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N
EW
R
ESEARCH
F
INDINGS
T
HAT
A
RE
C
HANGING
C
LINICAL
P
RACTICE
Somatization: Diagnosing it sooner
through emotion-focused interviewing
Allan Abbass, MD, FRCPC
Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
Applied Evidence
somatization, the translation of emotions into
somatic problems or complaints. It is well docu-
mented—though still largely unrecognized in
practice—that somatization accounts for a large
proportion of office visits to primary care physi-
cians as well as specialists,
1,2
leading to unnec-
essary testing, treatment, and hospitalization,
disability and corporate financial loss,
3
likely
earlier mortality,
4
and frustration for patients
and physicians.
5
No longer a diagnosis of exclusion
Despite the burden somatization places on the
medical system, the diagnosis is often made by
indirect methods such as checklist, speculation,
or exclusion when other problems are ruled out.
6
The common position, even in recent reviews,
is that somatization should be treated by non-
specific measures, such as frequent office visits
to increase the patient’s and physician’s ability to
cope with what is often seen to be a chronic and
incurable disorder.
7–11
Such a position is no longer
warranted.
Based on recent quantitative and extensive
case-based research, specific emotion-focused
brief therapies and videotape-based research have
clarified how emotions are experienced in the
body and how somatization of emotions occurs
(see The physiology of emotions). These meth-
ods, including short-term dynamic psychotherapy
(STDP) have been used to diagnose and treat
somatization effectively since the 1980s.
Somatization, with its morbidity and chronicity,
Practice recommendations
■
Obvious anxiety in a patient with physical
complaints should prompt an evaluation
for somatization.
■
Become familiar with the 4 patterns of
somatization and their manifestations.
■
Learn how to conduct an emotion-focused
interview, which, when applied appropriately,
will help rule somatization in or out.
A
42-year-old man has chronic fatigue and
fibromyalgia that has led to a 13-month
disability leave from work. The reason
for his current office visit is longstanding pain
in his shoulders. As you take his history, he is
sitting with hands clenched and he generally
appears tense.
A 38-year-old woman with severe incapacitat-
ing gastroesophageal reflux disease, irritable
bowel syndrome, and depression has been too dis-
abled to work for 2 years. At the time of your
interview, her posture is relaxed and she shows
no signs of anxiety.
These 2 very different patients (whose cases
I will review in detail) share a common problem:
Correspondence: Allan Abbass, MD, FRCPC, Associate
Professor and Director of Education, Psychiatry, Director,
Center for Emotions and Health, 8th Floor, Abbie J. Lane
Memorial Building, Halifax, NS B3H 2E2, Canada. E-mail:
allan.abbass@dal.ca.
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 231
SOMATIZATION
232 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
need no longer be diagnosed by exclusion nor
treated palliatively without specific diagnostic
testing.
■
THE 4 PATTERNS
OF SOMATIZATION
Videotaped case-series research shows 4 main
patterns of somatization: 1) striated muscle uncon-
scious anxiety, 2) smooth muscle tension 3) cogni-
tive-perceptual disruption, and 4) conversion.
18
Striated muscle tension due to unconscious
anxiety manifests through hand clenching, sigh-
ing, and even hyperventilation that the patient is
not aware of. These patients may report panic
attacks, chest pain, headache, fibromyalgia, and
other musculoskeletal complaints. These condi-
tions are often frustrating to family, employers,
and physicians since conditions like chronic pain
respond to treatment slowly or not at all.
Smooth muscle tension due to unconscious
anxiety causes acute or chronic spasm of blood ves-
sels, GI tract, airways, and the bladder. Patients
exhibiting smooth muscle tension may present with
GI symptoms, migraine, hypertension, urinary fre-
quency, and upper airway constriction mimicking
asthma. They often report histories of depression,
panic, substance abuse, personality disorders, and
past sexual or physical abuse.
Cognitive perceptual disruption due to uncon-
scious anxiety typically involves visual blurring,
tunnel vision, loss of train of thought, and “drift-
ing,” wherein the patient is temporarily mentally
absent from the room. These patients have
chronically poor memories and concentration.
They are commonly victims or perpetrators of
partner abuse, have frequent accidents, and have
transient paranoia. They often end up seeing
neurologists and undergoing expensive testing.
Most have histories of dissociative disorders,
personality disorders, or childhood abuse. In the
family doctor’s office they frequently forget what
was said and call back after the appointment.
They appear confused and easily flustered and
either avoid physical examinations entirely or
endure them with great anxiety.
The physiology of emotions
To diagnose and manage somatization we
must know how emotions are experienced
and how they may become somatized.
Davanloo discovered through studying sever-
al hundred case videotapes that specific
emotions manifest in specific ways regardless
of gender, age, or ethnicity.
12
This emotion
physiology constitutes a norm to compare
with a patient who somatizes emotions.
For example, rage is experienced as an
internal energy sensation, heat, or “volcano”
that rises from the lower abdomen to the
chest, neck, and finally to the hands with an
urge to grab and do some form of violence.
Guilt about rage is experienced with upper
chest constriction or even pain, intense
painful feeling with waves of tears and with
thoughts of remorse about experiencing the
rage.
13
When feelings are experienced con-
sciously, by definition they are not being som-
atized at that moment.
Why somatization occurs
When feelings are intense, frightening, or con-
flicted, they create anxiety and defense mech-
anisms to cover the anxiety (see the Figure on
page 234). If these feelings are unconscious to
the patient, the subsequent anxiety and
defenses may also be outside of awareness.
This is the finding common in people who
have been traumatized by someone close to
them: feelings of rage toward a loved one are
unacceptable, frightening, and avoided through
somatization and other defenses.
14
Diverse
research has found that patients with hyperten-
sion, migraine, irritable bowel syndrome, and
other conditions internalize anger and thus
increase their somatic problems.
15–17
Blocking
and inhibiting of emotions, including anger, is a
common finding in somatizing patients.
SOMATIZATION
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 233
Major types of defense
Two important categories of defense include
isolation of affect and repression.
Isolation of affect is awareness of emotions in
one’s head without experiencing them in the body.
Intellectualization is a form of isolation of affect.
Repression is the unconscious process by
which emotions are shunted into the body rather
than reaching consciousness at all. For example,
strong emotions, including rage, may directly cause
sighing and a panic attack without the person being
aware of either the emotion or the sighing.
20
Experiencing the emotions
overcomes somatization
Videotaped research also shows that if a person
can experience true feelings in the moment,
somatization of these feelings is weakened and
overcome. The feelings being experienced push
out the anxiety and somatization (Figure). Thus,
somatization can be reduced or removed by help-
ing a patient feel emotions being stirred by recent
events or from past events. Through this process
Conversion manifests as muscle weakness or
paralysis in any voluntary muscle. Patients with
acute conversion describe dropping items or even
dropping to the floor as muscles give way without
explanation. They will often report histories of
witnessing or experiencing violent abuse.
One pattern usually predominates
The total amount of somatized emotion is dis-
tributed over the 4 pathways
(Table 1)
. One
pathway generally prevails at any given time,
though different pathways may come into play
as anxiety waxes or wanes. When anxiety is
expressed primarily through smooth muscle
tension, cognitive perceptual disruption, or con-
version, the striated muscles are relatively
relaxed.
This finding of apparent calm while somatiz-
ing has been noted elsewhere in research of
patients with hypertension.
This is the “belle
indifference” a patient expresses as they are tem-
porarily relieved of muscle tension through somati-
zation elsewhere.
19
Examples of diagnosable somatization patterns
Somatization Observations during emotion-focused Examples of related health
format diagnostic assessment complaints or health problems
Striated muscle Progression from hand clenching, arm Fibromyalgia, headache, muscle
tension tension, neck tension, sighing spasm, backache, chest pain,
respirations to whole-body tension shortness of breath, abdominal
(wall) pain, fatigue
Smooth muscle Relative absence of striated muscle Irritable bowel symptoms, abdominal
tension tension. Instead activation of smooth pain, nausea, bladder spasm,
muscles causes, for example, cramps in bronchospasm, coronary artery
the abdomen or heartburn. spasm, hypertension, migraine
Cognitive-perceptual Relative absence of striated muscle Visual blurring, blindness, mental
disruption tension. Instead patient loses track of confusion, memory loss, dizziness,
thoughts, becomes confused, gets weakness, pseudo-seizures,
blurry vision paresthesias, fainting, conversion
Conversion Relative absence of striated muscle Falling, aphonia, paralysis,
tension. Instead patient goes weak weakness
in some or all voluntary muscle
TABLE 1
SOMATIZATION
234 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
one may diagnose somatization and also produce
a therapeutic effect for a patient.
■
DIRECT DIAGNOSIS
OF SOMATIZATION
An objective assessment
Because the process of somatization is uncon-
scious to the patient, diagnosis is based on objec-
tive findings during examination rather than on a
patient’s report. This is similar to evaluating a
patient with abdominal pathology: we would not
expect the patient to report an abdominal mass,
even though we could detect it and train the
patient to palpate it. The somatizing patient
believes the problem is physical, so the history
reported is more likely to lead to physical testing
and medical treatments than to a direct examina-
tion of the emotional system. Although clues in
the history may suggest a patient is somatizing,
20
the definitive test, like that of an abdominal exam-
ination, is “hands on,” observing the patient’s
direct response to an emotion-focused interview.
Actively exploring emotions
Examination of the emotional system is analogous
to a physical examination of other systems, and
progresses from observation to “palpation” or
“percussion” (Table 2).
Observe the patient for visible unconscious
anxiety. Then, in the context of a supportive
patient-doctor relationship, explore emotionally
charged situations that generate symptoms.
Alternatively, one may ask in what way strong
emotions like anger affect the patient’s physical
problems. Asking about specific recent events and
feelings that were triggered usually mobilizes
emotions, giving you and the patient a direct look
at how emotions affect them physically.
If a patient is anxious in the office, it will be
most meaningful to examine the feelings they
experience during the interview.
Managing defenses
At times, the defenses used to avoid feelings must
be pointed out before the patient can see and
interrupt these behaviors. If the process is too
detached or intellectual, then feelings will not be
activated and the system cannot be assessed. The
physician’s rapport allows him or her to clarify the
process and the need for the patient to try to
approach and experience feelings when speaking
about them. This is analogous to the process of
Relationship between unconscious feelings, anxiety, and defenses
FIGURE
Unconscious feelings
Grief
Rage
Guilt about rage
▲
▲
▲
Unconscious defenses
Isolation of affect
Repression of affect
Conversion
Unconscious anxiety
Striated muscle tension
Smooth muscle tension
Cognitive-perceptual disruption
SOMATIZATION
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 235
examining a sore abdomen when a patient is
guarding: the patient must relax for examination
to take place, and we help them do this by
explaining the process.
Patients who are defensive and insist the prob-
lem is not related to emotions are managed differ-
ently. These patients usually are quite tense and
already emotionally activated. An open examina-
tion of feelings the patient has about coming to see
you that day is a good way to begin. Through this
focus one can see the patient’s somatizing patterns
directly as well as develop a working rapport.
Managing anxiety
If the patient becomes anxious when asked about
emotions, introduce a calming step by asking the
patient to intellectualize about the specific bodily
anxiety symptoms. This reduces the anxiety by
using the defense of intellectualization.
Recap and planning
The interview is concluded by reviewing the
findings with the patient in the same way
one would share findings of a blood test.
Management options would depend on the find-
ings and may include another interview, further
medical investigations, referral for treatment,
or follow-up to gauge the patient’s response to
the interview itself.
■
INTERPRETING THE PATIENT’S
RESPONSES
With the focused assessment, the somatic
symptoms will transiently increase or decrease,
disappear, or not change at all (Table 3).
An increase in symptoms with emotional
focus suggests that emotions aggravate or
directly cause the problems. A decrease in
symptoms during the test also suggests a link-
age to emotions. Disappearance of the symp-
toms by bringing emotional experiences to
awareness is the best direct evidence that som-
atization of these emotions was causing the
patient’s symptoms.
No change in a patient’s symptoms or signs—
provided there was adequate emotional activa-
tion—suggests no somatization of emotions. In
these cases, other physical factors must be
sought. For example, a woman with chronic left
leg weakness and numbness had no shift in symp-
toms with this test: she was found to have neu-
ropathy due to multiple sclerosis. We have found
Exploring emotions in a patient-centered interview
Action Example
Observation Note any signs of unconscious tension, somatic distress, or
defensiveness from the start of the interview
Ask about emotions Can you describe a situation when the symptoms get worse?
What feelings do you have when you talk about that?
How do you experience the feeling of anger in your body when it is there?
Distinguish feelings from The tension you had was anxiety, but how did the anger feel?
anxiety or defenses Becoming quiet was what you did but how did you feel inside?
Observe physical Observe the physical and behavioral responses in the patient
responses when the emotional system is activated
Give feedback and plan Review all findings with the patient. Verify the patient agrees with
what you have observed. Plan any further treatments or referral
TABLE 2
SOMATIZATION
236 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
that 5% to 10% of patients referred to our diag-
nostic clinic have physical problems that were
mistaken for somatization.
False negatives
False negatives occur when the test does not
detect the process of somatization when it is pres-
ent. This will occur if the level of emotion mobi-
lized was too low, if the patient is too sedated, if
the defenses the patient used were not sufficient-
ly interrupted, or when the patient is not working
collaboratively with the doctor during the test. In
each case the patient must allow emotions to be
mobilized and the doctor must focus adequately
on the emotional experiences to yield an inter-
pretable response.
False positives
False positives occur when the patient has a
rise or fall in symptoms during the test for other
reasons—eg, coincidental shifts in episodic
conditions like muscle spasm or symptom
reduction due to distraction during the test
itself. It is important in these cases to repeat
the test more than once and see if the results
are reproducible.
■
TREATMENT: SHORT-TERM
DYNAMIC PSYCHOTHERAPY
STDP is clinically effective
for patients with somatization
Short-term dynamic psychotherapy (STDP)
formats specifically help a patient to examine
trauma and loss-related emotions that result in
somatization, depression, anxiety, and self-defeat-
ing behaviors. Case-series videotaped research
over the past 30 years has established the effec-
tiveness of the methods in both short and long
term follow-up.
21
STDP is efficacious in controlled trials
and meta-analyses
In 1995, Anderson and Lambert
22
conducted a
meta-analysis of 26 controlled studies and found
Interpretation of responses to emotionally focused assessment
Response Interpretation and action Beware of
Response 1: Symptoms go The diagnosis is likely False positives due to coincidental
up with emotional focus then somatization. Prescribe symptom changes in interview
down after focusing away emotion-focused psychotherapy
from emotions and monitor for gradual Health problems unrelated to the
symptom removal somatization could always be present
Response 2: Symptoms are The diagnosis is (was)
improved or removed by somatization of those
emotional focus or emotional emotions. Follow-up to see
experience in the office if gains are maintained
Response 3: No change in Somatization is unlikely to be the False negatives due to high defenses,
symptoms cause of the symptoms. Look for sedation, lack of cooperation,
physical causes. inadequate focus by physician
Response 4: Unclear May or may not be an emotion-
response based component in the symptoms.
Repeat test, consider other
diagnostic tests or referral for
emotion-focused diagnostic testing
TABLE 3
SOMATIZATION
MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice 237
STDP to be superior to minimal treatment con-
trols and wait lists including in samples with som-
atization. It was found to be as effective in remov-
ing anxiety and depressive symptoms as cognitive
behavioral therapy. A recent meta-analysis,
23
using more strict inclusion criteria, yielded the
same findings. In a recent randomized controlled
trial of symptomatic patients with personality dis-
orders, STDP brought significant symptom reduc-
tion while cognitive therapy did not, suggesting
that STDP may have added benefits in more
resistant and complex symptomatic patients.
24
In our current Cochrane review search,
25
we
have found 40 published randomized controlled
trials supporting its efficacy with a range of dis-
orders including ulcer disease, irritable bowel
syndrome, dyspepsia, and urethral syndrome.
26–29
Our review has likewise found STDP to be superi-
or to minimal treatment or waitlist controls and
that the gains are maintained in follow-up averag-
ing over 1 year.
STDP is cost-effective
and reduces health care utilization
STDP has been shown to reduce healthcare uti-
lization and to be cost-effective in treating
patients with dyspepsia, irritable bowel syn-
drome, depression, and self-harm and treatment-
resistant conditions.
30
Of specific cost figures
cited in reviewed papers, 27 out of 34 showed cost
savings with STDP including reduction in total
costs, medication costs, disability, hospital, and
physician use.
■
CASE ILLUSTRATIONS
Case 1: Striated muscle anxiety
This 42-year-old man had chronic fatigue and
fibromyalgia which lead to a 13 month disability
up to the time of consultation. He came to the
office with longstanding pain in his shoulders.
His hands were clenched during the interview,
and he appeared tense while giving his history.
DOCTOR: Can you tell about a specific time when
you had an emotional upset so we can understand
how exactly it affects you?
P
ATIENT: Yeah, problems at home with my wife….
Saturday she wanted me to do some work on the
garage. She started to yell. Every day it’s the same
thing and I’m getting tired of it.…
D
OCTOR: So how do you feel toward her?
P
ATIENT: [Takes a deep sigh, hands become
clenched] Mad.
D
OCTOR: You mean mad … angry?
P
ATIENT:: Yeah.
D
OCTOR: How do you experience the anger inside
physically?
P
ATIENT: Very, very… tense
D
OCTOR: That is tension…anxiety?
P
ATIENT: Yeah.
D
OCTOR: How did you experience the anger?
P
ATIENT: I start to ignore her.
D
OCTOR: Is that a mechanism to deal with anger?
But how do you experience anger underneath?
P
ATIENT: It’s really hard to put a word on it…. I get
really mad...it’s like a rage.
D
OCTOR: So how do you experience the rage?
P
ATIENT: [Patient takes a big sigh and clenches his
hands tightly]
D
OCTOR: Do you notice you sigh and become tense
when you talk about the rage.
P
ATIENT: No, I didn’t. I don’t feel anxious.
D
OCTOR: But, do you notice the sigh and your
hands?
P
ATIENT: I do now, but didn’t see it before.
D
OCTOR: Is this what is happening to you … that
you are getting all tensed up about these feelings?
P
ATIENT: Yeah, it must be.
At a later point in the 1-hour session, the
patient was able to feel the visceral emotions of
rage, guilt about the rage, and sadness over sev-
eral years of conflict. When the feelings were
experienced in the office, he had an abrupt drop
in muscle tension and bodily pain: this was fur-
ther evidence he had been somatizing, or as he
said, “bottling up” these complex feelings.
As is typical of patients with primarily striat-
ed muscle anxiety, he denies being nervous
despite showing obvious anxiety in the inter-
view. He denies anxiety because it has been
unconscious to him, thus free to create
fibromyalgia pain. Through this single interview
a link is made for both patient and doctor
between blocked feelings and body pain. With
10 treatment sessions focused on this process, his
fibromyalgia resolved; he returned to work and no
longer needed antidepressants.
Case 2: Smooth muscle anxiety
This patient is a 38 year-old woman with severe
incapacitating GERD, irritable bowel syndrome,
and depression who was disabled from work for
2 years at the time of consultation. This woman
had a very relaxed posture with relaxed hands
and an absence of obvious anxiety. After 10 min-
utes of exploring situations and events that
make her stomach worse, we arrive at the
following point.
DOCTOR: Can you tell me about another time when
your stomach felt worse?
P
ATIENT: Yes. There was once when my sister-in-
law did something and it made me angry. Yeah,
when people make me angry I don’t tell them, I just
avoid them.
D
OCTOR: Can you describe one of those times, so
we can see how that affects you.
P
ATIENT: Once she was arguing with my brother,
like they usually do….
D
OCTOR: How did you feel then?
P
ATIENT: … Now I just got that again [pointing to her
stomach and chest with upward motion and burps]
D
OCTOR: Heartburn? Just came on?
P
ATIENT: Yeah, heartburn, just came on.
D
OCTOR: Is there anything else you notice? Like in
your stomach?
P
ATIENT: No, just that … but I can hear my stomach
churning.
D
OCTOR: So is it when you have anger your stom-
ach churns and you get this acid?
P
ATIENT: Must be….
D
OCTOR: ...because in your approach to talk about
anger you got cramps and acid. So is that one way
the anger goes?
P
ATIENT: Yes it must be, but I never thought of that
part. [Stomach stops churning and heartburn stops
as we talk about it for few minutes.] You know, this
all started to get worse when my fiancé dumped
me. [She goes onto describe a story of being not
only rejected but also feeling humiliated by how it
was done. She never felt emotional about it but just
got severe diarrhea and was confined to her room
for 3 weeks.]
D
OCTOR: How did you feel toward your fiancé when
he dumped you that way?
P
ATIENT: I was just so sick and depressed. I didn’t
feel any anger. [Patient burps again this time rubs
abdomen due to some discomfort.]
D
OCTOR: Did you get the stomach upset just now
again?
P
ATIENT: My stomach is upset again. Just the noise
and acid again.
D
OCTOR: So again, when we focus on the feelings,
the cramps and acid come back.
P
ATIENT: For sure. What can we do about that?
D
OCTOR: Can we try to help you identify these feel-
ings before they go to your stomach, to try to inter-
rupt that process. Can you tell me about another
incident like that?
The patient required 3 one-hour sessions to
improve her tolerance of anxiety, so she could intel-
lectualize about feelings rather than have them
directly affect her stomach. The feelings of rejec-
tion had triggered rage and guilt about rage associ-
ated with sexual abuse by her brother and the
abandonment she felt from her mother when she
told her mother about it. With 12 sessions of ther-
apy, she was able to stop her IBS medication, anx-
iolytic, and antidepressant.
This vignette is typical for patients with
primarily smooth muscle unconscious anxiety.
The patient had no visible anxiety but had GI
symptoms when focusing on emotions about
recent trauma. The symptoms were mobilized
and reduced repeatedly, confirming a link with
emotions. Note that outwardly she looked calm,
but the emotions mobilized were being shunted
to her GI tract.
238 MARCH 2005 / VOL 54, NO 3 · The Journal of Family Practice
SOMATIZATION
■
INCORPORATING EMOTION
DIAGNOSTICS INTO PRACTICE
To perform these interview procedures, the physi-
cian must understand emotion physiology and
the patterns of somatization as outlined above.
This is entirely intuitive to many physicians the
first time seeing this material: they can readily
employ that which they already know. In general,
though, physicians reading this will want to pon-
der it and see how it may apply case by case as
they develop skills with it over time. Senior clini-
cians have usually done these assessments by
default, by pressure from patients, or because
they learned elements of this over time from var-
ious experiences.
Helpful short-cuts
Family physicians trained in emotion assessment
note that abbreviated elements can easily be
incorporated into a patient-centered assessment
process. For example, one may ask how “stress,”
“emotions,” or “anger” affects the person and
their body or ask how the person handles anger in
specific incidents.
In an initial patient questionnaire, one can
include a few questions that encourage the
patient to think about how stress affects them and
to describe their body’s tendency to experience
anxiety. When they later present with symptoms,
one can use these baseline data to aid in the new
assessment. Thus, a culture of considering emo-
tional factors can be woven into practice, weak-
ening any resistance to the idea that emotions and
health, mind and body, are tightly bound.
Time factors
Based on our experience, family physicians can
perform two thirds of these diagnostic assess-
ments during 15 minutes of focused interviewing.
More complex cases, such as patients with cogni-
tive disruption or multiple manifestations of anxi-
ety, may take longer to diagnose and generally
need more specialized care or referral. If required,
a patient could be asked back for a 1 half-hour
session later in the day or week.
Taking care of ourselves
Despite the importance of the emotional system in
medicine, medical curricula generally fail to pro-
vide sufficient education in this area. At the same
time, up to half of our own ranks report emotion-
al burnout.
31
Even with the lack of mainstream
medical teaching about emotions and health, it
behooves us to learn what we can about the emo-
tional system as it applies to the patient and to
ourselves in relation to these most challenging
problems. Focused seminars, peer case review,
select reading, and videotape training can all help
in this educational process.
32
ACKNOWLEDGMENTS
The author wishes to thank the many colleagues who
reviewed and commented on this manuscript. This work is
supported by Dalhousie University, Capital Health and the
Nova Scotia Department of Health.
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