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Using Diagnoses to Improve Treatment Robert M. Gordon, Ph.D. ABPP J&K Seminar 2013. 1. How does diagnoses (DSM, ICD, PDM) affect treatment ? 2. How to tailor treatment to the diagnoses of personality organization and personality patterns . . My Eclectic Background.

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Using diagnoses to improve treatment robert m gordon ph d abpp j k seminar 2013
Using Diagnoses to Improve TreatmentRobert M. Gordon, Ph.D. ABPPJ&K Seminar 2013

1. How does diagnoses (DSM, ICD, PDM) affect treatment?

2. How to tailor treatment to the diagnoses of personality organization and personality patterns.


My eclectic background
My Eclectic Background

  • Undergrad focus on science and epistemology

  • Temple’s psychology department heavily influenced by Wolpe and Lazarus. It was anti-psychoanalytic.

  • I studied with Rosnow and Lana the artifacts and assumptions in research (applied epistemology).

  • After my Ph.D., I studied with Albert Ellis (Rational Emotive Therapy), Salvador Manuchin, Jim Framo, and Peggy Papp (family therapy).

  • For a while my primary identification was, “family therapist.” (AFTA, AAMFT Supervisor)

  • Eventually, I became convinced that projections and transferences were the main issues in couples work and went on to study object relations (institute training and my psychoanalysis).



An integrative theoretical formulation precedes an integrative treatment
An Integrative Theoretical Formulation Precedes an Integrative Treatment

  • Need for the best theoretical formulation that integrates research about the mind, brain, affects, cognitions, behaviors, temperament, and their interactions in an interpersonal context.

  • Need for technical eclecticism based on the needs of the patient and EBP.


The new three core competencies in psychiatry
The New Three Core Competencies in Psychiatry Integrative Treatment

  • Supportive Therapy (Rogerian)

  • Cognitive- Behavioral Therapy (CBT)

  • Long-Term Psychodynamic Psychotherapy



Hypothalamic Sites that Generate Instinctual Behavioral and Affective States in MammalsPanksepp (1982)



Superego ego and id was a first step in understanding a brain in conflict
Superego, Ego and Id was a First Step in Understanding a Brain in Conflict

  • The Amygdalae (A) are involved in the processing of emotions.

  • The Ventromedial prefrontal cortex (VMPC) moderates emotional reactions and sends signals to the Striatum (S) with input from past experiences.

  • If the associations are negative, the VMPC signals are inhibitory. The Striatum translates signals from the Amygdala and VMPC into body action.

S

VMPC A


Ventromedial prefrontal cortex and neurosis
Ventromedial Prefrontal Cortex and Neurosis Brain in Conflict

Studies with PTSD support the idea that the ventromedial prefrontal cortex is an important component for reactivating past emotional associations and events, mediating pathogenesis of PTSD.


Brains of borderlines have less grey matter in anterior cingulate cortex
Brains of Borderlines Have Less Grey Matter in Anterior Cingulate Cortex

Patients with borderline personality disorder had significantly lower density of grey matter (the brain's working tissue) in the anterior cingulate cortex, an area (yellow right) that regulates the brain's fear hub (amygdala-yellow left).

MRI scan data shows the difference between patients and controls.


Brains of borderlines have more grey matter in amygdala
Brains of Borderlines Have More Grey Matter in Amygdala Cingulate Cortex

Patients with borderline personality disorder had significantly higher density of grey matter in the brain's fear hub, the amygdala (red areas). MRI scan data shows where patients and controls differed.


Emotions and attachment drives in mammals are similar and evolved for functional reasons. They may be affected by thoughts, but they are not created by them.

Damasio, et al., 2002

Panksepp, J. (2003).

Science, Oct 10th.

Herman & Panksepp, 1979


Attachment Security in Infancy and Early Adulthood: A Twenty-Year Longitudinal Study.Walters, E. Merrick., S.; Treboux, D.; Crowell, J. and Albersheim, L. (2000), Child Development.

  • Researchers looked at relationship patterns in 50 young adults who were studied 20 years earlier as infants.

  • Overall, 72% of the adults received the same secure verses insecure attachment classification they had in infancy.


Experimental Test of Unconscious Transference Twenty-Year Longitudinal Study.

  • Study: subjects are subliminally shown aggressive (A) or positive (B) stimuli

    • and then rate a neutral stimulus (C)

    • Subjects shown panel A subsequently rated the boy in panel C more negatively(Eagle, 1959)


Treat the whole person
Treat the Whole Person Twenty-Year Longitudinal Study.

  • Blatt, (2006), Norcross (2002), Wampold (2001) have concluded that the nature of the psychotherapeutic relationship, reflecting interconnected aspects of mind and brain operating together in an interpersonal context, predicts outcome more robustly than any specific treatment approach per se.

  • Westen, Novotny, and Thompson-Brenner (2004) have presented evidence that treatments that focus on isolated symptoms or behaviors (rather than personality, emotional, and interpersonal patterns ) are not effective in sustaining even narrowly defined changes.


Value of insight into the self
Value of Insight into the Self Twenty-Year Longitudinal Study.

  • 800 Psychologists ranked a list of 38 of the most beneficial things they got from their own psychotherapy.

  • They listed first, “Self-understanding.”

  • “Symptom relief” was halfway down the list

  • Included in the survey were psychologists from all theoretical orientations (Behaviorists, Cognitive-Behaviorists, Psychoanalytic, etc.).

  • Pope, K. T., B.G. (1994). Therapists as patients: A national survey of psychologists' experiences, problems, and beliefs. Professional Psychology: Research & Practice, 25(3), 247-258.


Effectiveness of Long-term Psychodynamic Psychotherapy A Meta-analysisLeichsenring and Rabung (2008) JAMA, 3000,13,1551-1565.

  • 23 LTPP studies (11 RCT efficacy and 12 effectiveness) total of 1053 patients with personality disorders, and multiple and complex problems.

  • LTPP at least 1 year (an average of 151 sessions).

  • Results LTPP better than 96% of those in short term therapies (CBT, DBT, SFT, CAT, FT, STPP, etc.) with changes in not only symptoms relief but with increases in mental capacities.


Importance of transference and attachment with bpd
Importance of Transference and Attachment with BPD Meta-analysis

  • Clarkin, et al. (2007): 90 BPD randomly assigned to transference-focused psychotherapy (TFT), dialectical behavior therapy (DBT), or supportive therapy (ST).

  • Patients in all 3 treatments showed significant positive change in depression, anxiety, global functioning, and social adjustment.

  • Both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality.

  • Only transference-focused psychotherapy and supportive treatment were associated with improvement in anger.

  • Transference- focused psychotherapy and supportive treatment were each associated with improvement in impulsivity.

  • Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault.


Over all research
Over-all Research Meta-analysis

  • Evidence Based short-term symptom focused treatments are allequally effective.

  • Long-term psychodynamic therapies that focus on temperament, conflicts, affects, cognitions, behaviors, interpersonal context, child development, conscious and unconscious levels are better than symptom focused treatments in treating personality disorders.


Integrative psychotherapeutic interventions going from supportive cbt and psychodynamic
Integrative Psychotherapeutic Interventions Meta-analysisGoing From Supportive, CBT and Psychodynamic

  • Personal Qualities of the Therapist

  • Maintaining the Therapeutic Frame

  • Reassurance

  • Listening

  • Behavioral Mastery: Self-Soothing

  • Cognitive Learning

  • Clarifications

  • Interpretations of mental life that affects subjective well-being and relationships


Treatment of the borderline level personality disorder
Treatment of the Borderline Level Personality Meta-analysisDisorder

  • Behavioral Mastery: desensitization and self-soothing

  • Cognitive Learning: how to better understand thoughts, feelings, and behaviors

  • Clarifications and Confrontations: of the patient’s confusions, distortions and consequences of judgment and impulses

  • Interpretations: focus on here and now defenses, transferences, enactments, and mentalization


Treatment of the neurotic level personality disorder
Treatment of the Neurotic Level Personality Disorder Meta-analysis

  • Reconstructions: patients may benefit from a coherent, insightful narrative of their psychological history. Despite problems with recall and subjectivity, traumatic events can be recalled, masteredand integrated into a more cohesive identity.

  • Interpretations:insight into unconscious resistances, defenses, transferences and enactments.


Kernberg s differentiation of personality organization that preceded the pdm

Kernberg’s Differentiation of Personality Organization That Preceded the PDM

NeuroticBorderline Psychotic

Identity +integrated - diffused -

Integration

Defensive +higher -primitive -

Operations

Reality + + -

Testing


Borderline personality organization basic characteristics kernberg
Borderline Personality Organization That Preceded the PDMBasic Characteristics- Kernberg

Identity Diffusion

No integrated concept of self

No integrated concept of significant others

Primitive Defenses

– Splitting

– Idealization/devaluation

– Projective identification

– Omnipotent control

– Denial

Variable Reality Testing


Healthy defense mechanisms

Healthy Defense Mechanisms That Preceded the PDM

AnticipationAffiliation AltruismHumorSelf-AssertionSelf-ObservationSublimationSuppression


Neurotic level defenses
Neurotic Level Defenses That Preceded the PDM

Displacement

Dissociation

Intellectualization

Rationalization

Isolation of Affect

Reaction Formation

Repression

Undoing


Borderline level defenses
Borderline level Defenses That Preceded the PDM

Idealization / Devaluation

Omnipotence and Omnipotent control

Denial

Projective identification

Splitting of self-image or image of others

Acting out

Projection


Psychotic level
Psychotic Level That Preceded the PDM

Delusional projection

Psychotic denial

Psychotic distortion


Anaclitic vs introjective according to s blatt
Anaclitic That Preceded the PDM vs Introjective(accordingtoS.Blatt)

  • Anaclitic: Borderline, Histrionic, Dependent, Avoidant, Depressive anaclitic.

  • Introjective: Schizoid, Paranoid, Antisocial, Narcissistic, Obsessive, Depressive introjective.

  • Reference tools: Object Relations Inventory (ORI; Blatt et al., 2006)


Personality disorders p axis

Personality Disorders That Preceded the PDMP Axis

Temperamental,

Thematic,

Affective,

Cognitive, and

Defense patterns


P101 schizoid personality disorders
P101. Schizoid Personality Disorders That Preceded the PDM

  • Contributing constitutional-maturational patterns: Highly sensitive,shy, easily overstimulated

  • Central tension/preoccupation: Fear of closeness/longing for closeness

  • Central affects: General emotional pain when overstimulated, affects so powerful they feel they must suppress them

  • Characteristic pathogenic belief about self: Dependency and love are dangerous

  • Characteristic pathogenic belief about others: The social world is impinging, dangerously engulfing

  • Central ways of defending: Withdrawal, both physically and into fantasy and idiosyncratic preoccupations


P102 paranoid personality disorders
P102. Paranoid Personality Disorders That Preceded the PDM

  • Contributing constitutional-maturational patterns: Possibly irritable/aggressive

  • Central tension/preoccupation: Attacking/being attacked by humiliating others

  • Central affects: Fear, rage, shame, contempt

  • Characteristic pathogenic belief about self: Hatred, aggression and dependency are dangerous

  • Characteristic pathogenic belief about others: The world is full of potential attackers and users

  • Central ways of defending: Projection, projective identification, denial, reaction formation


P103. Psychopathic (Antisocial) Personality Disorder That Preceded the PDM P103.1  Passive/Parasitic: “con artist” P103.2  Aggressive: explosive, predatory, often violent

  • Contributing constitutional-maturational patterns: aggressiveness, high threshold for emotional stimulation

  • Central tension/preoccupation: Manipulating/being manipulated

  • Central affects: Rage, envy

  • Characteristic pathogenic belief about self: I can make anything happen

  • Characteristic pathogenic belief about others: Everyone is selfish, manipulative, dishonest

  • Central ways of defending: Reaching for omnipotent control


P104. Narcissistic Personality Disorders That Preceded the PDM   P104.1  Arrogant/Entitled: devalues, vain, commanding   P104.2  Depressed/Depleted: idealizing, envious, easily hurt

  • Contributing constitutional-maturational patterns: No clear data

  • Central tension/preoccupation: Inflation/deflation of self-esteem

  • Central affects: Shame, contempt, envy

  • Characteristic pathogenic belief about self: I need to feel okay

  • Characteristic pathogenic belief about others: Others enjoy riches, beauty, power, and fame; the more I have of those, the better I will feel

  • Central ways of defending: Idealization/devaluation


Narcissistic pd narcissistic injury
Narcissistic PD: Narcissistic Injury That Preceded the PDM

The Doberman threw himself out the second-story window after he realized the family had indeed named him “Binky.”


P105. Sadistic and Sadomasochistic Personality Disorders That Preceded the PDM P105.1  Intermediate Manifestation: Sadomasochistic Personality Disorders:alternate between attacking and feeling insulted

  • Contributing constitutional-maturational patterns: Unknown

  • Central tension/preoccupation: Suffering indignity/inflicting such suffering

  • Central affects: Hatred, contempt, pleasure (sadistic glee)

  • Characteristic pathogenic belief about self: I am entitled to hurt and humiliate others

  • Characteristic pathogenic belief about others: Others exist as objects for my domination

  • Central ways of defending: Detachment, omnipotent control, reversal, enactment



P106. Masochistic (Self-Defeating) Personality Disorders That Preceded the PDM   P106.1  Moral Masochistic: self-esteem depends on suffering   P106.2  Relational Masochistic: suffer for sake of relationship

  • Contributing constitutional-maturational patterns: None known

  • Central tension/preoccupation: Suffering/losing relationship or self-esteem

  • Central affects: Sadness, anger, guilt

  • Characteristic pathogenic belief about self: By manifestly suffering, I can demonstrate my moral superiority and/or maintain my attachments

  • Characteristic pathogenic belief about others: People pay attention only when one is in trouble

  • Central ways of defending: Introjection, introjective identification, turning against the self, moralizing


Masochistic personality disorder
Masochistic Personality Disorder That Preceded the PDM

“Penny for your thoughts, Arnold!”


P107. Depressive Personality Disorders That Preceded the PDM   P107.1  Introjective: self-critical, self-worth   P107.2  Anaclitic: concern with attachment issues

  • Contributing constitutional-maturational patterns: Possible genetic predisposition

  • Central tension/preoccupation: Goodness/badness or aloneness/relatedness of self

  • Central affects: Sadness, guilt, shame

  • Characteristic pathogenic belief about self: There is something essentially bad or incomplete about me

  • Characteristic pathogenic belief about others: People who really get to know me will reject me

  • Central ways of defending: Introjection, reversal, idealization of others, devaluation of self


Depressive personality disorder

Depressive Personality Disorder That Preceded the PDM

Lodge owner Harold Shuffle saw only the negative side of things.


P107 3 converse manifestation hypomanic personality disorder
P107.3  Converse Manifestation: Hypomanic Personality Disorder

  • Contributing constitutional-maturational patterns: Possibly high energy

  • Central tension/preoccupation: Overriding grief/succumbing to grief

  • Central affects: Elation, rage, unconscious sadness and grief

  • Characteristic pathogenic belief about self: If I stop running and get close to someone, I’ll be traumatically abandoned, so I’ll leave first

  • Characteristic pathogenic belief about others: Others can be charmed into not seeing the qualities that make people inevitably reject me

  • Central ways of defending: Denial, idealization of self, devaluation of others


P108 somatizing personality disorders
P108. Somatizing Personality Disorders Disorder

  • Contributing constitutional-maturational patterns: Possible physical fragility, early sickliness, early abuse

  • Central tension/preoccupation: Integrity/fragmentation of bodily self

  • Central affects: alexithymia, inferred rage, distress

  • Characteristic pathogenic belief about self: I am fragile, vulnerable, in danger of dying

  • Characteristic pathogenic belief about others: Others are powerful, healthy, and indifferent

  • Central ways of defending: Somatization, regression


Somatizing personality disorder
Somatizing Personality Disorder Disorder

“My brother, Tilford, had trouble with hemorrhoids and he never did anything like this!”


P109 dependent personality disorders
P109. Dependent Personality Disorders Disorder

  • Contributing constitutional-maturational patterns: Possible

    placidity, sociophila

  • Central tension/preoccupation: Keeping/lossing relationships

  • Central affects: Pleasure when securely attached; sadness and fear when alone

  • Characteristic pathogenic belief about self: I am inadequate, needy, impotent

  • Characteristic pathogenic belief about others: Others are powerful and I need their care

  • Central ways of defending: Regression, reversal, avoidance

  • Subtypes:Passive-Aggressive,   Counterdependent


Dependent pd others are powerful and i need their care
Dependent PD: DisorderOthers are powerful and I need their care

“You’re gonna spoil that dog, Annie!”


P109. Dependent Personality Disorders DisorderP109.1  Passive-Aggressive Versions of Dependent Personality Disorders

  • Contributing constitutional-maturational patterns: Possibly irritable, aggressive

  • Central tension/preoccupation: Tolerating mistreatment/getting revenge

  • Central affects: Anger, resentment, pleasure in hostile enactments

  • Characteristic pathogenic belief about self: I am inadequate, needy, impotent

  • Characteristic pathogenic belief about others: Others are powerful and I need their care

  • Central ways of defending: Regression, reversal, avoidance


Passive aggressive personality disorder
Passive-Aggressive Personality Disorder Disorder

“It’s almost like they do it on purpose, isn’t it, Fred?!”


P109. Dependent Personality Disorders DisorderP109.2  Converse Manifestation: Counterdependent Personality Disorder

  • Contributing constitutional-maturational patterns: Possibly more aggressive than the overtly dependent type

  • Central tension/preoccupation: Demonstrating lack of or shameful dependence

  • Central affects: Contempt, denial of “weaker” emotions

  • Characteristic pathogenic belief about self: I don’t need anyone

  • Characteristic pathogenic belief about others: Others depend on me and require me to be “strong”

  • Central ways of defending: Denial, reversal, enactment


P110 phobic avoidant personality disorders
P110. Phobic (Avoidant) Personality Disorders Disorder

  • Contributing constitutional-maturational patterns: Possible anxious or timid disposition

  • Central tension/preoccupation: Safety/danger relative to specific objects

  • Central affects: Fear

  • Characteristic pathogenic belief about self: I am safe if I avoid certain specific dangers

  • Characteristic pathogenic belief about others: More powerful people can magically keep me safe

  • Central ways of defending: Symbolization, displacement, projection, rationalization, avoidance

  • Subtypes: Counterphobic


P110 1 converse manifestation of phobic counterphobic personality disorders
P110.1  Converse Manifestation of Phobic: Counterphobic Personality Disorders

  • Contributing constitutional-maturational patterns: Unknown

  • Central tension/preoccupation: Safety/danger

  • Central affects: Contempt, denial of fear

  • Characteristic pathogenic belief about self: I can face anything without fear

  • Characteristic pathogenic belief about others: Others frighten easily and admire my bravery

  • Central ways of defending: Denial, reaction formation, projection


P111 anxious personality disorders
P111. Anxious Personality Disorders Personality Disorders

  • Contributing constitutional-maturational patterns: Anxious or timid temperament

  • Central tension/preoccupation: Safety/danger

  • Central affects: Fear

  • Characteristic pathogenic belief about self: I am in constant danger from forces unknown

  • Characteristic pathogenic belief about others: Others are sources of either danger or protection

  • Central ways of defending: Failure of defenses against anxiety, surface anxiety may mask unconscious deeper anxiety


P112. Obsessive-Compulsive Personality Disorders Personality Disorders  P112.1  Obsessive: Self-esteem depends on thinking,ruminative  P112.2  Compulsive: Self-esteem depends on doing, meticulous

  • Contributing constitutional-maturational patterns: Possible irritability, orderliness

  • Central tension/preoccupation: Submission to/rebellion against controlling authority

  • Central affects: Anger, guilt, shame, fear

  • Characteristic pathogenic belief about self: My aggression is dangerous and must be controlled

  • Characteristic pathogenic belief about others: Others try to exert control, which I must resist

  • Central ways of defending: Isolation of affect, reaction formation, intellectualization, moralizing, undoing


Obsessive compulsive pd compulsive type
Obsessive-Compulsive PD: Compulsive type Personality Disorders

Once again Elliot Zambini’s tidiness ruins the act.


P113. Hysterical (Histrionic) Personality Disorders Personality Disorders   P113.1  Inhibited: reserved, naiveté, somatization   P113.2  Demonstrative or Flamboyant: seductive, dramatic

  • Contributing constitutional-maturational patterns: Possibly sensitivity, sociophila

  • Central tension/preoccupation: Power and sexuality/other gender

  • Central affects: Fear, shame, guilt (over competition)

  • Characteristic pathogenic belief about self: My gender makes me weak, castrated, vulnerable

  • Characteristic pathogenic belief about others: People of my own gender are of little value, people of the other gender are powerful, exciting, potentially exploitive and damaging

  • Central ways of defending: Repression, regression, conversion, sexualization, acting out


P114.  Dissociative Personality Disorders (Dissociative Identity Disorder/Multiple Personality Disorder)

  • Contributing constitutional-maturational patterns: Constitutional capacity for self-hypnosis; severe early and repeated physical and/or sexual trauma

  • Central tension/preoccupation: Acknowledging trauma/disavowing trauma

  • Central affects: Fear, rage

  • Characteristic pathogenic belief about self: I am small, weak, and vulnerable to recurring trauma

  • Characteristic pathogenic belief about others: Others are perpetrators, exploiters, or rescuers

  • Central ways of defending: Dissociation


P115 mixed other
P115.  Mixed/Other Identity Disorder/Multiple Personality Disorder)

  • For individuals with combinations of personality types or with particular patterns or themes


Implications for Identity Disorder/Multiple Personality Disorder)TreatmentDepressive Personality Disorder(Most Common type in Clinical Situations)P107.1  Introjective: self-critical, preoccupied with self-worth, guilt P107.2  Anaclitic: concerned with attachment issues, relatedness, trust, inadequacy (May combine with dependent or narcissistic personality disorder)


Treatment for depressive p d
Treatment for Depressive P.D. Identity Disorder/Multiple Personality Disorder)

  • The Mood disorder responds to medication, but not the personality disorder, which requires long-term intensive treatment.

  • The introjective type tends to respond better to interpretations and insight.

  • The anaclitic type tends to respond better to the actual therapeutic relationship. May respond well to short term interventions.


P107 3 converse manifestation hypomanic personality disorder1
P107.3  Converse Manifestation: Hypomanic Personality Disorder

  • Relatively stable state of inflated mood, high energy

  • Little guilt

  • Overly positive view of self

  • Superficial relationships due to fear of being attached

  • Highly resistant to therapy

  • The mood disorder responds better to pharmacological interventions, but medication does not help the personality disorder.


Treatment implications p107 3 converse manifestation hypomanic personality disorder
Treatment Implications: DisorderP107.3  Converse Manifestation: Hypomanic Personality Disorder

  • The hypomanic type often flees from commitment and therefore does not stay long enough in treatment. The PDM suggests emphasizing that the commitment to the treatment is important to improvement.

  • People with hypomanic personality disorders are most likely to be at the borderline level favoring defenses such as denial and the idealization of self and the devaluation others, as compared to those with depressive personalities who favor defensives such as repression, and the devaluation of self and the idealization of others.


Personality structure and treatment
Personality Structure and Treatment Disorder

  • McWilliams points out that for many neurotic level people, the best time to make interpretations is when the patient is a state of emotional arousal, so that the patient is less likely to intellectualize the affect.

  • With borderline clients, who require a supportive approach, the opposite consideration applies, because when they are very upset, it is hard for them to take anything in.


Take home message
Take Home Message Disorder

  • Neurotic Level Personality Disorders

    focus more on using insight into past traumas that need to be worked through.

  • Borderline Level Personality Disorders focus more on using here and now interventions to help with reality testing, better self control and self soothing.


Take home message1
Take Home Message Disorder

  • Be technically eclectic mixing Supportive, CBT and Psychodynamic according to the needs of the patient (not according to your biases).

  • Use a psychodynamic formulation so you will know what interventions are likely be most effective, and to communicate that you understand your patient at all levels of existence (not just seeing symptoms).


Consider instruments such as the pdc
Consider Instruments Such as the PDC Disorder

  • To guide your diagnostic and case formulation

  • To keep in your chart

  • To assess progress


Take home message use the icd with the pdm
Take Home Message: DisorderUse the ICD with the PDM

  • Consider the over-all level of personality organization

  • Consider the personality patterns or disorders

  • Consider the mental capacities

  • Consider the subjective experience of the symptoms and use the ICD codes

    You will find that your greater empathy will be felt by your patient, and this can greatly improve any treatment.


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