Open Journal of Medical Psychology
Vol.3 No.2(2014), Article ID:42104,7 pages DOI:10.4236/ojmp.2014.32014

The Onset of Schizophrenia in Adolescence: Developments from a Structural and Clinical Point of View

Sonia Alberti1,2,3

1Institute of Psychology, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brasil 2Conselho Nacional de Pesquisa, Brasil 3School of Psychoanalysis of the Forums of the Lacanian Field


Copyright © 2014 Sonia Alberti. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In accordance of the Creative Commons Attribution License all Copyrights © 2014 are reserved for SCIRP and the owner of the intellectual property Sonia Alberti. All Copyright © 2014 are guarded by law and by SCIRP as a guardian.

Received October 16, 2013; revised November 16, 2013; accepted November 23, 2013

Keywords: Schizophrenia; Psychoanalysis; Adolescence; Reality Loss; Real; Transference


In 1899, Kraepelin identified schizophrenia as early dementia. The precocity of the onset of schizophrenia may be verified in psychotic episodes in the clinic of adolescence, which this article explores both from the point of view of psychoanalytic theory, and from the point of view of its clinic, in particular regarding the transference of the psychotic adolescent. It departs from the importance of differential diagnosis in relation to neurosis, using the guidelines of Freud about the loss of reality, then studies the contributions of Lacan in relation to that which returns from the real when not included in the symbolic. Finally, it articulates the drive theory to identify the issue of jouissance in transference.

1. Introduction

“[...] it would be a mistake to ignore more integrated approaches for understanding the mysteries of schizophrenia or other psychiatric disorders. The complexity of the biopsychosocial paradigm should not lead to ignoring its potential value for understanding these disorders. The role of subjective data other than those identified as ‘symptoms’ is also likely to be crucial” (John Strauss, 2013) [1].

The study of schizophrenia in adolescence is, more than anything, a study of the onset of schizophrenia. It is also the study of the first vicissitudes that result from this onset, or how the subject tries to deal with attempts to cure him, on the one hand, and autism—in Bleuler’s point of view [2]—on the other hand.

There is a very good reason why Kraepelin referred to schizophrenia as premature dementia. It is actually the psychosis that is more likely to emerge in adolescence, where its precocity distinguishes such a form of dementia from the senile form. Usually it is the parents themselves who can no longer stand their child’s state and seek the help of an analyst.

By the time the adolescent gets to an analyst he is already experiencing an episode. And even if the analyst is able to see the subject immediately, he also usually has to provide close support to the parents. The level at which they have been mentally affected will also determine how much they will be able to assist in the adolescent’s treatment. Cases where the analyst cannot count on minimal assistance from the parents during the beginning of treatment will be the most serious, because initially the adolescent is at the greatest risk: at risk of suicide, homicide, committing violent acts, etc.

It is common, after the initial evaluations, for the parents to seek out the analyst very often. The diagnosis will guide the course of treatment and it is the analyst who diagnoses the subject, with transference, as schizophrenic. Though parents would never suspect this disease in their children, providing them the diagnosis is not of great importance in our clinic. We reveal the seriousness of the situation to the parents very gradually, in meetings and in the many phone calls that the analyst receives from the parents once he agrees to treat a schizophrenic teenager. The parents will also very gradually begin to remember some of the bizarre childhood incidences that have occurred with their child. Schizophrenia in adolescence points to previous episodes that were not appropriately identified by the parents. There should be significant support for such parents whose narcissism is injured and who are now trying to support their child in finding a solution.

It is also very common that during the first episode, the analyst will decide on a referral to a psychiatrist who can support the therapy. This does not mean that the psychiatrist and the analyst need to share exactly the same diagnostic orientation on the case. Sometimes they are theoretically oriented in a different way, often they have different observations on the same case. It is also not overly important to share diagnoses with psychiatrists since medication necessarily treats different phenomena than therapy. I am thinking of the case of a subject diagnosed in his first episode by an analyst whose assessment was that the subject’s life was in danger, referring him to a psychiatrist. The analyst and the psychiatrist worked together, even agreeing that the subject had to be admitted to a clinic. Back at home, the subject would spend most of his time in bed so the psychiatrist diagnosed depression and decided to get him out of the depression. Except that the subject had told the analyst in their sessions that he remained in bed because that was how he contained his delusional activities, which he did not know how to fight otherwise. The psychiatrist medicated for depression, while with the analyst the adolescent discussed those delusional activities...

In the beginning of the 20th century, psychiatry and psychoanalysis joined forces to discover the fundamental basis of schizophrenia. I am referring here to the relationship between Freud and the Burghölzli. Nowadays psychiatric and psychoanalytical treatments seem to be moving further and further apart, which certainly has to do with the different clinical orientations. This article joins the theory of Freud and Lacan.

2. Spaltung (Split) and Adolescence

A divided mind is not specific to a psychotic subject. As a matter of fact, wherever we look, adolescence is marked by σχίζειν [schizein], to split, or as Freud [3] translated it: Spaltung. Jacques Lacan also shares this opinion in his Seminar on the formations of the unconscious: “(...) there is always a Spaltung, this means that there are always two lines that constitute the subject. And this is where all our structural problems originate” [4] (p. 394).

Adolescence is the clinic in which this is most evident; it is “the opening of a tunnel on both ends” [5], and puts the subject’s relationship with castration to the test. In any culture, adolescents are effectively put to the test, as demonstrated by initiation rituals, and they should respond as castrated. Freud [3] derives the splitting from the castration that divides every subject in his relationship with reality. It is reality that harbors that which does not cease to not be written [6], meaning the impossible ones. When the subject encounters an impossibility—and in adolescence this impossibility is usually the non-existence of a sexual relationship—reality can be frustrating, and that is how the individual becomes sick [7]. The term used by Freud—Versagung—does not exactly mean “frustration”, nor does it refer to the concept of frustration developed by Lacan in the Seminar on object relations. In this Seminar, Lacan refers to frustration based on the paternal metaphor as a signifier (S) of the mother (M): S (M) in the registering of appeal, or rather demand [8]. Some pages later he explains: “frustration with something occurs when you have been deprived by someone who you would expect to give you what you demanded. What is mostly at stake here is not so much the object but more the love of the person who could fulfill this need” [8] (p. 101). It is concluded that frustration implies the need that establishes the subject as a person with desire.

Two years later, Lacan returns to the idea of Versagung, this time based on obsessive neurosis: its symptom, that of asking the Other for permission, implies an extreme dependency on the Other who refuses this permission. That is the Freudian concept of Versagung. “The pact is refused on grounds of a promise, which is better than speaking about frustration” [4] (p. 413). But we know that this pact is nothing more than the demand of a pact that conceals the castration of the Other, which is interpreted by the obsessive subject as a refusal—he interprets it that way to conceal it. Versagung leads the subject to the castration of the Other and this is where we find the following three forms of denial: repression (Verdrängung), negation (Verleugnung) and foreclosure (Verwerfung). In the case of repression, as Lacan demonstrates with the obsessive subject, the promise is maintained as a demand, because the Other is of great importance [9]. In the case of negation, the individual is always trying to get the Other to make the pact, denying the refusal, and in the case of foreclosure there is no promise that supports the refused pact, so the individual literally feels spurned; and what is important here is the body itself.

With Lacan, we need to introduce a difference between Versagung in psychosis and Versagung in neurosis, as in terms of the former there is a lack of primordial Bejahung (affirmation or acceptance). Versagung on the background of Verneinung implies the impossibility of reuniting the object of the split (Spaltung), for the single reason that there never was a separation from this object to constitute a subject of desire.

In addition to the loss of parental authority and life drive, adolescence is predominantly a time of fantasies. At the place where the subject cannot meet the Other sex —where there is Versagung in reality—he fantasies about finding it. In the fantasy the subject will carry out everything that he has not been able to do in reality. If the subject is neurotic, he will carry this out in his fantasy because he is incapable of carrying it out in reality. He will fantasize while he is unable to “act, with the specific purpose of changing the outside world to make it more effective for him” [10] (p. 69). Therefore the fantasy is the subordinate Oedipus recourse that allows the subject to bear the Versagung. But as we have seen, there is a form of Versagung without any recourse: the kind that does not correlate to fantasy, that cannot be substituted by fantasy because reality exposes the non-affirmation to the subject [11].

In many of his passages Freud suggests that both neurosis and psychosis imply a regression. In 1926, he demonstrates this on the basis of an obsessive symptom: faced with the Versagung of reality, the subject, unable to deal with the situation, regresses to the anal-sadistic phase to seek his satisfaction there [12]. This implies the defusion of the drive—separating the erotic components from the destructive ones. In hysteria, we agree with Freud that regression in the light of Versagung of reality is that which goes from the investment in the choice of a sexual object to the identifying investment where we can also verify a defusion [13].

The subject of desire is formed through the paternal metaphor and the subject relies on this metaphor when he enters adolescence. Freud [5] defines adolescence on the basis of two parameters: 1) The loss of the authority of the parents, 2) A surplus of energy which comes from the drive demands.

Every loss of parental authority requires the subject to use the structural reference of the Name-of-the-Father which, as we have learned from Lacan, is foreclosed in psychosis, so that the psychotic subject is unable to use it. Hence the risk that a subject structured this way will develop a psychosis—or more particularly schizophrenia— during adolescence.

Each time that the subject deals with the loss of parental authority and does not find the Name-of-the-Father, the psychotic episode is the effect, on the subject, of exposing the lack of anchorage between the Real, Symbolic and Imaginary, in other words it is the imaginary deterioration itself [14] (p. 9). The imaginary is the register that normally provides consistency to the subject and his world. There is no better example than the movie The Matrix, which closely resembles the experiences of adolescents today: the imaginary is the (virtual) reality that gives consistency to the existence whose reality would otherwise have a side as terrible as a psychotic experience. We are all governed by this symbolic matrix, this Other that imposes itself and to which the neurotic person attributes sustenance. When the Other does not provide sustenance, it invades both reality as well as the body itself, just like the arachnid machines of the movie. And when we do not have the Name-of-the-Father, this non-sustenance prevents us from using desire as a means to modify reality for our own purposes. Freud [7] observes that both neurosis and psychosis are an expression of our incapacity to adapt to anankê—the real need (reale Not)—and there where neurosis avoids it, repressing it, psychosis will deny it, and create another reality. Freud observes as well that normality or health combines certain aspects of both responses, not denying reality as in neurosis, but trying hard to change it, as in psychosis [7]. Freud continues by saying that a normal relationship requires an effort in the external world and is not satisfied with an internal transformation, it is alloplastic and not autoplastic. That is exactly what the hero in our movie tried, in an act beyond our imagination.

Prevented from resorting to the Name-of-the-Father in a phase as decisive as adolescence, the subject tries to reconstitute the imaginary consistency of parental authority. That is the reason why, in treating adolescent schizophrenia, we observe that the subject will very easily subject himself to parental authority—or whoever takes its place—when he no longer knows what to do.

The problem is that subjecting himself to it leads the subject to submitting once again to an absolute Other that does not allow a place for his desire; an Other which speaks in the subject who will rather be inhabited by language than inhabiting it. This Other is the body, his own body—that no longer is—the Other body that infiltrates in that which is his own and the Other that creates a body presenting an otherness that the subject cannot doubt because of this embodiment.

A Spaltung is that of an ethical subject, in which he sees himself either as a subject of desire or not. In the first case, it derives from a bet on the Name-of-the-Father as an exception. A second Spaltung is that of the drive, in which the subject is at the same time the object of eroticization. The drive involves the subject’s relationships with his demands, in which the Other is merely implied as a code, a determinant of alienation. Here we are talking about neurosis.

In psychosis, Spaltung brings out the absence of a bet on the Name-of-the-Father as a symptom, and brings out the terrible truth that the fundamental helplessness (Hilflosigkeit) of the human being means that the subject can only rely on the father in the symbolic sense. Psychosis also exposes the fact that drives are completely determined by the Other, but in this case, the subject does not receive back his own message in an inverted way. First, because the Other misleads, lies—the person cannot claim the message as his own—and second, because there is no speech between, at least, the two different people—for the subject to receive his own inverted message from the Other requires speech [4,15]. In commenting on one of his patient presentations, Lacan concludes that in hearing “Pig!” the actual subject emits a message: “I come from the sausage maker”, it is the other side of the same coin. The subject identifies one speech as coming from inside of him, the other from outside. That is how the two lines of Spaltung are represented in psychosis.

3. The Loss of Reality

Freud [7] defines psychosis as the effect of the loss of reality of the ego at the service of the id. As a result of this, unlike what occurs in neurosis where the erotic investments [16] are kept in the fantasy—substituting reality—there is no more investment. For Freud, when there are any investments, we are already in the process of a cure, for example in hallucinatory processes: the hallucinatory phase of schizophrenia seems to consist of several forms, but “should basically correspond to a restitution attempt to restore the libidinal investment to the representations of the object” [17] (p. 186). During the schizophrenic episode there is no libidinal investment in representations of the object. This is what Freud defines as “the extinction of libido” in schizophrenia [18]. We cannot but conclude that, unlike an increase in energy coming from the drive demands—according to the generally accepted model for the conceptualization of adolescence —the onset of schizophrenia in adolescence reduces investments to zero. Once again we should ask ourselves about the role of adolescence in this process: is it not the increase in drive activity—that the subject is unable to signify—that causes the exposure of the unconscious?

In “The Loss of Reality in Neurosis and Psychosis” Freud [19] observes that the fundamental difference is that the neurotic subject distinguishes—because there has been the implementation of the reality principle—the fantasy world from reality. The schizophrenic subject does not. When he reconstitutes his world he sees fantasy as reality, replacing it completely. As Kraepelin said, reality loses its value, it does not matter. However, this does not imply that the subject is no longer aware of it. The issue here is the investment that Freud classifies as attention at the level of conscience. It is because there is a lack of the exercise of the reality principle that there is not any support for the pleasure principle or the regulation of the psychic energy level. 

On one hand, in schizophrenia there is a loss of the regulation of the energy level in the psyche that corresponds, on the other hand, to the extinction of the libido because the libido is the psychic energy relating to the phallus, and therefore to the imaginary consistency of the subject and his world, references that, as we have seen earlier, have been abolished. Finally, a third approach raises the issue about the life drive in a schizophrenic episode beyond the extinction of libido. In his Seminar on the object relations, in a passage already noted above, Lacan does not translate the term Befriedigung—the goal of the drive—as satisfaction, as we normally would, but as “appeasement” [8] (p. 60). As a matter of fact, Friede, in German, means “Peace”. The object of the drive could be quite diverse, with the possibility of appeasing it. With the lack of an object—of an investment in objects—the drive cannot be appeased. This lack of an object is also the result of the lack of proof of reality that, as stated by Jean Hyppolite, serves first of all to recover the object, convince itself that it is still present, since Freud bases the proof of reality “on the possibility of refinding its object once again” [20] (p. 751). This object that is the metaphoric equivalent of the lost object, and is highly variable, is nothing more than the object of the demand, which is why Lacan writes the drive as $<>D. Every drive involves the subject’s relationships with the demands. In this case, the oral drive (the subject’s relationship to his demand for the Other) and anal drive (the subject’s relationship to the demand from the Other) are paradigmatic. But without the proof of reality, without an investment in the object, there is also no appeasement, or Befriedigung, of the drive and the Quelle (source) and Drang (urge) remain. What to do with the mere source and urge of the drive when it is not possible to express a metaphor or its equivalencies? They impose the inscription on the flesh, representing and eternalizing autoeroticism without mediation, or rather, transforming the drive into a drive of destruction.

Every drive is a death drive because the drive involves the relationship with the Other that kills the being, creating the Spaltung [21]. It is exactly there where the Spaltung does not operate in the subject that it returns in the real. The defusion of the drive, a later concept in Freud’s work, interferes in the actual structure of the drives. But both in hysteria, as well as in obsessive neurosis, the fantasy compensates for the defusion, recreating the fusions. Eros continues to have a greater presence than the death drive [22]. At least in fantasy, the neurotic subject sustains his desire, or rather, he maintains his libidinal investments that result from the fusion or a “more or less complete synthesis” [18].

This does not occur in schizophrenia, where the organ jouissance, Organlust [18], is maintained and the fusion does not function to permit the transformation into sexual drives. In the face of defusion, the subject is thrown into a place where there was never any fusion—the episode that we are addressing here is the arrival into this place, with no way back. The clinical statements that we studied express the despair of these adolescents when faced with what is impossible to remedy after the first episode: “It will never be the same”, “Now there is nothing”, “Here (pointing to the area of the penis) there is nothing” —where “nothing” refers specifically to the absence of demand. These testimonials portray a desperate struggle to revert the situation in which the subject finds himself, giving the impression that there never was any drive fusion, as Freud states in commenting on Bleuler’s concept of ambivalence, based on the defusion of drive: ambivalence is the product of a defusion, or rather, because ambivalence “is so original it should be counted as unrealized fusion” [22] (p. 309). If we can still talk about drives here it is to the extent in which they clarify the Freudian formula of the contiguous concept between the psychic and the somatic. We are no longer dealing with demand here, but with that which constitutes it from the start: the fact that there is knowledge in the real. Dehumanized, the drives in schizophrenia imply horror in the light of the fact that every Trieb is first and foremost a Wissen (knowledge) of the real—humanized by the demand.

The world falls apart, breaking the ego. Before megalomania takes hold, in a rescue attempt, the subject is dominated by elementary phenomena and mental automatisms. The family environment becomes restless, and the family wants to limit his dispersal; he seeks to rid himself of this movement, he wants to limit the Other, return to his autonomy. But as he is unable to do so, he fights against the environment, against the disease, risks his life by even undertaking actions out of a need for autonomy and often, reaching the point when hospitalization is inevitable. Slowly, little by little, the analyst guides the subject in reclaiming his responsibility as subject, by working on the definitive loss of a part of himself that no proof of reality can recover, learning to live with the limitations of the disease.

This is where there may be a risk of autism—the main characteristic of the drive [23] (p. 146)—or as a selfabsorbed adolescent described: I will never be the same. There is nothing, so what for? There is no sense in doing anything... I only think of my parents and I don’t want them to suffer because of this. I will try a little for them. Again, this is an attempt to invest in objects, in the demand, to start over again, the eternal task of achieving drive fusion which does not happen easily.

4. Transference

In research, I discovered a significant amount of testimonials about transference in schizophrenia. In the eyes of the schizophrenic adolescent the analyst knows about that which is real. Therefore he does not place the analyst in an assumption of knowledge the way a neurotic subject would—who believes that the analyst knows what determines him—but the analyst represents the actual knowledge of the real. In the case of neurosis, the subject sees his analyst as the ideal, implying not only imagining him at the place of the ideal, but also identification. In the case of the schizophrenic adolescent there is no identification with the analyst, let alone idealization. They are radically different, or rather, the analyst is so similar to others and to those who the adolescents interacts with— for example his parents—and he is the only different one, subject of and to experiences that others do not have. So also in the realm of transference the schizophrenic subject reveals the truth that neurotic subjects try so hard to mask: there is no intersubjectivity in the psychoanalytical relationship. But even though his analyst is like all the others, he serves as an analyst—occupying an exceptional position for the subject—as the analyst intervenes in the subject’s jouissance. The schizophrenic adolescent asks the analyst to say and intervene in that which he, the subject, knows about his jouissance. A neurotic subject would arrive at his analysis with a question about his symptom, whereas a psychotic subject would have an answer about his jouissance.

“What will I do when I come here?” “Why am I here?”

“When you come here, you tell me the things you think, I listen to you, you tell me your experiences, right? And when you tell me about it, as you have said to me before, it allows you to maintain a certain distance from it, remember?”

“Yes, but I think this is very slow. I don’t see any progress. I don’t see what it is for. You know what, I had a great idea when I was thinking about coming here today!”

“Really?! What?”

“I could bring a disc or a tape. Do you have a recorder? A disc player?”


“I would give you the disc and you would play it while I lay down and relax. So in the middle of the music you would interrupt the sound and my relaxation and say something for me to associate and I would have to associate it with something.”


“What do you think? There is the possibility for us to work here. I don’t have anything else to say to you. I have already said everything I wanted to say.”

“Well, there are things that you don’t want to say.”

“Yes. Not now. So shall we try this next time?! (starts to get up from the chair to leave).

“Wait a minute, hold on! Let’s talk a little bit about it!! Tell me a little about how you got this idea?”

This was certainly a difficult session in terms of dealing with transference. Of course the analyst will not collaborate with the subject’s attempt to put the analyst in the place of the Other that makes the subject his own puppet. Certainly the subject’s “indecent proposal”, that the analyst takes him out of his tranquility and interrupts his desire for pleasure and relaxation, reflects a demand that will not be answered, just as any demand in an analysis should not be answered. As much as we ask ourselves how an analyst could deal with this psychosis, this is certainly not the way to a viable treatment in analytical transference. The analyst is warned about this: in his role he needs to say no, to all imperative attempts. In this specific case, the subject was also looking for a course for his therapy in the light of the model imposed by his mother—who was also in therapy—instructing him how to use that space the same way she used hers. In an attempt to find his own way, the patient proposes this strategy to the analyst who, in accepting it not only gives up that position but would also impede the subject from continuing his search for a possible separation. This subject taught the analyst that it is not enough to be a secretary of the alienated, as Lacan [15] suggested, and the analyst needs to work on the transference, which would result in an analysis that is not reduced to the reconstruction of a story. The schizophrenic subject knows that his story will never account for his experience because he does not believe in the Other, even if he does not doubt the ex-sistence or omnipresence of the Other. He does not believe in the Other because he notices, early on, that the truth is somewhere else. This is the place that he desperately tries to find and it does not matter if the proposal is indecent, he wants to believe that the analyst could extirpate the truth from the tangle of his unconscious—for example with the association games that caught the attention of Freud at the start of Jung’s work. To signify the truth, however, would require the signification of the phallus and that is something that neither the analyst nor the patient can expect. The truth matters to the subject as an absolute, suddenly and unexpectedly revealed by the rupture in the discursive chain. This is the emergence of a signifier that does not refer to another signifier and breaks in, into the “real”. In this “real”, the subject can only be certain of his own experience.

Transference is justified as the cause for treatment in the following three registers: at the symbolic level, the schizophrenic adolescent speaks and, when he speaks, the subject is formed. The caution with words is extreme, which supports Lacan’s [24] (p. 45) statement that autistic children are “simply people for whom words have a great significance”. And even when making language mistakes, the subject is concerned about the analyst understanding him or it is the analyst who will ask for an explanation. On the one hand, the subject’s speech reconstitutes the demand and, on the other hand, the analyst as a witness of speech is a certain guarantee of this reconstitution. This is not always delusional because sometimes there still has not been time for an attempt to create a metaphor. However, this does not mean that the elementary phenomena do not include delusions. “I am transparent, on the street everybody knows what I think, but I don’t think what I think, these thoughts are imposed on me.” “My mother wants to have sex with me,” said another person, or actually screaming it out in the hallway. A third person said: “This ball is growing on my leg. Look, doctor! What do I do now?” and a few sessions later: “This ball appeared one day when I was walking down the street with my mother. I tripped and fell. And then I saw that everything had changed. I wasn’t the same anymore, I was little.” This last person came to see the analyst because of her own persistence. After a long break and after the first treatment had been interrupted by the parents who started taking her to numerous specialists, years later the subject insisted on returning to that analyst, the only “specialist” with whom she had transference.

As secretary of the alienated, the analyst cannot interfere in the work of the subject but needs to be unequivocal and say no to any passage to the act that brings jouissance. The neurotic believes in the subject’s supposed knowledge that masks what Lacan already pointed out in his published first Seminar, in the year of 1953- 1954, the presence of the analyst [25] (p. 51), version of the real in transference. But the psychotic always experiences the real. He is the receiver of what the voices say, he is subjected to the transformations in his body and can easily put the analyst in the place of the unimpeded Other who directs him and subjects him. 

As the imaginary is impoverished by the profusion of the unknotted real, the imaginary transference in schizophrenia has a small chance of being constituted in one-on-one sessions and for short periods of time. But this is where great caution is required, when a gesture, a glance, far from constituting a gestalt, lead again to the real and to the horror that the adolescent is so familiar with because there is no intersubjectivity. Surprisingly it is through the aesthetic sense that something happens in the gestaltisation of transference. “You have very good taste”, said the subject of the indecent proposal on a different occasion. “Your foot is beautiful!” said another subject, scaring his analyst.

If the strategy of an analyst in treating a neurotic subject implies that he can increasingly position him in the place of object a, so that the real transference allows the subject to face the obstacle of castration, the strategy of an analyst who works with a schizophrenic subject aims to avoid the real transference, to allow the subject to use some of his signifiers to shield his relationship with the real.


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