait a minute. Now we've got this fake O, we can make a three millimeter incision. Why would we expand it to six to put in an IOL? And so this was the impetus toward making a foldable IOL. So it's interesting how cataract removal technology and IOL technology have gone kind of footstep with each other. So you'd get an advance in how you do cataracts or then you'd get an advance of IOLs and they'd move up. And so the smaller incision really was the impetus to foldable ends. And this was the first foldable IOL. It was a plate silicone and guy named Tom Mazako invented it. So they call this the Mazako taco. Looked like a rolled up taco. This was the first foldable IOL. So this is what it looked like was a plate silicone lens would go into the capsular bag nicely well. People looked at that and said, well that's good and fine but why would we get away from our standard three piece lenses which work well? So that led to the development of a three piece silicone lens. So the idea is you fold it with a folder put it in the eye unfolded in the bag and it would work well. They eventually came up with injectors that did this. And people looked at silicone and said, well okay silicone is a relatively low refractive index. So these lenses had to be pretty thick. You saw how thick that silicone lens was yesterday because in order to bend the light they'd be pretty thick and they weren't terribly compatible. And so they looked at different materials. This is a hydrophilic acrylic what was called hydrogel. And then they started looking at different ways of doing hydrogels. This is in a rabbit, very compatible material. And lastly, they started looking at hydrophobic acrylics. And this is the acrylic material we use to this day. So this was when Alcon first came out it was a three piece hydrophobic acrylic. And now we've got one piece with half the hydrophobic acrylic. So I'm not talking about modern Iowals. Lilian will talk to you guys about that. And why don't you do this as a history?  You know you saw in the lab the other day we still see these lenses 30 years down the road.  But I'm hoping that by giving you guys a little bit about the history of these lenses you'll know what the issues were at the time but also if you see these in clinic what the issues that you have to look for now. So that was just to call that a trip down memory lane. And again this is like going to Whoville here. So going back to the main cast of the very interesting English mash of different architectural styles. But again up on a hill beautiful views out onto the ocean from here. So next week we can get back to real pathology. Read your glaucoma and we're gonna talk a lot about glaucoma next week, okay? Questions? All right, very good.