PSYCHIATRIC NURSING

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PSYCHOANALYTICAL THEORY
Adarsh.s 13th batch MSc nursing Govt. college of nursing calicut

Psychoanalytical theory is a branch of psychology developed in the late 1800s and early 1900s by Austrian psychologist Sigmund Freud. Psychoanalysis expanded, criticized and developed in different directions, mostly by Freud's students (Alfred Adler and Carl G. Jung, and later the neoFreudians as Erich Fromm, Karen Horney and H. S. Sullivan).

PERSONALITY 
Derived from the Greek word ³persona´

The DSM ±IV-TR (2000)defines personality traits as ³enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts´  ³It is the pattern developed by the integrated functioning of all the traits and characteristics of an individual´. (Cruze) 

SIGMUND FREUD THE FATHER FREUD: OF PSYCHOANALYSIS 
Born on May 6, 1856, in Freiburg, a small town in

Moravia, which is now part of the Czech Republic  At 4 years old, his father moved the family to Vienna, where Freud spent most of his life  After his education in France, he returned to Vienna and began clinical work with hysterical patients.  Between 1887 and 1897, his work with these patients led him to develop psychoanalysis.  He died in London in 1939.

FREUD'S PSYCHOANALYTIC THEORY OF PERSONALITY DEVELOPMENT Freud's theory of personality development describes three major categories:  The development of personality  The organization or structure of personality  The dynamics of personality

THE DEVELOPMENT OF PERSONALITYTOPOGRAPHIC MIND¶ THE µTOPOGRAPHIC THEORY OF MIND  This concept was advanced by Freud in the year 1900. in the book called µthe interpretation of dreams¶.  Freud explains the development of the personality by describing three levels of consciousness: -The conscious -Preconscious (subconscious) -Unconscious .

The Conscious  The conscious system in Freud's topographical model is the part of the mind in which perceptions coming from the outside world or from within the body or mind are brought into awareness. .  Consciousness is a subjective phenomenon whose content can be communicated only by means of language or behavior. whereby persons were aware of a particular idea or feeling as a result of investing a discrete amount of psychic energy in the idea or feeling.  Freud assumed that consciousness used a form of neutralized psychic energy that he referred to as attention cathexis.

 The preconscious system also serves to maintain the repressive barrier and to censor unacceptable wishes and desires. processes. contents of the unconscious must become linked with words and thus become preconscious.  The preconscious interfaces with both unconscious and conscious regions of the mind. .The Preconscious  The preconscious system is composed of those mental events. and contents that can be brought into conscious awareness by the act of focusing attention. To reach conscious awareness.

Its mental contents and processes are kept from conscious awareness through the force of censorship or repression and it is closely related to instinctual drives. disregards logical connections.  Memories in the unconscious have been divorced from their connection with verbal symbols. therefore.  The unconscious system is characterized by primary process thinking. It is governed by the pleasure principle and.The Unconscious  The unconscious system is dynamic. . which is principally aimed at facilitating wish fulfilment and instinctual discharge.

in µThe Ego and The Id¶. 1960) consists of the id. ego.THE ORGANIZATION OR STRUCTURE OF PERSONALITY. Freud divided the mental apparatus into three dynamic structures: The id.THE µSTRUCTURAL THEORY OF MIND¶  The organization or structure of the personality (Freud. and superego Reality Id Pleasure principle Ego Reality principle Super Ego Morality principle . the ego and the superego  In 1923.

 It is the part of one¶s nature that reflects basic or innate desires such as pleasure-seeking behavior.  it is totally unconscious . causes impulsive. and has no regard for rules or social convention.  The id seeks instant gratification. unthinking behavior.  It is characterised by primary process thinking and is based on pleasure principle. and sexual impulses.The Id  The Id is the original state of human mental apparatus with which a new born baby is born. lacking any direct link with reality . aggression.

values. and feelings. it is in direct opposition to the id. thoughts.  The superego establishes and maintains an individual's moral conscience on the basis of a complex system of ideals and values internalized from parents.The superego  The superego is the part of a person¶s nature that reflects moral and ethical concepts. it makes comparisons. (5 or 6 years)  Freud viewed the superego as the heir to the Oedipus complex. and parental and social expectations. It is based on morality principle/ perfection principles .  The superego then serves as an agency that provides ongoing scrutiny of a person's behavior. therefore.

. adapts to it.The ego  The ego.  Ego is also called the rational self or the reality principles.  Freud believed that anxiety resulted from the ego¶s attempts to balance the impulsive instincts of the id with the stringent rules of the superego.  The ego experiences the reality of the external world. and responds to it.  The ego represents mature and adaptive behavior that allows a person to function successfully in the world. begins to develop between the ages of 4 and 6 months. is the balancing or mediating force between the id and the superego.

Freud¶s components of personality .

or eating.THE DYNAMICS OF PERSONALITY  According to Freud's explanation of the dynamics of the personality.  The ego's energy controls the impulsive actions of the id and the moralistic and idealistic actions of the superego. each person has a certain amount of psychic energy to cope with the problems of everyday living. by frequency of urination.  The id's energy is used to reduce tension and may be exhibited. daydreaming. for example.  One whose energy is controlled primarily by the superego generally behaves in an overly moralistic manner because the structure of the personality (eg. superego) monopolizes the psychic energy that governs the person's behavior .

. a person who has been diagnosed with cancer and told he has 6 months to live but refuses to talk about his illness is using the defense mechanism of denial. which are methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts. or refusal to accept the reality of the situation.  For example.EGO DEFENSE MECHANISMS  Freud believed the self or ego used ego defense mechanisms. feelings. or events.

usually sensorimotor in nature ‡ A teenager forbidden to see X-rated movies is tempted to do so by friends and develops blindness.  Conversion: Expression of an emotional conflict through the development of a physical symptom.EGO DEFENSE MECHANISMS  Compensation :Overachievement in one area to offset real or perceived deficiencies in another area ‡ Napoleon complex: diminutive man becoming emperor ‡ Nurse with low self-esteem works double shifts so her supervisor will like her. and the teenager is unconcerned about the loss of sight .

‡ A child who is harassed by a bully at school mistreats a younger sibling . failure to admit the reality of a situation. or how one enables the problem to continue ‡ Diabetic eating chocolate candy ‡ Spending money freely when broke ‡ Waiting 3 days to seek help for severe abdominal pain  Displacement: Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings ‡ A person who is mad at the boss yells at his or her spouse.EGO DEFENSE MECHANISMS  Denial: Failure to acknowledge an unbearable condition.

‡ Never learning to delay gratification ‡ Lack of a clear sense of identity as an adult .EGO DEFENSE MECHANISMS  Dissociation: Dealing with emotional conflict by a temporary alteration in consciousness or identity ‡ Amnesia that prevents recall of yesterday¶s auto accident ‡ An adult remembers nothing of childhood sexual abuse  Fixation: Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage.

social.  Intellectualization: Separation of the emotions of a painful event or situation from the facts involved.EGO DEFENSE MECHANISMS  Identification: Modelling actions and opinions of influential others while searching for identity. acknowledging the facts but not the emotions ‡ Person shows no emotional expression when discussing serious car accident. or occupational goal ‡ Nursing student becoming a critical care nurse because this is the specialty of an instructor she admires. or aspiring to reach a personal. .

and values as one¶s own ‡ A person who dislikes guns becomes an avid hunter. just like a best friend  Projection: Unconscious blaming of unacceptable inclinations or thoughts on an external object ‡ Man who has thought about same-gender sexualrelationship but never had one. ‡ A person with many prejudices loudly identifies others as bigots . beats a man who is gay. beliefs.EGO DEFENSE MECHANISMS  Introjection: Accepting another person¶s attitudes.

conflict.EGO DEFENSE MECHANISMS  Rationalization: Excusing own behavior to avoid guilt. ‡ Man says he beats his wife because she doesn¶t listen to him. . responsibility. ‡ Person who despises the boss tells everyone what a great boss she is. anxiety. or loss of self-respect ‡ Student blames failure on teacher being mean.  Reaction Formation: Acting the opposite of what one thinks or feels ‡ Woman who never wanted to have children becomes a super-mom.

‡ Man pouts like a four-year-old if he is not the center of his girlfriend¶s attention  Repression: Excluding emotionally painful or anxietyprovoking thoughts and feelings from conscious awareness ‡ Woman has no memory of the mugging she suffered yesterday. ‡ Woman has no memory before age 7 when she was removed from abusive parents .EGO DEFENSE MECHANISMS  Regression: Moving back to a previous developmental stage in order to feel safe or have needs met ‡ Five-year-old asks for a bottle when new baby brother is being fed.

‡ Person goes for a 15-minute walk when tempted to eat junk food.EGO DEFENSE MECHANISMS  Resistance: Overt or covert antagonism toward remembering or processing anxiety-producing information ‡ Nurse is too busy with tasks to spend time talking to a dying patient. ‡ Person attends court-ordered treatment for alcoholism but refuses to participate  Sublimation: Substituting a socially acceptable activity for an impulse that is unacceptable ‡ Person who has quit smoking sucks on hard candy when the urge to smoke arises. .

 Undoing: Exhibiting acceptable behavior to make up for or negate unacceptable behavior ‡ A person who cheats on a spouse brings the spouse a bouquet of roses. .  Suppression: Conscious exclusion of unacceptable thoughts and feelings from conscious awareness ‡ A student decides not to think about a parent¶s illness in order to study for a test. ‡ A man who is ruthless in business donates large amounts of money to charity.EGO DEFENSE MECHANISMS  Substitution: Replacing the desired gratification with one that is more readily available ‡ one who would like to have her own children opens a day care centre. ‡ A woman tells a friend she cannot think about her son¶s death right now.

 In his psychosexual theory. and genital . Freud also describes five phases of the psychobiologic process that have a great impact on personality development: oral. anal. latency. phallic or oedipal. Freud enunciated his theory of infantile sexuality and described the psychosexual stages of development.THE THEORY OF PSYCHOSEXUAL DEVELOPMENT  In 1905. in µThree essays on the theory of sexuality¶.

Major site of gratification is the oral region. It consists of 2 phases: 1) Oral erotic phase(Sucking) 2) Oral sadistic phase(biting)  Psychiatric syndromes result from fixation at this stage: 1) Dependent personality traits and disorder 2) Schizophrenia ( oral and pre oral stage) 3) Severe mood disorder 4) Alcohol dependence syndrome and drug dependence .THE ORAL PHASE  The oral phase (0 to 18 months) is a period in which pleasure is derived mainly through the mouth by the actions of sucking or biting.

 Major site of gratification is the anal and pre anal area.(Sphincter control). It consist of 2 phases: 1) Anal erotic phase(Excretion) 2) Anal sadistic phase(µHolding¶ and µletting go¶ at will )  Psychiatric syndromes result from fixation at this stage: 1)Obsessive compulsive personality traits and disorder 2) )Obsessive compulsive disorder(Anal sadistic phase) . and the foundation is laid for the development of the superego.THE ANAL PHASE  During the anal phase (18 months to 3 years). Major achievement is the toilet training. attention focuses on the excretory function.

the child identifies with the parent of the same sex. develops a sexual identity of male or female role. genital masturbation is common at this stage. and begins to experience guilt. forms a deep attachment to the parent of the opposite sex. a stage of growth and development.  Major site of gratification is the genital area.THE PHALLIC OR OEDIPAL STAGE  In the phallic or oedipal stage (3 to 7 years).  Psychiatric syndromes result from fixation at this stage: 1) Sexual deviations 2) Sexual dysfunction 3) Neurotic disorders .

this is theorized by Freud to lead a wish to µreceive¶ the penis and to bear a child.  Male development: The boy develops castration anxiety (fear of castration at the hand of his father in retaliation for the boy¶s desire to replace his father in his mothers affections. Resolution occurs by identification with the mother. development is different in both sexes.).According to Freud .  Female development: The girl develops penis envy(discontent with female genitalia following a fantasy that they result from loss of penis). This phase has been called as Electra complex. . This leads to formation of the Oedipus complex Oedipus complex is usually resolves by identification with father attempting to adopt his characteristics.

This is a stage of relative sexual quiescence.  Oedipus and Electra complex is usually resolved at the beginning of this stage.THE LATENCY PHASE  During the latency phase (7 years to adolescence). sports. Superego is formed at this stage. and experiences intellectual and social growth. has a limited sexual image. the person learns to recognize and handle reality. schoolwork etc  Psychiatric syndromes result from fixation at this stage: Neurotic disorders . Sexual drive is chanalised in to socially appropriate goals like development of interpersonal relationships. develops an inner control over aggressive or destructive impulses.

 Psychiatric syndromes result from fixation at this stage: Neurotic disorders .)true self identity develops.  Adult sexuality develops with capacity for intimacy(puberty and respect for others. the individual develops the capacity for object love and mature sexuality and establishes identity and independence. gradual release from parental controls with more influence of peer group. the final stage of psychosexual development.THE GENITAL PHASE  In the genital phase (puberty or adolescence into adult life).

.  Basing his analysis on these data.  The dream images represented unconscious wishes or thoughts disguised through a process of symbolization and other distorting mechanisms. Freud presented a theory of the dream that paralleled his analysis of psychoneurotic symptoms.THEORY OF DREAMS  The rich complex of data derived from Freud's clinical exploration of his patients' dreams and the profound insights derived from his associated investigation of his own dreams were distilled into the landmark publication in 1900 of µThe Interpretation of Dreams¶. He viewed the dream experience as a conscious expression of an unconscious fantasy or wish not readily accessible to conscious waking experience.

making it possible for more neutral images to represent repressed infantile components. projection.  SYMBOLISM Symbolism is a complex process of indirect representation that in which the symbol is representative of or substitute for some other idea from which it derives a secondary significance that it does not possess itself.  These mechanisms included symbolism.DREAM WORK  The dream work used a variety of mechanisms. condensation. and secondary revision. . displacement.

 DISPLACEMENT The mechanism of displacement refers to the transfer of amounts of energy (cathexis) from an original object to a substitute or symbolic representation of the object.  CONDENSATION Condensation is the mechanism by which several unconscious wishes. or attitudes can be combined into a single image in the manifest dream content. . impulses.

It is through secondary revision. PROJECTION The process of projection allows dreamers to rid themselves of their own unacceptable wishes or impulses and experience them as emanating in the dream from other people or independent sources.  SECONDARY REVISION Secondary revision uses intellectual processes that more closely resemble organized thought processes governing rational states of consciousness. . then. that the logical mental operations characteristic of the secondary process are introduced into and modify dream work.

 The current practice of psychoanalysis and psychoanalytic psychotherapy represents a century of revolution and evolution radical revision and gradual refinement by both its creator Sigmund Freud and his followers and detractors .PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY  The term psychoanalysis literally means the breaking down of the psyche into its constituent elements and their dynamic processes.

Using a procedure referred to as the magnetic pass. Mesmer and his patient would sit face to face with knees touching. or hysterical seizure.PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY HISTORY  Pre-Freud: 18th and Early 19th Centuries  Eighteenth-century mesmerism. In successful cases. and the charismatic Mesmer would cast a spell through sweeping movements across the patient's body. Changes in theory were minor until James Braid originated the term hypnotism to describe the earlier process. ensued. sowed the earliest seed of psychoanalytic practice. a magnetic crisis. retaining both the general theory of magnetic fluid and the patient's acting as a passive recipient of the therapist's active maneuvers.  Nineteenth-century followers of Mesmer remained within the same basic framework. after which the patient's symptoms would disappear. . originated by Franz Anton Mesmer (1733 to 1815).

attempting to gain access to patients' reminiscences that they could not remember under any other conditions. Freud used hypnosis only to enable patients to suppress or deny their symptoms while under its influence.  Cathartic Method At that time. originally Breuer's invention. that Freud revived 10 years later in 1887 at Breuer's personal suggestion . the hypnotic method was used strictly for psychic catharsis that is.PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY HISTORY Freud: Late 19th and Early 20th Century  Use of Hypnosis The emergence of psychoanalysis as created by Freud in the late 1800s was a direct outgrowth of the treatment of neurotic patients at that time by physicians in general practice the use of hypnosis for hysteria. The particular method that Freud borrowed was a form of cathartic therapy.

The method of free association is.  Free Association Freud discovered the method that is identified with the true creation of psychoanalysis.PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY HISTORY  Concentration Method Freud developed a strategy in which he requested that the patient lie on a couch with eyes closed and then concentrate on a particular symptom and attempt to recall past memories. thus. . the gradual consequence of experimentation with technique from hypnosis and the cathartic method to a concentration method to an approach almost antithetical to the original suggestive methods. free association. unpleasant. or trivial material. Freud would place his hands on the patient's forehead as a physical way of facilitating the memory process. He began to instruct his patients to express even the most irrelevant.

. he observed that the same instinctive forces that brought about repression to obliterate pathogenic material from consciousness continued to exert force (resistance) against full disclosure through free association.. unexpected feelings toward the analyst (transference) provided additional resistance to treatment.PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY HISTORY  Transference and Resistance With the new emphasis on the removal of amnesia and the recovery of repressed memories. Moreover.

from classic psychoanalysis to current practices. .PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY HISTORY  . as well as by reappraisals and rebellions by neo-Freudian and non-Freudian contemporaries and descendants. Post-Freud: Early 20th Century to the Present The history and growth of the psychoanalytic movement. have been marked by repeated revisions by Freud himself. as chronically manifest in internecine conflicts over diverse and intricate points of theory and practice.

´ . Analysis is lengthy with weekly or more frequent sessions for several years. thus.CURRENT PSYCHOANALYTIC PRACTICE Psychoanalysis is still practiced today but on a very limited basis. it has become known as ³therapy for the wealthy. It is costly and not covered by conventional health insurance programs.

 Stage two: there is a continual battle within the psyche of the patient and between patient and analyst. Basic rules are established. and requirements and a realistic therapeutic alliance is formed between patient and analyst.. the patient describes his or her problems.PSYCHOANALYTIC PROCESS The psychoanalytic process involves bringing to the surface repressed memories and feelings .The analytical course may be subdivided into three major stages:  Stage one: the patient becomes familiar with the methods..  Stage three: The termination phase is marked by the dissolution of the analytical bond as the patient prepares for leave-taking. there is some review of history.The patient invariably has to continue to work through any problems outside of the therapy situation without the analyst . routines. wherein infantile problems of childhood are played out with the analyst as the object of the patient's repressed strivings.

GOALS  Psychoanalysis aims at the gradual removal of amnesias rooted in early childhood.PATIENT REQUISITES High motivation. Ability to form a relationship. Psychological-mindedness and capacity for insight Ego strength. more adaptive ones. particularly as he or she learns the reasons for his or her behavior .  The patient should be better able to relinquish former regressive patterns and to develop new.

 In practice..  Achieve some measure of self-understanding or insight.GOALS. inability to enjoy life. underachievement.  Psychoanalytic goals are often considered formidable (for example. framed as they are in theoretical intrapsychic terms (such as greater ego strength) or conceptually ambiguous ones (resolution of the transference neurosis). involving the radical reorganization of old developmental patterns based on earlier affects and the entrenched defenses built up against them. . or excessive anxiety.. The form that the neurosis takes unsatisfactory sexual or object relationships. as do the many manifestations of neuroses. the goals of psychoanalysis for any patient naturally vary. a total personality change). guilt. as well as the specific goals. or depressive ideation determines the focus of attention and the general direction of treatment.. and fear of work or academic success.  Goals may also be elusive.

and the physical concomitants of substance abuse .  patients with neurotic depression has met with success. including all forms of symptomatic anxiety.  Patients with hysteria and other neuroses Contraindications  dangerous behavioral or physical symptoms require more immediate attention or for virtually        the entire realm of the psychoses. impaired social judgment. in which severe ego deficits and tenuous reality are apparent. obsessional. poor impulse control. and hysterical neurotic manifestations.Indications  chronic cases of psychoneuroses (and relatively mild psychopathology). Narcissistic character disorders patients with deviant behaviors sexual disorders patients with psychosomatic illness Persons with schizoid or paranoid personality disorders substance use disorders (narcotic addictions and alcoholism) and antisocial personality disorder Infantile demands. an inability to tolerate frustration.

hobbies and freedom of expression for children in education and training. expressed desired and wishes and also the importance of planning co-curricular and extracurricular activities. biological function .  Child centered education can be imported by identifying the needs. need for spontaneous expression of the sex instinct. Identification of behavioural deviations become easier . their by precautionary measures for preventing the problems related to maladjusted personalities. childhood education was modified by giving a maximum freedom to the children for expression of their biological urges and minimum freedom to the children for expression of their biological urges and minimum interferences in the course of their natural growth and development. It promotes preservation of mental health and timely identification and treatment of the behavioural problems of individuals. Sex education has been developed-stages of psychosexual development. essential. instincts and wishes of       children.ADVANTAGES OF PSYCHOANALYSIS  Good method to study human behaviour. It also contributed to highlight the role of sex in one¶s life in terms of shaping the personality and determining the behaviour. It highlighted the importance of catharsis for releasing pent up emotions. By identification of earlier childhood experiences. changing the attitude of individuals towards sex a natural.

 At present.  These limitations involve the complex issues of the universality and validity of major psychoanalytic constructs (from the Oedipus complex to the tripartite mental structure of id. . ego. biological orientation. which is considered the most subjective form of research observation in establishing effectiveness. the predominant treatment constraints are often economic. and superego) and the reliability of the case study method. deterministic viewpoint) and as a scientific instrument (for example. relating to the high cost in time and money. idiographic approach) have implications for its credibility as a form of therapy. both for patients and in the training of future practitioners.LIMITATIONS OF PSYCHOANALYSIS  Limitations of psychoanalysis as a body of theory (for example.

Although those two types of methods are sometimes regarded as antithetical. uncovering.PSYCHOANALYTIC PSYCHOTHERAPY Psychoanalytic psychotherapy is based on fundamental dynamic formulations and techniques that derive from psychoanalysis and is designed to broaden its scope. evocative. their precise definitions and the distinctions between them are by no means absolute. or interpretive) techniques to supportive (relationship-oriented. Psychoanalytic psychotherapy in its narrowest sense is the use of insight-oriented methods only. suppressive. suggestive.  The strategies of psychoanalytic psychotherapy currently range from expressive (insight-oriented. or repressive) techniques.  .

express love and belonging towards the child. high standards of values and the ability to develop healthy interpersonal relationships.  Knowledge of the structure of personality can assist nurse who work in the mental health setting. and use of maladaptive defense mechanisms. mental alertness. sympathetic understanding.  Education regarding child rearing practice. the ego and the super ego assist in assessment of developmental level. . self confidence.  A successful nurse needs to develop a pleasing and strong personality. early stages of sexual development. to help the child to get rid off from the traumatic experience. Such qualities as integrity.RELEVANCE OF PSYCHOANALYTIC THEORY IN NURSING  Nurses began to focus on human behavior. Understanding the use of ego defence mechanism is important in making determinations about maladaptive behaviours. dignity. a strong desire to help. or in helping patients accept as unique individuals. are generally associated with the personality of a successful nurse. in planning care for patients to assist in creating change(if desired). The ability to recognize behaviours associated with the id. dependability.

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1st edition.BIBLIOGRAPHY  Harold I Kaplan &Benjamin J Sadock (2001) Comprehensive      Textbook of psychiatry. Kapoor B (2003) Text Book of Psychiatric Nursing. Ahuja N(2000)A short text book of psychiatry.P. K. Philadelphia. Townsend CM . Sandeen S J & Stuart G W (1991) Principles and Practice of Psychiatric Nursing. New Delhi. Lippincott William and Wilkins. 4th edition.Jay Pee publishers .(2008) Psychiatric mental health nursing.New Delhi . Vol II. Kumar Publishing House. Jaypee Brothers.Psychiatric/Mental Health Nursing: Concepts of Care in Evidence-Based Practice (6 Edition)Davis FA Publishers Neeraja.

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