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A Self-Report Scale to Help Make Psychiatric Diagnoses
The Psychiatric Diagnostic Screening Questionnaire
Mark Zimmerman, MD;
Jill I. Mattia, PhD
Arch Gen Psychiatry. 2001;58:787-794.
ABSTRACT
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Background The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief,
psychometrically strong, self-report scale designed to screen for the most
common DSM-IV Axis I disorders encountered in outpatient
mental health settings. In the present report, we describe the diagnostic
performance (sensitivity, specificity, and positive and negative predictive
values) of the PDSQ in an outpatient setting.
Methods Six hundred thirty psychiatric outpatients presenting for treatment
were evaluated with the Structured Clinical Interview for DSM-IV after completing the PDSQ. Patients arrived approximately 20
minutes before the scheduled time of the appointment to complete the scale.
Diagnostic raters were blind to responses on the scale.
Results The PDSQ's subscales' diagnostic performance varied in a predictable
manner according to the cutoff score—as the threshold for case identification
increased, subscale sensitivity decreased and specificity increased. Mean
subscale sensitivities of 80%, 85%, and 90% resulted in mean subscale specificities
of 78%, 73%, and 66%, respectively, and negative predictive values of 95%,
96%, and 97%. Receiver operating curves were determined for each subscale
and all areas under the curve were significant.
Conclusions The PDSQ is a diagnostic aid designed to be used in clinical practice
to facilitate the efficiency of conducting initial diagnostic evaluations.
From a clinical perspective, it is most important that a diagnostic aid have
good sensitivity, so that most cases are detected, and high negative predictive
value, so that most noncases on the measure are indeed noncases. Our results
indicate that most of the PDSQ subscales were able to achieve this goal.
INTRODUCTION
THE PSYCHIATRIC Diagnostic Screening Questionnaire (PDSQ) is a self-report
scale designed to screen for the most common DSM-IV
Axis I disorders encountered in outpatient mental health settings. Five research
and clinical factors occurring during the past 2 decades contributed to the
development of the PDSQ. First, the publication of specific inclusion criteria
to make psychiatric diagnoses, complemented by the development of standardized
interviews to reliably assess the criteria, set the stage for the construction
of self-administered questionnaires, such as the PDSQ, which screen for or
make provisional psychiatric diagnoses. While research diagnostic interviews,
such as the Schedule for Affective Disorders and Schizophrenia,1
Diagnostic Interview Schedule,2 and the Structured
Clinical Interview for DSM-IV (SCID),3
are not infallible, they have been accepted as diagnostic standards to which
the diagnostic performance of other tests (be they biological or self-report)
are compared.
Second, several research groups demonstrated that it was possible to
construct a self-report questionnaire that "diagnosed" individual DSM-IV disorders. One of the first such measures was constructed in
the early 1980s by Zimmerman and colleagues,4
who developed the Inventory to Diagnose Depression to evaluate the DSM-III criteria for major depressive disorder (MDD). Their initial
work on the Inventory to Diagnose Depression was replicated by other research
groups,5, 6 and subsequently other
questionnaires have been designed to screen for specific DSM-IV Axis I disorders, such as posttraumatic stress disorder (PTSD)
and bulimia nervosa.7, 8
The third influence on our decision to develop a questionnaire assessing
several Axis I diagnoses was the increasing recognition of the frequency and
importance of diagnostic comorbidity.9, 10
High rates of comorbidity may be caused by covariation of truly distinct syndromes
or may well be an artifact of the nomenclature; nonetheless, detection of
comorbidity is considered clinically important because patients with multiple
disorders tend to have poorer outcomes.11, 12, 13, 14
Fourth, there has been accumulating evidence that diagnostic comorbidity
is underrecognized in routine clinical practice.15, 16
Studies of comorbidity rates in patients whose conditions were diagnosed by
clinicians in the routine clinical setting are one half to one third the comorbidity
rates reported in studies using standardized research diagnostic interviews.16
Fifth, the changing health care delivery system has placed increasing
time constraints on conducting diagnostic evaluations. When clinicians' time
to conduct diagnostic evaluations is reduced, it is more likely that additional
psychiatric disorders beyond the presenting complaint will not be detected.
These 5 factors were the impetus for the development of the PDSQ. Our
goal was to develop a psychometrically sound, clinically useful instrument
that was brief enough to be completed by patients before their initial diagnostic
evaluation, yet comprehensive enough to cover the most common disorders for
which individuals seek treatment. Finally, the scoring and organization of
the measure should be clear and straightforward enough so that a clinician,
or office worker can rapidly review and score the scale and obtain clinically
meaningful information. In previous reports from the Rhode Island Methods
to Improve Diagnostic Assessment and Services (MIDAS) project, we presented
the psychometric properties of the successive versions of the PDSQ.17, 18 In the present report from the MIDAS
project, we describe the diagnostic performance of the PDSQ in an outpatient
setting.
SUBJECTS AND METHODS
SUBJECTS
A subset of patients (n = 630) evaluated in the Rhode Island Hospital
Department of Psychiatry outpatient practice were interviewed by a trained
diagnostic rater who administered the SCID and presented the results to the
treating clinician. We previously reported that the patients who were and
were not interviewed with the SCID were similar in their demographic characteristics
and scores on self-report measures of symptom severity.16
The Rhode Island Hospital Institutional Review Committee approved the research
protocol, and all patients provided informed, written consent. Details regarding
interviewer experience, training, supervision, and reliability are presented
in other reports from the MIDAS project.16, 19, 20
When scheduling their appointments, patients were told to arrive early
to complete some standard forms. The PDSQ takes approximately 15 to 20 minutes
to complete, and its administration did not disrupt usual clinical practice.
Because we were planning to test the PDSQ's validity by examining the relationship
between subscale scores and psychiatric diagnoses, SCID interviewers were
kept blind to subjects' responses on the measure. The PDSQ was always completed
before the SCID.
MEASURES
The PDSQ has undergone several rounds of study involving more than 3000
primary care and psychiatric outpatients. After each large validation study,
the scale was revised based on a psychometric analysis of the subscales and
items. The final version of the PDSQ consists of 126 questions assessing the
symptoms of 13 DSM-IV disorders in 5 areas: eating
disorders (bulimia/binge-eating disorder); mood disorders (major depressive
disorder [MDD]); anxiety disorders (panic disorder, agoraphobia, PTSD, obsessive-compulsive
disorder, generalized anxiety disorder [GAD], and social phobia); substance
use disorders (alcohol abuse/dependence and drug abuse/dependence); and somatoform
disorders (somatization disorder and hypochondriasis). In addition, there
is a 6-item psychosis screen. The disorders chosen for coverage were selected
because they are the most prevalent in epidemiological surveys of the community21, 22 and the most frequently reported
in large clinical samples.16, 23, 24
Three subscales (mania, dysthymic disorder, and anorexia) were dropped because
of poor psychometric performance after extensive investigation.
In determining the length of the PDSQ subscales, we tried to balance
the desire to keep the scale brief so that it would be feasible to incorporate
it into routine clinical practice with the desire to make the scale comprehensive
so that most or all diagnostic criteria of the included disorders were assessed.
The MDD subscale was the longest PDSQ subscale, at 22 items, because it assessed
each of the 9 DSM-IV symptom criteria, and a separate
question for each element of compound MDD criteria was included (eg, the sleep
disturbance criterion includes questions of both increased and decreased sleep).
The reason for including this level of detail was the potential treatment
implications of the presence of vegetative and reverse vegetative symptoms
of MDD. The number of items on the other PDSQ subscales were as follows: PTSD
(n = 15), bulimia/binge-eating disorder (n = 10), obsessive-compulsive disorder
(n = 8), panic disorder (n = 8), psychosis (n = 6), agoraphobia (n = 11),
social phobia (n = 15), alcohol abuse/dependence (n = 6), drug abuse/dependence
(n = 6), GAD (n = 10), somatization (n = 5), and hypochondriasis (n = 5).
The PDSQ inquires about current and recent symptoms. Because the DSM-IV symptom-duration requirement varies by disorder,
we adopted multiple time frames. We thought it would be too confusing and
awkward to follow all of the DSM-IV duration requirements;
therefore we simplified this by using 2 different time frames. All but 2 questions
on the first 6 subscales (MDD, PTSD, bulimia/binge-eating disorder, obsessive-compulsive
disorder, panic disorder, and psychosis) refer to the past 2 weeks. The exceptions
are the first 2 questions on the PTSD subscale, which ask about having ever
experienced or witnessed a traumatic event. The time frame for the other 7
subscales (agoraphobia, social phobia, alcohol abuse/dependence, drug abuse/dependence,
GAD, somatization, and hypochondriasis) is the 6 months before the evaluation.
We chose a longer time frame for these domains of psychopathology because
the symptoms of some of these disorders are more intermittent and may not
have been present during the 2 weeks before the evaluation. For example, problems
associated with drugs and alcohol are often sporadic, in contrast to the daily
symptoms of MDD. Similarly, phobic situations may be encountered on an irregular
basis. For GAD and hypochondriasis, symptoms are assessed for the past 6 months
because DSM-IV requires a 6-month duration to be
diagnosed.
The PDSQ was intended to be administered and scored in the office before
the initial diagnostic evaluation. Respondents easily understand the yes/no
response format of the scale. To illustrate the content of the scale, Table 1 lists the items and format of the
generalized anxiety disorder subscale. Items answered yes are scored 1, items
answered no, 0. The items on each diagnostic subscale are grouped, and the
subscales are clearly demarcated from each other. This organization of the
PDSQ facilitates rapid hand-scoring that makes it feasible to be used in routine
clinical practice. (Copies of the PDSQ are available from Western Psychological
Services, 12031 Wilshire Blvd, Los Angeles, CA 90025-1251 [e-mail: CustSvc{at}wpspublish.com]).
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Table 1. Generalized Anxiety Disorder Subscale of the Psychiatric Diagnostic
Screening Questionnaire (PDSQ)*
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In the validity study of the final version of the PDSQ, 994 psychiatric
outpatients completed the scale.17 The 13 PDSQ
subscales demonstrated good to excellent levels of internal consistency. Cronbach 
was greater than .80 for 12 of the 13 subscales, and the mean of the
coefficients was .86. Test-retest reliability was examined in the 185 subjects
who completed the PDSQ 2 times less than a week apart. Test-retest reliability
coefficients were greater than 0.80 for 9 subscales, and the mean of the test-retest
correlation coefficients was 0.83. The convergent and discriminant validity
of the PDSQ subscales25 was examined in 361
patients who completed a package of questionnaires at home less than a week
after completing the PDSQ. The booklet included measures of symptoms related
to each of the PDSQ symptoms domains.7, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40
Every PDSQ subscale was more highly correlated with the concordant validity
scale assessing the same symptom domain vs other symptoms domains. Across
all subscales, the mean correlation between the PDSQ subscales and their respective
validity scale was 0.66, while the mean correlation between PDSQ subscales
and measures of other symptom domains was 0.25. Finally, for each of the disorders
assessed by the PDSQ, the mean diagnosis-specific subscale score in patients
with and without that DSM-IV diagnosis were compared.
For every PDSQ subscale, scores were significantly higher for patients with,
vs without, the corresponding diagnosis.
The core of the diagnostic evaluation was the January 1995 DSM-IV patient version of the SCID. The Axis I version of the SCID
covers 7 DSM-IV sections: mood, psychotic, substance
use, anxiety, somatoform, adjustment, and eating disorders. For 3 symptom
domains—psychosis, bulimia, and somatization—we combined patients
with related diagnoses. The psychosis group included patients diagnosed as
having schizophrenia, schizoaffective disorder, psychotic disorder not otherwise
specified (NOS), MDD with psychotic features, and bipolar depression with
psychotic features. The bulimia group included subjects diagnosed as having
binge-eating disorder (a DSM-IV appendix diagnosis
that would otherwise be captured as part of the eating disorder NOS category),
as well as bulimia nervosa. The somatization group included patients diagnosed
as having somatization disorder and undifferentiated somatoform disorder.
Finally, when examining the PDSQ MDD subscale, we combined patients with MDD,
bipolar I depression, bipolar II depression, and 4 patients who met full criteria
for MDD but also had nonbizarre delusions outside of the mood episode. According
to DSM-IV, these 4 patients were diagnosed as having
psychotic disorder NOS and depressive disorder NOS.
DATA ANALYSIS
There are several excellent articles describing the descriptive statistics
of test performance.41, 42, 43, 44, 45
Despite these, in several studies of the performance of self-administered
screening tests, incorrect definitions and miscalculations of these statistics
were found46; therefore, we present a brief
overview of this area.
Sensitivity refers to a test's ability to correctly identify individuals
with the disorder, whereas specificity refers to a test's ability to identify
persons who are not ill. Sensitivity and specificity provide useful psychometric
information about a test; however, the clinically more meaningful conditional
probabilities are positive and negative predictive values. These values indicate
the probability that an individual is ill or not ill given that the test identifies
them as ill or not ill. Accordingly, positive predictive value is the percentage
of individuals classified as ill by the test who truly are ill, whereas negative
predictive value is the percentage of individuals classified not ill by the
test who truly are not ill.
Sensitivity, specificity, and positive and negative predictive values
are not invariant properties of a test—they are a function of the cutoff
point used to distinguish cases from noncases, they are influenced by disease
prevalence, and they are related to each other. Four axioms characterize these
relationships: (1) Lowering a test's cutoff score to identify cases increases
the test's sensitivity and decreases its specificity. (2) Conversely, raising
the test threshold to identify cases decreases the test's sensitivity and
increases its specificity. (3) At constant sensitivity and specificity, a
test's positive predictive value is higher in samples where disease prevalence
is greater. (4) At constant sensitivity and specificity, a test's negative
predictive value is higher in samples where disease prevalence is lower.
Depending on the instrument's purpose, cutoff scores might be selected
to optimize the sensitivity or specificity of the scale.47, 48
In the present report, we describe the diagnostic performance of the PDSQ
subscales across the range of cutoff scores. We determined the average specificity
and positive and negative predictive value across the PDSQ subscales when
sensitivity was 80%, 85%, and 90%. When the values of sensitivity were not
exactly 80%, 85%, or 90%, we extrapolated the values of the other diagnostic
performance statistics. For example, the agoraphobia subscale had no corresponding
cutoff for a sensitivity of 85%. We extrapolated from the sensitivity of 82%
and 88% (specificity of 83% and 75%), and estimated that at a sensitivity
of 85% the agoraphobia subscale would have a specificity of 79%. We conducted
receiver operating curve analyses to completely determine the subscales' diagnostic
performance across the range of cutoff points and to allow us to evaluate
the diagnostic performance of the different subscales by examining their areas
under the curve (AUCs).48, 49
RESULTS
The data in Table 2 show
the demographic and diagnostic characteristics of the sample. The majority
of the subjects were white, female, married or single, and had some college
education. The mean (SD) age of the sample was 37.8 (11.9) years. The most
frequent DSM-IV diagnoses were MDD (47.9%), social
phobia (26.5%), GAD (17.5%), and panic disorder (17.0%).
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Table 2. Demographic and Clinical Characteristics of 630 Psychiatric
Outpatients*
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The data in Table 3 and Table 4 show that the PDSQ subscales' diagnostic
properties varied in a predictable manner according to the cutoff score—as
the threshold increased sensitivity decreased and specificity increased. At
respective cutoff scores resulting in a sensitivity of 80%, subscale specificities
ranged from a high of 91% for the bulimia and drug abuse/dependence subscales
to a low of 58% for the somatization subscale. The mean specificity across
all subscales when subscale sensitivity was 80%, 85%, and 90% was 78%, 73%,
and 66%, respectively. (It should be noted that the psychosis subscale did
not achieve a sensitivity of 80%. For this subscale, our analysis included
the corresponding diagnostic statistics for the subscale's maximum sensitivity
of 75%. In our other analyses, if the subscale did not achieve a sensitivity
of 85% or 90%, the subscale was not included in the calculation of average
specificity and predictive values across subscales.) When subscale sensitivity
was 80%, 85%, and 90%, the mean positive predictive value across the subscales
was 32%, 31%, and 30%, and the mean negative predictive value was 95%, 96%,
and 97%, respectively.
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Table 3. Sensitivity and Specificity of Psychiatric Diagnostic Screening
Questionnaire Subscales at Different Cutoff Scores in 630 Psychiatric Outpatients*
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Table 4. Positive and Negative Predictive Value of Psychiatric Diagnostic
Screening Questionnaire Subscales at Different Cutoff Scores in 630 Psychiatric
Outpatients*
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Receiver operating characteristic curves were determined for each subscale
and all AUCs were significant (Figure 1).
All areas under the curve were above 0.75, ranging from 0.76 to 0.92 with
a mean of 0.85.
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Receiver operating curves for each of the Psychiatric Diagnostic
Screening Questionnaire subscales in 630 psychiatric outpatients. All curves
were significant at P<.001. AUC indicates area under the curve;
please see the first footnote to Table 3 for additional subscale abbreviations.
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COMMENT
In the present article, we have described the diagnostic properties
of the PDSQ, a self-report scale designed to assess the most common DSM-IV Axis I disorders presenting in outpatient settings.
Longer, multidimensional questionnaires, such as the Minnesota Multiphasic
Personality Inventory 250 and the Millon Clinical
Multiaxial Inventory,51 have been used as diagnostic
aids; however, they were not designed to be congruent with the current diagnostic
nomenclature. Moreover, these inventories are too long, and their scoring
too time-consuming, to be routinely completed in the early 1980sand scored
in an office waiting area before the initial evaluation. Other scales have
been developed to assess specific DSM-IV Axis I disorders
such as MDD,4 PTSD,7
and bulimia,8 but they are limited to only
one type of pathology. The self-report version of the Primary Care Evaluation
of Mental Disorders assesses multiple disorders, but it was developed for
use in primary care settings.52
The PDSQ was intended as a diagnostic aid to be used in clinical practice
to facilitate the efficiency of conducting the initial diagnostic evaluation.
Consequently, we recommend that a cutoff resulting in diagnostic sensitivity
of 90% be chosen when using the scale in clinical practice. Table 4 highlights the cutoff scores on each subscale corresponding
to a sensitivity of 90%. From a clinical perspective, it is most important
that the diagnostic aid have good sensitivity and corresponding high negative
predictive value. With high negative predictive value, the clinician can be
confident that when the test indicates that the disorder is not present there
is little need to inquire about that disorder's symptoms. False positives
are less of a problem for a screening questionnaire because their major cost
is the time a clinician takes to determine that the disorder is not present.
Presumably, this is time the clinician would have nonetheless spent for the
same purpose. Based on the cutoffs resulting in a sensitivity of 90%, the
mean negative predictive value of the PDSQ subscales was 97%, and the false
positive rate was 34%.
It is important to understand what might contribute to false-positive
results. In our analyses, patients diagnosed as having "subthreshold" DSM-IV disorders (ie, partial remission, or NOS) were not
counted as cases. Cases below the threshold of full diagnostic criteria were
not rare. Elsewhere, we examined the frequency of anxiety disorders in depressed
outpatients and found that 10.7% of the patients had an anxiety disorder in
partial remission at the time of the evaluation and 15.3% had a current anxiety
disorder NOS.53 Not surprisingly, patients
with subthreshold disorders scored significantly higher on the PDSQ subscale
than patients without the disorder, although lower than patients who met full
diagnostic criteria. Thus, some of the patients who were false positives had
clinically significant symptoms of the disorder being assessed, although they
did not meet full diagnostic criteria for a current disorder.
Criteria overlap among the DSM-IV disorders
will result in false positives in any scale that follows the DSM-IV diagnostic criteria. As has been discussed by others, the high
rates of comorbidity among the DSM-IV disorders may
be caused, in part, by the difficulty in clearly demarcating the boundary
between different syndromes,54, 55, 56
and some symptoms are inclusion criteria of more than 1 disorder.
Another assessment issue that could result in false-positive results
on some of the PDSQ subscales is different time frames covered by the SCID
and PDSQ. Our rule for distinguishing between current and past episodes on
the SCID was the same for all disorders—after 2 months of symptom resolution,
the disorder was considered a past diagnosis. This followed the DSM-IV suggestion for defining remission of a depressive episode. However,
on the PDSQ, the questions assessing some disorders, such as alcohol and substance
abuse/dependence, referred to the past 6 months. Thus, some subjects who quit
drinking or abusing drugs more than 2 months before the evaluation, but less
than 6 months ago, might be false positive on the PDSQ because we would have
diagnosed them as having a past, not a current, substance use problem. In
fact, it was our experience that even some individuals who quit abusing substances
before 6 months ago would respond positively to the PDSQ questions. Consistent
with this, patients with a past diagnosis of alcohol or drug abuse/dependence
scored significantly higher than patients without a history of alcohol or
drug problems. These post hoc analyses indicate that many of the false positives
on the PDSQ are the result of the detection of clinically important symptoms.
A possible limitation of the study was our failure to randomize the
order of presentation of the PDSQ and SCID assessments; thus, we were unable
to examine the influence of order effects. Instead, we studied the PDSQ as
we expect a screening measure to be used—preceding the more detailed
diagnostic evaluation.
The present sample was drawn from a large general adult outpatient private
practice setting in which the most common presenting problems were mood and
anxiety disorders. Rhode Island has a strong community mental health center
network that treats most of the chronically mentally ill patients, and this
accounts, in part, for the low prevalence rates of psychotic disorders. The
practice does not have a specialist in the treatment of substance use disorders;
thus patients with a primary substance use problem are infrequently encountered.
It will be important to replicate and extend the present findings to samples
with different demographic and clinical characteristics. Another direction
for future research is the performance of the PDSQ in primary care settings.
Studies of an earlier version of the scale found that it was well received
by primary care patients, and it possessed favorable psychometric properties.57, 58
We developed the PDSQ to aid clinicians in making psychiatric diagnoses.
It is common in medical practices to have patients complete some initial paperwork
that is reviewed before the initial visit. We recommend that the PDSQ be used
in a similar way. That is, the responses to the scale should be reviewed before
the face-to-face encounter, and the information should make it less likely
that areas of psychopathology are overlooked. Of course, a thorough diagnostic
interview is the diagnostic standard of care. There are no special questions
on the PDSQ that allows it to detect psychopathology that otherwise would
go undetected during a clinical evaluation. However, clinicians often do not
have the time to be as comprehensive as they would like. It is our hope that
the PDSQ can improve the efficiency of the diagnostic evaluation by guiding
clinicians toward symptom areas that require more vs less assessment. Elsewhere,
we described how the PDSQ validly detected PTSD in patients whose conditions
were not diagnosed with PTSD by their treating clinicians.59
During the past few years, a cottage industry has arisen promoting products
that assist in diagnostic and outcome assessment. The American Psychological
Association60 has clearly written guidelines
for test development; however, most of the tools marketed at professional
meetings as DSM-IV diagnostic aids have not been
subjected to these rigorous test development procedures. Research demonstrating
the reliability and validity of these tools rarely has been published in peer-reviewed
journals. Nevertheless, these products are advertised and sold, and some insurance
companies require their use. Diagnostic (and outcomes) evaluations are an
important component of case formulation and treatment planning, and professional
organizations might want to take a more active role in monitoring instruments
that are intended to influence the diagnostic process.
AUTHOR INFORMATION
Accepted for publication October 3, 2000.
Supported in part by grant MH56404 from the National Institute of Mental
Health, Bethesda, Md (Dr Mattia).
From the Department of Psychiatry and Human Behavior, Brown University
School of Medicine, Rhode Island Hospital, Providence.
Reprints: Mark Zimmerman, MD, Department of Psychiatry, Rhode Island
Hospital, 235 Plain St, Suite 501, Providence, RI 02905 (e-mail: mzimmerman{at}lifespan.org).
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