Avances en Salud Mental Relacional / Advances in relational mental health
Vol.5, núm.3 - Noviembre 2006
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
THE OUTCOME OF PATIENTS WITH BORDERLINE PERSONALITY
DISORDER
IN
DAY
A
DYNAMICALLY
HOSPITAL
ORIENTED
PROGRAM
J.Guimón, A.Boyra, C.Maruottolo,
J. Bilbao, A. Mascaró
University of the Basque Country and AMSA, Bilbao
1. INTRODUCTION
While the biological approach has led to considerable advances in the treatment
of patients with borderline personality disorders over the last 15 years, it has not
weakened the relational approaches. With the changes that have taken place in
psychiatric practice in terms of cost containment ("managed care"), group therapy is
becoming the treatment of choice in many programs due to its relatively good
cost/benefit ratio..
On the other hand, during the last twenty five years, there has been a rebirth of
milieu therapy along inpatient units , crisis centers for severe patients . Several studies,
of variable methodological quality, show favorable results in borderline patients with
this type of approach based on the experiences of therapeutic communities. In 2003 we
organized in Bilbao a program in a day unit for a maximum of 27 patients
simultaneously. In this paper we are describing the socio-demographic and clinical
variables of 109 patients (64,2 % Borderline and 35,8% Non-Borderline) , during the
year preceding their admission and after their discharge from a dynamically-oriented
day hospital program with a 50 days average hospital stay.
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Avances en Salud Mental Relacional / Advances in relational mental health
Vol.5, núm.3 - Noviembre 2006
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
2.METHODOLOGY
2.1.Patients
There were significant differences between BPD and Non-BPD. Patients with
Borderline personality disorder were more frequently male (p=0,012), single (p=0,000),
of a younger age (p=0,01), coming from dysfunctional families (p=0,000), occupied
(p=0,05), with diagnostic co morbidity (p=0,021), having made self-harm activities and
suicidal attempts (p=0,09) and
presenting substance and alcohol abuse (p=0,000).
(p=0,000)
2.2. Diagnoses
64,2 % of the patients had a Bipolar Personality Disorder diagnosis and 35,8%
other Non-BPD diagnoses (5,7%
Psychoses, 47,2% Anxious/Depressive, 18,9%
Substance abuse and 23,6% Other Personality Disorders).
2.2. The therapeutic programs
A maximum of 27 patients were treated simultaneously, with an average age of
37,64 years and a mean stay of 50 days (22,7%: less than 1 month, 25%: more than 3
months), five days a week, four hours a day.
The two therapeutic teams included psychiatrists, psychologists, social workers,
occupational therapists and psychomotor therapists, trained in individual dynamic
therapy and group and family therapy
The program included : medication prescription and control of; three small
verbal therapy groups (staff-patients once a week, dynamic 5 days a week, cognitive 5
days a week) and several group activities (artistic expression 2 days a week, body
movement 2 days a week, relaxation once a week, daily activities 5 days a week). The
multifamily group met once a week
2.3. The instruments. Several instruments were used at program admittance and
at discharge:SCID ( Structured Clinical Interview for DSM IV-TR), BDI (Borderline
Diagnostic Inventory, Gunderson, 1992), BSI (Brief Symptoms Inventory, Lipman and
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Derogatis), HS (Beck´s Hopelessness Scale, STAI (State-Trait Anxiety Inventory), BDI
(Beck´s Depression Inventory), ERA ( Questionnaire d`évaluation des relations avec les
autres, Fredenrich & Zanetti, QFS ( Questionnaire de Fonctionnement Social, WeberRouget & Zanello
3. RESULTS
3.1.Compliance
We find a lack of differences in attendance (type of discharge and length of stay)
between BPD and Non BPD, contradicting our hypotheses, based in the literature, that
BPD would have a more irregular attendance. In fact, the drop-out rate was smaller in
BPD than in Non-BPD (p= 0,499) (Table 1)
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Table 1. DROP-OUT RATE
There was a statiscally significant smaller drop-out rate in BPD than in Non-BPD (p=
0,499)
3.2.Symptoms
There was an overal significantly important improvement of the symptoms
without statistical differences between BPD and Non- BBP. However, in the BSI , BPD
patients had a larger range in symptoms (Table 2).
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-5
95% IC MEJORÍA BSI
-10
-15
-20
-25
-30
-35
-40
NO
BORDERLINE
BORDERLINE
Table 2 . BSI , BPD patients had a larger range in symptoms
There was a significant improvement in the 9 factors of the BSI (Somatization,
Obsesive-compulsive, Interpersonal Sensibility, Depression, Anxiety, Hostility, Phobic
Anxiety, Paranoid thinking and Psychoticism )
On the other hand, some variables affected significantly the outcome of some
symptoms: depression improved more in those with higher socio-economical status,
higher educational level and a history of self-harm. Suicidal ideation improved more in
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those who were University students . Anxiety improved more in those with a history of
Substance abuse
There were also some significant differences in improvement between BPD and
Non-BPD that we find difficult to interpret: BPD without co morbidity at the admission
showed more improvement than Non-BPD. Non- BPD with co morbidity at the
admission improved more in anxiety than BPD. On the other hand, anxiety improved
more in those who had a Substance abuse history.
Depression improved more in people with higher socio-economical status.
higher educational level and heavier history of self-harm. Suicidal ideation improved
more in those who were University students
3.3.Global functioning
There was also an important improvement in global functioning without
differences between BPD and Non-BPD in the ERA Questionnaire of relationships
with others. However BPD obtained a statistically significant higher improvement than
Non-BPD in the Factor 1 QFS ·"Daily life activities" (P= 0,035) (Table 3)
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95% IC MEJORÍA QFS FRECUENCIA
15
10
5
0
-5
NO
BORDERLINE
BORDERLINE
Table 3. BPD obtained a statistically significant higher improvement than NonBPD in the Factor 1 QFS "Daily life activities" (P= 0,035)
4.DISCUSION
4.1. Overall results: The limits of "evidence based" studies
The program we have presented in this article is one of the group therapy
programs we have developed over the past 30 years, involving many severe patients,
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with an orientation towards community therapy, in a dozen different care units (shortstay units in general hospitals, rehabilitation units, and day hospitals) in Spain and in
Switzerland .
These programs (we have named "decaffeinated therapeutic communities")
include, as a minimum: a "medium size"daily group, bringing together patients and
staff; a patients "small group", with a dynamic orientation, but with occasional
cognitive-behavioral techniques; and several group activities ("group work", in a
Foulkian sense). The use of multifamily groups is a significant component of this type
of programs.
This article shows important improvements in symptoms and global functioning
after the program discharge. BPD patients showed, on the other hand, a non-expected
good compliance. The evaluation we are currently doing in the 6, 12 and 18 months
follow-up will tell us more about the medium term interest of our model.
We have not been able to make randomized controlled trial of our programs the
results since the research designs were always "naturalistic"..
The treatments efficacy assessment is presently acquiring growing importance
for psychiatric practice. "Empirically Supported Treatments" are proposed through
useful techniques such as randomised controlled trials, the meta-analysis, the
"Consumer Reports" studies and the Cochrane collaboration systematic reviews.
However, they also have important biases such as the gaps in interpreting the available
evidence, the neglect of individual patient uniqueness and the high artificiality of the
settings.
The results of some evidence based programs of this kind that have been
evaluated are rather optimistic. A Cochrane Review concludes that home care crisis
treatment, coupled with an ongoing home care package, `is a viable and acceptable way
of treating people with serious mental illnesses'. Another Cochrane Review compared
day hospital versus outpatient care for severe psychiatric disorders, and found that there
was evidence from one trial suggesting that day treatment programs were superior to
continuing outpatient care in terms of improving psychiatric symptoms. However, on
the contrary, another Cochrane review did not find any randomized trial evaluating the
effects of non-medical day center care for people with severe mental illness.
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A recent Cochrane Review by concludes that, although some of the problems
frequently encountered by people with borderline personality disorder may be amenable
to talking/behavioural treatments, all therapies remain experimental and the studies are
too few and small to inspire full confidence in their results.
These frustrating conclusion highlights other limits of "empirically supported
psychological treatments" with BPD: they have not been effectively disseminated to the
mental health professionals; they are not readily available to the public who requires
them; and they have only a remote resemblance to what goes on in actual clinical
practice.
But, how to overcome these difficulties?. Many authors emphasise the need to
overcome the problems of rigid manuals and to avoid forcing clinicians to adhere to
theories and practices that are outside their interest. Most proclaim the need of
naturalistic psychotherapy studies.
The "evidence-based" movement has appeared in psychiatry as a research
method . It is, however, also a powerful socio-political endeavour. It has, last but not
least, important ethical implications since moral neutrality is a myth when referring to
the incompatible ethical positions inherent in clinical and research practices.
4.2. The programs effect on the treatment environments.
Group Psychotherapy is a basic therapeutic resource in psychiatric care. In our
experiences some specific groups produce important attitudinal and clinical changes . Most
importantly groups improve the quality of psychiatric programs by the creation of a better
climate in the wards .
In a research, we compared, by means of Moos´ Ward Atmosphere Questionnaire
, the atmosphere in 200 psychiatric wards (both in general and psychiatric hospitals) in Spain.
The ratings of the personnel in the wards where a group program was used showed
significantly higher scores on some items such as "support", "interpersonal orientation", and
less "control". The ratings of the patients were higher on "spontaneity", "autonomy" and
"support".
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In short-stay psychiatric units, the patients have to deal with a high degree of
stress, arising from short stays, acute symptomatology, auto- and hetero-aggression,
rapid turnover of patients, and limited space. Group analysis, with its particular
emphasis on the `here and now' and on inter-member cohesiveness, has shown itself to
be, in our experience, a useful stabilising (`buffer') tool, through fostering involvement
and support and allowing a controlled expression of anger and aggressiveness.
The patients-staff group is the key element, from the standpoint of its creation of
a good ward atmosphere and through the information it provides to patients. The other
groups also give the patient orientation and emotional support. All this has enabled us to
decrease the dosages of medication required and to create an agreable atmosphere in the
sessions, as well as lowered the number of incidents (e.g., aggression, suicide attempts,
and runaways). The tensions in the therapeutic teams have diminished and incoming
nursing personnel notice how their previous fears and apprehensions diminish.
In this kind of settings it is assumed that the staff should play an «alter familia»
role that would enable the patients a "corrective emotional experience ». However,
various difficulties arise in the team coming from real problems and from projective
identifications that clients put on the staff members. Conductors frequently feel
compelled to act transferentially as if they were moved by the projections of the
patients. Tensions arises in the team while its members essay to become an adequate
continent, a «loving therapeutic team», able to take on the needs of the clients and avoid
having to assume the difficulties of the staff members.
Post groups in therapeutic communities are of great help to avoid severe
emotional difficulties arising in these professionals.
These different groups constitute a network for group analysis, which is
favorable to the harmonious communication between the different services. This
systemic vision of the Mental Health system is conducive to easier, quicker detection of
problems and conflicts inside the institutions. All of these elements furnish the input
which feeds "healthy anticipatory paranoia" , which is so indispensable to managing
these organizations.
SUMMARY
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INTRODUCTIONThe authors have organized in 2003 a naturalistic programs
in Bilbao for a maximum of 27 patients simultaneously. They describe in this paper the
socio-demographic and clinical variables of 109 patients (64,2 % Borderline and 35,8%
Non-Borderline) , during the year preceding their admission and after their discharge
from a dynamically-oriented day hospital programme with an average hospital stay of
50 days.
METHODOLOGY. Several instruments were used at the time of the admittance
and at the discharge from the program:SCID ( Structured Clinical Interview for DSM
IV-TR), BDI (Borderline Diagnostic Inventory), BSI (Brief Symptoms Inventory, HS
(Beck´s Hopelessness Scale, STAI (State-Trait Anxiety Inventory), BDI (Beck´s
Depression Inventory), ERA ( Questionnaire d`évaluation des relations avec les autres,
Fredenrich & Zanetti), QFS ( Questionnaire de Fonctionnement Social, Weber-Rouget
& Zanello)
RESULTS. The authors find a lack of differences in attendance (type of
discharge and length of stay) between BPD and Non BPD, contradicting our
hypotheses, based in the literature, that BPD would have a more irregular attendance. In
fact, the drop-out rate was smaller in BPD than in Non-BPD (p= 0,499). There was a
significanttly important improvement of the symptoms whithout statistical differences
between BPD and Non- BBP. However, in the BSI , BPD patients had a larger range in
symptoms. Some variables affected
significantly the outcome of some symptos:
depression improved more in those with higher socio-economical status,
higher
educational level and a history of self-harm. There was also an important improvement
in global functioning without differences between BPD and Non-BPD in the ERA
Questionnaire of relationships with others.
However BPD obtained a statistically
significant higher improvement than Non-BPD in the Factor 1 QFS ·"Daily life
activities" (P= 0,035).
The authors support the need for more naturalistic studies and, based on their
experience, they favour eclectic, brief, dynamic, day hospital approaches with
heterogeneous patients as an optimal emergency approach for people with BPD
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RESUMEN
INTRODUCCIÓN: Los autores organizaron en Bilbao en 2003 una unidad de día para
pacientes graves (64,2 % con TLP y 35,8% con otros diagnósticos) que se ocupa de un
máximo de 27 pacientes simultáneamente repartidos en dos programas, con una
duración media de 50 días.
METODOLOGÍA. En un reciente estudio "naturalístico" comparan diversas variables
de los pacientes al inicio del tratamiento, en el año anterior y en el momento del alta con
diversos instrumentos:SCID ( Structured Clinical Interview for DSM IV-TR), BDI
(Borderline Diagnostic
Inventory), BSI (Brief Symptoms Inventory, HS (Beck´s
Hopelessness Scale, STAI (State-Trait Anxiety Inventory), BDI (Beck´s Depression
Inventory), ERA ( Questionnaire d`évaluation des relations avec les autres, Fredenrich
& Zanetti), QFS ( Questionnaire de Fonctionnement Social, Weber-Rouget & Zanello)
RESULTADOS. En contra de lo que se había predicho, los pacientes con TRLP
tuvieron un cumplimiento terapéutico semejante a los no TLP e incluso el porcentaje de
abandonos fue menor. Desde el punto de vista sintomatológico las mejorías fueron
importantes sin diferencias entre los dos grupos, aunque el rango era mayor en los que
presentaban TLP. La mejoría en el funcionamiento social fue también semejante,
aunque los que tenían TLPO mejoraron más en las actividades de la vida diaria. Ante
estos datos alentadores consideramos que las aproximaciones basadas en unidades de
día con programas breves, intensivos, dinámicos (o eclécticos) son una indicación
excelente para los pacientes con TLP.
REFERENCES
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1.
Guimón J, Sartorius N, editors. Manage or Perish ? The challenges of
managed mental health care in Europe. New York: Kluwer Academic/Plenum
Publishers; 1999.
2.
Yalom ID. Inpatient Group Psychotherapy. New York: Basic Books
Publishers; 1983.
3.
Yalom ID. Inpatient Group Psychotherapy. New York: Basic Books
Publishers; 1983.
4.
Alanen YO, Lehtinen V, Lehtinen K, Aaltonen J, Räkköläinen V. The
Finnish integrated model for the early treatment of schizophrenia and related
psychoses. In: Martindale B, Bateman A, Crowe M, Margison F, editors.
Psychosis. Psychological Approaches and their Effectiveness. London: Gaskell;
2000. p. 235-265.
5.
Whiteley JS. The Henderson Hospital: a community study. International
Journal of Therapeutic Communities 1980;1(1):38-57.
6.
Whiteley JS, Collis M. The therapeutic factors in group psychotherapy
applied to the therapeutic community. International Journal of Therapeutic
Communities 1987;8:21-32.
7.
Guimón J, Boyra A, Maruottolo C, Bilbao J, Mascaró A. Predictors of
outcome of BPD patients in a dynamically oriented day hospital programme. In:
EAP european Conference; 2007; Madrid,; 2007.
8.
Guimón J, Ozamiz A, Ylla L. Adaptacion espanola del SCL-90 de
Lipman y Derogatis. Jaca - Actas del congreso de la Sociedad espanola de
Psiquiatria: Edita la Universidad de Zaragoza - Catedra de Psiquiatria; 1983.
9.
Beck AT, Rush AJ, Shaw BF, al. e. Cognitive Therapy of Depression.
New York: Guilford; 1979.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2006
13
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.5, núm.3 - Noviembre 2006
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Revista Internacional On-line / An International On-line Journal
10.
Zanello A, Weber Rouget B, Gex-Fabry M, Maercker A, Guimon J.
Validation du Questionnaire de Fonctionnement Social (QFS), un autoquestionnaire mesurant la fréquence et la satisfaction des comportements
sociaux d'une population adulte psychiatrique. L´Encephale 2006.
11.
Zanello A, Weber-Rouget B, Gex-Fabry M, Maercker A, Guimón J. A
New Instrument to Assess Social Function in Mental Health Settings. European
Journal of Psychiatry 2004;18(Supp):76-85.
12.
Guimón J, Erehnsperger S, Weber B, Fredenrich A, Vucetic V, Zanello
A, et al. Evaluación de la psicoterapia grupal en la asistencia psiquiátrica : la
Batería " Bel-Air ". Psiquis 2000;21(6):277-287.
13.
Guimón J. The use of group programs to improve medication
compliance in patients with chronic diseases. Patient Education Couns
1995;26:189-193.
14.
Guimón J. Thérapie groupale dynamique intensive et brève.
Psychothérapies 1998;18(1):15-21.
15.
Guimón J. Scope and Limitations of Psychonalysis in Clinical
Psychiatry. In: (Eds.) JGSZdF, editor. Challenges of Psychoanalysis in the 21st
Century. New York: Kluwer Academic; 2001. p. 133-149.
16.
17.
Guimón J. Introduction aux thérapies de groupe. Paris: Masson; 2001.
Guimón J. Psychodynamic/Object-Relations group Therapy with
Schizophrenic Patients. In: Kaslow FW, Magnavita JJ, editors. Comprehensive
Handbook of Psychotherapy. New York: John Wiley & Sons, Inc.; 2002. p. 481501.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
Copyright © 2006
14
Avances en Salud Mental Relacional / Advances in relational mental health
Vol.5, núm.3 - Noviembre 2006
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
18.
Guimón J. Groups in Therapeutic Communities. In: Kaslow FW,
Magnavita JJ, editors. Comprehensive Handbook of Psychotherapy. New York:
John Wiley & Sons, Inc; 2002. p. 529-549.
19.
Guimón J. Eficacia de las terapias en salud mental. Bilbao: Desclée de
Brower; 2004.
20.
Guimón J. Evidence-Based Research Studies on the Results of Group
Psychotherapy: A Critical Review. The European Journal of Psychiatry.
2004;18(Sup):49-61.
21.
Guimon J, Eguiluz I, Bulbena A. Group pharmacotherapy in
schizophrenics : Attitudinal and clinical changes. The European Journal of
Psychiatry 1993;7(3):147-154.
22.
Guimón J, Eiselé R, Zanello A. Psicoterapia de grupo cognoscitiva en
esquizofrénicos: la experiencia de Ginebra. In: Sota E, editor. Tratamiento de
las Psicosis. Palencia: Hnas. Hospitalarias; 1998.
23.
Guimon J, et a. Pharmacotherapy in Schizophrenics: Attitudinal and
Clinical Changes. The European Journal of Psychiatry 1993;7(3):147-154.
24.
Guimon J, Luna D, Totorika K, Diez L, Puertas P. Group psychotherapy
as a basic therapeutic resource in psychiatric community care from the general
hospital. In: Lopez-Ibor Jr JJ, Saiz J, Lopez-Ibor JM, editors. General Hospital
Psychiatry. Amsterdam: Excerpta Medica; 1983. p. 95-100.
25.
Guimon J, Sunyer M, Sanchez de Vega J, Trojaola B. Group analysis
and ward atmosphere. In: Ferrero FP, Haynal AE, Sartorius N, editors.
Schizophrenia and affective psychoses. Nosology in contemporary psychiatry:
John Libbey CIC; 1992. p. 157-166.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
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Copyright © 2006
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26.
Guimón J, Weber B, editors. Thérapies groupales Brèves. Paris:
Masson; 2002.
27.
Ogrodniczuk J, Piper W, McCallum M, Joyce A, Rosie J. Interpersonal
predictors of group therapy outcome for complicated grief. Int J Group
Psychother 2002;52(4)):511-35.
28.
Marshall M, Crowther R, Almaraz-Serrano A, Tyrer P. Day hospital
versus out-patient care for psychiatric disorders (Cochrane Review). Oxford:
Update Software; 2002.
29.
Catty J, Burns T, Comas A. Day centres for severe mental illness
(Cochrane Review). Oxford: Update Software; 2002.
30.
Binks C, Fenton M, McCarthy L, Lee T, Adams C, Duggan C.
Psychological therapies for people with borderline personality disorder.
Cochrane Database of Systematic Reviews 2007(1).
31.
Guimón J, Luna D, Totorika K, Diez L, Puertas P. Group Psychotherapy
as a basic therapeutic resource in psychiatric community care from the General
Hospital. In: Ibor JML, editor. General Hospital Psychiatry. Amsterdam:
Excerpta Medica; 1983.
32.
Guimón J, Eguiluz I, Bulbena A. Group pharmacotherapy in
schizophrenics: attitudinal and clinical changes. European Journal of Psychiatry
1993;7(3):147-154.
33.
Moos RH. The social climate scales. A user's guide: Consulting
Psychologists Press; 1987.
34.
Moos RH. Evaluating treatment environments. The quality of psychiatric
and substance abuse programs. 2nd ed. New Brunswick: Transaction; 1997.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
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Avances en Salud Mental Relacional / Advances in relational mental health
Vol.5, núm.3 - Noviembre 2006
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal
35.
Kernberg O. Leadership and organizational functioning: Organizational
regression. IInternational Journal of Group Psychotherapy 1978;1978(27):3-25.
36.
Kernberg O. Regression in organizational leadership. Psychiatry
1979;42:24-39.
ASMR Revista Internacional On-line - Dep. Leg. BI-2824-01 - ISSN 1579-3516
CORE Academic, Instituto de Psicoterapia, Manuel Allende 19, 48010 Bilbao (España)
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