Dual diagnosis of eating disorders and co-occurring mental health conditions
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Eating disorders alone are serious mental illnesses. But often there are other co-occurring mental health disorders that contribute to and complicate these conditions.
Co-occurring, or comorbid, disorders refer to when a person experiences two or more mental health conditions at once. And there are some conditions that seem to have a higher rate of comorbidity with eating disorders.
Many causes and symptoms of various disorders can be similar, which may be why they tend to exist together at such a high rate. This can also make it hard to discern which is the primary condition, which, in turn, makes it difficult to develop an appropriate treatment plan for someone with these co-occurring disorders.
Eating disorders and depression
Eating disorders are deeply connected to mood disorders, including depression. One study of 2,400 individuals found 94% of participants with eating disorders had a co-occurring mood disorder, and 92% of those affected struggled with a depressive disorder. (1)
Further research has reported up to 32-39% of people with anorexia nervosa, 36-50% of people with bulimia nervosa, and 33% of people with binge eating disorder are also diagnosed with major depressive disorder. This is the most commonly diagnosed form of depression. (1)
In fact, the two conditions are so closely linked, research has found eating disorders and depression—as well as anxiety—can all be traced back to a shared etiology, or set of common causes. (2) Other research has posited that eating disorders are offshoots of depression itself, representing more “variant” forms of depression But these theories are more controversial. (3)
Whatever the cause, the unfortunate reality is, because these conditions occur together, often symptoms are more severe, prognosis is poorer, and the burden of illness is greater. (2)
Eating disorders and anxiety
Although anxiety disorders are the most commonly occurring types of mental health disorders in the United States, this class of condition is particularly prevalent among people struggling with eating disorders.
The same study of 2,400 patients with eating disorders found that 48-51% of people with anorexia nervosa, 54-81% of people with bulimia nervosa, and 55-65% of people with binge eating disorder were also diagnosed with an anxiety disorder of some kind. (1)
Other studies have shown that having an anxiety disorder increases the likelihood of having or developing a comorbid eating disorder—or vice versa—thanks to many related underlying factors in both conditions. (4)
Anxiety disorders and eating disorders both frequently evolve as dysfunctional mechanisms for coping with unpleasant feelings or traumatic events, a powerful shared trait that ties the conditions tightly to one another. This close relationship may also explain, or at least suggest, why persisting symptoms of anxiety after an eating disorder goes into remission can increase the risk of relapse. (2)
For example, someone with a parent or partner who criticizes them and feels badly about themselves as a result may turn to food and disordered eating patterns for comfort or control. Someone who experiences stressful situations and doesn’t know how to alleviate their stress may turn to food to help themselves calm down.
Eating disorders and obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder technically falls under the umbrella of generalized anxiety disorders. Still, many people struggling with eating disorders experience co-occurring symptoms of OCD specifically.
Research has estimated that anywhere from 11-69% of people with eating disorders also have OCD, while 10-17% of people primarily diagnosed with obsessive-compulsive disorder also struggle with an eating disorder. (5) And another study found that women who had experienced OCD in childhood had a higher likelihood of developing an eating disorder later on in life. (6)
The biggest tie that binds between these two conditions may be the very obsessions and compulsions OCD takes its name from. “Obsessions,” as they’re understood in obsessive-compulsive disorder, describe frequent and recurrent thoughts or impulses, which eventually become intrusive upon daily life. “Compulsions” are the behaviors or thoughts performed in response to obsessions.
It’s quite common for both an obsession and a compulsion to revolve around the ideas of food, body shape, or weight—for example, someone obsessed with thinness, who then compulsively purges in response to that obsession. This is an example of bulimia. Or someone who becomes obsessed with “healthy” eating may compulsively read labels and stop eating certain ingredients (sugar), foods (bread) and entire food groups (carbohydrates) to the point of becoming malnourished. This is an example of orthorexia.
In this way, OCD can act almost as a turbine, powering the behaviors of an eating disorder. The key, in both cases, is that obsessions often lead to rising levels of anxiety that can only be alleviated by performing ritualistic compulsions. (5)
Eating disorders and post-traumatic stress disorder (PTSD)
The trauma experienced and subsequently carried by a person struggling with post-traumatic stress disorder (PTSD), which is trauma that is unresolved, tends to leave them particularly vulnerable or sensitive to stress and all its worst effects, including the development of eating disorders.
Unfortunately, the numbers seem to bear out this observation, with several studies examining the co-occurring relationship between PTSD and bulimia nervosa finding lifetime comorbidity rates between 38-44%. (7)
The presence of trauma—or, stress that has reached the point of causing regular mental or physical difficulties in a person’s life—and PTSD, or the impact unresolved trauma has on a person, can have a detrimental and cascading impact on how that person reacts to subsequent stressful experiences. And that can, in turn, go on to have an impact on which future stressful experiences become traumatic for that person.
Perhaps the biggest link between these experiences and eating disorders is the coping style people who have trauma in their life tend to adopt. When struggling with PTSD, or unresolved trauma that is triggered by an occurrence that’s similar to the original traumatic event, many people revert to something called avoidant coping. This mechanism is characterized by self-punishing and self-defeating thoughts—for example, I’ll never be okay, so nothing good can come from trying. Both of these are also risk factors for developing eating disorders. (7)
Eating disorders and bipolar disorder
Research examining the comorbid connections between eating disorders and bipolar disorder has been less robust. But at least one study found a co-occurring rate of around 33% between the two conditions. (8)
An earlier study on the topic found a higher rate of comorbidity in cases where women had earlier ages of onset and more severe symptoms of bipolar disorder. (9)
Still, some theories on why or how the two conditions impact each other have been developed, mostly through examining qualitative data. In the later study, for example, participants reported struggling with different facets of eating disorders, or, indeed, different eating disorders altogether, during manic and depressive phases.
Generally, mania was related to overeating, while depression was linked to suppression, leading researchers in this case to posit that some common factors were directing both these mood swings and the various disordered eating patterns presented during their onset. (8)
Eating disorders and substance use disorder
Statistically, substance use disorders and eating disorders co-occur at much higher rates than either condition occurs on its own within the general population.
Up to 50% of people struggling with eating disorders also use alcohol or illicit drugs, a rate that’s five times higher than people without eating disorders. And up to 35% of people with a substance use disorder also have an eating disorder, a rate eleven times higher than the general population. (10) Some studies have suggested that people who struggle with binging and purging behaviors, specifically, are at the highest risk of struggling with a comorbid substance use problem. (11)
As with many other comorbid relationships, the correlation may hinge on a number of shared traits and risk factors between substance use disorder and many eating disorders, including social pressures, family history, genetics, and brain chemistry. (10) Mood disorders, like anxiety and depression, are also common contributing factors to both substance use disorder and eating disorders, as well as the types of compulsive thinking associated with OCD. (10)
While these various overlapping causes and symptoms are likely what’s behind such high rates of comorbidity, they can also make it difficult to discern which is the primary condition. This then makes it hard to develop an appropriate treatment plan for someone with these co-occurring disorders.
Eating disorders and dementia
Eating behaviors can change during the aging process due to a number of factors, including the many physiological, psychological, and social changes a person undergoes at that time.
Eating disorders among older people occur at often-surprising rates. One study examined 48 patients aged 50 or older and found 81% of participants struggled with anorexia and 10% with bulimia. (12) Meanwhile, 60% of participants exhibited co-occurring mental health conditions, while only 42% were deemed “successfully treated.” (12)
One of the most common co-occurring conditions in the elderly is dementia.
The age-related disorder presents a number of risk factors for developing a comorbid eating disorder, including appetite changes, sleep disturbance, and depression, among other biochemical changes. (13)
For specific presentations of dementia, like Alzheimer’s, there are further risk factors, including the cognitive changes that may make a patient forget to eat, or forget if they have eaten already. (13) Alzheimer’s can also impact a person’s sense of smell and bring on social risk-factors for developing eating disorders, including loneliness, isolation, and depression. (13)
Shared risk factors of eating disorders and co-occurring disorders
One reason so many people struggle with eating disorders and comorbid mental health conditions is that many of these disorders share several overlapping risk factors, from biological to psychological to environmental and sociocultural attributes.
It may not even be possible to discern which disorder came first, or which influenced the other. Regardless, in their search for potential triggering factors on either side, scientists continue to discover different traits these disorders have in common, which may help explain the higher rates of comorbidity between certain conditions.
It is possible to be born with the predisposition for developing either an eating disorder, a number of different mental health disorders, or both.
Eating disorders, mental health disorders and risk factors that can be inherited:
Substance use disorder
Response to stress
Many studies have shown at least some degree of heritability for both bulimia and anorexia. (14) And a breadth of other work has shown genetic connections to substance use disorder, depression, anxiety, and other mood disorders.
In many of these cases, the passed-on tendencies aren’t the disorder itself but a number of risk factors that may make a person more susceptible to developing the disorder. For example, the way a person reacts to stress—which could impact a number of other mechanisms that lead to developing or maintaining mental health disorders—has been found to be heritable. (14)
Other key inheritable risk factors include negative emotionality and harm avoidance, which inform personality traits such as shyness, fearfulness, or worrying behavior. (10,14)
Serotonin is an important neurotransmitter the body manufactures that modulates many bodily processes. It’s mostly known as a mood stabilizer, capable of boosting feelings of happiness, but it can also function as an appetite suppressant, creating feelings of satiety–which means feeling satisfied after eating.
Because it plays a key role in both appetite and emotions, it is a common link between eating disorders and comorbid mental health conditions. And several studies have shown that serotonin dysfunction or imbalance may, indeed, play a role in developing or sustaining several co-occurring eating disorders and mental health conditions. (15)
Regardless of the pattern of a person’s disordered eating, one of the biggest repercussions is an unbalanced diet. And while malnutrition is more of a consequence of eating disorders, rather than a risk factor, it can have a cascading effect on the body that can lead to the development or support of comorbid conditions.
Anxiety and depression, in particular, have been linked to malnutrition, with some studies finding that the absence of certain proteins can promote “anxiety- and depression-related behavior.” (16)
Nutritional psychology continues to be an emerging field. But several other studies have also shown potential links to certain nutritional deficiencies and depressive or anxious tendencies. (17)
Maladaptive emotion regulation strategies
Broadly, emotion regulation refers to someone’s awareness and recognition of their emotional state, as well as any attempt to regulate, or modulate, it. And, whether conscious or subconscious, these mechanisms can play a key part in driving eating disorders and commonly co-occurring conditions.
Indeed, many eating disorders, as well as anxiety and depression, can arise as attempts to cope with unpleasant feelings, especially during the onset of puberty or other times in life that see a number of physiological, psychological, and social changes. (2)
Likewise, higher levels of depression or anxiety can lead to the development of disordered eating behaviors as a maladaptive–or harmful–emotion regulation strategy, and vice versa. (2)
Low self-esteem is a driving factor in eating disorders and commonly co-occurring mental health conditions. It can manifest as the result of these disorders, the cause of these disorders, or both. But the trait plays a very big role in the relationship between eating disorders and depression.
In fact, low self-esteem has been found to be a key maintaining aspect in many eating disorders, thanks especially to its links to poor body image and body dissatisfaction. These negative self-perceptions and senses of self-worth can result from depression or help maintain that co-occurring disorder, as well. (2)
Perfectionism is more often associated with anxiety, be it generalized anxiety disorder or more specific manifestations of the condition, such as obsessive-compulsive disorder.
Briefly, the anxious trait involves the setting and pursuit of high standards for oneself, and the highly critical self-evaluation when failing to meet these goals. People struggling with a perfectionist aspect of their anxiety disorder are particularly hard on themselves, often for small, exaggerated or even imagined transgressions.
This level of sensitivity has been noted as a key maintaining factor in many different eating disorders, anxiety, and, to a lesser extent, depression. (2)
Treatment for people with co-occurring disorders
While most forms of therapy were originally designed to treat a specific type of mental health disorder, some psychotherapy approaches have been found beneficial for addressing the needs and causes behind some commonly co-occurring conditions.
Acceptance and commitment therapy (ACT)
As its name may suggest, acceptance and commitment therapy (ACT) posits the concept of acceptance as the healthiest and most beneficial way for people to deal with the unhelpful thoughts, feelings, symptoms or circumstances caused by their disorder(s). Once again, the broad approach of this method makes it very adaptable to treating co-occurring conditions for many people.
The underlying thought is that increasing someone’s ability to accept both themselves and the circumstances around them can help improve well-being. This is called cognitive flexibility, and many psychologists have pegged this capacity as a key factor for maintaining more helpful and healthy thought and behavioral patterns of all sorts. (18)
ACT works almost in an equal and opposite way to CBT. Rather than focusing on reducing the frequency of unhelpful thoughts, this method promotes the idea of reducing the effort or energy spent on attempting to control these unhelpful thoughts. This can actually be more effective than reducing the frequency of a person’s actual thoughts, as that is a normal cognitive function of the brain.
Rather, ACT implores its patients to let these thoughts come and go—a concept bolstered by teaching strategies for cognitive diffusion, which helps a person separate themselves from their inner experiences. Instead, patients are encouraged to get past unhealthy patterns and fixations by actively engaging in activities that are both meaningful to them and consistent with their personal values.
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy (CBT) has long been the leading form of therapy used to combat eating disorders, particularly bulimia nervosa, as well as a number of common comorbid conditions, such as anxiety, depression, and substance use disorder. Perhaps because it has been the subject of the most research to date. Many other forms of psychotherapy, or “talk” therapy have also been found to be very effective, but they haven’t been studied as extensively..
The practice focuses on helping a patient first identify, and then change, negative thought patterns they may experience as part of their disorder(s). The goal of CBT is for these changes to become automatic until, eventually, the patient no longer experiences these negative thoughts at all – or, at least, is aware of their existence and the tools to make an impactful change should they start experiencing them again.
The keystone belief of cognitive behavioral therapy—that a person’s thoughts and feelings play a fundamental role in their behavior—makes this practice highly adaptable and suitable to treat a number of mental health disorders, including when those conditions occur simultaneously. In other words, the tools CBT can offer to patients can be used in a wide range of scenarios, both in the therapist’s office and at home.
Dialectical behavior therapy (DBT)
Technically a modified version of cognitive behavior therapy, dialectical behavior therapy (DBT) was originally developed to help people with borderline personality disorder but has since been adapted to address a wide range of conditions. These include a number of eating disorders, as well as substance use disorder, bipolar disorder, generalized anxiety disorder, major depressive disorder, obsessive-compulsive disorder, and PTSD.
The reason this method is so effective for so many conditions may lie in its foundational goals: to help patients learn to live more in the moment, develop healthy strategies for coping with stress, regulate their emotions in a more balanced way, and improve their relationships with others.
The method goes about reaching these goals by teaching the major tenets of several important concepts. These include mindfulness, which can help a person create a heightened sense of awareness of their own thoughts and feelings without judging those observations, and distress tolerance, which includes techniques for calmly handling crises.
All told, the method works to bring about a sense of self-assurance and, subsequently, self-acceptance. This helps a person feel they can rely on themselves to handle any situation without resorting to unhealthy coping mechanisms.
Exposure therapy is another method whose core philosophy is exactly what it says. The concept behind this therapeutic technique is, indeed, offering a person some level of exposure to a thing or experience they fear.
That exposure doesn’t have to be a direct or physical experience. Patients undergoing exposure therapy use a number of different techniques, including visualization and virtual reality, to achieve these encounters. Regardless, exposure therapy entails the repeated confrontation with a feared object or scenario to help desensitize a person to the issue and give them vital insight into what, exactly, it is about the thing or circumstance they’re reacting to, as well as build effective coping strategies.
This therapeutic practice is commonly used to help people struggling with post-traumatic stress disorder, OCD, social anxiety, generalized anxiety, among other mental health conditions. And while there’s little empirical evidence on how exposure therapy can be specifically used to help people with co-occurring eating disorders, some aspects of the method are already used in other popular forms of treatment for eating disorders, including CBT, which sometimes “assigns” patients to expose themselves to feared foods as part of their at-home treatment regimen.
Emotion-focused therapy (EFT)
Another newer approach to eating disorders treatment than CBT that is proving to be very effective is emotion-focused therapy (EFT). Emotion-focused therapy helps individuals better regulate their emotions, build resilience, and strengthen relationships. To do this, individuals learn strategies to increase awareness of their emotions, identify and accept negative emotions, tolerate painful underlying experiences, express their emotions–instead of ignoring or suppressing them, and practice regulating them to meet their needs using positive coping skills without resorting to binge eating, purging and restricting. (21,22)
Because experiencing negative emotions is one of the most accurate predictors of binge eating episodes and those with BED tend to lack emotional processing skills, focusing on the role emotions and interpersonal relationships play in binge eating disorder in particular can improve binge eating patterns. (21,22)
People who have eating disorders tend to use the cycle of binging, purging, and starving as a way to control, avoid, or soothe difficult emotions. Recent research using EFT has found marked improvement in binge eating episodes and days, as well as associated disordered behaviors. (21)
Psychotherapy, or “talk therapy,” is just one component of treating co-occurring mental health disorders. An effective multidisciplinary treatment plan for most mental health disorders often includes experiential therapies that help a person heal by getting them “out of their head” and into their body. Since feelings are felt in the body and it can be hard to talk about them, using alternative modes of expression can often be more helpful than talking about or analyzing them.
Experiential treatments allow individuals to tap into their “right brain,” the side more responsible for imagination, intuition, and the senses. This can help them “turn off” their conscious brain, access deeper feelings than they’d otherwise be able to articulate, and bring different perspectives to experiences.
Different types of experiential therapies include:
Internal family systems (IFS)
The internal family systems approach to psychotherapy, while a relatively new model compared to CBT, has proven to be very effective for treating eating disorders. The IFS model views symptoms and behaviors as “parts” of a complex internal system that develop throughout a person’s life. Experiences that occur in a person’s younger, formative years play a role in how those “parts” show up in a person’s behavior. IFS has the same goal as other therapeutic models–to reduce the harmful behaviors, but from a different perspective–with curiosity and compassion.
Instead of viewing those parts negatively as driving bad behavior in response to difficult life experiences, as other therapeutic models do, the IFS model welcomes all parts of a person’s being as aspects of a person’s whole self. These parts serve specific helpful purposes for survival and will always be present in some capacity.
One example is the “protector” part, which serves a necessary and useful purpose when a person is overwhelmed, scared, embarrassed, or hurt. Only when the protector goes overboard to make the person’s overwhelming emotions go away does this become a problem, as with binge eating, substance abuse, or excessive spending. When people move toward these “parts” and befriend them, without judgment and shame, the parts can “be seen,” release their burdens, and heal their pain. (19,20)
While the practices of mindfulness and meditation are an ancient Eastern tradition, they have become increasingly popular in mainstream Western societies recently as a way to reduce stress and improve well-being. Mindfulness is the practice of bringing your attention to the present moment and cultivating an objective awareness of your experiences and surroundings in that moment without an immediate reaction or judgment. Meditation is the practice of being still, focusing on the breath, and bringing attention back to breathing when the mind wanders.
Mindfulness and meditation have a positive impact on psychological health and overall well-being. Results from a review of several studies on mindfulness and meditation report several improvements in emotional and behavioral functioning. These include higher levels of life satisfaction, conscientiousness, vitality, self-esteem, empathy, sense of autonomy, competence, optimism, and pleasant affect. Participants in these studies also reported lower levels of depression, neuroticism, absent-mindedness, dissociation, rumination, reactivity, and social anxiety. (23)
Mindfulness-Based eating awareness training (MB-EAT) combines mindful eating with mindfulness strategies and has shown promise in treating binge eating disorder in particular. People with BED learn mindfulness techniques to become more aware of hunger and fullness cues, change eating behaviors, and reduce binge episodes. (24)
Potential treatment complications
Unfortunately, the complex and interlocking nature of comorbid conditions can also present a number of challenges to treatment for people struggling with multiple mental health disorders.
Complicating issues can range from the common emotional reactions a person may have to struggling with these disorders to problems that become clear only once a person has entered into treatment.
Aversion to treatment
A reluctance to seek out or embrace help may be an issue for anyone struggling with a mental health disorder, for many reasons. Shame, guilt, and embarrassment are just a few common, yet inhibiting, emotions that may surface around talking about their conditions and prevent someone from seeking treatment.
The presentation of depression or anxiety in someone who also has an eating disorder may make this task especially hard. Anxiety and depression are both often accompanied by avoidant coping mechanisms, which can manifest as efforts to evade the exact type of interpersonal relationships psychotherapy encourages. (2) Both conditions also typically entail a fear of being negatively evaluated by others, which may further dissuade someone from pursuing treatment. (2)
The overlapping or similar symptoms of two different conditions can make it difficult to properly diagnose a patient, determine which is the primary condition and how it should be addressed, or set a course of treatment that may be the most beneficial.
The types of compulsions and obsessions that define OCD, for example, are also expressed as part of many types of eating disorders, making it challenging to discern if a patient with these co-occurring conditions is struggling with a particular form of OCD or an entirely separate but related disorder whose symptoms carry an obsessive-compulsive quality. (5) This can go on, in turn, to impact the recommended course of treatment a clinician may advise.
These grey areas can also lead to the unfortunate situation where a condition isn’t recognized at all, as it can hide behind common symptoms that either get misdiagnosed or overlooked entirely.
Unresolved trauma stemming from a comorbid condition can be another complicating factor in treatment for many people. This specific issue can be a particular problem with people struggling with both an eating disorder and PTSD.
Post-traumatic stress disorder, which is the body and mind’s reaction to unresolved trauma, tends to go underdiagnosed, undiagnosed entirely, or inadequately addressed. In fact nearly 30% of participants with PTSD still experience the full symptoms 10 years later, according to one study. (7)
One of the most harmful groups of PTSD symptoms are dissociative strategies, or thoughts that allow a person to separate themselves from, or even suppress entirely, the details of a traumatic event. (7) These amnesic responses can present additional challenges when seeking proper treatment for either disorder.
Still, regardless of the disorder they stem from, these types of lingering symptoms of trauma can act as both a perpetuating factor for an eating disorder and an extra barrier that can complicate treatment for clinicians hoping to address the eating disorder.
Medication is not always recommended as a course of treatment for mental health disorders. But, in cases when it is, it can prove another complicating factor when treating people with multiple conditions.
Cases where people struggle with both bipolar disorder and an eating disorder are examples of this tricky balancing act.
Antidepressants are one of the most widely prescribed medical treatments for eating disorders in general, as depression and anxiety frequently co-occur. This class of medication, however, is not recommended for people struggling with bipolar disorder, as they can trigger manic mood swings. (23) mood stabilizers or antipsychotics are generally recommended for people with bipolar disorder, but these types of drugs can prompt binge-eating episodes for people with bulimia or binge eating disorder. (23)
Like bipolar disorder, each mental health condition tends to respond better or worse to certain medications, and clinicians must be very careful when considering how these drugs may potentially interact with each other, and the patient, when prescribing them.
Lack of comprehensive clinical programs
While some types of therapy may lend themselves to treating several different types of mental health disorders simultaneously, treating co-occurring conditions together is rare in the psychological world. This can often cause complications, especially when traditional approaches for treating individual disorders vary.
For example, substance use disorder and eating disorders are rarely treated together in a comprehensive way. Eating disorder treatment programs may not accept patients who compulsively use alcohol, illicit drugs, or even over-the-counter medications like laxatives. And many substance use programs will exclude patients struggling with eating disorders. (24)
As a result, patients must instead go through both types of programs individually, which can cost a great deal of both money and time, be highly disruptive, and cause issues with insurance coverage. It can also leave patients at risk of seeing one disorder intensify while the other is being treated. For example, more symptoms of an eating disorder may present while the person is being treated for substance use, though more empirical data is needed to support this effect. (24)
When to seek help for an eating disorder
The best time to seek treatment for an eating disorder is always “as soon as possible.” If you’re asking yourself whether you or a loved one should seek help, it is likely time to do so.
Eating disorders can cause a number of short- and long-term complications And the negative effects of these on both a person’s mental and physical health tend to get worse with time. The condition can be especially dangerous when combined with co-occurring mental health disorders. These can present their own unique set of complications to the situation and make treatment and recovery especially challenging.
Still, full recovery is always possible, even in cases of comorbid conditions. The most important thing to always remember is never to give up hope.
Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.
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