No, irritable bowel syndrome is not all in your head.

Updated May 22, 2016. I have added an opening summary, as well as a few links for readers who may want to learn more about IBS as a physical health problem about which we are learning a lot, not a mental health issue.

Irritable bowel syndrome (IBS) has symptoms in common with other physical conditions. IBS ranges in severity from mild and infrequent episodes to more frequent,severe, longer, and more debilitating episodes. It is thus a  recurrent, episodic condition. For many patients in many healthcare contexts, IBS remains an undiagnosed pattern of recurrent, but different symptoms that are presented without much relief.

Often IBS is effectively managed in primary care with lifestyle management and monitoring and identifying of triggers. However, when IBS is not effectively dealt with in primary care, a patient may need a referral to a specialist. This article argues that first specialist who  is considered should be a gastroenterologist, not a mental health professional.

Evidence is accumulating that IBS is often a disturbance in the gut-brain relationship. In that sense, it has a psychological component. But it is important to recognize that it is a matter of the gut influencing the brain by way of well-documented pathways.

IBS is increasingly seen as a  disturbance in the microbiota or microbiome (I explain what that means below) of the gut. President Obama has directed the NIH to study the human microbiota or microbiome as part of a larger initiative studying these phenomena in other ecological systems, including soil. There is a lot of enthusiasm for this broad initiative, but also some caution that the enthusiasm should not get too far ahead of the data. I have added some links about this.

Anxiety and depression often accompany IBS. The symptoms may reflect the uncertainty and discomfort of trying to managing an ill-defined condition. But this distress also may be a direct effect of the gut on the brain, again through increasingly known pathways.

Patients with undiagnosed IBS challenge and ultimately frustrate physicians. When physicians cannot resolve their complaints, patients sometimes get mistreated and blamed for their condition.

Previous explanations for IBS focused on it being an expression of unconscious conflicts. Psychoanalytically oriented explanations suggest anal conflicts in which the patient struggles with hostility that she cannot express directly. IBS can been seen as a conflict between retaining in expelling fecal contents. Diarrhea or loose bowel movements can be seen as symbolically crapping on somebody in a situation where anger cannot be directly expressed. Such explanations are creative and  even literary, but they are  testable hypotheses about an individual patient. Such ideas just do not hold up in research studies, often because the hypotheses cannot be coherently expressed with key variables  assessed with validated measures.

I’m not a physician and I’m not a position to offer advice to individual sufferers from IBS. But if I or a family member developed what looked like IBS, and it could not be brought under control in primary care. I would not recommend referral not to a mental health professional as the next step.

In the UK, IBS is considered a medically unexplained symptom (MUS). IBS patients are likely to be referred to psychological interventions for which there is only weak evidence. Patients with IBS may have to get educated on their own about the condition and fend for themselves in a medical system that is unresponsive to them.

Finally, some readers have attempted to leave comments on this blog post discussing benefits they sincerely believe they have received from treatments, including dietary supplements for which there is not scientific evidence. I have not accepted those comments for posting. I’m very skeptical of alternative and complementary medicine which is basically  unproven medicine. I also see suffers from IBS vulnerable to exploitation by all sorts of deliberate or innocent quackery.

A segment of CBS This Morning Saturday News showed the view of Irritable Bowel Syndrome (IBS) as  “all in your head” is outmoded. Placing the source of IBS as “all in the head” is unlikely to lead to improvement in a chronic, intermittent condition affecting millions of people, and disproportionately women.

Jonathan LaPookThe Host Was CBS News Chief Medical Correspondent, Jonathan LaPook.







Mark Pimental

Mark Pimentel MD (@MarkPimentelMD) on Twitter

He was interviewing Mark Pimental, MD, Associate Professor of Medicine, and Director of the G.I. Motility Program of Cedars-Sinai in Los Angeles.








At one point, Dr. LaPook poked fun at the obsolete approach to IBS in which physicians patted women on the head and told them that their condition was result of anxiety and depression.

pat on the head.PNGDr. Pimentel offered a view of IBS coming out of his research and specialty practice:

Irritable Bowel Syndrome (IBS) is one of the most common chronic medical conditions, affecting 10%-15% of the population in the United States and worldwide. Work on two distinct fronts has suggested that the pathophysiology of IBS may have microbial origins. First, a series of studies and meta-analyses over the last decade suggests that IBS can develop after a single episode of acute bacterial gastroenteritis (referred to as post-infectious IBS (PI-IBS). While these subjects exhibit characteristic gut immunologic changes (in the mucosa and myenteric ganglia), the mechanisms underlying the transition to an IBS phenotype remain unknown. Second, subjects with IBS have been shown to have specific changes in luminal bacterial contents, the most common of which is small intestinal bacterial overgrowth (SIBO), a condition whereby coliform bacterial counts in the small bowel become excessive. The presence of SIBO in IBS subjects has recently been confirmed by both small bowel culture and by quantitative PCR (qPCR) of duodenal contents.

Dr. LaPook advised sufferers of IBS to work with their primary care physicians to determine whether lifestyle changes could avoid episodes of IBS or at least make them less frequent and severe. If these efforts were not successful, Dr. LaPook recommended that they consult a specialist – a gastroenterologist, not a mental health professional!

More resources about contemporary views of IBS

Here’s a link to a US National Institute of Health webpage about Symptoms and Causes of Irritable Bowel Syndrome:

What causes IBS?

Doctors aren’t sure what causes IBS. Experts think that a combination of problems can lead to IBS.

Physical Problems

Brain-Gut Signal Problems

Signals between your brain and the nerves of your gut, or small and large intestines, control how your gut works. Problems with brain-gut signals may cause IBS symptoms.

GI Motility Problems

If you have IBS, you may not have normal motility in your colon. Slow motility can lead to constipation and fast motility can lead to diarrhea. Spasms can cause abdominal pain. If you have IBS, you may also experience hyperreactivity—a dramatic increase in bowel contractions when you feel stress or after you eat.

Pain Sensitivity

If you have IBS, the nerves in your gut may be extra sensitive, causing you to feel more pain or discomfort than normal when gas or stool is in your gut. Your brain may process pain signals from your bowel differently if you have IBS.


A bacterial infection in the GI tract may cause some people to develop IBS. Researchers don’t know why infections in the GI tract lead to IBS in some people and not others, although abnormalities of the GI tract lining and mental health problems may play a role.

Small Intestinal Bacterial Overgrowth

Normally, few bacteria live in your small intestine. Small intestinal bacterial overgrowth is an increase in the number or a change in the type of bacteria in your small intestine. These bacteria can produce extra gas and may also cause diarrhea and weight loss. Some experts think small intestinal bacterial overgrowth may lead to IBS. Research continues to explore a possible link between the two conditions.

Neurotransmitters (Body Chemicals)

People with IBS have altered levels of neurotransmitters—chemicals in the body that transmit nerve signals—and GI hormones. The role these chemicals play in IBS is unclear.

Younger women with IBS often have more symptoms during their menstrual periods. Post-menopausal women have fewer symptoms compared with women who are still menstruating. These findings suggest that reproductive hormones can worsen IBS problems.

Only at the bottom of the page is any reference to the traditional view that IBS somehow expresses psychological conflicts.

The dominant theme of the fact sheet is that IBS is often a disorder of the brain-gut signaling. However, the signaling problem originates in the gut which influences the brain.

Here is a link to a freely available  article in JAMA, the Journal of the American Medical Association, Small Intestinal Bacterial Overgrowth: A Framework for Understanding Irritable Bowel Syndrome.

IBS as a disorder of the microbiota or microbiome.

A microbiota is “the ecological community of commensal, symbiotic and pathogenic microorganisms that literally share our body space”.[1][2] Joshua Lederberg coined the term, emphasising the importance of microorganisms inhabiting the human body in health and disease. Many scientific articles distinguish microbiome and microbiota to describe either the collective genomes of the microorganisms that reside in an environmental niche or the microorganisms themselves, respectively.[3][4][5] However, by the original definitions these terms are largely synonymous There are trillions of microbes in the human microbiome, although the entire microbiome only accounts for about for 1-3% total body mass,[6] with some weight-estimates ranging as high as 3 pounds (approximately 48 ounces or 1,400 grams).[n 1] Research into the role that microbiota in the gut might play in the human immune system started in the late 1990s.[9] The microbiome of the gut has been characterised as a “forgotten organ”,[10] and the possibility has been raised that “the mammalian immune system, which seems to be designed to control microorganisms, is in fact controlled by microorganisms”.[11] The human microbiome may have a role in auto-immune diseases like diabetes, rheumatoid arthritis, muscular dystrophy, multiple sclerosis, fibromyalgia, and perhaps some cancers.[12] A poor mix of microbes in the gut may also aggravate common obesity.[13][14][15] Since some of the microbes in the human body can modify the regulation of some neurotransmitters, it may be possible to use certain microorganisms to supplement treatments for depression, bipolar disorder and other stress-related psychiatric disorders.[16]

BMC Medicine is assembling a new article collection “The Microbiome and Man,” guest edited by Dr Omry Koren.

But I warn you it is heavy going and highly technical.

Here’s a more accessible link describing President Barack Obama’s National Microbiome Initiative:

Microbiomes are the communities of microorganisms that live on or in people, plants, soil, oceans, and the atmosphere. Microbiomes maintain healthy function of these diverse ecosystems, influencing human health, climate change, food security, and other factors. Dysfunctional microbiomes are associated with issues including human chronic diseases such as obesity, diabetes, and asthma; local ecological disruptions such as the hypoxic zone in the Gulf of Mexico; and reductions in agricultural productivity.

Here is an interesting link to an account of a participant in a citizen scientist effort to map the human microbiota, Some of My Best Friends Are Germs:

 Microbiomes are the communities of microorganisms that live on or in people, plants, soil, oceans, and the atmosphere. Microbiomes maintain healthy function of these diverse ecosystems, influencing human health, climate change, food security, and other factors. Dysfunctional microbiomes are associated with issues including human chronic diseases such as obesity, diabetes, and asthma; local ecological disruptions such as the hypoxic zone in the Gulf of Mexico; and reductions in agricultural productivity.

This article from USA Today is reasonably well-informed:There’s 10 trillion microbes on you; the White House wants to figure them out.

This freely available article from Nature expresses enthusiasm about the US initiative, but indicates that there are some challenges ahead that require an international effort. It’s balanced: Microbiology: Create a global microbiome effort.

The outmoded view of IBS is dominant in the UK

Suzanne O’Sullivan’s  “It’s All in Your Head “is a collection of obsolete and simply wrong ideas about “psychosomatic conditions” in itself an outmoded term, but still in circulation in the UK. She specifically mentions IBS in an editorial based on the book in The Lancet:

 Some 20% of people in the UK have irritable bowel syndrome. This is one of the most common reasons for people to present to a gastroenterology clinic. It is also a condition that is affected by psychological distress and where no organic bowel disease is evident. And yet, to convince patients that psychosomatic disorders are an everyday problem that could affect any sort of person is very difficult. To tell somebody that their medical complaint might have an emotional cause is often met with anger. It is hard to believe that we can lose control of our bodies so completely and without our knowledge. And if our subconscious has chosen to mask our psychological distress and express it in a way more palatable to us then it follows that to remove the mask will be painful.

Suzanne O’Sullivan suggests the role of the physician in the UK is to convince the patient that IBS is all in her head. The notion that “our subconscious is choosing to mask psychological distress” is at the root of the problem would be considered rubbish by informed American professionals. It’s one of many neo-crypto-psychoanalytic ideas that of have crept into CBT in the UK, despite lacking empirical evidence and being untestable with the individual patient.

O’Sullivan doesn’t tell us, but she’s referring to the old psychoanalytic literature that considers IBS as expressing unresolved anal issues acquired in potty training. Then she expresses confusion why some patients are offended by this.

Stay tuned for a blog post in Mind the Brain that traces this idea to the fraudulent data of Hans Eysenck.

Simon Wessely has praised Suzanne O’Sullivan’s book.  It was picked for Wellcome book award as a ‘thoughtful, humane and heartfelt’ study” by Baroness Joan Bakewall. The  Baroness  closed her Twitter account and fled social media after making uninformed comments blaming sufferers of anorexia for their condition:

Bakewell, 82, said: “I am alarmed by anorexia among young people, which arises presumably because they are preoccupied with being beautiful and healthy and thin.

“No one has anorexia in societies where there is not enough food. They do not have anorexia in the camps in Syria. I think it’s possible anorexia could be about narcissism.”

She added: “To be unhappy because you are the wrong weight is a sign of the overindulgence of our society, over-introspection, narcissism, really.”

It’s all in your head”is also the view of IBS promoted by Trudie Chalder and her co-investigator Simon Wessely in a King’s College, London slide presentation aimed at getting primary-care physicians to refer patients to their PRINCE Project. PRINCE is an clumsy acronym for Persistent physical symptoms Reduction INtervention:  a system Change & Evaluation in Primary and Secondary Care.

first slide MUS presentation 2015-2-page-0

second slide MUS presentation 2015-2-page-0

third slide MUS presentation 2015-2-page-0

As can be seen, the brain-gut connection is portrayed as running from the controlling brain  down to the gut.

An article about CBT for medically unexplained symptoms is recommended for the GP’s self-study.

fourth slide MUS presentation 2015-2-page-0.jpg

The preferred treatment for IBS is CBT.

fifth slide-page-0.jpg

As an American, I can’t make a positive identification of this, but I strongly suspect a British attempt at humor. However, I find it quite revealing of how psychoanalysis intrudes into what passes for CBT in the UK. This is associated with lots of patient-blaming notions about somatic conditions expressing hidden conflicts about sex and aggression and dependency.

Participation in clinical trials should be based on patients being fully informed about alternatives. I don’t know if modern treatment of IBS is available in the UK. But if I had a friend who was approached by their GP in the UK about participating in PRINCE, I would recommend that the friend become acquainted with the contemporary view of IBS in the rest of the world, and if necessary, educate their GP.

18 thoughts on “No, irritable bowel syndrome is not all in your head.

  1. I am in the uk and suffer from IBS. My bad IBS bouts ARE always triggered by my anxiety, and the worse the anxiety the worse the ‘flare’. Problem is that after that the IBS can stay bad for days or weeks after whatever triggered the anxiety has passed. My Gp was dismissive of it, though- because I also lost a lot of weight due to the diarrhoea and appetite loss, she seemed to think I just had an eating disorder. Experimenting with probiotics at home hasn’t really helped me much, I’d love for more research to be done in this area.


  2. CFS patient here. I’m not up to date on IBS but do suffer from some gut issues that seem to be related to poorly tollerating some meals (I have never been able to figure out what exactly). When it happens, I get systemic effects. Feeling of malaise, despair, depression, inflammation in the gut and extremities (one doesn’t need any tests, it is as obvious as sunburn), sudden drop in energy levels. Needless to say I’m convinced there is much to discover in this area.


  3. I’m also in the UK, also have ME and irritable bowel. While I am aware that the psyche can have an effect on the bowels, I am convinced that in my case the main trigger of my IBS symptoms is dietary.
    My GP had no help to offer after a bad attack last year, (thankfully she didn’t mention psychotherapy!) so I looked IBS up on line and found the low FODMAP diet which has helped enormously.
    It took a few weeks for my gut to settle down, and then I gradually introduced the higher FODMAP foods to test their effects. I now have a much better idea of which foods trigger bloating and pain, and have worked out for myself a healthy varied balanced diet being careful not to eat too many high FODMAP foods in any one day.
    I’ve been off wheat and dairy foods for years, having worked out for myself that they were causing bloating, pain and bouts of vomiting that I suffered throughout childhood (no, Mr Wessley et al, I wasn’t abused – I had a happy, secure, stable childhood, so there!)
    My recent testing has highlighted apples as one of the worst offenders for me, but everyone’s different.
    Incidentally the source of the low FODMAP dietary advice came from Australian and USA universities. I think some Universities here are also researching it too. There is also gut microbiome research going on in the UK, I think. I doubt if all doctors here believe the biopsychosocial model, though, as with ME, fibromyalgia etc. it is clearly a huge problem. I confess I’ve given up on asking my GP for help with any of these conditions.


    • Yes indeed – excellent research into the gut microbiota is being done by Invest in ME, a very wonderful UK charity entirely run by volunteers. Donations to research are welcome! (they sure won’t be getting funded by the government to the tune of £5m like the silly PACE trial was!)
      Glad to hear your dietary changes help. I also found out for myself that gluten affects my gut very badly. I also make, and eat, kefir, which should be helping provide beneficial gut bacteria.


  4. Ive had IBS – D for 20 years. Way before they had a name for it. Mine i the hyperactive kind. I do agree that stress can cause a flare at times. But I can also get a flare out of the blue for no reason at all. Spicy foods use to do it. And sometimes if I wait all day to eat and then eat a big meal, that will do it. Its definitely not in my head though. And seeing a psychiatrist might help with stress but I doubt it would get rid of it. Ive learned to live with it. It doesnt bother me at all or cause me any life altering issues. Sometimes its inconvenient especially if Im at a public event and it happens but I know and can expect the outcome so im good.


  5. Regarding clumsy acronyms, which the all-in-your-headers seem so fond of – oh dear, we have seen so many. The current PRINCE does rather push the limits of clumsiness, so may I propose a slightly more concise one, applicable at least to the IBS aspect of this Chalder and co. study – namely “Cognitive Restructuring Applicable to Pooing”, or “CRAP”.

    I suggest this in the spirit of good humour and levity; I thought I should show some emotion, having recently learned from Dr Chalder that people with what she calls CFS have “lower emotional expression” than controls (they were shown a sad film. Wow, the limits of science know no bounds.)

    It’s all very confusing. So are we vexatious, vituperative and given to unwarranted attacks on those poor researchers who were” only trying to help,” or are we emotionally repressed!
    Sounds like we need King’s to run up another little study to help us make our minds up. Perhaps we could hold a competition for catchiest acronym.

    Liked by 1 person

  6. I finally identified that it was dairy products causing my GI issues (late thirties onset) when I had to fast for a procedure and didn’t go back to eating cereal and milk every morning. Once I started eating it again the GI distress and some of the severe symptoms of major depression returned. After that I identified it was tied to casein and whey since lactose free dairy had the same effect.

    To this day I can return to having GI symptoms and those of major depression by consuming dairy products for several days in a row. Unfortunately, this has grown to include wheat and eggs – the foods I ate most often while avoiding dairy.

    I really don’t know what the answer is as far as why this is happening to me but I keep looking for research studies on this because I have a repeatable condition. Even when I am not aware that there is dairy, eggs or gluten products in a food item.


  7. I think I’m diagnosed with IBS (though I’m convinced that label is about as meaningful as “fever of unknown origin”–possibly less useful though because IBS seems to indicate a single syndrome while it’s used for people with IBS alone, gut issues from Sjogrn’s, gut issues from ME, gut issues from dysautonomia, and so on and so forth: maybe they are related, maybe not, but probably in the cases where one has a systemic disease already, it could easily be related to the systemic disease).

    Regarding a gastroenterologist, that’s all well and good (and preferable to going to psychiatry for a physiological problem), but when mine failed to find Crohns (which I have “red flag” signs and symptoms for and which would actually be a good fit) or anything else that was checked for (a number of possible things), they decided the only thing to do was use antidepressants. Supposedly this goes with the nerve issue you mentioned, but as no one attempted to test the levels of neurotransmitters in my nerves in particular, I didn’t find it a better hypothesis than the dysautomonia one the doc dismissed because he didn’t know how to test for it (though I am actually diagnosed with something related to that). As I cannot use TCA’s, they suggested serotonin modifiers. I looked up a review article and there is no evidence that these have any effect on GI symptoms whatsoever (though IBS patients report feeling a bit better due to improved mood). So although I’m happy to have had testing for more treatable things, going to GI did not net me any useable treatments.

    I actually had somewhat better luck at the cardiologist’s office. There I got treated for low blood volume, which caused me to gain some much-needed weight, and my GI symptoms are sometimes better with improved hydration (medication + electrolytes).

    Though I still can’t eat at least 85% of the foods in the world, even the “authentic unprocessed” kind. (Can’t really afford much organic.)


  8. I’m a UK patient who previously had some problematic gastrointestinal symptoms. I was referred to a NHS consultant gastroenterologist who refused point blank to run a single test on me and told me straight out that: “You are a woman. Women get stressed. Stress causes IBS but your pain is real.” The only person in the room who brought the “reality” of my pain into question was the doctor. I’ve never felt so demeaned in my life to be treated in this way due to my gender. I knew that stress was not the cause of the gastrointestinal symptoms as they occurred whether I was stress-free or stressed-out.

    In any case I went abroad to see a foreign physician who did tests and recommended I completely cut gluten out of my diet. As long as I stick to the diet the doctor recommended, I’ve never had another episode of gastrointestinal pain or any of the other symptoms (regardless of my stress levels or my gender!!!).

    If you’re British – you don’t have to buy this British crap. Save your cash and go abroad where doctors will treat you respectfully like human beings (not as silly little women to be patronised) and will help you sort out your health problems. I wish more people would stand up to these sexist, patronising cowboys instead of deifying them.


    • “If you’re British – you don’t have to buy this British crap. Save your cash and go abroad where doctors will treat you respectfully like human beings (not as silly little women to be patronised) ”

      Nice idea, mate, but most sick Brits don’t have the cash to make this choice! You many remember that UK sick and disabled have been subjected to a 6 year onslaught on disability benefits, courtesy of the Tories. Many chronically ill and disabled people have had to access foodbanks to survive.

      I am, quite frankly, thoroughly ashamed and embarrassed by what’s been happening here, and how the behavioural model of illness has reached its spiny tentacles into so much of healthcare and social security policy, based upon what I was going to call ” flawed” research, but I am so bloody angry about I will say “bogus” instead – but as I said, few people here can just up and off to access private medicine elsewhere, so we are sitting targets for all the patronising crap that’s being thrown our way.


      • I agree that people who are on benefits are at the mercy of the NHS and have no defence against poor treatment. The people who are the most vulnerable can expect the worst care – the government’s treatment of people with disabilities is heinous.

        Also the NHS is a system that does not support the concept of patient choice. If you are unhappy with your care, there isn’t really any where else for you to go due to the archaic boundaries and gatekeeping system along with the blind adherence to and blanket application of poorly evidenced guidelines eg. NICE. I was only able to travel abroad (and exercise choice) due to the help of my family.

        My comment was aimed more at the general population where a fair number of people get fobbed off with an “IBS – it’s all in your head you silly woman” diagnosis. A fair proportion of these will be people in work who could be getting actual tests and treatment plans but instead get the fob-off “all in your mind” attitude from doctors like those described in James Coyne’s blog post. I’m thinking here of my own relatives who have full time jobs and could afford to go abroad if they saved up a bit.

        Liked by 1 person

  9. I got diagnosed with IBS and told to try and not be so stressed. My GP told me that frequently Endometriosis and IBS go together and that was ‘probably’ why my symptoms got worse around menstruation. She couldn’t really explain why it also happened mid cycle but said it probably ‘popping ovaries’. If I’d hear that one once I’d heard it a thousand times before being diagnosed with Extensive Endometriosis at the age of 18. Something that I was apparently ‘to young to get’ and ‘a silly girl’ for not seeking medical intervention sooner!

    Multiple laparoscopies later and seven years after being diagnosed with IBS I gave in and had a Hysterectomy at 32. I’ve never experienced the same IBS symptoms again. The gynaecologist and I’m sure many people say the same thing said ‘that it was one of the worst cases she had seen’ as she went onto explain the extent of the endometriotic deposits which she said were literally all over my abdominal cavity. That there was also a mass of scar tissue from previous surgeries and that my womb had literally been torn apart by it. That she had spent three hours picking away at the deposits around my bowels, rectum and vagina but in the end had given up but hoped she had got the worst of it.

    One year after the surgery I began to get blood in my stools which surprisingly was actually treated seriously. Quite a novelty for me having Endometriosis, ME and ‘IBS’. I was duly sent off for a look see, the procedure failed as the camera could not be inserted far enough. I was booked to return and given sedatives I was wheeled into a tiny room with many medics of what type I don’t know, I did as was asked and prepared myself as best you can and this time it was no better than the first except for the fact that the General Surgeon was not going to admit defeat. I was pinned down to the table whilst screaming at the top of my voice for them to stop. I know abuse when I experience it and that was abuse.

    The results basically they couldn’t see past the Sigmund colon because of Adhesions restricting the movement of the camera. I’m now at a point where I risk my bowels being twisted and the surgeon won’t operate to remove the adhesions because she feels there is too great a risk of perforating my bowels.

    I often wonder if I hadn’t been written off as having ‘all in the head’ IBS if things might be different. I also wonder how many other women with Endometriosis are similarly diagnosed with IBS when in reality it is the Endometriosis that is irritating their bowels. I suspect it’s many as women are still being fed the same outdated and harmful messages as they were 30 years ago when I was first diagnosed with Endo.


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