The boundaries of sanity

There seem to me to be two extreme, and implausible, strands of thought knocking around in the area of what we might problematically call “mental health”. The first leads to the medicalisation or pathologising of any kind of psychic distress. You know the kind of thing: fried chicken lickin’ anxiety, boorish party phobia, post egg and spoon race defeat trauma. The other is the view that there’s no such thing as mental illness at all (even if you call it something other than illness).
I’m not going to attempt to argue as to why these two extremes should be rejected. All I want to do here is ask how, if we agree the extreme views are both wrong, we distinguish between ordinary distress and differences in thought, and pathological states or conditions.
I’m not aware of a good way of drawing this line (which is not to say there isn’t one). It seems probable that no line could ever be sharp here, but as we all know (I hope) real distinctions often have fuzzy borderlines and grey areas between them. So let’s not fall into the trap of saying that hard borderline cases show the distinction can’t be real.
I can think of two criteria that can be used, each necessary but not sufficient as conditions. One is to do with having irrational ways of thinking. Of course, we all of us think irrationally, more often than we might wish to believe. But there is a sliding scale and go beyond a certain point and the irrationality is pathological.
The second is to do with functionality. So, for example, a severely depressed person can’t get on with life, and nor can someone with a paranoid fear of door handles.
Colloquially, we do describe as “totally mad” people’s whose world views are wildly incoherent. But we don’t think of them as suffering from a pathological condition unless this creates functional problems. The person who believes we’re all lizards is merely eccentric, just as long as he can do things like hold down a job and a relationship, and isn’t a danger to anyone.
It’s also the case that dysfunction is not a sign of mental pathology if it is for good reasons. One can imagine someone for whom being depressed is a perfectly rational response to what they are going through, for example.
So although perhaps extreme dysfunction without apparent incoherence of belief could be seen as pathological, as could extreme incoherence without dysfunction, in practice, a pathological state of mind seems to require both. I say this descriptively: this is how, in fact, we seem to distinguish between the sane and the insane, even if we don’t use such un-PC language.
I have no problem with the fact that it implies a continuum, and that there have be judgement calls as to whether someone is “far enough gone” to be considered a pathological case. But it still seems unsatisfactory. Surely there are some better criteria than these? As far as I know (I could well be wrong), the diagnostic manual DSM lists criteria for specific “disorders” but does not specify general principles for identifying something as a mental disorder.
Cab anyone do better or point to a better answer? I’m sure there’s a big field of work here in the philosophy of psychology and psychiatry.
(Underlying neurological dysfunction won’t work, by the way, because in order for that to cause a mental disorder, we have to decide that the disorder is real at the psychological level. So, for example, someone who sees sounds and hears colours has a weird brain, but they are not mentally ill. The individuation of mental disorders cannot take place at the neural level, even if in certain cases we find that neural indicators are 100% reliable predictors of them.)

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  1. You say that for a mental condition to be pathological, it requires both extreme dysfunction and incoherence of belief. I’ve known one case of a person suffering from severe paranoia, who was neither dysfunctional (he worked as a security guard) and nor incoherent. His paranoia was completely coherent, if one accepted his initial premises (which were delusions).

  2. Good point – coherence is probably the wrong word. But I don’t just mean internal coherence, I mean coherence in a wider (looser sense). His delusions were not coherent with the way the world is, we might say.
    We could debate what the right word is (and I’d be interested to hear suggestions) but I don’t want to stray from the substance. Hopefully this clarification puts things straight.

  3. I think irrational thinking is a key point here, but like you say, we are all prone to it more often than we’d like to admit. But the key difference is what we think irrationally about. Although I’m not terribly sure that I could come up with a neat and organized way to determine what subjects of thought are irrational in an allowable way (ordinary people being irrational) and when it becomes a pathology.

    Perhaps another point is that upon reflection, non-pathological people understand that they are being irrational about a subject, and pathological can’t see their own irrationality? just a guess there.

  4. “His delusions were not coherent with the way the world is…”

    As, say, with certain fundamentalist Christian beliefs?

    One thing that speaks to whether a delusional belief is an indicium of insanity is its etiology. For instance, you might have a delusional belief that Jesus talks to you because of multimodal hallucinations to the effect that Jesus is talking to you. If so, you might want to seek help. On the other hand, if you have the belief that Jesus is talking to you because your social group has adopted the habit of construing gut feelings, intuitions, or the deliverances of one’s own conscience as Jesus talking to you, then there’s probably nothing much wrong with you. (Though I recommend this little book to you.)

    In any case, the problem of setting boundary conditions for a “mental disorder” is much the same as the one besetting the medical term ‘disorder’ generally. In the interstitial cases, there’s a lot of muddling through based on some notion of normal functioning modulated by whatever set of values happens to be prevailing at the time (whether within the profession or within society at large. The question is made all the more difficult by “commercial pressures“, the anti-psychiatry movement, and so forth.

    In sum, even if you could lay out an immutable, authoritative set of criteria, I’d still expect the extension of ‘disorder’ to continue to change over time, much as it has in the past (cf. “sexual orientation disturbance,” once the clinical diagnosis for homosexuality). You might say that concept ‘disorder’ suffers from some kind of chronic disorder. And it’s probably a valid complaint.

  5. The criterion of irrationality appears stronger than dysfunctionality, since a person can rationally decide to be dysfunctional, and the criterion of dysfunctionality in some ways recalls Soviet psychiatry which labeled those who did not work or could not work as mentally ill, for example, the Nobel-Prize poet, Joseph Brodsky. On the other hand, what about religion? If I believe that my mother was a virgin, I am totally irrational and mentally ill. If I believe that the mother of Jesus was a virgin, am I sane?

  6. well you don’t have to be totally irrational to believe in a virgin birth. With invitro fertilization, and artificial insemination, I’m sure there is at least one human who ha given virgin birth….

    And there was this recent case of a shark giving virgin birth:

  7. So if one person thinks irrationally, they are insane but if a large amount of people think irrationally, it’s religion? (meaning it’s ok?) Woe to the solitary person, I suppose.

  8. Nietzsche (Beyond Good and Evil): Madness is rare in individuals–but in groups, parties, nations and ages it is the rule.

  9. I’ve been on the receiving end of therapy, have had therapists as friends, have had many friends in therapy, and have played amateur therapist at times, and therapy is an art, not a science. A good therapist (and I’ve known really good ones) picks up on very subtle clues that differentiate, say, the eccentric individual (who, for example, decides not to work, not to participate in society and to spend his or her day playing online chess) and the mentally troubled person who uses online chess as a psychological defense against a reality that overwhelms him or her. The good therapist notices small resistances to good sense, quirks, minor contradictions, blind spots, ruptures in the flow of the dialogue, unnecessary lies, serious distortions in the self-image, among many other things.

  10. Funnily enough, we’re having a similar debate over at Lake Cocytus (a psychiatrist blog)

    I defend the view that we should move beyond terms such as ‘mental illness’ and ‘disorder’ and speak solely of 1) distress / disability (subjectively defined) and 2) impaired decision making capacity (NOT irrationality). That is, when it comes to deciding who we should offer or provide treatment to these are the only important considerations. I’m not sure risk to self or others is required as an additional justification for psychiatric intervention (although it certainly ups the stakes). I think this issue is dealt with sufficiently by the requirement for impaired capacity.

    1) Distress and disability

    Although there are exceptions, distress and disability defined as mental illness (excluding organic conditions) differs only in degree (not kind) from distress and disability we all experience. The cut-off point for treatment ought to be determined not by objective scientific scrutiny, but subjectively by the individual seeking help, by available resources and by value judgements made by the health care system, the individual and society at large. These value judgements are unavoidable therefore the best approach is to make them explicit and open to debate and challenge. Negotiating diverse values is the philosophy behind value-based practice in mental health, developed by philosopher and psychiatrist Bill Fulford.

    2) Capacity

    As per the England and Wales Mental Capacity Act (2005) impaired capacity to make a decision is assessed by looking at;

    1) a person’s ability to understand the information relevant to a given decision
    2) a person’s ability to remember that information for long enough
    3) a person’s ability to use and weigh up the information (including being free from pressure from others)
    4) a person’s ability to communicate that information

    You can measure these different domains using a variety of neuropsychological tests and interviews with family and carers.

    One main principle driving the Capacity Act is the right of people to be able to make unwise decisions – hence the distinction between impaired capacity and irrationality. There are real advantages of this approach (with respect to preservation of liberty) however my fear is that it gives capacity assessment more apparent objectivity than is actually the case. For example, valid disagreement over values can be disguised as an inability to weigh information.

    Nonetheless, I can’t think of any example where treatment or classification as ‘mentally ill’ is warranted without a significant degree of distress or disability and / or impairment in capacity.

    With respect to the term ‘delusion’, I’d happily defend the view that it is no longer useful. Most people agree the term is impossible to define. Rather than accept this why don’t we challenge use of the term itself?. My view is that we should examine closely our intuitions as to why we want to provide help to people who we may classify as delusional. Instead of ‘is this person delusional or not?’ I think the more useful questions are ‘is this person’s capacity impaired?’ or ‘is this person distressed and help-seeking?’. Without the first requirement there is a risk that we pathologise culturally unacceptable beliefs (which is often what happens).

    Anyway, for a humane and philosophically sensible approach to understanding phenomena classified as ‘mental illness’ go to:

    I used to think this was radical but now I don’t think it goes far enough.

  11. Paul: You seem to be challenging the traditional model of mental pathology, and I agree with you. I may be terribly distressed and seek therapy when by traditional forms of classifying mental illness, I am sane and only passing through a difficult moment in life, while X, who could be classified as suffering from severe paranoia by traditional classifications, may feel no distress at all. As to capacities, isn’t that dependent on intelligence? What seems important in real life is the capacity to understand the rules, written and unwritten, of the psychiatric interview. A personal experience: a woman friend, B, calls me and begins to explain her problems with an extremely accelerated voice. She has attempted suicide in the past, so I insist that she accompany me to a hospital emergency room for outpatient treatment. I have taken others to the same hospital where they are quickly assessed and receive medication, generally, a shot of some tranquilizer.
    I am allowed to enter the psychiatric interview with her, and she immediately begins to insult the doctor, to call him a representative of the repressive, thought police. The doctor keeps looking at me for a clue. I tell B: stop insulting the doctor, he’s read Foucault too, and he’ll give you a shot of something and you can go home. Her insults increase in tone, and the doctor says that she’ll have to be hospitalized for observation. She throws a cushion at the doctor, and instead of being sent to the nice open ward, she’s sent to the closed ward, where she begins to shout that she has been jailed (which is true, but not the correct thing to say) and as a result, she ends up in the state mental hospital for a long stay.

  12. “As to capacities, isn’t that dependent on intelligence? What seems important in real life is the capacity to understand the rules, written and unwritten, of the psychiatric interview.”

    Yes, the processes involved in decisions making are dependant on general intelligence, amongst other things.

    However capacity assessment (ideally) should not depend upon the subjective norms (values, rules etc) held by a particular professional. Assessing capacity according to the legislation I discussed means the person’s (dis)abilities ought to be judged against statistically derived norms. This is a good thing in my view, particularly with respect to things such as memory, cognitive ability, executive function etc.

    The Mental Capacity Act (2005) also states that we should assume people have capacity unless proven otherwise. I would also argue strongly that we should assume that the experiences and beliefs and problems an individual has are meaningful and understandable within the context of their lives, unless proven otherwise.

    This is certainly not an antipsychiatry position, but it is a position which challenges the primacy of biological ‘disease’ approaches on ethical grounds, rather than solely empirical ones.

    This may or may not be of relevance to the example you discuss. But let’s imagine that this particular professional was looking for signs and symptoms of biological ‘mental illness’ (whatever that is), as opposed to taking his time to really understand what your friend was going through. If so then throwing cushions and saying things he doesn’t understand become symptoms of underlying psychopathology – essentially meaningless or ‘un-understandable’. Of course this may be the case, but he needs to make his case. Unfortunately for him, the evidence for such an organic disease process actually existing is not looking good (in my biased opinion!). In lieu of this evidence, let’s simply talk about distress and capacity. Your friend may have had impaired capacity (for instance to make decisions about her health and wellbeing), but that ought to have been carefully assessed (perhaps it was?).

  13. Paul: The doctor could have made more effort to put himself in her place, and I sided with the doctor, since I wanted to show him that unlike her, I was sane. In her case, distress was present or she would not have called me. The doctor, like anyone in a busy hospital emergency room, had limited time to deal with the case. He gave her a chance to “be a good girl and submit to his authority”, which would have been a sign of relative sanity in the context, at least from the doctor’s point of view. She choose to rebel against the doctor’s authority (although, curiously, she never showed hostility to me for bringing her to the hospital), and paid the consequences for her rebellion, which was partly the result of an ideological anti-psychiatric position (Laing, Foucault, etc.) . On the other hand, from the distress point of view, she had almost successfully committed suicide (jumping from a window) several years before. Should the doctor have left a highly agitated and aggressive potentially suicidal patient walk out the door? Did she have a right to throw herself out of a window again? I suppose that ideally, the doctor or I should have stayed up all night, accompanying her until she calmed down out of pure tiredness, but none of us are saints. By the way, I have talked all night to troubled friends until they simply fell asleep, but in this case, I had less patience. You have certainly raised a lot of valid questions, for which I have no answers.

  14. So basically, one rarely judges oneself to be mentally ill (whatever, choose your own label) but this assesment comes from others, and then it becomes a power issue fraught (spelling?) with misdiagnoses and abuse.

    For example, oftentimes a person is experiencing a spiritual crisis/awakening and is judged instead to be mentally ill. This does a great deal of damage to the person and can inhibit their spiritual/emotional/mental growth and well being.

    I think overall that psychiatry is a frightening joke and is ultimately used as a way to control people, especially women. And please don’t throw Foucault at me.

  15. Tree: Paul’s criterion of distress is subjective. People seek help or treatment or therapy because they feel distressed. There is no need to call distress an illness, of course. Let’s just call it “distress”.

    Paul: If you’re listening, could you be more specific about what you mean by capacity? Is it just another way of referring to the ability to reason? Thanks.

  16. I think overall that psychiatry is a frightening joke and is ultimately used as a way to control people

    This is often the case. But the other extreme view (that there should be no psychiatric services) is equally dangerous in so far as it would deny incredibly distressed and vulnerable people the help they want and need.

    What alternative is there?

  17. How about the likelyhood of the condition causing harm to self or others and the degree of harm being caused?

    It’s more of a sliding-scale thing than a clear cuborder, but I think that’s pretty appropriate.

  18. Quick response:
    I am for the other extreme view, I think that here in America psychiatric services are an astounding failure. There are many, many mentally ill who are not receiving the help they need, so I can’t even pretend in theory and argument that it’s a viable means of help for people.

  19. The ability to understand the factors involved in a decision and the ability to weigh those factors against each other is a big part of it. The focus is on the process though, not the actual decision made.

    For instance, say you’re assessing someone’s capacity to make a decision about their health. You may assess things like their ability to concentrate, their ability to wait before all the evidence is presented before making a decision or their ability to resist pressure from others (for instance, many vulnerable adults are highly suggestible).

    Here’s a link to a British Psychological Society document on assessing capacity:

    Julian’s original post was about how do we tell the boundaries between the ‘mentally ill’ and the sane. The best analogy is blood pressure I suppose. Blood pressure is clearly on a continuum. The decision over when to classify someone as having ‘high blood pressure’ is made for pragmatic reasons (increasing risk of associated problems, available resources and so on) and evaluative ones (heart disease = bad).

    The same holds true for mental health. If, as a society, we did not care about those who experience profound psychological distress and if we did not wish to absolve some individuals of responsibility for their actions, then there would be no concept of ‘mental illness’ to speak of. As in physical health, we are free to choose what we classify as ‘disorder’ or ‘order’, ‘health’ or ‘illness’. The factors which constrain the decision are pragmatic (will the condition get worse if untreated?) and evaluative (e.g., depression = bad).

    The difference between physical health and mental health is that the value judgements being made in the latter are a lot more controversial, to say the least (e.g., homesexuality = bad*; hearing voices = bad, misery = bad). The solution of course is debate and dialogue. The problem with current psychiatric classification systems like the DSM (mentioned in Julian’s post) is that they stifle debate and reify social norms.

    *homosexuality was only removed from the DSM in 1973

  20. How about the likelyhood of the condition causing harm to self or others and the degree of harm being caused?

    I’m not sure risk to self or others is required as an additional justification for psychiatric intervention. That is, I think this issue is dealt with sufficiently by the requirement for impaired capacity.

    That is, if someone states they are thinking about harming themselves or others (or indeed fully intend to), then their capacity to make that decision ought to be tested. If impaired, then efforts should be made to increase capacity. If efforts to increase capacity fail and the risk is still high, then it is likely (but not always) to be in their best interests to prevent the harm occuring.

    If capacity is preserved and intact, then it ought to be viewed as a matter of personal choice re self-harm / suicide and a criminal justice matter re harm to others (of course this does not preclude helping that person if they are distressed and seeking help)

    Perhaps this sound harsh but do we really want a paternalistic society where a capable individual loses their sovereign rights over their body, or where a capable individual who chooses to engage in crime and violence is medicated rather than punished?

  21. Thanks for all the contributions. I haven’t had time to read them all properly yet, or follow some of the interesting sounding links, but I will. Apologies for not following up myself (yet).

  22. Paul: Thanks for clarifying various concepts. Today I read most of the Stanford Encyclopedia article on mental illness. Worth looking at.

  23. Thanks Amos. Just had a skim – wish I’d read it sooner! Particularly keen to read Hacking’s work on interaction effects between diagnosis and the condition being diagnosed.

  24. BMJ Group blogs: Journal of Medical Ethics blog » Blog Archive - pingback on September 24, 2008 at 10:11 am
  25. Profit appears to be a great stimulus to disease/syndrome identification.

    Men used to get old and fertilize fewer ova. With the advent of Viagra, we now have Erectile Dysfunction.

    Finally, no more periods and no worrying about another pregnancy. What’s a little sweat in the good old days. Now menopause is a disease full of treatable symptoms. Lots of profit there.

    People used to get old and bored and out of it, finally dumbing down. Now we can treat A.D. or garden variety Dementia with Aricept.

    Half the guys in the physics department sat in a corner at parties, mumbling some theory to nobody. I suppose there’s a pill they can now take for Asperger’s?

    In my 5th grade class were kids of every type: blabber mouths, mighty mice, drama princesses, mopes. We were a colorful lot. No more. There’s a pill for all those *syndromes.*

    I wouldn’t suggest there are not extremes in the above groups that deserve concern and possible remedy, but industry is greedy and diagnostically creative.

    Today, as is my wont, I will swim, bike, and run. Or I can sit on the couch with some pills for ummm…hypomania? AD, maybe? No, thank you.

  26. rtk – given your apparent views on Alzheimer’s disease (which has a known pathological basis), presumably you think that people used to just die, now industry has created things like ‘cancer’ and ‘diabetes’ with pills to treat these so called syndromes?

  27. The subject is the boundaries of sanity, not tumors and pancreatic disorders.

  28. I’m not sure why it’s important to draw a line between “normal” and “pathological.” Someone loses their entire family in a war or natural disaster, and now they’re severely depressed. Is this normal or pathological? I don’t see why it matters. It’s entirely reasonable for them to seek and receive treatment.

    Some kid is so completely distractible in school that he can’t learn and will inevitably have future problems. If it’s bad enough, why worry over much whether this is normal or pathological? The problem is stopping the person from thriving. If there’s a medical solution, why not?

    In legal contexts where judgments of responsibility have to be made, I can see you might need to draw a line between normal and pathological….and there are some issues about what should be covered by insurance or national health care, but other than that…

    Wait, now that I scroll up and read Paul’s comments, I think he said something similar much more carefully.

  29. If there’s a medical solution, why not?

    In this case I think we need to make a distinction between the actual treatment offered (e.g., meds) and the rationale given to the family / child for the treatment.

    That is, there’s a world of difference between;

    1. Take drug X because there’s something wrong with your brain and this will fix it.


    2. Take drug X because it will help you (a) conform to the demands of society and (b) ensure you still get an education in the context of limited resources to support you adequately .

    A lot of the problems and controversy arise not from the use of medication per se but from the sophisticated sounding nonsense peddled by greedy drug companies (i.e., rationale 1)

  30. OK, that’s fair. And I see that a lot–people being told their kids have a disorder, and therefore accepting a medical solution, when they would otherwise have thought things were in an acceptable range. Still, people have problems they’d seriously like to get rid of, and I don’t see why the problems have to be classified as abnormal or pathological before they opt for a medical solution.

  31. rtk – the subject I was addressing was your apparently ill informed views on disease mongering where you laughably imply that Alzheimer’s disease is made up by industry.

  32. Paul, you can’t just blame the drug companies, the psychiatric and broader medical professions have embraced biochemical imbalance theories of mental illness because they are easy to convey, favoured by many patients (particularly the parents of patients), and help justify the rationale of medication.

    I think people are too quick to draw distinctions between mental and physical illness. Physical medicine is filled with conditions that could be considered variations of ‘natural’ but we don’t have the same hangups that we have with psychiatry .

  33. pj, I agree. I don’t think it is just drug companies. But I don’t think it’s uncontroversial to say they have a large influence.

  34. sorry (freudian slip) that should read…

    “i don’t think its controversial to say they have a large influence”

  35. True story:
    Sitting in the doc’s waiting room, along comes a man about 60 or more. He says to a buddy or acquaintance, Hey ! I got 17 medications! He’s smiling and proud. His friend answers, Oh yeah, I’ll count mine tonignt. Bet I’ve got more. Proud? It’s a pissing contest.

    Another true story:
    Man in early eighties goes for a psa (is that what the prostrate test is called?) and passes with flying colors. Doc asks if he gets up at night to pee, but doesn’t ask what he drinks before he goes to bed. Pill. Blood pressure? 130/85. Doc says it’s been borderline for a long time. Beta blocker. How’s your memory? He makes joke about keys. Knees hurting? Another light response. No questions asked. Whaddya know? Viagra. Itchy scalp?

    He went home with Finasteride, Atenolol, Nizoral, Vitamin D, Aricept, Triamcinolone Acetonide, Fosamax. This is a healthy man with NO health issues, walks two miles per day, bikes, lifts weights and is never sick.

    Why? I can only guess. Besides the barrage of free samples and hard sell, there are lawsuits. The doctor is between a rock and a hard place. Do or don’t prescribe. Damned either way.

    And it’s our fault. We want a quick fix. We want our kids to conform to a norm that would bore hell out of me and friends. ADD was our norm. Children are under such ugly pressure at 1st grade to do their abundant homework and get into college. If a pill helps them down the narrow path, why demand a pathology to warrant it? I wish there were a pill for a pathological society.

    Sorry about this rant. I’m in a bad mood. My saltwater tank needs too much attention. Pass the valium, please.

  36. rtk: Can a society be pathological? That’s a semi-serious question. People like Erich Fromm used to talk a lot about a sick society. If I recall correctly, R.D. Laing affirms that madness is a journey in search of well-being in response to a sick society. Then people stopped talking about society being sick. I don’t know why they stopped or, for that matter, why they began to talk about it. Maybe you’ll begin a new trend and people will start talking about society being sick again. Please, I’m not being ironic. By the way, valium was long ago replaced by newer and more expensive tranquilizers, when the patent ran out and diazepam became generic. Ditto with atenolol.

  37. Amos: I think those who are in charge of marketeering our prez and vice-prez candidates are depending on the U.S. society’s pathological state. Maybe that was Rove’s immense cleverness, the understanding that we in the U.S. are so sick, we can be sold anyone if the techniques can be found to massage our fears. In fact, he went further by creating the fears and then the awful solutions. The price for all this is paid for around the world, especially in the mideast, where our government thinks lives are less precious.

    I really like the R.D.Laing quote.

  38. Here’s some Laing, if you’re interested.

  39. rtk: I don’t want to minimize Laing’s merits (I’m going to reread those links myself), but as Paul says above, if we see everything in terms of pathology, the concept of ethical responsibility evaporates. That is, is the U.S. a pathological society or a greedy one or an imperialistic one? By the way, I’m not claiming that the U.S. is more greedy than where I live. There is a lot of oil in the Middle East, and “we” really can’t leave all that oil in the hands of terrorists, can “we”?

  40. Can we say pathologically greedy? Sickeningly unethical? Even cancerously imperialistic?

    But I’m really seeming way too gloomy. Some governments are truly evil, but I have considerable faith in the populations. Take away the Palestinian and Israeli governments and I believe you have people who could work out a future together today as they were long ago. Indeed, the Muslim countries are where the Jews escaping the Inquisition found least hostility. Nothing wrong with Alaskans in spite of The Possible Future Occupant.

    None of this has enough to do with the The Boundaries of Sanity, so I’ll stop.

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