Beverly E. Thorn, PhD
The incidence of chronic pain is epidemic and contributes to millions of dollars in lost wages, disability payments, and health care costs. Besides the enormous economic impact, the emotional suffering that persons with chronic pain experience is substantial and contributes to problems in all areas. In attempting to cope with unrelenting pain, individuals often experience myriad negative emotions such as anxiety, anger, and frustration, which is compounded by attempts to escape the pain. In particular, pain catastrophizing is associated with high levels of reported pain severity and disability, and leads to poor adaptation to living with chronic pain. This paper specifically targets the cognitive psychological processes (pain-related thoughts, attitudes, and beliefs) shown to be important predictors of satisfactory adjustment to chronic painful conditions. In particular, I examine the role of catastrophic thinking and provide specific suggestions for the targeted treatment of catastrophizing.
The filtered light from the window blinds felt like swords stabbing me through my closed eyes. My body was doing the sweaty shakes, and the muscles surrounding my skull had turned to steel bands, growing tighter by the minute…. I had been juggling a heavy professional travel schedule and was walking into delivering my first lecture for a class a colleague had cajoled me into teaching. It required new preparation, and was totally out of my field, but the single seductive phrase of "You'd be great at this, Bev" sold me on taking it. This was a multi-disciplinary seminar taught to a select group of very bright undergraduates. I had met them the week before, handed out the syllabus, and promptly left town for a professional meeting, during which I ate and drank too much, exercised very little, and consumed virtually no water, but huge quantities of caffeine. The first lecture of the semester had been handed off to my graduate teaching assistant, whom I had not met. I was now going to attempt to take the reins. I opened my notebook, smiled at these new and precocious faces, and suddenly detected a tiny spot of light in my right field of vision. Although barely perceptible, it was familiar enough - the beginnings of a migraine aura. "Not now!" I snarled at my brain. I tried closing my eyes, as a test to see if IT was really there. IT was. "I can't have a migraine now," I whispered to my inner self. These kids didn't know anything about me, except that I had skipped out on their first two classes. What would they think if I suddenly packed up and left again? How would I establish credibility? Here it was, the first of the semester, and I was already shirking the responsibilities I had agreed to in taking on this class. I began berating myself for taking on this class, and for taking on too many travel commitments, knowing it was my own fault that my body was rebelling. The spot in my visual field was growing. I had thirty minutes to abort the migraine or suffer the consequences. I excused myself and chugged a Midrin, came back to the classroom and decided to begin the lecture - poor choice. My vision started to scintillate. I talked, without the benefit of my notes, with one eye squinted closed, for another 10 minutes and took a 2nd Midrin - usually enough to make me goofy for the rest of the day. I continued talking. The sweats came. The vomiting was soon to follow. I had to get out of there. Feeling like a complete fool, I confessed to my class that I was having a migraine and had to cut class short, knowing they were thinking, "What a loser!" Surely, they would be dropping the class in droves, moving to a more competent professor's section, one whose intellect was worthy of their presence. I called my husband to come and rescue me and spent the next 8 hours lying in bed when I wasn't vomiting in the bathroom.
The reason I recount this real-life anecdote is to illustrate the importance of one's thoughts as they relate to managing pain -be it acute pain, recurrent pain, or pain flares in chronic conditions. The story above exemplifies a common recurrent pain problem - migraine headache pain - a topic I am both professionally and personally involved in.
Both migraine and tension-type headaches are highly prevalent disorders. In the United States alone, migraine headaches affect 25 to 30 million people, and 11 million are disabled by their headaches (Lipton, Stewart, & Von Korff, 1997). More important than highlighting the type of pain problem, though, the paragraph above is meant to draw your attention to the importance of cognitions, and the role they play in pain perception and the management of many different types of pain problems.
Many of our thoughts are automatic and as such, are not even immediately consciously available to us. For individuals with chronic pain, many pain-related automatic thoughts are negative, emotionally supercharged, and have a profound impact on short-term and long-term adjustment to painful states, including emotional, behavioral, and cognitive adjustment. Although Cognitive-Behavioral Therapy (CBT) now includes some cognitive interventions, the treatment descriptions available in the literature often contain only passing mention or very brief coverage of the cognitive components.
One reason for the lack of focus on the cognitive aspects of pain management in CBT may be related to the history of the advent of multidisciplinary pain treatment clinics. The first pain clinics to include a psychological component were based on the operant model of pain (Fordyce, 1976) and as such, were strongly behavioral. Although the psychological treatment of chronic pain has since expanded to include the cognitive, as well as the behavioral, our heritage is decidedly behavioral. Additionally, the behavioral aspects of psychological treatment for pain, because they have been around longer, are arguably more thoroughly researched than the cognitive aspects. Simply put, there is a shortage of specific information focusing on cognitive therapeutic interventions for pain management.
Defining Pain - Making Room for Psychosocial Factors
The evolution of scientific thought regarding what constitutes pain takes us from a biomedical framework, the dominating illness conceptualization for almost 300 years, to a biopsychosocial model. Until the mid 1960s, pain was assessed and treated almost exclusively within the framework of a biomedical model, leaving the influence of psychological factors in the experience of pain unknown and unaddressed in traditional medical interventions. Available evidence clearly suggested that there were some patients who experienced significant pain in the absence of documented physical injury, and conversely, physical injury did not always produce the perception of pain. Nevertheless, the biomedical view of pain held tenaciously to the idea that amount of tissue damage = amount of pain. When the two sides of that equation did not balance, patients were referred to psychologists, and questions such as "is it organic or psychogenic?" were asked.
Although a pure biomedical model of illness is slowly becoming obsolete, psychologists in the trenches complain that patients with pain are often assessed using only a biomedical approach and psychologists are consulted to make functional/organic distinctions. Moreover, the lay public still holds a biomedical view of pain, expecting that if there is pain, there is associated tissue damage that should be diagnosed and eradicated, or at least adequately medicated. An additional conundrum is that it has become very clear that the acute-care model operative in our present health care system is not working for most of the chronically ill individuals requiring the greatest bulk of our care. Certainly, patients with chronic pain fall into a chronic care need that is not yet adequately addressed in our health care infrastructure. These problems notwithstanding, we are making headway in recognizing the multidimensional nature of the experience of pain, and this is reflected in changing assessment strategies as well as treatment strategies.
In the biomedical conceptualization of pain, physical evidence is considered of primary importance in determining the extent of one's pain, though there has been movement away from relying on physical evidence alone to validate pain. However, it is also problematic to consider only subjective self-report in order to validate pain. To be rigorous, biopsychosocial pain assessment should be comprehensive and multimodal, including physiological parameters, self-report variables, and an assessment of pain behaviors (verbal and nonverbal expressions associated with discomfort), disability (loss of capacity to perform normal activities), and dysfunction (lack of participation in normal activity).
Distinctions between acute pain and chronic pain often include arbitrary chronological demarcations (e.g., 3 months, 6 months), or are often based on subjective judgments about whether the pain extends beyond the expected healing period. More useful definitions are the following. Chronic pain is often (but not always) elicited by an injury but worsened by factors removed from the original cause, usually lasts a long time, and is oftentimes not explained by underlying pathology. Acute pain is pain that is elicited by injury and activation of pain receptors (e.g., trauma, surgery), usually lasts a short time, and remits when the affected tissue is healed. In the acute pain situation, biomedical health care interventions are typically sought and often effective, whereas in chronic pain, biomedical interventions are usually not effective (Turk & Okifuji, 2001). Recurrent pain (e.g. cancer pain, migraine headache) is episodic, but occurs across an extended time period, thus sharing characteristics of both acute and chronic pain.
What are the Psychological Issues Associated with Chronic Pain?
Living with chronic or recurrent pain taxes coping resources and can have devastating effects on patients and those around them, including family, friends, employers, and coworkers. In many cases, patients' lives may revolve around attempts to escape the pain or in chasing an illusive cure for the pain that is not forthcoming. In far too many cases, individuals with chronic pain develop a core identity as a disabled pain patient, and proceed along a downward spiral of dysfunction related to that identity. Depression is a prominent co-morbid condition, and it has been estimated that up to one-half (or greater) of all chronic pain patients become depressed (Turk & Flor, 1999). Additionally, these patients experience many other negative emotions including anxiety, anger, and frustration. This psychological distress is strongly influenced by cognitive factors, including automatic negative thoughts about the pain, as well as beliefs about the cause of the pain, or the best way to treat it, judgments regarding the level of stress associated with the pain, and thoughts about what can be done to manage the pain on a daily basis. Fortunately, all of these cognitive factors are appropriate targets of interventions within a cognitive therapy context. Helping patients in pain to reframe their thoughts does at least two things: 1) it clears the way for them to take more responsibility for the management of their own condition, thus relying less on an already strapped, inefficient, and ineffective health care system; and 2) it creates a sense of self-efficacy and self-determinism so clearly lacking in many individuals dealing with chronic painful conditions.
Cognitive-Behavioral Treatment of Pain
Cognitive-Behavioral Therapy (CBT) has become the gold standard for psychosocial intervention for pain (Morley, Eccleston, & Williams, 1999), and involves the application of a structured, often manualized, treatment aimed at behavior change or maintenance of function, as well as treatment related to patients' thoughts and emotions. CBT differs from the biomedical management of chronic pain in that the biomedical focus is on reducing the perception of the pain itself, whereas the CBT goal is to help the patient minimize the impact of pain on his or her life (i.e., to function despite the pain). Parenthetically, CBT often does result in reductions of perceived pain, but that is not the main focus of this treatment approach. The cognitive aspects of CBT are often incorporated to remove barriers that might otherwise prevent appropriate behavioral change. Empirical support for the efficacy of CBT in this population is abundant. Cognitive-behavioral interventions increase adaptive coping responses, self-efficacy, and physical functioning, decrease maladaptive cognitions, and in many cases, these therapies reduce pain (Wilson & Gil, 1996). Furthermore, CBT is cost-effective relative to medication and/or hospitalization (Turk, 2001). Despite our successes, a continuous challenge in this patient population is in getting the individual to maintain function, or change behavior as necessary to regain function.
What are the Important Components of CBT?
Although this question has not been answered unequivocally, the clinical research literature offers some clues regarding the potential agents of change in CBT. There is evidence that changes in beliefs and cognitive coping strategies produce improved patient functioning and decrease health care use following CBT, but changes in behavioral coping strategies produce only weak improvements (Holroyd, Penzien, Hursey et al., 1984; Jensen & Karoly, 1991). Furthermore when cognitive treatment modules are offered before more behaviorally focused treatments, greater cumulative improvement occurs (Knapp & Florin, 1981). Even more impressive, two recent studies have shown that changes in catastrophic thinking and perceived helplessness early in treatment were significantly related to later changes in pain severity and functioning, but early treatment changes in pain severity and functioning were not related to later changes in catastrophic thinking and perceptions of helplessness (Burns, Kubilus, Breuhl et al., 2003; Burns, Glenn, & Breuhl, 2003). An important implication from these and other studies is that changes in what patients think about their pain influences what they ultimately do about the pain, and targeting cognitive factors may be of greatest importance for patient improvement. It follows that CBT focused primarily on teaching behavioral self-management skills without incorporation of cognitive therapeutic techniques is likely to be less effective, especially for patients who engage in high levels of negative automatic thinking about their pain (Geisser, Robinson, & Riley, 1999).
Rationale and Format of Cognitive Treatment Approach
Many CBT interventions may already include, to some degree, a cognitive restructuring component in the treatment approach. However, my aim in writing this paper is to provide a framework for focusing on a particular category of negative cognitions-pain catastrophizing, and to provide an overview of how to implement this focused treatment approach. Most people forced to cope with chronic pain engage in some amount of catastrophic thinking and therefore it is appropriate to incorporate this approach into an existing CBT format. However, it is also possible to employ this intervention with only those patients who are identified as high in catastrophic thinking, or those who have an inadequate response to a traditional CBT approach.
I prefer a group therapy format for cognitive and cognitive- behavioral treatment of chronic pain. The research literature supports the efficacy of group treatment for chronic pain (Keefe, Beaupre, & Gil, 2002), and in many ways it is more cost effective to offer group treatment. Group treatment is also the standard in inpatient pain management clinics (Keefe et al.). At the clinical/process level, group interaction serves an instructional function as well as a supportive function. Clients learn vicariously from the example of other group members: when one patient identifies a thought pattern and begins to change her thinking, others can benefit from observing the process and tracking the outcome. Group treatment has also been documented to provide an emotional support function. Chronic pain patients often feel isolated and misunderstood. Being able to disclose thoughts and feelings to others who have shared similar circumstances lends a greater sense of legitimacy to a client. Also, when a fellow pain patient confronts another patient by pointing out a cognitive error or maladaptive behavior, it is often easier to accept than when it comes from a health care professional. My preferences aside, the techniques discussed in this paper can be adapted for individual clients.
Assessing Pain-Related Cognitions (Catastrophizing):
Distorted thoughts, particularly negatively distorted cognitions, are often referred to as cognitive errors (Beck, 1976). Automatic pain-related thoughts are cognitions that arise, independent of one's immediate awareness, in response to a pain-related event. People affected by chronic painful conditions also develop beliefs about the cause, meaning, and ability to influence pain. These acquired beliefs roughly correspond to Beck's terminology of intermediate beliefs. Furthermore, individuals with chronic pain develop beliefs about themselves as a person in pain, and over time, these acquired beliefs become deeply ingrained and can be viewed as corresponding to Beck's terminology of core beliefs.
In this paper, I focus on a particular category of negative cognition called catastrophizing. In traditional 'Beckian' cognitive therapy terminology, catastrophizing is one specific category among a number of cognitive errors, and it refers to making negative predictions about future outcomes that may not be realistic (Beck, 1976). When used in the pain literature, the term catastrophizing denotes a wide variety of negative pain-related cognitions, including having difficulty focusing one's attention away from the pain, perceiving the pain as unusually intense, and feeling helpless to control the pain (Sullivan, Bishop & Pivik, 1995). In the treatment program outlined in this paper, catastrophizing is targeted at multiple levels of cognitions: automatic thoughts, intermediate beliefs, and core beliefs.
The Pain Catastrophizing Scale (PCS, Sullivan et al., 1995) has received the most research attention as a comprehensive instrument assessing this important construct. The PCS has 13 items, which makes the scale quite practical in terms of clinical utility. The patient is instructed to reflect on a pain experience and indicate the extent to which she thought about each statement using a 5-point item response format where zero indicates not at all and four represents all the time. The PCS consists of one general factor and three correlated but distinct subscales: Magnification, or exaggeration of the threat value of pain (e.g., "I wonder whether something serious may happen"); Rumination, or focused attention on the pain (e.g., "I can't seem to keep it out of my mind"); and Helplessness, or pessimistic appraisal of the ability to cope (e.g., "There's nothing I can do to feel better").
The PCS is useful as a pre-treatment assessment tool as well as for mid-treatment and post-treatment assessments. It can also be helpful to use patient responses to the PCS as an educational tool when introducing the concept of negative automatic thoughts. Since the treatment program outlined in this paper targets dysfunctional thinking and because pain-related catastrophizing is certainly a central aspect of dysfunctional thinking, it is crucial to track, and hopefully, change, the client's catastrophic thought processes. The PCS, and its scoring key, can be found in Thorn, 2004.
Association of Negative Cognitions to Pain Adaptation:
Pain-related catastrophic thinking has proven to be an incredibly robust predictor of pain, disability, and adaptation to chronic painful conditions, and it does so over and above other factors such as disease, pain intensity, depression, anxiety, fear of pain, and neuroticism. (Sullivan, Thorn, et al., 2001). This means that catastrophic thinking about pain is something uniquely related to pain, and not simply a manifestation of cognitions associated with depressive states or anxiety disorders. These findings have led clinicians as well as researchers to call for more attention to the development of intervention strategies that specifically target catastrophic thinking in individuals with chronic and recurrent pain.
In the following paragraphs, I describe some of the major components of incorporating a cognitive therapy intervention into the pain management regimen. For comprehensive coverage of cognitive therapy for chronic pain, including the theory and research, as well as treatment manual and patient handouts, see Thorn (2004), Cognitive Therapy for Chronic Pain: A Step-by-Step Approach.
To provide a theoretical framework for this cognitive approach to treatment, I adapted Lazarus and Folkman's (1984) transactional model of stress. This conceptualization views the stress response as multi-faceted and emphasizes the role of cognition in coping with stressful situations. According to Lazarus and Folkman's model of stress, dispositional variables such as personality, stable social roles and/or biological parameters can all affect a person's interaction with a stressor. Additionally, people engage in a series of dynamic appraisal processes that influence their response to the stressor, including whether, and which, coping responses will be attempted. Using this model, we can better understand the dysfunctional thought processes that may accompany present or anticipated pain. The model also helps to explain how someone might develop enduring maladaptive beliefs about pain. A simple schematic, with narrative explanation, is provided on the last page of the article.
In the view presented on the last page, personality predispositions or previous experiences with pain promote the tendency to appraise pain or potential pain as threatening or damaging. Threat appraisal consumes one's focus of attention, limiting one's ability to concentrate on or appreciate other environmental events. Such hypervigilance leads to rumination about the pain as well as a magnification of the perception of pain. These thought processes, in turn, result in an avoidance of situations or behaviors that could potentially result in pain. Behavioral avoidance, as well as a seeming inability to stop the negative pain-associated thoughts, leads to reduced perceived self-efficacy to deal with the pain, and hence a sense of helplessness and other associated negative emotional sequelae. As the downward spiral continues, thoughts in response to specific pain-related events turn into more deeply held beliefs that are even more difficult to change.
The overarching idea is that interventions targeting catastrophic thinking help patients with pain to become aware of their appraisal processes and to challenge distorted thinking resulting from heightened attention to the pain stimulus. Once this is accomplished, we assume the individual will be more receptive to behavioral interventions aimed at increasing function, which will increase self-efficacy, and reduce a sense of helplessness and other associated negative emotions.
Overview of the Treatment
In this section, I provide descriptions for three specific cognitive treatment modules that can be integrated into any cognitive-behavioral treatment program for chronic pain. In the comprehensive treatment manual provided in my book (Thorn, 2004), these components comprise 6 sessions of a 10 week group CBT program offered weekly for 90 minutes per session. The treatment, which is psychoeducational in nature, includes active collaboration between the patients and the practitioner, use of discussions and worksheets, and homework assignments between sessions.
Phase 1. The first element of cognitive treatment for pain provides education and insight regarding the fact that pain is both real and stress-related. I emphasize the impact of stress on pain, particularly in the way one interprets potentially stressful events. In session, group members list situations they find stressful and/or that trigger pain flare-ups. The concept of stress appraisal is also introduced. Environmental events are judged as harmless or stressful, with those situations perceived to be stressful further appraised as a challenge (perception that the ability to cope is not outweighed by the potential danger of the stimulus), a threat (perception that the danger posed by the situation outweighs the individual's ability to cope), or a loss (perception that damage has occurred as a result of the stimulus). I emphasize that, depending upon one's appraisal of a situation, one will think about it differently, feel different emotions about it, and behave differently. Participants discuss how their own appraisal of a pain-related stressor might impact their thoughts, feelings, and subsequent behavior. A sample Stress/Pain Connection Worksheet used in-session and as homework, is provided on the last page.
Phase 2. The second element of cognitive treatment for pain is to teach patients to identify, challenge, and replace maladaptive pain-related thoughts. Notice that the last column in the previous Stress/Pain Connection Worksheet sets the stage for introducing the concept of negative pain-related thoughts. The power of one's thought processes is introduced, but specifically, the role of catastrophizing thoughts on adjustment to chronic pain is emphasized. Several sessions are spent helping group members define and discuss catastrophic thoughts, with participants learning to monitor and change their thinking patterns. Pain-related catastrophizing is discussed as often being an automatic thought process - thoughts that might occur outside one's immediate awareness. Group members discuss how catastrophic thoughts might impact their emotions, behaviors, and even their physical functioning. This aspect of the treatment protocol closely resembles cognitive restructuring typical of traditional cognitive therapy for depression or anxiety, but the cognitions upon which I focus the patient are pain-related cognitions.
In the next part of this component of treatment, I introduce the idea that, while catastrophic thoughts might contain some truth, certain aspects of any catastrophic thought may be distorted, or not completely realistic. Group members are educated about the importance of evaluating the validity of thoughts and challenging aspects of those thoughts that are unrealistic. Finally, group members are educated about choosing alternative, more realistic thoughts to replace those thoughts or the parts of thoughts that are not valid. Automatic thoughts worksheets are introduced as a means of recording catastrophic thoughts and their accompanying emotional / behavioral / physiological consequences. For each maladaptive thought identified, participants work together to develop a more realistic, adaptive thought. A sample Automatic Thoughts Worksheet used just prior to developing alternative adaptive thoughts is provided on the next page.
Phase 3. People develop belief systems to make sense of the world, and people with chronic pain develop belief systems in an attempt to make sense of their pain condition. In other words, individuals with chronic pain develop underlying beliefs, attitudes, and assumptions unique to their pain condition. These pain- related beliefs include beliefs about the cause of pain, the meaning of the pain, the amount of control over the pain, attitudes about appropriate and inappropriate means of treating the pain, and beliefs about themselves as a person living with chronic pain. These pain-related beliefs are often couched in should, must, and ought to terms, and they are experienced by the individual as rules or facts. When negatively distorted, these attitudes and beliefs about the pain, and about the self as someone in pain, create a cognitive set that works against the goal of developing pain self-management skills and move patients more quickly down the spiral of pain-related dysfunction and disability. Therefore, it is essential to help chronic pain patients identify dysfunctional underlying beliefs about the pain, help them challenge negatively distorted beliefs, and construct more realistic, and more adaptive, alternative underlying belief systems regarding the pain condition.
In the session, I introduce patients to the concept of pain-related beliefs and attitudes, and use pain beliefs to work through examples. Patients are first guided in identifying pain-related beliefs and attitudes, and then encouraged to list the facts supporting and disproving these beliefs. The potential behavioral, emotionaL, and physical consequence of continuing to hold such beliefs is discussed. After helping them examine both the disadvantages and the advantages of holding onto their beliefs, patients are asked to consider whether an alternative belief could be adopted and tested out. A therapeutic challenge is to help the patient buy into possible alternative beliefs once they are identified. A belief that is moderately more positive, or one that has taken the distorted aspect of the belief and corrected that part, is usually easier to adopt than an unrealistically positive belief. Even if the patient does not wholly accept the alternative belief, she is asked to experiment with acting as if the new belief were true. Most participants who try this exercise will report that at least certain elements of their old belief system were challenged when they tried the exercise, and invariably, they feel better about themselves in the process. A sample Changing Pain Beliefs Worksheet used early in the process of making connections between automatic thoughts, intermediate beliefs, and core beliefs, is provided.
There is ample empirical evidence that helping patients reduce their negative thinking, especially catastrophizing, enhances adaptive functioning and thereby dispenses of the "disabled pain patient" persona. This process is greatly facilitated by specifically targeting and thus decreasing the amount of time engaged in catastrophic thinking. Although we know that catastrophizing strongly predicts poor pain outcomes, the typical pain treatment approach of CBT does not focus on the reduction of catastrophizing. Some pain treatment programs do mention catastrophizing and even spend time on interventions such as cognitive restructuring to alter maladaptive thinking patterns. However, the theory and focus of treatment is not specifically on the reduction of catastrophizing per se. The treatment outline proposed in this paper differs in that it strives to directly target the reduction of pain-related catastrophic thinking from multiple perspectives.
Although several targeted treatment approaches have recently been developed and utilized to decrease catastrophizing (Sullivan, Ward, Tripp et al., in press; Thorn, 2004), and our outcome data suggest that it is effective in reducing catastrophizing and improving other positive outcomes, such as mood, pain intensity, and activity level, there have been no empirical studies comparing the described interventions to other, more general, pain treatment approaches or to credible placebo control interventions. Clearly, such clinical research is needed. With managed care organizations demanding evidence-based, time-limited treatments, we may increasingly rely on this kind of research to promote the development of interventions that are more streamlined and powerful. The translation of that research into user-friendly and practitioner oriented techniques is also a sorely needed component that involves the collaboration between clinical researchers and practicing clinicians - a true scientist-practitioner orientation to health care.
Beverly E. Thorn, Ph.D., is Professor and Director of the Clinical Psychology program at the University of Alabama (Tusc.) where she has been employed for 20 years. Her Ph.D. is from Southern Illinois University. She currently serves on the AL State Board of Psychology and APA Council of Representatives. She has had extensive experience with problems of sexual harassment, providing expert testimony on discipline in the university. She has served as mediator of sexual exploitation issues with other boards. Dr. Thorn is also developing ideas on the best approach to assessment of competence of students in interaction with others. Her research interests are in medical/health psychology, chronic pain, sexual dysfunctions, and assessment. She recently published Cognitive Therapy for Chronic Pain (Guilford Publications). Dr. Thorn has been a Registrant since 2001.
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