Borderline personality disorder is a mental disorder characterized by a longstanding pattern of instability in one’s relationships with others, with a person’s own image of themselves, and their own emotions. It’s marked by impulsivity and, like most personality disorders, usually begins in early adulthood (early 20s) and pervades every aspect of a person’s life.
People with borderline personality disorder live tumultuous lives. Their romantic relationships rarely last more than a year, and their relationships with their own family tends to be unstable — some weeks they love them and want to spend all of their time with them, some weeks they hate them and won’t even talk to them (to extremes not usually experienced by the rest of us).
Traditionally, the treatment method most often recommended for people with borderline personality disorder has been a form of psychotherapy called dialectical behavior therapy (DBT). This form of psychotherapy has decades’ worth of research backing and is considered the “gold standard” for the treatment of borderline personality disorder. While DBT is effective, it requires an experienced and specially trained therapist, and long-term commitment on the client’s end. This can sometime limit a person’s ability to obtain this type of therapy. Many times it’s used as a group therapy process, which can also be scary to some potential clients.
And while DBT’s effectiveness is well accepted, it’s not as well known how it compares with other forms of treatment for borderline personality disorder over the long-term. A new research study (McMain et al., 2009) sheds some light on this issue.
Researchers studied 180 participants who were diagnosed with borderline personality disorder, of which 111 completed the year-long study. They were divided into two treatment groups — dialectical behavior therapy and general psychiatric management. What’s general psychiatric management?
General psychiatric management was based on the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder and manualized for this trial. This coherent, high-standard outpatient treatment consisted of case management, dynamically informed psychotherapy, and symptom-targeted medication management. Pharmacotherapy was based on the symptom-targeted approach but prioritized treatment of mood lability, impulsivity, and aggressiveness, as presented in the APA guideline.
What did they find? Surprisingly, the researchers found that after a year’s worth of treatment for both groups, both groups significantly improved. And worse yet for DBT, there were no significant differences between the two treatment groups.
This trial demonstrated that 1 year of dialectical behavior therapy or general psychiatric management for the treatment of suicidal patients with borderline personality disorder brought about significant reductions in suicidal behavior, borderline symptoms, general distress from symptoms, depression, anger, and health care utilization, along with improvements in interpersonal functioning. Contrary to our expectations, dialectical behavior therapy was not superior to general psychiatric management with both intent-to-treat and per-protocol analyses; the two were equally effective across a range of outcomes.
One interesting data point, however, that the researchers didn’t discuss. You can see it pretty clearly in this graph:
Although this difference was reportedly not “statistically significant,” people in the general psychiatric management group had nearly 3 times the number of self-injurious episodes every month than those in the DBT group at the end of the one year treatment. That seems pretty significant, if not statistically, then at least clinically.
The other concern this article again points to is that between 38 and 39 percent of patients dropped out of treatment before the year was up. So while it’s interesting that both treatment groups benefited from the intervention, nearly 40 percent of people still aren’t helped by either (of those who returned survey about why they stopped treatment, 42 percent of subjects said that the treatment wasn’t helpful).
This is the largest trial to compare DBT against another standardized treatment and another datapoint that dispels the myth that borderline personality disorder is “untreatable.” Borderline personality disorder is treatable and this study demonstrates yet another treatment approach that appears equally effective as the “gold standard” DBT.
Reference:
McMain, S.F., Links,P.S., Gnam, W.H., Guimond, T., Cardish, R.J., Korman, L. & Streiner, D.L. (2009). A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder. Am J Psychiatry.
DOI: 10.1176/appi.ajp.2009.09010039
34 comments
Hi John,
Thank you for yet another interesting article.
Just wanted to add to the discussion and make reference to;
“The other concern this article again points to is that between 38 and 39 percent of patients dropped out of treatment before the year was upâ€.
This seems to be yet another symptom of Border line personality disorder, taking into account that their relationships rarely last longer than 12 months.
“People with borderline personality disorder live tumultuous lives. Their romantic relationships rarely last more than a yearâ€
“….dispelling the myth that borderline personality disorder is “untreatable.†Borderline personality disorder is treatable and this study demonstrates yet another treatment approach that appears equally effective as the “gold standard†DBT.â€
Again treatments are only effective if completed. Commitment and momentum being a crucial aspect of any therapeutic intervention.
Many thanks
Regards
Dawn Pugh
Ah, you’ve misunderstood the meaning of statistical significance. It means that a check was made between two results, and checks to see how much these numbers could deviate purely by chance, and thus the possibility that the two groups are indeed different. Usually it’s calculated taking into account the sample size and the standard deviation, and checks to see if there is a 95% or 99% chance that the results overlap.
Yes, it was thought provoking too.
I have been on the recieving end of a ‘treated’ borderline. He was living quite happily in a long term relationship.
But he reacted so strongly because I wouldnt comply with the general expectations of the group we were both involved in, I found myself on the recieving end of ‘talionic rage’. It was so toxic that eventually, it got inside me and contributing to me having to leave the group, at least, take some time out.
The problem being, if you measure the recovery by absence of the symptoms of distress, because you have done what it takes to patch up the problem, this is what you get. All has been restored to status quo. On the other hand, if you see these symptoms as a cry for meaning, and a sign of the expression of a personal and societal pathology, and aim recovery at the underlying intrapscychic structure and it motivations, theres a chance of genuine change.
Seeing as one disorder inevitably gives rise to or perpetuates other people’s disorders, and various forms of disorder are pervasive in society, from knife crime to absurd consumerism, to wars etc, from what I can see, the only genuine way to treat the disorders must include this more inclusive focus on intrapschycic struture.
More info can be found eg: Masterson+ Klein literature. It can be accessed on Amazon, or many other places.
best wishes,
river
More information on: http://www.selfinexile.com
Speaking from the position of someone who has undergone the DBT program at a facility by the name of Adult and Child located in Indianapolis Indiana, I am troubled that there are vague descriptions of the DBT treatment. I was not told the title of the treatment was “intensive adult therapy” also called DBT. Upon having the facility cancel services to me due to missed appointments which were due to the no children allowed into the therapy sessions and my lack of financial ability to afford childcare, a year later I began researching my own diagnosis. Though there are a few symptoms that match my diagnosis I believe that the strong therapist relationship never developed because I saw three to four different therapists before being settled into the promised strong patient therapist relationship. This DBT is a half ass treatment. It is impractical to the lifestyle needs of the patient. Though patients need therapy it is unfair to leave a patient with open psychological doors due to incomplete treatment. It is a psychological rape. The recipients of the grants fill their roster to boost numbers of patients who are being helped. The truth is that the nightmares and unemployment risks that the patient is left with is an unfair exchange of yet more mental torture. There were no nightmares before therapy. This door has been opened and the facilities roster is all full now. I suffer from more problems NOW then I did before this token therapy was begun and left unfinished.
A correction to my previous post… The vague description of the DBT is given by the facility. There is more description online. Also, omitt the word not in my second sentence. I was indeed told that the name of the treatment was “intensive adult therapy.” It was an overgeneralization of what I needed. The title does no justice to what a person is exposed to.
Perhaps, we as patients should demand each session be recorded by video or audio for our own protection and peace of mind. To teach a patient self mind control is one thing but to have a therapist exercising mind control over the patient is a totoally different matter. Buddhism is described as the source of the mind control element in DBT treatment in one particular aritcle so this leaves me wondering if my Christian values have been compromised due to this exposure. I was NOT informed of this at the time of services. I had to read it for myself online.
In DBT there is absolutely no “mind control†being done to a client by a therapist. The skills used in DBT are teaching the client how to change his/her negative and self deprecating thoughts into more effective self-compassionate ones.
i am just beginning a type of DBT that is what my counselor is calling self-based because they #1 have no DBT counseling at the VA where she is based and #2 I am some 3 hours away having sessions with her over a teleconference television set. How this is going to work out I don’t know but it sure seems like alot is being put on me to get to the library to do my own research and then report back to her what I feel I have learned. In the process if I feel like I’m going to hurt myself or worse I call the “hotline”. Does this sound right to you?
I suffer from borderline personallity disorder. After my last therapist, I decided not to engage secular therapist anymore. I am still friends with my last therapist. She was the only therapist I could talk to, after looking for over 20 years, because she did encourage me to educate myself about my diagonosis and to educate myself about alternative methods to use to effect my healing and she was not threatened that I did so, and brought back the results. At the time I was buddhist when I met her, and I since have become EOChristian.
I’m so glad to see in this description of the disorder that they have not used the word manipulative. Because my foster mother was extremely and ruthlessly manipulative, I at age 11 made a solemn promise never to be that way, or to cause harm to others, just because my mom caused harm to me. In fact that aspect of the diagnosis, hurt me more, since my mom would often blame me for things I did not do, and then mercilessly beat me…so you see, socialization patterns definitely play a part in how i interact with people.
the biggest inability is the inability to bond well with people. However, I’m with Marion Beedy that we live in an addictive society, and most people in our society are addicted to power and a feeling of omniscience–if you reject this–and I have, and I’m not goody two shoes, I think your problems as a borderline personality disorder sufferer escalates. Because most people are surviving a very dysfunctional society, and doing what it takes, that is selling their soul to do so.
So that I’ve noticed that my symptoms are situational. I was just living in a room where the two male members in the home, where the room was situate, began to make sexual advances to me, even though I’m told I dress either like a muslim or a nun. I did not interact with them before or after the first approach, and it got so bad, I had to call the police. Did the signs of borderline personality disorder flare up? You bet. But the police came, and read the riot act, the mother, later apologise, and I did some research and learned that the men were operating from a cultural belief that women could be treated this way. My Church sustained with because there I had positive interactions, and at the room, I had a key, and even though I was having nightmares–I think I managed to not let the symptoms derail me.
Secondly, the current place I live in has different issues. The person here is a screamer, and they play favorites–they are very nice people otherwise, but somehow they have decided that they need to ‘put me in my place’; In this case I feel I’m being extremely challenged; I feel isolated, and unheard; I feel as though they are seeing me through cultural filters and their own idiosyncratic filters, which make them unable to respond to me as human being. Even when I’m being of service to them, I feel that they are threatened by me–so I feel scapegoated here as well, and I have had moments of feeling as though I don’t really exist, for these people. Only their perception of me exist, that when they see me they see a cardboard stereotype and they have stock ways of interacting with that stereotype. Feeling trapped I have responded passively aggressively, since I don’t feel as though I’m being heard, by I confessed all to my Priest–and I’m committed to working this through, although right now I’m very frightened and basically have to learn how to trust in the things that have worked for me in the past, namely for me the commandments and injunctions of the Church. And to forgive even those members of it, who don’t understand this disorder, and can not counsel well.
The woman I work for has created a hostile environemnt by talking derisively about the different aides to each other. Then they complain to the tenants they have sharing the house, and it causes alot of bad feeling all around. I’m privately hired caretaker, and the day aides work for an agency. The aide that comes during the week, also does extracurricular work for the agency that interferes with her being able to get to work on time, when I will have to leave for my own day job, and for school. I cannot leave the client, for I will be liable for abandonment charges. So this is a little bit of what is going on, plus the fact that there is no teamwork atmosphere in this thing–and the Lady of the House, who employs us to take care of her mother actually encourages this…she did admit to me that she was a control freak.
So I have to fight feeling lack of self esteem and on the other hand pumping my self up unduly to compensate for what I feel is happening to my psyche and soul as a result of their ignorant and exploitive behaviour.
It is a beautiful house, clean and immaculate and they are very sweet people; except when they engage in this dismissive and exploitive behaviour.
Upon first meeting them, one becomes somewhat enamoured of them, living with them is another matter–yet-since no one is perfect, especially myself who have no social skills at all, I have to learn how to live with the negativity of others, without descending into the hell of this disorder.
The Church helps–usually I have someone to talk to about it who can walk me out of the panic modes of responding and into healthier modes of responding. I don’t have that anymore, because my therapist is now my good friend; and it seems that I just need to try and practice everything I learned in the Church, but its easier to do what I’ve always done, even if it is distructive. So I have to fight sloth in the application of the medicine.
I guess I’m finally learning to see it as trying to heal myself, and not trying to change them.
And without trying to give back what I feel I am unjustly receiving. Not trade evil for evil, so to speak.
So, anyway, that is how it is. I think there are so many obstacles to getting good curative care for any psycho-social disorder; and since most of us are compromised economically because of the disorder, I think it needs to be addressed to make sure people are getting this care. I think the DBT sounds promising, and I tend to not want to have a drug be a cure for what ails my soul–which is broken by what I’ve experienced in an abusive family enviroment, that included mental, physical, sexual, and emotional abuse, and deliberately being told I was unworthy of love.
So I think one should go ahead and educate oneself, not be dependent on others so much for validation; and also find really good supporter-therapists of your recovery who are part of your team to beat this monster, who encourage you to rely on your own sources of strength within you; (For me that includes my belief in God as a chief healing agent as well as advisor).
I managed to work through the last darkness, that I came from by education, not demonizing my oppressors, and actually leaving on good terms.
How it will fare here, I do not know…but I have to not give into sloth-habit and be in panic-mode.
There is a way out–if one really works the program.
I think you have to see the generalized approach that incorporates pharmacotherapeutic agents, and the dialectic behavioural approach as two sides of the same coin, as they both include a dialectic approach through the conversation that happens between the client and the therapists.
I think creating healthy envionments through group therapy where folks practice what they are learning–is good too. They should probably both be employed.
I was diagnosed with BPD many many years ago. I have undergone DBT and frankly it was a joke. I had a 15 year stable period due to a great therapist. She practiced rogerian therapy… costly but it seemed to keep me fairly grounded. My therapist retired in 2000 and since 2007 I lost my teaching position with the College and have been hospitalized many times. I am trying to get back on the road, but it is not easy. I am a Buddhist and find that my religion does help.. but I would like to find another Rogerian Therapist who was as good as my previous therapist. Oh, well.. just thought that I would comment.. Thanks for listening. G
Simply laying out the criteria for BPD is offensive to read. Without a known absolute boundary for every emotion, how can anyone say my commitment to my friends is not important? (20+ years) Or that my thinking is black/white: how so? It isn’t. But I was accepted to DBT, anyway. It was silly, so I lost interest. They encouraged clients to behave badly (to cry, complain excessively, gesture to cut). For me, failed suicide attempts gave me the dx. But I really don’t think life is very nice. I really have HIV/AIDS (and can prove it). I’m too shy to be overly manipulative, or cruel. I don’t run from love to hate. Until there is some science to back up the claim that BPD exists, independent of Manic Depression or some other mood lability issue, I remain skeptical. But not too skeptical! Meanwhile, everything I write or say can end up being seen as a (mere) symptom. Peace to all, and best of luck navigating this age of efficiency.
-Sylvester, New York City
Hi all and Dr,
I have an interesting concept and perception. I am not sure how accurate I am in my understanding, and run the risk of sounding ignorant. Another cure for BPD might be, a healthy relationship. I am not sure it would be possible to reproduce this in a lab though.
Trying to make a very long story short. Over the past year, I have found a need to familiarize myself with different psychiatric diagnosis. I believe it is possible that my soon to be ex-wife suffered from BPD. I was amazed when I read the NIH’s description of it. I remember reading the description and thinking, this “these types of behaviors have been deomstrated for the past 12 years.â€
My nature is that of a patient person. I am not easily offended or embarrassed. If somebody I care about does something that disappoints me I tell them “I love you, but this action or is disappointing.†My flaw is that often avoid conflict and sit on something disappointing for days or even a week before I speak up. (the classic passive aggressive “silent treatmentâ€.)
Once things got serious, “I love you†flowed like wedding wine from both of us. The “how was your dayâ€, “good jobâ€, “I appreciate you†attitudes that are common in maintaining healthy relationships were daily routine. We never had so much as a raised voice argument.
Slowly over the course of the first 3 to 4 yrs., those behaviors described in the BPD symptoms lists drifted away. We were the couple that everybody envied. Nobody thought for a second we wouldn’t go the distance. Especially not me.
At 9 years we were financially set and decided to have a baby. After having to abandon breast feeding my now wife became a little depressed. She was quickly prescribed Zoloft. I was adapting to the meaning of the new role of father. I had been told to be patient while my wife’s hormonal system settled after having the child. So I didn’t even think to think of the situation as the result anything else. Slowly, those behaviors that listed as BPD symptoms returned. At first towards neighbors and co-workers. Then towards family members. Then towards the baby. Finally the agitation was turned on me. I became agitated myself and my protection mechanisms kicked in to protect the baby. There wasn’t as many “I love you’s†and “great job’s†as there was in the past. Then my wife who had abandoned Zoloft, was prescribed Prozac. Shortly after that, what can only be described as “manic behavior†started. That behavior lasted at least 6 month. It may be still going on today, I don’t know. Legal proceedings have separated us.
Is it possible that a healthy relationship could at least make dormant these symptoms of BPD?
LOL,
You raise an interesting point. My 15 year period of stability was very much due to a solid relationship with my partner, my therapist, and having a great job… and a great dog. When all of these were gone all of my disfunctional ways of thinking returned. You do have a great point. Thanks. Gregory
If the myth that Borderline Personality Disorder is not treatable is cultural within the institution at large then I am curious as to which cultural values would reinforce the myth or the lack of treatment for those individuals?
The good thing is that some institutions are slow to change so it may be easier to spot the cultural reasons if you look back at the history of the institutions policies and procedures.
Pardon my bluntness, but it really sucks searching for a therapist/group/treatment that really gets BPD. I live in Indy and would appreciate any suggestions.
Sincerely.
New here and trying to find other people with BPD to discuss what has helped them. I spent a year in therapy many years ago and was never properly diagnosed. With help from the Internet, my physician-and now ex-boyfriend-I most definitely have BPD.
I’ve been divorced twice and just lost the real love of my life after almost 10 years. I’m devastated, no longer have health insurance and can’t afford therapy. My BPD seems to be worsening, I’m 46 years old. Has anyone got any suggestions?
This is a while ago; I so hope this person found help. For others reading, I’ve found dbtselfhelp.com to be life-changing. I also journal, as it’s the stable surrogate friend/listener to get issues out where I can examine them.
Marsha Lineham also has her own website. What an inspiration! She went through terrible times with BPD, including awful periods of being institutionalized. Now she’s a respected leader in the field she pioneered, and teaches others how to free people from BPD.
I’d also encourage others suffering without insurance or funds to look again for resources. I’ve had to suck it up and admit I didn’t have money to agencies I was taught were for “those other people” but, there is help available. I also found affordable help from grad school student, supervised counseling. This was actually of a very high quality; I’d rate it as the highest I received from any source.
You can feel better.
AJ
Its so amazing I have the same life story as yourself. Am just in the process of starting some treatment. Would love to hear from others too. Best of luck
I’m not coping with my life situation at all and have managed to lose everything and everyone I and the damage I’ve done to relationships and my own life is beyond help.
I envy those who have secure relationships to build upon.
Worsening for me too despite being 56.
well now i know whats wrong with me. i am disabled and my kids don;t give a rats arse about me. so what do i do. there is on one, not one single person who cares about what happens to me. everyone is too busy. if i disapeared tomorrow, people would be relieved.i want to live, i want someone to see me, and maybe love me.nobody knows who i am, no one has ever bothered to take the time to get to know me. how could anyone care about me when i cant stand myself??my life is over, sometimes i think about standing on the train tracks and waiting on the train. life is just too difficult. i am tired of being alone.i am tired of giving everything i have ti someone who just throws me away like trash on the side of the road. or treating me like i am something nasty that is stuck on the bottom of their shoe.i am too broken to be fixed.i am tired of being ignored disrespected, laughed at.this struggle is just to much.
I have said everything that you have said. Trust me, EXACTLY THE SAME WORDS. You got to hang in there. Somehow, someway. I love to laugh so just find something that makes you laugh. God bless u!
You wrote this in 2013, what has become of you. I have the same issues and can ask no one to help. I just keep pushing till I am standing alone on the railroad tracks asking what the F did I do this time. At no time in my life have I ever felt love, in any way by any one, just keep smiling and no one will see me. As of write now I say f this life and all that call me there friend or family. I hate being!
I think BPD is not such a big ogre as it is made out to be.In cases where professional help is not available or not feasible due to financial considerations,or the patient is not able to relate to any therapist;self-help & earnest efforts can go a long way towards aiding recovery.A forgiving attitude on part of the family too is a must so that after any set-back the patient is motivated to continue his/her journey towards self improvement.
Yes that’s very easy to say when you are not considering the fact that many people with BPD also have co-morbid disorders,take clinical depression for example which is worsened by BPD.Ever tried studying while going through a depressive episode? Then you would know that most of your energy is gone and you are having great difficulties with concentration & memory making it almost impossible.Being and staying motivated is very difficult as well as coping with the mood swings & suicidal tendencies,it affects almost every aspect of your life,not to mention the energy draining from frequent crises.It depends on the severity of your condition of course.Why is such intense regular therapy prescribed if it’s not that big a deal? If you had a severe or moderate form of the disorder I don’t think you would be saying “BPD is not such a big ogre as it is made out to be”
Considering the families some BPDs were raised in, you might want to re-think that idea.
You have made a very good point Patrick about the advantages of DBT being a non-drug based therapy.
I was diagnosed 8 months ago. I`ve read as much as I can. I disagree with this diagnosis. I was admitted to the psych ward after a suicide attempt, (my 2nd) I never spoke with a psychiatrist until after I left the hospital. I left because after 6 weeks, I hadn`t spoken with a doctor or attended a group therapy If he was asked any real questions about me personally, I don`t think he could reveal very much. Had he diagnosed this disorder after 3-5 appointments maybe I`d feel differently. I am 50 years old and find my situation becoming worse. According to everything I have read, this shouldn`t be the case. Stating my opinion such as it is, my doctor would probably say this opionion is typical of BPD!!!!
My daughter has BPD. First step: Knowing something is wrong. Second Step: MEDS HELP (prescribed)!! Third Step: Therapy HELPS. Fourth Step if you can and this is hard: LIFESTYLE CHANGES VERY IMPORTANT- Get correct nutirtion– there are foods vitamins, etc that HELP mood swings and depression. Make sure non interfere with meds. GET EXERCISE: HELPS serotonin in brain. CRITICAL. MEDITATE: Go to a professional class and learn how. CHANGES BRAIN WAVES. YOGA- Excellent. TRY TRY TRY to stay away from Alcohol and DRUGS. BAD BAD BAD for people with BPD. FiFTH GET A NETWORK that you can contact immediately when in danger. Whether it be texting, calling, visiting. HELP and SUPPORT necessary to help with isolation!!!
make sense.
But many sufferers lack proper environments they feel content in and with. It is difficult when you feel alone and unfriendly too. some people need a friendly hand to get moving or doing, some dont.
The Guru of dbt herself surrounded and immersed herself in religious fields to feel better. She is involve wt life and surrounding. that is very hard for most to achieve without help and who can afford that????
The dropout factor is quite common among all Personality Disorders, since one of the main symptoms of all PD’s is that the client does not consider their disorder to be a problem of any kind, and thus doesn’t see value in treatment.
Another important difference between the two modalities is that the DBT approach accomplished it’s success without drugs. This is VERY significant. If a non-drug therapy can equal a medication assisted therapy, it saves, not only money but side effects and (in many cases) brain damage, obesity and other harmful baggage that attends antipsychotic drugs.
I find it appalling that this huge difference was not even mentioned in the article. This glib, casual acceptance of psych meds is inherently damaging. Other than that, I thought this article was well-written.
Pls stop generalizing pple wiv BDP, we are also individuals too.
Yes. It’s hard work and a huge commitment. I have depression. & PTSD. Breakdown after my marriage and now in DBT. I don’t see much change and it’s darn expensive . I believe talk therapy n meds r just as good. Focusing on the lil rages and calming down. But DBT- weird. Sorry n for those who get relief….I’m truthfully happy for u! DBT really doesnt help w: deep deep grief
I was surprised (unless I have missed it in one of the above comments or the research itself) that there was no discussion regarding the final figures represented in the graph: for ‘general psychiatry’, the rate of self-harm/injury increased from 8-12 months, whereas for the ‘DBT’ group it continued to decline. This could be interpreted as the significance of the therapeutic relationship and ongoing support for general psychiatry as possibly being the beneficial factor. I am assuming the participants would be aware that the year’s research/support would be coming to an end and may lead to increased anxiety/feelings of abandonment perhaps towards the latter months and may help explain the increase in rate of self-harm/injury. In comparison, DBT provides the tools required for the individual to manage their own difficulties and behaviours, hence the rate of self-harm/injury reduced again between 8 and 12 months. Surely this final statistic is quite a significant difference, albeit open to interpretation?
Nice to know I am not alone.I wish BPD on no one,I wonder what it would be like to feel/live like a normal person.Hopefully my next life will be better.
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