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Definition of Personality Trait

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1 Definition of Personality Trait
Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts

2 Definitional Features of Personality Disorder
Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas:

3 Definitional Features of Personality Disorder
The pattern is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A) The enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) Leads to significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C)

4 Definitional Features of Personality Disorder
The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood (Criterion D) The pattern is not better accounted for as a manifestation or consequence of another mental disorder (Criterion E) The pattern is not due to the direct physiologic effects of a substance or a general medical condition (Criterion F)

5 Three Clusters of Personality Disorders
Cluster A (odd eccentric) Paranoid Schizoid Schizotypal

6 Three Clusters of Personality Disorders
Cluster B (dramatic-emotional) Antisocial Borderline Histrionic Narcissistic

7 Three Clusters of Personality Disorders
Cluster C (anxious-fearful) Avoidant Dependent Obsessive-compulsive

8 The Challenge of Working With Personality Disorders
Patients typically come for therapy with presenting problems other than personality problems They require more work within the session Longer duration of treatment Greater strain on the therapist’s skills and patience Greater difficulty in treatment compliance

9 “Red Flags” for Identifying Personality Disorders
A patient or significant other reports that the patient “has always done that” or has always been that way” The patient is not compliant with the therapeutic regimen Therapy progress seems to have come to a complete stop for no apparent reason Patients often will seem unaware of the effect their behavior has on others Patient’s problems appear to be acceptable and natural for them

10 Beck’s Theory of Personality Disorders
Certain behavioral patterns or strategies that had adaptive value in evolutionary terms, become maladaptive in today’s society when these “strategies” become exaggerated

11 Beck’s Theory of Personality Disorders
A strong relationship exists between the cognitive patterns on the one hand and the affective and behavioral patterns on the other

12 Definition of Schemas Schemas are relatively stable information processing structures that operate in a feed-forward system to guide the processing of information. They are not themselves conscious, although they can be recognized, evaluated, and their interpretations tested.

13 Characteristics of Schemas
They integrate and attach meaning to events They can be described in terms of valence or level of activation They can be of a highly idiosyncratic content

14 Characteristics of Schemas
They vary according to their function When particular schemas are hypervalent, the threshold for activation of the constituent schemas is low

15 Beck’s Theory of Personality Disorders
Each personality disorder has its own profile that can be characterized by core beliefs about the self and others and compensatory strategies associated with those core beliefs

16 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Avoidant Vulnerable to rejection, Inept, Incompetent Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

17 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Avoidant Vulnerable to rejection, Inept, Incompetent Critical Superior Demeaning Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

18 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Avoidant Vulnerable to rejection, Inept, Incompetent Critical Superior Demeaning It’s terrible to be rejected; If people know the real me, they will reject me Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

19 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Avoidant Vulnerable to rejection, Inept, Incompetent Critical Superior Demeaning It’s terrible to be rejected; If people know the real me they will reject me Avoids evaluative situations Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

20 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Paranoid Righteous Innocent Noble Vulnerable Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

21 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Paranoid Righteous Innocent Noble Vulnerable Interfering Malicious Abusive motives Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

22 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Paranoid Righteous Innocent Noble Vulnerable Interfering Malicious Abusive motives Be on guard, Don’t trust, Motives are suspect Accuse or Counter-attack Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

23 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Paranoid Righteous Innocent Noble Vulnerable Interfering Malicious Abusive motives Be on guard, Don’t trust, Motives are suspect Accuse or Counter-attack Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

24 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Dependent Needy Weak Helpless Incompetent Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

25 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Dependent Needy Weak Helpless Incompetent Nurturant Supportive Competent Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

26 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Dependent Needy Weak Helpless Incompetent Nurturant Supportive Competent Need people to survive; Need steady flow of support, encouragement Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

27 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Dependent Needy Weak Helpless Incompetent Nurturant Supportive Competent Need people to survive; Need steady flow of support, encouragement Cultivate dependent relationships Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

28 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Obsessive-compulsive Responsible Accountable Competent Fastidious Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

29 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Obsessive-compulsive Responsible Accountable Competent Fastidious Irresponsible Casual Incompetent Self-indulgent Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

30 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Obsessive-compulsive Responsible Accountable Competent Fastidious Irresponsible Casual Incompetent Self-indulgent I know what’s best Details are crucial People should do better, try harder Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

31 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Obsessive-compulsive Responsible Accountable Competent Fastidious Irresponsible Casual Incompetent Self-indulgent I know what’s best Details are crucial People should do better, try harder Apply rules Perfectionism Evaluate Control Criticize Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

32 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Narcisstic Special, unique Superior Deserve special rules Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

33 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Narcisstic Special, unique Superior Deserve special rules Inferior Admirers of me Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

34 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Narcisstic Special, unique Superior Deserve special rules Inferior Admirers of me Since I’m special I deserve special rules I’m better than others Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

35 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Narcisstic Special, unique Superior Deserve special rules Inferior Admirers of me Since I’m special I deserve special rules I’m better than others Use others Transcend rules Manipulate Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

36 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Schizoid Self-sufficient Loner Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

37 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Schizoid Self-sufficient Loner Intrusive Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

38 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Schizoid Self-sufficient Loner Intrusive Others are unrewarding Relationships are undesirable Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

39 Beck’s Profile of Personality Disorders
View of Self View of Others Main Belief Main Strategy Schizoid Self-sufficient Loner Intrusive Others are unrewarding Relationships are undesirable Stay Away Table 2.1 on page 26 of your chapter illustrates the relationship between basic beliefs on the one hand, and compensatory strategies on the other for most of the personality disorders.

40 Cognitive Therapy for Personality Disorder
Background The personality disorder is probably one of the most striking representations of Beck’s concept of “schema”. With the Axis II patient, the schematic work is the heart of the intervention. Cognitive therapy for personality disorders share a fundamental assumption with psychodynamic therapies, namely that it is more productive to identify and modify the core problem. The two schools differ in their views of the nature of this core structure, specifically the psychoanalytic school sees these structures as unconscious and not easily available to the patient. The cognitive therapy view holds that the products of this process are largely in the realm of awareness. The cognitive therapy approach sees the dysfunctional feelings and conduct as the result of certain maladaptive schemas that produce consistently biased judgments and a consistent tendency to make cognitive errors in certain types of situations.

41 Therapeutic Assumptions
Therapy will often evoke anxiety because the patient is being asked to change “who they are” Patients with personality disorders often come to therapy with presenting issues other than personality problems Patients with personality disorders are more difficult to treat Therapy must take a tripartite approach Schema work takes a much more central role in CT with personality disorders A much greater emphasis is placed on the client-therapist relationship Therapeutic Assumptions Therapy will often evoke anxiety because the patient is being asked to change "who they are. Patients with personality disorders often come to therapy with presenting issues other than personality problems; Patients with personality disorders are more difficult to treat; This translates into: 1. Less favorable outcome; 2. Therapy takes longer; 3. Greater strain on the therapist; 4. More problems with treatment compliance; 5. Less change than those with Axis I conditions. Therapy must take a tripartite approach Taking a strictly cognitive approach and attempting to persuade or argue patients out of their distortions will not work. Therapy must address the three major elements of cognitions, behavior, and affect. Schema work takes a much more central role in CT with personality disorders; Case conceptualization, treatment planning, treatment outcome monitoring, etc. are all guided by the maladaptive schemas. A much greater emphasis is placed on the client-therapist relationship The personality disorder itself plays out in the therapeutic relationship. Its manifestation becomes important material for therapeutic work. EXAMPLES: NON-COMPLIANCE

42 Problems in Collaboration
Therapist or patient may lack the skill to be collaborative Patients’ beliefs regarding the potential failure in therapy Patients’ beliefs (fears) regarding the effects of changing on significant others or himself Poor socialization to the cognitive therapy model Frustration due to lack of progress

43 Cognitive Techniques Guided discovery
Labeling of inaccurate inferences Collaborative empiricism Examining explanations of others’ behavior Scaling Reattribution training Deliberate exaggeration Decatastrophizing GUIDED DISCOVERY: Exploring with the patient the meanings they attach to their everyday experiences SCALING: Translating extreme interpretations into dimensional terms to counteract dichotomous thinking

44 Behavioral Techniques

45 Goals of Behavioral Techniques
Alter self-defeating compensatory behaviors Skill building (e.g., assertiveness) Behavioral experiments designed to weaken maladaptive beliefs

46 Specific Behavioral Techniques
Role playing Use of imagery Reliving childhood experiences Assisting in decision-making Role Playing: Provides a versatile and powerful clinical tool for (a) assessment; (b) teaching (social skills); (c) eliciting affect; and (d) facilitating perspective-taking. Reverse role-playing is particularly helpful in working with those PD’s where empathy deficits exist. Use of Imagery: used to help the patient relive traumatic memories so as to help restructure the experience and consequently the derivative attitudes. Imagery elicits affect and the misconstruction thus facilitating cognitive restructuring. Reliving Childhood experiences: 1. Reviewing childhood material opens up windows for understanding the origins of maladaptive patterns; 2. They can mobilize affect and help change the schemas. 3. Consistent with what we know about state-dependent learning; Role-plays of childhood events may activate the “hot schemas”.

47 Borderline Personality Disorder

48 Significance of BPD 2% of general population meet for BPD
11% of outpatients and 19% of inpatients meet criteria for BPD (Widiger & Francis, 1989) Of those meeting for some personality disorder, 33% of outpatients and 63% of inpatients meet for BPD 70-75% of BPD patients have a history of self-injurious acts

49 Significance of BPD Cont.
Estimates of suicide rates for BPD patients are approximately 10% 74% of BPD referred patients are women

50 Diagnostic Features of BPD
Hypersensitivity to abandonment Pattern of unstable and intense interpersonal relationships Unstable self-image or sense of self Marked impulsivity Recurrent suicidal behavior Affective instability Chronic feelings of emptiness Inappropriate or intense anger or difficulty controlling anger Transient stress-related paranoid ideation or dissociative symptoms

51 CBT for Borderline Personality Disorder (Linehan)

52 Linehan Model

53 Components of Emotional Dysregulation
Emotional vulnerability High sensitivity to emotional stimuli Intense response to emotional stimuli Slow return to emotional baseline once emotional arousal has occurred

54 Components of Emotional Dysregulation
Deficits in emotion modulation strategies Ability to inhibit inappropriate behavior related to strong negative or positive emotions Ability to act in a way that is not mood-dependent Ability to self-soothe any physiological arousal that the strong emotion has induced Ability to refocus attention in the presence of strong emotion

55 Features of the Invalidating Environment
During development, people respond to the communication of the child's preferences, thoughts, and emotions with either nonresponsiveness or more extreme negative consequences An invalidating environment emphasizes the inhibition of emotional expressiveness Painful experiences are trivialized and attributed to negative traits such as low motivation

56 Role of the Invalidating Environment
Persistent discrepancies between a child’s private experience and what others in the environment respond to as her experience provide the fundamental learning environment for many of the behavioral problems associated with BPD

57 Consequences of the Invalidating Environment
Child fails to learn how to label emotion or modulate emotional arousal Child fails to learn to tolerate distress or form realistic goals and expectations Child learns that extreme emotional reactions will sometimes provoke a helpful environmental response Child fails to learn to trust her own internal experiences and hence looks for external cues about how to think, act, and feel The invalidating environment contributes to emotional dysregulation by failing to teach the child to label and modulate arousal, to tolerate distress, or to trust her own emotional responses as valid interpretations of events. Moreover, by punishing the expression of negative emotion and erratically reinforcing emotional communication only after escalation of the child, the family shapes an emotional expression style that vacillates between extreme inhibition and extreme disinhibition. One of the most traumatic invalidating experiences is childhood sexual abuse. Up to 75% of those with BPD have experienced some sort of sexual abuse in childhood.

58 Linkage of Emotional Dysregulation and BPD Behavioral Characteristics
The behavioral characteristics of borderline individuals (i.e., self-mutilation, suicide attempts) can be conceptualized as the effects of emotional dysregulation and maladaptive emotional regulation strategies

59 Linkage of Emotional Dysregulation and BPD Behavioral Characteristics
Emotional lability leads to unpredictable behavior and cognitive inconsistency, thus interfering with identity development The chaotic relationships seen with BDPs is understandable given the person’s difficulties in controlling impulsive behaviors and negative emotions

60 Areas of Divergence From Standard CBT
Emphasis on acceptance and validation of behavior as it is in the moment DBT emphasizes the importance of balancing the technology of change with the technology of acceptance DBT goes a step further than most CBTs in that it attempts to teach clients to fully accept themselves and their world as they are in the moment

61 Areas of Divergence From Standard CBT
Emphasis on treating therapy-interfering behaviors of both client and therapist Emphasis on the therapeutic relationship as essential to treatment Emphasis on dialectic processes DBT goes a step further than most CBTs in that it attempts to teach clients to fully accept themselves and their world as they are in the moment

62 Characteristics of the DBT Treatment
Applies many standard CBT principles and techniques Attempts to reframe suicidal and other dysfunctional behaviors

63 Characteristics of the DBT Treatment
Adopts a problem-solving focus Encourages exposure to fear-eliciting stimuli

64 Characteristics of the DBT Treatment
Gives some attention to cognitive change techniques

65 Characteristics of the DBT Treatment
Emphasizes strategies for validating client's thoughts, feelings, and actions

66 Characteristics of the DBT Treatment
Emphasis on modifying current maladaptive behaviors before ameliorating long-standing interpersonal conflicts or the effects of early trauma and abuse Combines therapy into two conceptual components – psychosocial skills training and motivational issues

67 Major Modes of Treatment in DBT
Individual psychotherapy Group skills training Telephone consultation Case consultation for therapists Major Modes of Treatment Individual psychotherapy Usually held once a week. Individual therapist is the leader of the treatment team. Primarily responsible for helping the client learn more adaptive ways to cope. The agenda is not set in advance but rather flows from the client's problems/ issues that week! Required for participating in group treatment! Group skills training Since skill training is exceedingly difficult in the context of individual therapy, DBT splits the treatment into two components. Structured skill training is conducted separately from individual treatment. Sessions are about 2.5 hours once a week and follow a psychoeducational format. Telephone consultation Conducted by individual therapist. Goals: (1) teach clients to ask for help, (2) help clients generalize skills to natural environment, and (3) resolve conflict with the therapist. Case consultation for therapists Because working with BDP clients can be very draining and because therapists may engage in behaviors that interfere with treatment, DBT includes a mechanism for providing therapist ongoing support and coaching.

68 Specific Skill Training Modules in DBT
Emotional regulation skills Understanding emotions and their reactions Observing emotions Experiencing emotions Reducing emotional vulnerability through exercise and reducing alcohol/drugs Specific Skill Training Modules in DBT The skill training component of the treatment was designed to address the major symptom areas of BPD as described in DSM-III. Emotional Regulation Skills Given the important role of emotional dysregulation in BPD, the treatment includes specific skill training to help BPD clients regulate their emotions more effectively.

69 Specific Skill Training Modules in DBT
Interpersonal effectiveness skills Interpersonal Effectiveness Skills BPD clients often experience interpersonal dysregulation. Their relationships are often chaotic, intense, and marked with difficulties. Yet, BPD clients tend to function much better when in stable relationships. Hence, DBT includes specific training to teach more effective interpersonal skills.

70 Specific Skill Training Modules in DBT
Distress tolerance skills Distraction techniques Self-soothing procedures Realistically evaluating the pros and cons of tolerating events Acceptance strategies Distress Tolerance Skills BPD clients typically experience patterns of behavioral dysregulation evidenced by extreme and problematic impulsive behaviors as well as attempts to injure, mutilate, or kill themselves. These are viewed as maladaptive problem-solving strategies to deal with emotional distress. Therefore DBT includes a specific training module to teach distress tolerance skills. Specific techniques include

71 Specific Skill Training Modules in DBT
Mindfulness skills Paying attention to the ebb and flow of emotional experience Paying attention to thoughts in the moment Paying attention to action urges Practice labeling them correctly Practice accepting them w/o trying to suppress them Mindfulness Skills Often BPD clients will report no sense of self (identity disturbance) and brief nonpsychotic cognitive disturbances including derealization, dissociation, and delusions. The latter are usually triggered during times of stress. The final skills training module addresses these problems by attempting to teach BPD clients to consciously experience and observe oneself and surrounding events.

72 Efficacy Data (Linehan, 1991;1993) Linehan et al (1991)
Assigned 24 subjects to DBT and 23 to community control treatment! Low attrition rate: 17% Treatment: Indiv. and group therapy weekly for one year! Assessments at 4, 8, and 12 months Results: Significantly fewer parasuidal acts. 95.5% (Controls) versus 63.6% DBT (1.5 acts/yr versus 9 for controls) During last 4 mos. of treatment 61.9% of controls engaged in parasuicidal acts compared to only 35% for DBT. Greater medical risk scores for controls  Maintenance of treatment: DBT more likely to seek individual treatment (100% vs 73%) More inpatient days for controls. No differences in depression, or hopelessness. Linehan et al (1993) 12 month follow-up revealed good maintenance of treatment gains!

73 CBT Treatment of Avoidant Personality Disorder
Renneberg et al (1990)

74 Study Overview 17 patients were administered an intensive 4 day group treatment program consisting of (1) group systematic desensitization; (2) Behavioral rehearsal; (3) self-image enhancement

75 Major Findings Data from Renneberg et al (1990). Behavior Therapy, 21,

76 CBT Treatment of Avoidant Personality Disorder
Alden (1989)

77 Design 4-arm randomized clinical trial (constructive strategy design)
Graduated exposure Graduated exposure + Interpersonal skill training Graduated exposure + Interpersonal skill training + Intimacy Focus Wait-list control

78 Subjects 76 subjects (42 men, 34 women) all unmarried
Meeting DSM-III criteria based on clinical interview Must score above the 75% on Millon’s AVPD scale No current substance abuse or psychotropic medication

79 Treatments 10 weekly group sessions (2-2.5 hour duration)
Each group had 6-7 participants 6 masters-level therapists (2 therapists per group)

80 Results Patients in all three active treatments improved significantly compared to the wait-list There were no significant differences between the three active treatments suggesting skill training did not add to the efficacy of graduated exposure

81 Results Cont. Significant others rated the patients’ improvement as noticeable; Clinical significance analyses revealed that while treated patients improved 1 SD during treatment, their scores did not move into the range of a normative sample

82 Effectiveness of Psychotherapy for Personality Disorders: A Quantitative Review
Perry et al (1999)

83 Description of Included Studies
15 studies examining treatments for personality disorders that included pre-to posttreatment data Of these only 6 were randomized studies and 9 were uncontrolled treatment studies 5 focused on BPD, 1 schizotypal, 1 avoidant, and 8 mixed

84 Description of Included Studies Cont.
Treatment Modalities 7 studies – psychodynamic 4 studies – CBT 2 Interpersonal group psychotherapy 1 Supportive psychotherapy

85 Major Findings Drop-out rates varied considerably and averaged 21.8%
Drop-outs were positively associated with longer treatments Mean pre- to posttreatment effect sizes were 1.11 for self-report measures amd 1.29 for observer-rated measures These did not differ for the different types of treatment


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