Does bipolar get worse

Bipolar Is One Disorder With Many Faces

(GETTY IMAGES)Although the symptoms of bipolar disorder can vary significantly from person to person, mental health professionals have identified four main subtypes of the illness that are sometimes referred to as bipolar spectrum disorders: bipolar I, bipolar II, bipolar not otherwise specified, and cyclothymia.

Factors that differentiate the types of bipolar include the duration and intensity of the mood swings. Knowing which type you have can help doctors choose the right course of treatment, according to Gabrielle Carlson, MD, professor of psychiatry and pediatrics at Stony Brook University Medical Center in New York.

Bipolar I
People who have bipolar I—the “classic” bipolar disorder—have experienced one or more manic episodes lasting at least a week and almost always one or more major depressive episodes.

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Manic episodes bring an abnormally elevated mood. A person may be agitated, have grandiose ideas, need less sleep, be easily distracted, and act impulsively.

Depressive episodes bring feelings of sadness, hopelessness, guilt, worthlessness, and pessimism; patients may experience difficulty concentrating, a loss of interest in normal daily activities, and changes in eating and sleeping habits. Its considered a depressive episode if the person experiences several of these symptoms for most of the day for more than two weeks.

Bipolar disorder can also cause psychosis, which may include hallucinations (seeing things that arent there) or delusions (strongly held beliefs not based in reality and not influenced by rational thinking).

Men and women are equally likely to have bipolar disorder, although a 2005 study in the American Journal of Psychiatry found that men are more likely to have their first manic episode at a younger age.The disease is also evenly distributed among ethnicities, says S. Nassir Ghaemi, MD, the director of the Mood Disorders Program at Tufts Medical Center in Boston.

In bipolar disorder, periods of depression typically last longer than manic episodes. Depression can last for a year or longer, while manic episodes rarely go on for longer than a few months. If treatment is successful, bipolar patients may experience months or years of mood stability between episodes, although one-third have some residual symptoms, according to the National Institute of Mental Health (NIMH).

Bipolar II
Depression is the primary characteristic of bipolar II. While those with bipolar II do have “up” periods, these episodes are less marked. Instead of full-blown mania, people with bipolar II experience hypomania, a milder form of mania. Studies show that women are slightly more likely to have bipolar II.

Though a person with bipolar II may deny that anything is wrong, loved ones will probably notice that he or she seems agitated, is flying off the handle more often, or seems unusually upbeat.

Bipolar II is sometimes mistaken for depression because the hypomanic periods are harder to detect. Over time, without treatment, hypomania—the “up” period—can progress into mania or turn into a depressed state.

Bipolar disorder not otherwise specified (NOS)
This is a catchall category for those who seem to have bipolar disorder, but who dont fit neatly into any category.

For an illness to be considered bipolar I, for example, a manic episode needs to last at least a week. If the manic episode lasts only three days, doctors may say you have bipolar disorder not otherwise specified, Dr. Carlson says.

Other bipolar variations
Bipolar disorder is a complex condition that isnt easy to categorize. Some people have bipolar I without ever having experienced a major depressive episode, though this is unusual.

People with bipolar disorder may also experience a mixed episode, symptoms of depression and mania simultaneously.

“If youre manic, you may not be going 100 mph every second of every day,” Dr. Carlson says. “You may be moody and have ups and downs. You are wired but your emotions are completely dysregulated. Someone tells you they hate your lipstick, and you may burst into tears or hit them in the nose.”

And even if youve been diagnosed with a particular type of bipolar, it doesnt mean that your symptoms will remain the same over time, or even that you will remain in the same subtype.

Left untreated, bipolar disorder tends to worsen over time, according to the NIMH. Episodes can be more severe or can begin to cycle rapidly. About 20% to 25% of people have four or more distinct episodes of mania or depression in a year, according to Dr. Ghaemi. This is called rapid cycling, and it can occur in those with bipolar I, II, or NOS. Rapid cycling tends to happen later in the course of the illness and is more common in women than men.

Even within rapid-cycling bipolar disorder, there are many variables.

While some who are rapid cycling have periods of normality between episodes, a smaller number careen from high to low without any breaks in between; this is sometimes called continuous cycling.

An even smaller group has ultra rapid, ultra-ultra rapid, or ultradian cycling, which can bring multiple mood shifts in a single day.

Rapid-cycling bipolar disease poses challenges for physicians trying to determine the correct treatment, because antidepressants can cause manic episodes to flare or get worse.

Be sure to write down the details of your manic episodes, including your symptoms, feelings, and how long the episode lasts, so your doctor is better able to help.

People who have cyclothymia are often considered by their loved ones to be extremely moody. They have a history of cycling through “up” and “down” periods, none of which are so severe or last long enough to qualify as mania or major depression.

People with cyclothymia may have bursts of energy and need less sleep, followed by mild depression. “Very few people have to come to the doctor for treatment for cyclothymia,” says Dr. Carlson.

Some mental health professionals consider cyclothymia to be a condition distinct from bipolar. But not all mental health professionals agree. Dr. Ghaemi says cyclothymia is a personality trait, albeit one thats related to bipolar.

Research shows that people who have a parent or close family member with cyclothymia are more likely to have bipolar disorder. In addition, people with bipolar disorder have a greater tendency to experience cyclothymia between episodes of depression or mania.

“In my view, its a temperament,” Dr. Ghaemi adds.

Bipolar disorder speeds up biological aging

A recently published study demonstrates a link between telomere length, which is a mark of biological aging, and bipolar risk. The research helps to explain why bipolar disorder often comes hand-in-hand with other age-related diseases.

Share on PinterestIndividuals with bipolar disorder carry the hallmarks of increased cellular aging.

Individuals with bipolar disorder, which used to be referred to as manic depression, experience shifts in mood from feeling extremely energized and elated, to hopeless and depressed. It affects an estimated 2.6 percent of adults in the United States each year.

Aside from the psychological disruption, bipolar disorder is linked to a range of other diseases normally associated with advanced age, such as cardiovascular disease, type 2 diabetes, and obesity.

Recently, researchers from King’s College London in the United Kingdom and the Icahn School of Medicine at Mount Sinai in New York City, NY, set out to probe this relationship further. The team were particularly interested in telomeres, which are features of chromosomes that reflect the age of an organism.

Their findings are published in the journal Neuropsychopharmacology.

Telomeres and biological aging

Telomeres act as protective caps on the ends of DNA strands. Each time a cell divides, the telomere becomes shorter, until it is so short that the cell can no longer replicate.

In this way, telomere length can be used as a measure of biological aging and susceptibility to disease. In older people, telomeres are generally shorter. However, biological aging is different from chronological aging.

Various genetic and environmental factors can influence the rate of biological aging, meaning that two people of the same chronological age might be different ages biologically.

Telomere length is currently being investigated as a biomarker for neuropsychiatric conditions. For instance, shortened telomeres have been found in individuals with major depressive disorder, schizophrenia, and dementia.

An association has also been found between telomere length and the structure of the hippocampus, which is an area of the brain involved in memory and mood regulation. Similarly, shorter telomeres are associated with reduced memory function.

Lithium reduces bipolar-related aging

For the new study, scientists took DNA samples from 63 patients with bipolar disorder, 74 first-degree relatives, and 80 unrelated healthy individuals. Relatives of individuals with bipolar disorder were included because telomere length is known to be heritable.

They found that, in the first-degree relatives, telomere length was significantly shorter than in the healthy controls. In the bipolar group, telomere length was dependent on another factor: lithium.

Lithium is a drug commonly used to treat bipolar disorder. Individuals with the condition who had taken this drug did not have significantly shorter telomeres, but those that had not taken the medication showed the same reduced length as their relatives.

This suggests that lithium prevents or minimizes the premature aging associated with bipolar disorder, backing up previous findings.

Telomere length and the hippocampus

To investigate the relationship between telomere length and brain structure, the researchers conducted MRI scans on the participants. As predicted, the team found that shorter telomeres were associated with reduced hippocampal volume.

“Our study provides the first evidence that familial risk for bipolar disorder is associated with shorter telomeres, which may explain why bipolar disorder patients are also at a greater risk for aging-related diseases.”

First author Dr. Timothy Powell, King’s College London

These findings are interesting in their own right, but they open up a range of new questions to be answered. Dr. Powell gives an example, asking, “For instance, do those at risk for bipolar disorder carry genes predisposing them to faster biological aging, or are they more likely to partake in environmental factors which promote aging (e.g. smoking, poor diet)? Identifying modifiable risk factors to prevent advanced aging would be a really important next step.”

These findings may open up new avenues of research into new interventions. In fact, co-senior author Dr. Sophia Frangou says that the results suggest “that proteins which protect against telomere shortening may provide novel treatment targets for people with bipolar disorder and those predisposed to it.”

There is much work to be done, but the links between telomeres, premature aging, and neuropsychiatric conditions are sure to yield fascinating and useful results.

Young Adults May Outgrow Bipolar Disorder

“Using two large nationally representative studies, we found that there was a strikingly high peak prevalence of bipolar disorders in emerging adulthood,” said David Cicero, doctoral student in the Department of Psychological Sciences in the College of Arts and Science

and lead author of the paper. “During the third decade of life, the prevalence of the disorder appears to resolve substantially, suggesting patients become less symptomatic and may have a greater chance of recovery.”

By examining the results of two large national surveys, MU researchers found an “age gradient” in the prevalence of bipolar disorder, with part of the population appearing to outgrow the disorder. In the survey results, 5.5 to 6.2 percent of people between the ages of 18 and 24 suffer from bipolar disorder, but only about 3 percent of people older than 29 suffer from bipolar disorder.

“Young adults between the ages of 18 and 24 are going through significant life changes and social strain, which could influence both the onset and course of the disorder,” said Kenneth J. Sher, Curators’ Professor in the Department of Psychological Sciences and co-author of the study. “During this period of life, young adults are exploring new roles and relationships and begin to leave their parents’ homes for school or work. By the mid 20s, adults have begun to adjust to these changes and begin to settle down and form committed relationships.”

Researchers predict the prevalence of the disorder also could be affected by brain development, particularly the prefrontal cortex. The prefrontal cortex, the very front part of the brain, is thought to control perception, senses, personality and intelligence. In particular, it controls reactions to social situations, which can be a challenge for people with bipolar disorder.

“The maturing of the prefrontal cortex of the brain around 25 years of age could biologically explain the developmentally limited aspect of bipolar disorder,” Cicero said. “Other researchers have found a similar pattern in young adults with alcohol or substance abuse disorders.”

While some scholars suggest that the difference could be due to discounting factors such as early mortality, the sheer number of those who are recovering rules out this possibility, Sher said.

The study, “Are There Developmentally Limited Forms of Bipolar Disorder?” was published in the Journal of Abnormal Psychology. It was co-authored by Cicero, Sher and Amee Epler, a doctoral student in the Department of Psychological Sciences.

The Course of Bipolar Disorder Over Time

Bipolar Disorder: The Timeline

Bipolar symptoms usually appear during the late adolescent years, but they can emerge at any time from early childhood to your 50s. For a very few people diagnosed with bipolar disorder, symptoms will improve with medication to the point that medications will no longer be necessary.

But most people won’t be that lucky, since it is typical for manic and depressive episodes to recur later on.

“If you have a single episode of mania, the chances that you are going to have another one over your lifetime is virtually 100 percent,” says Sachs.

And there is a good chance that your manic and depressive episodes will become more frequent and severe over time. According to Sachs, most people can also expect more depressive episodes and fewer manic ones. “You will have fewer highs and more depression,” he says. Your illness may even progress to what is called rapid-cycling bipolar disorder, which is when you have four or more episodes a year.

And, Sach adds, “If you’ve had several episodes, there is probably a 60 to 80 percent chance that you will have one episode every year if untreated.” But with treatment, you can probably cut your risk of having an episode by half.

Bipolar Disorder: Remission

Most people who have bipolar disorder will have normal moods in between their manic and depressive episodes. However, in almost every case, bipolar disorder is a lifelong illness requiring treatment.

While there is no cure for bipolar disorder, there is every reason to believe that with proper treatment, you will get better. Proper treatment means taking all your medications and attending therapy sessions as recommended by your doctor. It is important to take the bipolar medications even between episodes of depression or mania. Consistency in taking the medications can stabilize your mood swings.

By learning to recognize the early signs of a manic or depressive episode, you will be empowered to take control of your bipolar disorder and deal with your symptoms before they become a full-blown episode.

Bipolar Disorder: Increasing the Effectiveness and Decreasing the Side Effects of Treatment

Drugs Mentioned in This Article

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Bipolar affective disorder (manic depression)

  • What is Bipolar Affective Disorder (Manic Depression)
  • Statistics on Bipolar Affective Disorder (Manic Depression)
  • Risk Factors for Bipolar Affective Disorder (Manic Depression)
  • Progression of Bipolar Affective Disorder (Manic Depression)
  • Symptoms of Bipolar Affective Disorder (Manic Depression)
  • Clinical Examination of Bipolar Affective Disorder (Manic Depression)
  • How is Bipolar Affective Disorder (Manic Depression) Diagnosed?
  • Prognosis of Bipolar Affective Disorder (Manic Depression)
  • How is Bipolar Affective Disorder (Manic Depression) Treated?
  • Bipolar Affective Disorder (Manic Depression) References

What is Bipolar Affective Disorder (Manic Depression)

Bipolar affective disorder (BPAD) is a psychological illness that involves severe mood swings. These mood swings take the form of depression or mania and may last for several months at a time.

During the time of depression patients often have great sadness, guilt, no appetite, poor sleep and can not enjoy themselves. Mania is the opposite of this with patients experiencing erratic and excited behaviour.

During mania patients often have increased libido, need less sleep, have excessive energy and can sometimes engage in risky behaviour (such as gambling excessively) or can even become violent.

Hypomania is a less extreme form of mania and while the symptoms are similar they are less intense. Some patients may also have a mixed episode that involves the symptoms of both a manic and depressed episode during a short period of time (less then 1 week).

There are 3 recognised types of BPAD:

  • Type I: Patients have very high manic periods and depressive episodes.
  • Type II: Patients have severe depressions but only mild manic (hypomanic) episodes.
  • Type III: Called Cyclothymic disorder, the patient has only mild depression and mild mania.

There is also a type called Rapid Cycling Bipolar Affective Disorder. With Rapid Cycling the patient changes from depression to manic at least 4 times a year and episodes of depression and mania are short.

Statistics on Bipolar Affective Disorder (Manic Depression)

There is a 2.5% chance of developing BPAD type I & II during your lifetime in Australia. The chance for combined BPAD and Cyclothymic disorder is reported as 5.2%. No racial differences exist. Males are more likely to develop BPAD than females.

Risk Factors for Bipolar Affective Disorder (Manic Depression)

The most significant risk factor for BPAD is a family history of either BPAD or depression, with two thirds of patients with BPAD having some family history of mental illness. Genes are thought to account for 80% of cases of BPAD and research is underway to find out more information about how family history and genetics influence the risk of BPAD.

Progression of Bipolar Affective Disorder (Manic Depression)

BPAD is a lifelong condition with episodes of low and high mood. The course of the illness varies greatly between individuals. Symptoms of BPAD (like depression) usually begin before age 20 with the 15 to 19 year old age group being most common. However, these symptoms are often ignored or misdiagnosed until a later age. The main reason is that almost half of all patients with BPAD will first have an episode of depression (only a quarter will first experience manic symptoms such as excited mood, excess energy, etc).

During life the patient will have episodes of low or high mood. Patients with Type I BPAD will have manic (high mood) episodes and depression (low mood) while Type II with have only mild manic episodes (called hypomanic) and more depressive episodes.

Episodes, even if treated, usually last 3-6 months but can last considerably longer. Depressive symptoms (such as low mood, low enjoyment with life, and a lack of energy) can last for years at a time.

How often episodes occur is extremely variable between patients, however the usual time between first and second episode is about four years and then episodes occur about every year. Episodes often become more frequent over time (especially if untreated). Untreated, a typical BPAD Type I patient will experience 10 episodes of mania during their life with a number of depressive episodes.

Symptoms of Bipolar Affective Disorder (Manic Depression)

Most patients will first present with an episode of depression. Patients will also often have considerable anxiety and sometimes an eating disorder (such as anorexia).

Depressive symptoms are low mood, lack of pleasure, low energy, feelings of guilt, decreased concentration, decreased appetite and decreased sleep. These however are symptoms that are also present with depression or even some forms of schizophrenia, making the diagnosis of bipolar difficult.

About a quarter of patients will present with a manic episode. These patients will present with an elevated mood, excessive energy, decreased sleep, fast talking, sensational ideas, and an inflated self-esteem.

Clinical Examination of Bipolar Affective Disorder (Manic Depression)

The clinical history should be taken from both the patient and a relation or friend as a patient who is in a manic episode will not be able to give an objective view of their condition and risk taking behaviour. The doctor will be looking for several important pieces of information in the history.

For a patient with mania, the doctor will be looking for inappropriate spending, increases in goal directed activities (especially doing extra work that is not required), poor judgement and less need for sleep. If the patient is presenting with depression the doctor will be looking for a loss of pleasure, low mood, social withdrawal, poor motivation, reduced libido, weight loss or gain and poor sleep.

The doctor will take a full detailed history of all the symptoms and when they started and if they have occurred before. Such an interview is the most important tool for making the diagnosis of BPAD and is usually a lengthy process (usually taking more then 45 minutes).

How is Bipolar Affective Disorder (Manic Depression) Diagnosed?

The diagnosis of BPAD is made on the clinical examination (see above) although there are some tests to exclude other causes for mania. These tests include thyroid function tests, calcium levels, tests for infection (especially for syphilis or HIV), an electroencephalogram (to rule out epilepsy) and possibly a CT scan (to exclude any brain injury). The doctor may also do a routine drug screen as drugs like amphetamines or cocaine can have the same signs as BPAD.

If a patient is diagnosed with BPAD and started on a medication called lithium the doctor will need to do blood tests every three or so months for lithium levels and several other blood tests.

Prognosis of Bipolar Affective Disorder (Manic Depression)

Almost all patients will recover form a depressive or manic episode in time. However, BPAD often has considerable effect on a person’s functioning and patients with BPAD often have relationship and occupational difficulties. During an episode of mania a person is likely to participate in risky behaviours (such as excessive gambling or risky sexual behaviours) and often places their finances and relationships at risk.

In recent studies about 25-35% of BPAD patients will return to the same level of functioning (education, work, social) that they had before they were diagnosed with BPAD. The majority however, will have continuing problems (especially in the work environment) despite having no ongoing symptoms, meaning the patient will have a normal mood but will continue to find it hard to function like they did before.

There is a high risk of suicide patients with BPAD. About 25% to 50% of patients with BPAD will attempt to commit suicide and about 80% will consider suicide. Although there is no truly accurate suicide figure it is estimated that 10-15% of BPAD patients die as a result of suicide. Suicide attempts are rare during mania but common during depressive episodes.

How is Bipolar Affective Disorder (Manic Depression) Treated?

The main treatment for BPAD is long term medication. There are several categories of treatment. There is different treatment for manic episodes, depressive episodes and rapid cycling. Apart for these treatments to stop episodes of depression and mania there is also long term maintenance therapy. There is also some psychotherapy available.

Treatment of a manic episode

For less severe episodes a single drug can be used. Such drugs include:

  • Lithium;
  • Valproate;
  • Carbamazepine.

For more severe cases of mania the best treatment is a combination of two drugs. The drugs that are used in severe mania are called anti-psychotics. The two drugs of this type that have been shown to be effective for treating mania are Risperidone (Risperdal) and Olanzapine. One of these drugs used in combination with lithium, Valproate or Carbamazepine is the best treatment of a severe manic episode. In extreme cases ECT can also be tried. In this therapy the patient is put to sleep and then a controlled dose of electricity is applied to the patient’s head.

Treatment of depressive episodes

Treatment of a depressive episode in BPAD is different to the treatment of depression. Traditional anti-depressant medication should not be used in BPAD as this medication can bring on episodes of mania or hypomania and cause severe mood swings. Lithium is often used. The other main drug that can be used is Lamotrigine which has been shown to be very good in the treatment of depressive episodes in BPAD. The final treatment for depressive episodes is ECT. The treatment has been shown to be a good alternative to drug treatment in patients with depressive episodes.

Rapid cycling

Treatment of rapid cycling can be difficult as some drugs can in fact make the condition worse. The drugs that are used are lithium and Lamotrigine. Lamotrigine has been shown to have excellent results in the treatment of rapid cycling and does not cause mania or hypomania. Valproate has also been suggested for rapid cycling although there is no good evidence to support its use.

Long term maintenance treatment

The goal of this therapy is to stop a patient with BPAD who is presently well going into an episode of mania or depression. This is often difficult and it is often impossible to stop these episodes. The drugs with the best scientific evidence supporting their use are lithium and Lamotrigine. Valproate also has some evidence supporting its use in long term maintenance therapy. Another use of lithium in long term treatment is its ability to decrease the risk of suicide.


Lithium has for a long time been the gold standard for mood stabilisation. It is effective in both manic and depressive episodes and for long term maintenance therapy. The most common side effects include slight shaking of the hands, thirst, queasiness (usually goes away after some time), headache, tiredness, irregular pulse, loss of appetite, weight gain, bloating and muscle weakness. When a patient is placed on lithium treatment their doctor will do routine blood tests.

Psychotherapy can be used in BPAD. The goals of psychotherapy in BPAD are to improve regular taking of medicines, reduce any substance abuse (such as alcohol), improve lifestyle and help patients recognise symptoms of depression or mania earlier so that they seek appropriate treatment as soon as possible.

There are 3 general types of psychotherapy that have been shown to be useful:

  • Psycho-education – This educates the patient about BPAD, early signs of a manic or depressive episode and the importance of long term medication. There is good evidence for psycho-education as it improves regular taking of medicines and can help patients identify any stresses that will lead to an episode and try to change them.
  • Family Focus Therapy – This includes psycho-education but also helps to improve communication and problem solving within the family. The therapy has been shown to be effective at reducing the number of manic or depressive episodes over time.
  • Cognitive Behavioural Therapy (CBT) – This works in a number of ways. Like psycho-education, it increases a patient’s knowledge of the illness but it also helps the patient with returning to full functioning. Many patients with BPAD do not return to full employment or social life even when they are symptom-free. Cognitive behavioural therapy works to help restore a patient back to full functioning (full employment, social life, relationships, etc).

Bipolar Affective Disorder (Manic Depression) References

Treatments Used in This Disease:

  • Antidepressants
  • Psychoeducation
  • Conventional Antipsychotics

Drugs/Products Used in the Treatment of This Disease:

  • Epilim (Sodium valproate)
  • Lamictal (Lamotrigine)
  • Lithicarb (Lithium carbonate)
  • Risperdal Oral Quicklet (Risperidone)
  • Risperdal Oral Solution (Risperidone)
  • Risperdal Oral Tablets (Risperidone)
  • Serenace (Haloperidol)
  • Tegretol (Carbamazepine)
  • Zyprexa (Olanzapine)

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Episodes of depression in bipolar disorder can be treated in a similar way to clinical depression. This includes using antidepressant medication.

Never try to self-medicate or change medicines without your doctors knowledge. It is important to keep taking the medicines long-term, even if you’re feeling well.

Psychological treatment

Some people find psychological treatment helpful when used alongside medicine in between episodes of mania or depression. This may include:

  • psychoeducation to help you find out more about bipolar disorder
  • cognitive behavioural therapy (CBT), which is most useful when treating depression
  • family therapy, a type of psychotherapy that focuses on family relationships (such as marriage) and encourages everyone within the family or relationship to work together to improve mental health
  • Electroconvulsive therapy (ECT) can be used for people who are very unwell and who aren’t responding to other treatments


Bipolar disorder can start during pregnancy or just after the birth of a baby, and pregnancy can make it worse.

Some medicines aren’t safe to use during pregnancy, especially in the first trimester. If you have bipolar disorder or someone in your family has it and you’re planning to get pregnant, talk to your doctor first.

It can be tricky to treat bipolar disorder while you’re pregnant. You might need to be looked after by a psychiatrist.

Where to get help

If you need help, talking to your doctor is a good place to start. If you’d like to find out more, or talk to someone else, here are some organisations that can help:

  • Black Dog Institute (people affected by mood disorders) – online help
  • Lifeline (anyone having a personal crisis) – call 13 11 14 or chat online
  • Suicide Call Back Service (anyone thinking about suicide) – call 1300 659 467
  • SANE Australia (people living with a mental illness) – call 1800 18 7263
  • beyondblue (anyone feeling depressed or anxious) – call 1300 22 4636 or chat online

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