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Historical Perspectives


Margaret Jordan Halter, PhD, APRN;

Donna Rolin-Kenny, PhD, APRN, PMHCNS-BC;
and Faye Grund, MS, APRN, PMHNP-BC


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The first major attempts to categorize psychiatric disorders in the
United States occurred in the mid-1800s, when census data were
collected that included insanity and idiocy of household members. In Europe, Florence Nightingale promoted the use of nonfatal disease classification for morbidity and treatment in 1860.
By the late 1800s, Kraepelin categorized disorders, and his sixth
edition of the Compendium der Psychiatrie was widely adopted by
both Europeans and Americans. In 1952, the American Psychiatric
Association published the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Since then, the manual
has been periodically updated, expanded, and edited to reflect
social and scientific beliefs about the etiology and categorization
of psychiatric illness and care. In this article, we explore the historical and ongoing development of the DSM and its implications for
psychiatric nurses.

he next edition of the American Psychiatric Associations [APA] Diagnostic and

Statistical Manual of Mental Disorders,
fifth edition (DSM-5), is scheduled
for publication in May 2013. This article is the first of two describing the
development of the DSM. An outline
of the historical perspectives, the
evolution of the classification, and
definition of mental illnesses will be
discussed. Also, contributions of psychiatric nurses in its development are
presented here. The article by Halter,
Rolin-Kenny, and Dzurec (pp. 3039) details the changes made in the
DSM-5, highlighting controversial
modifications, and the potential impact of this edition on both the providers and consumers of psychiatric


The development of a common
language for describing psychiatric
disorders assists in our understanding of global epidemiology and refinement of disease statistics. Classification aids in the replication of
research so that studies may be compared and analyzed, furthering diagnostic utility. A common language
also supports interdisciplinary case
collaboration, leading to improved
patient outcomes. It also facilitates
early diagnosis and problem identification for more immediate, proactive, and effective treatment for individuals with psychiatric syndromes
(Sanders, 2011).
Historically, countries and individual agencies within these countries had separate approaches to

Journal of Psychosocial Nursing Vol. 51, No. 4, 2013

classifying mental illnesses. Mental

illnesses were not understood, and
their descriptions were inadequately defined. At a time when naming
conditions was in the rudimentary
stages, descriptions were identified
based on gross departures from predictable, logical, and orderly behavioral patterns. These conditions were
merely observed, as root causes were
not comprehended, nor were any
effective treatments devised. Early
attempts to classify mental illnesses
were based on an evolving understanding of the nature of psychiatric
In the 1840 U.S. Census, respondents were asked to identify a variety
of demographic data (CensusFinder,
n.d.). One question, How many idiotic or insane Whites? was used to
determine the prevalence of mental retardation and mental illness of
people residing in public or private
residences. No definitions of these
conditions were provided, presuming
that everyone knew what was meant
by the terms, and this was one of the
earliest widespread attempts at the
categorization of mind-based disability. This census even provided a categorization of insanity as it applied to
non-free individuals by asking about
the number of insane or idiotic slaves
and free Blacks who resided in the
household. A disorder termed drapetomania (drapetes, a runaway [slave]
+ mania [mania, madness, frenzy])
was later used to refer to a mental illness that caused slaves to flee captivity (Cartwright, 1851).
Forty years later, the 1880 U.S.
Census included a special form,
Schedule for Insane, to categorize

people who were in asylums or dependent on others for support (Genealogy Trails, n.d.). The purpose of the
form was to learn more about people
in these situations. It included more
categories of mental illness: mania,
melancholia (depression), monomania (impulse control, conduct, and
delusional disorders), dementia, and
dipsomania (alcohol craving and
binge drinking). Epilepsy was also included as a psychiatric disorder.
The Compendium der Psychiatrie,
an early work by German psychiatrist
Emil Kraepelin (1883), argued that
psychiatric care was as legitimate as
general medical treatment and should
be investigated systematically. In the
sixth edition of the Compendium der
Psychiatrie, Kraepelin (1899) categorized disorders into a notable dichotomy with separate etiologies and treatment trajectories. His work was based
on longitudinal studies of clinical
presentations and generational family
histories (Sanders, 2011). Kraepelin
categorizations were quickly adopted
in Europe and America for the purposes of diagnosing psychiatric disorders
and are considered to be the foundation of modern psychiatric classification systems (Palm & Mller, 2011).
One Kraepelin category of diagnoses was exogenous (i.e., originating
outside of the person) and treatable.
This included manic-depressive disorders and melancholia (depression).
The other category was endogenous
(i.e., originating inside a person), organic, and incurable. Dementia praecox, which means premature dementia
and referred to schizophrenia, was included in the latter category. Kraepelin identified three clinical varieties of
this disease: catatonic, characterized
by motor activity disruption (excessively active or inhibited); hebephrenic, characterized by inappropriate
emotional reactions and behavior; and
paranoid, characterized by delusions of
grandeur and persecution.

While Kraepelin was developing
his own classifications of mental illness, other health care providers and
governments were searching for effective ways to classify and organize
medical data. Most focused solely on
recording death/mortality statistics.
At the Fourth International Statistical Congress in 1860, nursing
research pioneer, Florence Nightin-

The DSM-5 will result

in restructured
diagnostic criteria,
altered formulas for
the reimbursement
of care, and
therefore changes in
treatment patterns
and strategies.

gale, promoted the use of non-fatal

disease classification for morbidity
and treatment entitled Proposals for
a Uniform Plan of Hospital Statistics
(Gordon, 1998; Nightingale, 1860).
She urgently recommended the use
of a classification of diseases for hospital morbidity statistics. Nightingale
asserted that this would inform treatment options.
A series of international classification systems evolved shortly thereafter. The 40-page Bertillon Classification of Causes of Death was developed
in France in the late 1800s. In 1898,
the American Public Health Associ-

ation adopted this system, which was

the precursor to todays International
Statistical Classification of Diseases
(ICD) (World Health Organization
[WHO], n.d.). The association suggested that the system be updated on
a regular 10-year cycle.
To lay a foundation for the decennial revision process, the First International Conference to Revise Bertillon Classification of Causes of Death
followed in 1900 (Moriyama, Loy,
& Robb-Smith, 2011). After that
time, the next three revisions were
relatively minor, and early editions
were fairly short. Little attention was
given to mental illnesses. This lack of
attention may be due to the original
Bertillon text that focused on causes
of death from fatal medical conditions rather than morbidity (i.e., incidence of disease) statistics.
Although most sources credit the
sixth edition as the first ICD to include mental disorders, it was actually the fifth edition (Kramer, Sartorius, Jablensky, & Gulbinat, 1979).
In 1938, the ICD contained a section
on diseases of the nervous system and
sense organs. That section included
mental deficiency, dementia praecox,
manic-depressive psychosis, and other disorders. In another section, alcoholism was described.
The sixth edition of the ICD was
published in 1948 when the WHO
formed and assumed oversight for the
publication. The new edition would
include morbidity (disease and injury) in addition to the original focus
on mortality. Thus, the name changed
to the International Statistical Classification of Diseases, Injuries and Causes
of Death (ICD). This edition included
a greatly expanded section on mental disorders outlining psychoses and
psychoneuroses (10 categories) and
disorders of character (7 categories),
as well as intelligence (APA, 2012a).
Unfortunately, and despite the fact
that psychiatrists drafted this section
of the text, it was virtually ignored
by the medical community (Kendell,
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At the same time the ICD was
being developed, psychiatrists were
working to classify mental disorders in
a separate manual. In 1917, the Committee on Statistics of the American
(now the APA) in collaboration with
the National Commission on Mental Hygiene, published the Statistical
Manual for the Use of Institutions for
the Insane. This book contained 22
groups of mental illnesses. The focus
was on severe mental and neurological illnesses seen in institutionalized
patients (Tartakovsky, 2011). There
were 10 editions of this manual until
Military and Veterans Administration psychiatrists found little use in
the APAs publication, as most disorders they treated were absent. They
were primarily interested in stress and
anxiety reactions, personality disorders, and somatoform disorders. In
1943, the U.S. Office of the Surgeon
General, Army Services Forces, developed their own nomenclature, the
Medical 203 classification, which expanded the utility of this text to the
somewhat less acute outpatient conditions of soldiers and veterans. Psychiatrist and Brigadier General William
C. Menninger led the Group for Advancement of Psychiatry and heavily
influenced momentum to advance a
common language in the psychiatric
community (Millon, Krueger, & Simonsen, 2010).

In the first edition of the DSM

(APA, 1952), the structure and conceptual framework were the same as
the Medical 203, and many passages
of text were identical. Publication of
the DSM-I in 1952 followed the lead
of ICD-6 and added a glossary of clinical descriptions. DSM-I disorders were
viewed as reactions of personality,
using Freudian psychoanalytic bases
for etiologies (APA, 2012a). An ex-

Year Published

Number of

Page Count






















Note. TR = text revision.

ample of a diagnostic description in

the DSM-I is [Dissociative reaction]
represents a type of gross personality
disorganization, the basis of which is
a neurotic disturbance, although the
diffuse dissociation seen in some cases
may occasionally appear psychotic
(APA, 1952, p. 32).
What made the DSM different
from prior nosology was its expansion
beyond statistical classification into
a document with pragmatic, clinical
utility. The clinical descriptions aided
in establishing reliability in presentations, but the content remained subjectively consistent with current social
psychological thought and politics.
The DSM-I included 106 disorders
in 130 pages within three broad diagnostic categories, including organic
psychoses, psychogenic neuroses (or
reactions responding to psychoanalytic treatment), and character disorders,
otherwise known as forensic issues
(Millon et al., 2010). The psychotic
disorders included schizophrenic reactions. Anxiety and depression
were included in the category of psychoneurotic disorders. Personality or
character disorders also included addiction (Sanders, 2011).
The APA established a parallel classification system for psychiatry in the DSM
to what the ICD was issuing, but continued to pursue a more comprehensive,
utilitarian model for adoption by providers of clinical psychiatry in America.

Journal of Psychosocial Nursing Vol. 51, No. 4, 2013

Continued dissatisfaction with

the diagnostic scope of mental illness
by ICD-6 and ICD-7 resulted in the
WHO commissioning a comprehensive diagnostic review by British psychiatrist Erwin Stengel (APA, 2012a).
He recommended the inclusion of
explicit diagnostic criteria for clinical reliability, a recommendation that
was largely ignored until the development of the DSM-III in 1980. Sanders
(2011) asserted that if international
collaboration were as strong in the
mid-1900s as it is now, the United
States would have likely adopted the
ICD-6 and the now influential DSM
would not exist.

The DSM-II was published in 1968

with the aim of its terms coinciding
with those of the ICD-8 (Millon et
al., 2010). The APAs Nomenclature
and Statistic Committee circulated an
early draft of the DSM-II to 120 psychiatrists for their review and input
(Peele, 2008). The DSM-II covered
182 disorders in 134 pages.
The final version of the second edition retained the gap between neurosis and psychosis, but the reactions
terminology was removed (Millon et
al., 2010). The term reaction was considered to suggest an environmental
etiology, and the DSM-II developers
could not agree on this notion. Therefore, a diagnosis such as schizophrenic

Time Period

American Psychiatric Association (APA) Activity


DSM-5 pre-planning white papers are developed


APA, National Institutes of Health, and World Health

Organization conduct research-planning conferences


DSM-5 chairs, work group chairs, and members are

appointed and announced

April 2010
April 2012

Field trial testing for diagnostic categories and crosscutting dimensional measures are implemented

October 2011
April 2012

Data from field trials are analyzed

Spring 2012

Revisions are posted and open to a third public feedback

for 2 months and further edits are made

May 18-22, 2013

The DSM-5 will be released during the APAs 2013 annual

meeting in San Francisco.

Note. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, fifth edition.
Adapted from American Psychiatric Association (2012c).

reaction was changed to schizophrenia. A sample of a DSM-II diagnosis

Anxiety neurosis is characterized by
anxious over-concern extending to panic
and frequently associated with somatic
symptoms. Unlike phobic neurosis, anxiety may occur under any circumstances
and is not restricted to specific situations
or objects. This disorder must be distinguished from normal apprehension or
fear, which occurs in realistically dangerous situations. (APA, 1968, p. 39)

In a 1974 DSM-II revision, the diagnosis of homosexuality was replaced

with ego-dystonic homosexuality
(Peele, 2008). The APA Board of Directors instruction was influenced by
growing empirical research from the
1950s through the 1980s, which was
less biased, showing a lack of relationship between homosexuality and psychopathology or maladjustments.

The DSM-III was published in 1980

and represented a significant move toward empiricism in attempt to counter American suspicions and an overt
distrust of the psychiatric profession

(Taratovsky, 2011). A famous research study published by Rosenhan

in 1973, Being Sane in Insane Places, shocked the nation and likely influenced this shift. In the experiment,
eight healthy patients (three psychologists, a pediatrician, a psychiatrist,
a painter, and a housewife) briefly
faked psychosesspecifically, hearing voicesand were admitted to
psychiatric hospitals. After admission
they behaved normally and denied
any further symptoms. All eight pseudopatients were required to accept a
psychiatric diagnosis and take psychotropic medications as a condition
of their release. The average length of
stay was 19 days for these symptomless actors, and each was discharged
with a diagnosis of schizophrenia in
The climate was right for a group
called Neo-Kraepelinians who
wanted to reject psychoanalytic
language in favor of a scientific approach. This group advocated for a
system called Feighner criteria that
includes the systematic use of diagnostic elements, emphasized illness
course and outcome, and based diag-

nostic criteria on research and empirical evidence (Feighner et al., 1972).

Another significant change in this
edition was that people were no longer
viewed as either mentally healthy or
ill. A newer view represented mental
health and illness as endpoints on a
continuum, where health and illness
could take on a variety of values and
fluctuate at different points in time.
This change was controversial, as the
blurring of mental illness and health
was found by some to be distressing
(Tartakovsky, 2011). The logic of this
continuum eventually received widespread acceptance and continues as a
contemporary viewpoint where mental illnesses are a spectrum of intersecting symptoms and levels of severity of impairment.
The DSM-III grew to 265 diagnoses and 494 pages. Explicit diagnostic criteria resulted in a more neutral
language in the description of etiology
of disorders as compared to previous
editions (APA, 2012a). The DSMIII represented the input of more
than 1,000 APA members, including
workgroups, field trials, and revisions
(Peele, 2008). There was little representation from other disciplines in the
development of this edition.
The process of the DSM-III development was coordinated with the
development of the ICD-9 in 1975,
whereby terms were made consistent
between the two taxonomies (APA,
2012a). The two classifications were
used differently; the DSM was marketed primarily for clinical utility,
whereas the ICD was more suitable for
statistical collection and billing. The
U.S. government adopted ICD-9 coding for records of medical morbidity
and mortality.
A multi-axial psychiatric diagnostic
system that generated five dimensions
(axes) relating to different aspects of
disability or disorder was introduced.
They included:
l Axis I: Psychiatric disorders.
l Axis II: Personality disorders
and intellectual disabilities.
l Axis III: Medical conditions.
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l Axis
IV: Environmental and
psychosocial stressors.
l Axis V: A score based on the
Global Assessment of Functioning
Prominent diagnostic changes included the addition of posttraumatic stress
disorder and the exclusion of neuroses
(Peele, 2008). A DSM-III revision by
the APA in 1987 removed the diagnosis
of ego-dystonic homosexuality. Sexual
disorders not otherwise specified (NOS)
remained and included the specifier of
distress related to sexual orientation.
More than 1 million copies of
the DSM-III were sold to psychiatric
professionals and the general public
alike. Allen Frances (2012), chair of
the DSM-IV Task Force, notes that
the discussion of psychiatric diagnosis made a transition from the clinical
area to conversation at cocktail parties. While the psychiatric community
made a shift from Freudian hidden
motivations and dream analysis, so too
did the enlightened reader who began
to consider his own symptoms and
those of others.


The DSM-IV was published in 1994

and lasted 18 years with some revision.
The DSM-IV included 297 disorders
in 886 pages. National involvement
and consultation with other health
care providers informed its development to a greater degree than with
prior editions. In total, it was a 6-year
project and included empirical input
from a variety of professional organizations (APA, 2012a). Again, coordinated efforts were made to minimize
language inconsistencies with the current edition of ICD, ICD-10, which
was published in 1992 (APA, 2012a).
Many of the disorders included NOS
titles and comorbidities. This edition
added the requirement of distress or
disability in association with psychological or behavioral syndromes
(APA, 2000). The DSM-IV retained
some Freudian terms such as fetishism.
A major criticism of the DSM-IV
related to pediatric psychiatry. Use of


Halter, M.J., Rolin-Kenny, D., & Grund, F. (2013). DSM-5: Historical Perspectives. Journal
of Psychosocial Nursing and Mental Health Services, 51(4), 22-29.


A common language for describing psychiatric disorders assists health care

professionals in understanding and communicating information that is
essential to quality patient care.


The first edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) was published in 1952. The latest edition (DSM-5) is to be published in
May 2013.


Psychiatric nurses participated in the development of the DSM-5 by providing

comments to the draft criteria and by participating in the DSM-5 clinical field
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to the Journal at

the DSM-IV basically required conceptualization of children as little adults

rather than viewing their unique neurodevelopmental issues and potentials
from different categorical and assessment vantages (Rawnsley & Roberts,
1999). Considering the total percentage of life lived for a child, waiting
a full year with persistent symptoms
before diagnosing may be unnecessarily traumatic. Child psychiatric
nurses opined that the DSM-IV lacked
a comprehensive assessment, an assessment that should include family
strengths and resources, understanding of social contexts, and perinatal
histories (Rawnsley & Roberts, 1999).
The manual was also published by
the APA as a primary care version
(DSM-IV-PC) in 1995. This manual
supports primary care providers who
may underdiagnose commonly encountered psychiatric disorders. DSMIV-PC includes a diagnostic algorithm
for a quick, sequential process of assessment and application of the overall diagnostic criteria. A user-friendly
symptom index was also included
(Quinn, 1999).
The most recent version of the
manual (DSM-IV-TR) was published
in 2000 as a text revision. Updates
were made to reflect current research
by including updates to background
information within the descriptive

Journal of Psychosocial Nursing Vol. 51, No. 4, 2013

texts of the diagnoses. Relatively few

changes were made to diagnostic categories and criteria, but some corrections were made, and categories and
codes were realigned to parallel updates made to ICD-9.
expanded with each version of the
original DSM through DSM-IV-TR
(Table 1). Quantities of diagnoses
and pages in the upcoming DSM-5
were unavailable for this article, but
according to David Kupfer, co-chair
of the DSM-5 task force, the number
of diagnoses will stay approximately
the same. He notes that the leveling
off of diagnoses for psychiatry goes
against the trend for other areas of
medicine that experience annual increases (Falco, 2012).

The APA has scheduled the release

of the DSM-5 for May 2013, 19 years
after the publication of the DSM-IV.
Unlike previous editions, DSM-5 and
future editions will use Arabic numbers (e.g., DSM-5.1, DSM-5.2), which
are easier for most people to recognize
and reflect ongoing updates.
In this edition, the abbreviated
term psychobiological dysfunction
replaces behavioral, psychological, or
biological dysfunction. This version
purports to be more science based,

using a greater number of evidencebased recommendations than previous

A developmental approach is used
throughout this edition, and the exclusive category of Disorders Usually First
Evident in Infancy, Childhood, and
Adolescence is removed. The overall
list of disorders roughly follows the life
span, and the first category of disorders
is Neurodevelopmental Disorders, a
category of disorders that commonly
occur in infancy and childhood. Each
diagnostic category lists individual
disorders based on child through adult
progression wherever possible.
The DSM-5 developers propose
more dimensional approaches to diagnosing psychiatric disorders and take
into consideration common underlying characteristics that are shared
between disorders (Sanders, 2011).
With advancing knowledge of underlying genetics, there is a spectrum of
intersecting phenotypic presentations,
including clinical diagnoses ranging
from psychosis to mania to depression.
Genetic susceptibilities are found to be
overlapping, which lead to variations
in clinical presentations, as well as comorbidities. Increased understanding
should lead to broad-spectrum psychopharmacological treatments (Craddock & Owen, 2005). The timeline of
DSM-5 development is summarized in
Table 2.
The APA publicly requested feedback on DSM-5 draft diagnostic categories in the spring of 2010; this
input was considered for necessary
revisions to the manual and is essential for future buy-in from a variety
of stakeholders. The American Psychiatric Nurses Association (APNA)
responded to this request by soliciting their membership for comments
on DSM-5 draft categories. After receiving hundreds of suggestions and
comments, APNA summarized them
and in April 2010 provided APA with
seven manuscript pages of comments

from a national sample of generalist

and advanced practice psychiatric
nurses. These pages were among the
11,000 comments generated by the
public request for feedback (APA,
Subsequently, an APNA member notified the Executive Director
of the organization that DSM field
trials were to be conducted without
the input of psychiatric nurses. According to the Institute of Medicines
(2010) The Future of Nursing: Leading Change, Advancing Health, there
should be a full partnership between
nurses and physicians in health care
restructuring. Psychiatric nursing
voices are essential in forming the
health care structure for the individuals in their care. In response to the
members concern, APNAs Board of
Directors, its policy group (the Institute for Mental Health Advocacy),
and the collective membership requested that the APA include psychiatric nurses in the DSM-5 field trials.
The APA responded positively with
an invitation for psychiatric nurses to
join in the clinical field trials.
This move was unprecedented,
and 500 advanced practice psychiatric-mental health nurses were invited
to participate in these trials (Halter,
2011). Ultimately, psychiatrists, psychologists, licensed clinical social
workers, advanced practice psychiatric nurses, mental health nurses, licensed counselors, and licensed marriage and family therapists were the
professionals who helped shape diagnostic criteria and proposed dimensional measures for the new manual
(APA, 2012b).
One of this articles authors (D.R.-K.)
had the opportunity to participate in
the Routine Clinical Practice Settings Division of the clinical field
trials as an advanced practice psychiatric nurse. New diagnoses and diagnostic criteria were used in samples of
current and new patients in a community psychiatric practice. Newly
developed cross-cutting dimensional
measures for specific symptoms pres-

ence and severity, as well as measures

of overall disability, were also put
into practice. The assessment tools
were time consuming. However, the
trade-off of time for more accurate
symptom identification is important.
Also, she found that the global disability measures individualized the
deficits and helped target care and
resources more pointedly than the
DSM-IV-TR Global Assessment of
Functioning scale.
Although physicians have been
the dominant profession in defining illnesses for more than a century,
Florence Nightingale championed
the classification of health alterations
and generated some of the earliest
classifications of health and disease
statistics. More recently, nurses took
part in the development of the DSMIV in terms of task force advisers
and in conducting literature reviews
(Wilson & Skodol, 1994). It is likely
that this participation led the way for
the largest professional group of mental health providers in the United
States to more actively take part in
the development of this new manual.
Through psychiatric nursings professional organization, APNA, psychiatric nurses provided input in the
comment section of the DSM-5 and
advanced practice psychiatric nurses
participated in clinical field trials.
The DSM-5 will result in restructured assessments, reformulated diagnostic criteria, altered formulas
for the reimbursement of care, and
therefore changes in treatment patterns and strategies. Recovery for
those with psychiatric disorders will
be better advanced if all care providers understand changes in assessment,
diagnosis, and treatment that are facilitated through a common language
of a shared diagnostic system. The increased collaboration in the development of the DSM-5 is a good omen
for future interprofessional work that
is needed to improve and transform
mental health care.
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Dr. Halter is Associate Dean, Ms. Grund is
Interim Dean, Ashland University, Mansfield,
Ohio; and Dr. Rolin-Kenny is Assistant Professor,
University of Texas at Austin, School of Nursing,
Austin, Texas.
Dr. Rolin-Kenny and Ms. Grund have disclosed
no conflicts of interest, financial or otherwise. Dr.
Halter receives travel support from Contemporary
Forums and royalties from Elsevier.
Address correspondence to Margaret Jordan
Halter, PhD, APRN, Associate Dean, Ashland
University, 1020 S. Trimble Road, Mansfield,
OH 44906; e-mail:
Received: October 14, 2012
Accepted: February 7, 2013
Posted: March 6, 2013


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