Treating Performance Anxiety – Case Study Samples

Type of paper: Case Study

Topic: Psychology, Education, Anxiety, Client, Nursing, Patient, Study, Hypnosis

Pages: 8

Words: 2200

Published: 2020/12/19

Locus of Control and


Locus of Control and Cognition

The following scholastic dialogue provides a case study conducted with the client permission to present the work in this academic exercise in development of this case study report form of a client suffering performance anxiety and seeking CH as a treatment according to the precepts of locus of control and cognition. This document includes the profile and history of the patient in determining and creating the foundation for prescribed best practice in an academic environment (Defazio et al 2010) centred on the locus of control and cognition with applied hypnotherapy for treating performance anxiety reported by the patient connected to attending course scheduled tests(Bogel et al, 2010).
The ensuing information culminates from work with the subject feedback on her experiencing performance anxiety reported over several sessions working toward achieving a positive goal/outcome (Robbins et al 2009). In the preparation of the following case study the discourse includes the process determining the underlying psychological issue of the client’s performance anxiety as a student and the life circumstances of the environment(s) the client exists. This and identifying any other issues emerging contributing to the anxiety causing performance issues as a student having the ability to attend school for academic testing aligned to her course studies. This aligns to studies on test anxiety studies first published by Yarkes-Dodson (as cited in Buchwald, 2010, p. 283) and later with Hobfoll (1998 as cited by Buchwald, 2010, p. 283) “ introducing (And) interference and learning-deficit models which does not only stress individuals' perceptions but also takes environmental contingencies into account” as related to the subject’s anxiety about attending school taking academic tests. The context of this therefore connects

Hypnotherapy Treating Performance Anxiety

The use of hypnotherapy as a treatment for performance anxiety aligns to the body of cognitive therapies for adjusting unwanted behaviour as an effective intervention approach (Allison and Faith, 1996; Brewin, 1989; Brown and Barlow, 1995; Dowd et al, 2010; Gravitz, 1994; Green et al, 2014; Jensen and Patterson, 2014; Kirsch et al, 1995; McIntosh and Fischer, 2000; Milling, 2014, Overholser, 1988; Patterson and Jensen, 2003; Robbins et al, 2009; Tosi et al, 1982; Van Dyck and Spinhoven, 1994). As such, therefore, the proceeding case study addresses a patient suffering from performance anxiety relating to their status as a student having difficulties successfully performing required attendance to complete school exams.
The discourse covering the sessions completed with this study include evidence-based rationale for the management of the patient with the use of the cognitive benefits of hypnotherapy in treating this disorder as explained by Robbins et al (2009). As directed by this scholastic exercise, the following hypnotherapy includes a minimum of 3 sessions empathizing the stabilization, therapeutic intervention, and maintenance of change once the applied therapy shows progress for sustaining the desired outcome.
Consequently, as intended the following case study demonstrates critical analysis, critical thinking, and the synthesis of ideas according to applicable substantiation of accompanying literature located in relevant journal articles, research literature, as well as other academic publications as referenced throughout the writing presented in this document. Accordingly, this includes critical analyse and synthesise of advanced theories of hypnosis as well as demonstration of their application to the hypnotherapy intervention. Further, as prescribed for this scholastic endeavour the following case study provides an evidence based rationale for the induction, deepeners, and therapeutic process critically evaluating as included any indications or contraindications, an appropriate timescale for therapy, any safety or ethical implications, the therapeutic outcome, critical evaluation of the patient progress with any homework assignments, reflection on critical and insightful subjective input, reference to relevant studies, journal articles, and books where appropriate.
Consequently, the main focus of this case study demonstrates clinical competence including but not limited to technical expertise, an ability for exhibiting critical evaluative and synthesis of relevant research based/academically informed descriptive input of the treatment decision-making process including evidence of best ethical practice, rapport, and insight. This connects to what to Azjen (2005, p. 142), “A person’s current behavior must be determined by factors that exert their effects right here and now.” [Sic] To this end, the following documentation in writing ensues as a critical analysis of this case study, rather than a descriptive recounting of facts. By including this detailed introduction, the intention posits a guided direction for reading the following case study as literature provided by Defazio et al (2010) outlines.

Performance Anxiety

Patient is an 18 year old student maintaining a 4.0 GPA. Generally, the client comes from an above average income class of people with her father throughout her life making a very comfortable living. Her mother is a housewife. Her older brother received what the client implies was a hard push by her apparently assertive father to attend to his academic studies including frequent paid tutors aligned with the academic expectations of her parents having a strong focus that her brother needs to become a successful professional. On the other hand the client reports no such expectation toward her success in academics came from her parents and they withheld any encouragement for the patient to do well in school. After class, when she would study and on weekends, the mother always insisted that patient accompany her mum and as well as occasions with the grandma included. She reports how the older brother had little choice but constant focus on studying. She reports her lifelong perception to date was the expectation of the parents she eventually become the housewife in a marriage embodying the same role as her mother.
An acquaintance of the patient family member – a former patient of mine provided the client referral to my services. Her family member’s acquaintance who was treated by me for presenting social anxiety and panic attacks, the referral source, stated that therapy, “totally changed her life” and that I was “very insightful.” The focus of the client’s psychological issue was performance anxiety as it relates to taking school exams. She described the many issues she had around A2 Level exams from the previous school year. Upon the initial consultation, from my analysis it became clear she also has a general low self-confidence according to her perception of her capability obtaining and sustaining a professional job upon completing University. The initial assessment based on the background adheres to the Axis V: Highest Level of Functioning according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DAM-IV) of rating a patient as having a function level issue at the present time as well as the highest level from the previous year as related to the other axes affecting the client according to types of changes expected along with the desired outcomes of treatment (Heffner, 2015). As connected to the intentions of the outcome of hypnotherapy in a context of psychotherapy (Cook et al, 2010) therefore according to Omer and Strenger (1992, p. 253), “Viewed from a different perspective, psychotherapy works by transforming a person's self-narrative and the self-concept embodied in the narrative.” In this, therefore with the focus of the hypnotherapy first establishing the locus of control based upon the client’s self-narrative and self-concept contextually established the foundation of the treatment.
Further to this aspect finds Alladin (2014, p. 368) explaining how anxiety relating to the client seeking treatment for debilitating anxiety and the perception of the “wounded self” therefore tasks the clinician understanding of this concept in terms of as “ early unresolved emotional injuries. According to this conceptualization, anxiety represents an unconscious fear of unbearable insult to the wounded self, which is protected by maladaptive conscious strategies such as avoidance, cognitive distortions, or emotional constriction.” This occurs as a form of cognitive vulnerability (Beiling and Grant, 2007; Ajzen, 2005).
With the sessions these very components emerge and the locus of control as a focus of the outcome of the hypnotherapy treatment connected to the cognitive understanding of this process therefore, pragmatically provides how, “This perspective provides a theoretical basis for blending elements of psychodynamic, behavioral, cognitive, and experiential therapies in the psychological management of anxiety disorders.” [Sic] Even more relevant, “As cognitive hypnotherapy embodies all of these therapeutic elements, its application to anxiety disorders Various hypnotherapeutic techniques for symptomatic relief and for eliciting and healing the wounded self” by addressing the specific symptoms reported by the client provides a sound proactive means for treating the performance anxiety disorder. Consequently, as the sessions reveal, and analysis proceeds, the sustainability of the hypnotherapy as the locus of control based on the cognitive process looks at resolving any identified “ underlying conflicts that drive the anxiety.”
Further, to the analysis process includes assessing the extent of the patient coping abilities. According to Parkes (1984, p. 495) implications of research evidence shows “that internals and externals differ in the nature and effectiveness of their coping behaviour.” [Sic] In addition, the assessment of the data determined how patterns of coping connected to the target study internal related responses to the research mechanism reported proved having more potential adaptability relating to varieties of appraisal over external types. Consequently, any perception of importance attached to a particular episode bringing on anxiety and employing coping abilities related significantly as suppressive negativity whereas interfacing with the locus of control proved insignificant.

Initial Analysis for Clinical Hypnotherapy

Treating Performance Anxiety –

Locus of Control and Cognition Positive Aspects

Strong Rapport
A strong alliance in any behaviour modification work in the clinical setting remains a central component of the process. Primary to this case study, the client seeking my services based on a positive reference form a trusted family member, the alliance formed between the client and myself focusing on the nature of the task, and the willingness of the client trusting the process proves vital. The conscious cognitive version of this rapport nonetheless potentially remains subject to subversive unconscious reaction to the therapy (Murdin and Errington, 2005). From the primary interaction with the client the alliance fits an initial congruence over the manner of the attempted therapy, the trust factor already evident between the patient and my position in this collaborative effort as a form of goodwill based benevolence. According to .research by David Malan rapport waxes and wanes through the session process and continues as a measuring tool for the effectiveness of the intervention process of the hypnotherapy in treating this patient’s failure to perform anxiety (as cited in Murdin and Errington, 2005, p. 115).

Session I

This patient exhibited rapid eye defocus, contraindications as associated with optometric contact lens/eye injury. As prescribed during the induction process working with the patient according to Flemons (2005, p. 333), it remains important communication with “ (An) empathic understanding.” Further, “The best way to begin helping your clients change their relationship with themselves, facilitating a shift in their internal boundaries and the development of relaxation, is to help them change their relationship with you and their surroundings.” As a consequence, “Hypnosis doesn't begin when you start delivering an ‘induction’; it begins when your clients start trusting that you have a good handle on the intricacies of their experience.”
Gibbons reports the use of hypnosis induction methods sometimes require inducing relaxation in the patient including examples as the situation with my client having test taking anxiety (as cited by Alladin, 2008, pp. 245–249). In the process of induction slowing the mental process of the client remains the focus and goal and connects with the same condition of the first five minutes of normal sleep patterns. During the trance induced state of the mind on hypnosis the subliminal mind in ideal conditions then becomes more receptive to therapist induced suggestions and ideas as part of the treatment allowing more effective interventions taking place moving forward in the treatment process. Four primary advantages resulting from a proper induction in hypnotherapy connects with guiding to a desirable state of mental relaxation, incorporating the means for the therapist testing the degree of the patient suggestibility under hypnosis, provides the client the appropriate framework for experiencing hypnosis, and finally, the induction process provides the patient the ability centring their attention on something as directed by the clinician (McKenna, 2010)..


Hand rotation methodology for this patient chosen because it is a ratifier (convincer) and moves the patient use to IMR. Contraindications: pain when moving their shoulder, arm or back (Patterson and Jensen, 2003). The first session using the methodology for compounding the hypnotic induction provides further relaxation to the client experience as well as desired response to the process sending the client deeper into the initiated trance state. This allow the clients focusing and concentrating on the designated tasks they agree to perform as directed by the therapist during the hypnotic state. In doing so, the subconscious mind of the client works on the desired therapeutic signals provided by the therapist both during the hypnotic state as well as connected to the post-hypnotic directed suggestions of the therapist (Nongard, 2007).

Ideo Motor Response (IMR)

Deepeners provide opportunities for facilitating imagery and in turn imagery may facilitate the deepening process. This interaction of the therapist and subject also incorporates use of the client’s ideo-motor signals for non-verbal communication (such as blinking or a finger twitch) during the hypnotic state for measuring the depth of the desired trance. This occurs automatically, spontaneously, or as a subconscious conditioned response to either an internal or external idea, image, thought, or therapist directed suggestion. The ideo-motor responses by the client during hypnosis work on such cues as directing the client to physically indicate such as a raised pinky-finger when something in the hypnosis causes them discomfort connected to a memory or to performing a mental task led by the therapist (Nongard, 2007).


Early learning set; The Library of Life (ego boosting and resources) led as prescribed for the scripts focused on ego boosting varieties of hypnotic induction methods are useful for inducing relaxation in the client as necessary for this therapeutic best outcomes for treating anxiety disorders. The relaxation with counting method as a script is one method for inducing as well as deepening the client’s altered trance state. This script is capable of transferring its process so the client is able to achieve self-hypnosis for practicing relaxation when experiencing anxiety as well. Literature as offered by Alladin (2008, p. 103) explains how the majority of patients experiencing anxiety disorders such as the subject of this case study learn the empowerment of the hypnosis relaxation experience as a confidence boosting tool as well. As a result, with the end of a hypnotherapy session, the client may express positive feedback of the therapy producing first time experiences of full relaxation having the ultimate calming effect on the entire physical, mental, and emotional state.

Potential Negative

This first session with the client also assessed and considered the potentially negative aspects to treatment including the following:
-Her mum instructed her to attend, so it was not self-directed (potential motivation issues)
-I am not charging her for these sessions (potential motivation issues – not paying, therefore may enhance the will to “make it work”)
During the case history, my empirical observation of the client reveals she appears having a significant level of demoralisation manifesting in anxiety consequently exhibiting physical markers of some level of both depression and hopelessness connected to the obvious despondent nature of her reason for this session. This aligns according to Ellis’ studies concurring how depression disorder/condition depression incur other co-morbid symptoms include a lack of self-esteem (2007) and connects to the source of the onset of this anxiety disorder exacerbating the condition (as emerges in Session II with the client later in this case study discourse). Her discussion centred on self tends to emphasise negative self-esteem through self-statements full of criticism. Client advised no relevant medical history exists in her background and that she is not currently taking any type of prescribed medicine. Client explains how the She stated nearer the deadline for taking the school exam advances the thought induces dry mouth, increased heart activity resulting in higher pulse rate, feelings of nausea, some dizziness, and even mental episodes of blankness while taking the exam. It is here that Whitfield offers insights on healing the child within look at the how this applies as a secondary or underlying condition contributing to the client poor self-esteem (1967).
This arises with the child within not receiving parental nurturing that allows the patient opportunities for freedom of expression so there develops co-dependent self-images or false self-images. As with the psychological, emotion, and subsequent physical debilitation of anxiety attacks when taking academic tests since the implications the outcome of the failed development of the child within results in the issues facing this patient. Whitfield further explains this denial of the child within results in negative self-esteem, the positioning of self as the victim thus, experiencing the gradual accumulation of an inability for resolving emotional traumas that lead to performance anxiety as expressed by the patient in this case study. Further, this accumulation of unfinished emotional and mental issues definitely prove the underlying rationale of chronic anxiety (1967; Shahar and Lerman, 2013).
I assisted the patient in rephrasing her words from negative expressions of self-beliefs as well as discarding her use of negative labels about self. Example of this transformation of language describing self negatively in saying “losing it” as takes place during a period of heightened stimulation, an overstimulation response, an over-excitement response connected to the client’s anxiety about taking the academic test. Further collaborative work with the client advanced to goal setting combined with general orientation of the process. The agreed goal for the intervention hypnotherapy treating the performance issue aligned to academic test taking resulting in physical, emotional, and mental debilitation resulting from the accompanied anxiety has two aspects to achieve:
1) The ability to sit and take an exam with a healthy amount of anxiety that and transforming the excess anxiety into positive excitement, with an ability to relax and utilise breathing and anchors to achieve the state that is right for her;
2) To be able to assert to herself and to others that she is a very capable and able person, fit for a life as a professional. She agreed to attend therapy once a week and we measured how every week she can realistically move one step closer to the goal.
I provided an early learning script with ego boosting suggestions. Client collaboration of the use of the Library of Life Script assisted her find positive resources for building stronger ego and self-confidence. Woke up the patient and taught her self-hypnosis, focused on relaxation breathing exercises, then gradually moving into self-relaxation. Patient spent half an hour each evening before going to sleep practicing self-hypnosis. One of the anticipated benefits looked at the patient gaining more control over her ability to relax herself and experiencing this type of self-control. Part of hypnotherapy with this patient addressed her Performance Anxiety (Koocher et al, 2005). Directed suggestions given the patient led her attention away from monitoring herself positioning her attention to the actual exams. Targeting different suggestive cues (Jensen and Patterson, 2014), resulted in directing hypnotic based suggestions to the client such as, “ as soon as you get ready to take your exam all unnecessary nervous tension will instantly and automatically disappear you give all of your attention to what you have to do you forget about yourself and you give all of your attention to the exam with an appropriate sense of calmness that is right for you, that is optimal to provide the best results on your exam”. As part of self-hypnosis, she was to rehearse this feeling of control and calmness, seeing herself collected and calm before the exam, during the exam, and after the exam.

Session II

Rapid eye de-focus. Contraindications: contacts/eye injury. Chose because it’s authoritarian and quick. Deepener included the hand rotation as explained in rationale in the first session use. Early learning and IMR Script; The Library of Life (ego strengthening and resources); Symptom Manipulation via Regression (to recall what originally triggered the first problematic event and the first time the even occurred) (Reineke, 2002); then Assertiveness Script.

Symptom Manipulation via Regression

Patient seemed much more relaxed and provided positive results of self-hypnosis in thus second session. She explained how she did poorly on her AS Level exams and really wants to perform well on her A Level. She described herself as being really smart, and not needing to study like everyone else, but when she takes the exam, she can’t focus on her studies (seems to self-sabotage study opportunities), and just can’t seem to perform well on her exam (Morrison and Philips 2001).

Assertiveness Training

I wanted to ascertain the extent of the original event triggering the patient performance anxiety. Use of the IMR, the focus was centred on getting her to feel how the body can respond automatically; thus, the decision for using the Hand Rotation Deepener. We started off with the fixed eye on hand induction. Affect applying the bridge technique the focus brought into the process her self-wounds. The anxiety experienced recently elicited identification of and remembering the feeling of her first anxiety attack.
The onset of this chronic performance anxiety attributed to academic exam taking occurred when the patient reached 14 years of age and having dinner with her family mentioning her desire to become a doctor. Father, mother, and older brother shrugged her avowal off, with her mum jokingly and obviously ignoring her remark as insignificant telling her she would find her “Prince Charming”, adding that she would be “just fine” as a not so subtle insinuation there was something “wrong” with the idea of becoming a doctor. The client reports her attempt at asserting herself, drew the indignation of her father advising how becoming a doctor entailed a lot of hard work studying and that maybe she should consider being a nurse. The client reports the ensuing feeling from this blatant lack of support or encouragement about becoming a professional and she lacked the ability doing so left her feeling as if becoming a professional in their view meant she would be “faking” it from a lack of being capable of achieving such a goal. According to Chapman this constitutes an anxiety-provoking life situation creating maladaptive cognitive thoughts and subsequent behaviour in the patent resulting in a newly formed lack of assertiveness in academic test taking (2006).
The client explained with the ensuing years the internal anxiety developed as "butterflies” eventually exhibiting as further occasional co-morbidity in the form of developing the shakes and feeling nauseous just prior to having to take class exams. She also experienced blanking mentally while in the midst of taking an exam unable to focus on answers to questions she indeed knew. Exam questions asking answers from multiple choice queues she skipped over many of the questions as the anxiety enveloped her reasoning to focus on questions she had the answers. Client reports her image of self lacks confidence for gaining entry into a top school and graduating with the credentials of a professional. This view of self as explained by the client having so a low perception specifically connects to her inability to have control over the chronic anxiety that keeps her from doing well on her school exams standing as proof of her academic incompetence. Clearly such a view in light of her 4.0 GPA proves further psychosis contributing to the anxiety levels connected to academic test taking (Cerruti and Staddon, 2003).

Session III

Induction/ Deepener/ IMR/Scripts
Magnetic Field Induction (good for IMR’s) use of hand rotation. Chosen because it is a ratifier (convincer) and will get patient use to IMR/contraindications: pain when moving their shoulder, arm or back. Scripts incorporated the Assertiveness focus of CBM (again).
Patient competed the last session homework, everyday, practicing inducing self-hypnosis. We reviewed her progress towards her goals, and she is on track. She mentioned that all these changes have been so gradual and she realises how she has been “transforming”. She discussed how her family is seeing her in a more serious light when it comes to becoming a professional. She feels more real about the future belief of herself as a professional. As value added, she said that she seems to be a lot let anxious about things in her life and feels like she has more control of herself, her life, and her environment .
Each session so far we have had ego strengthening. That may be helping as well. She seems fully stabilised and this session focus will be on improvement. Used Assertiveness Script. The Performance Anxiety Protocol was employed. We used hypnotic-drama (dissociative) where she acted out common conversations with both of her parents to gain insights as to why they say what they say and how she can respond in a better way while being assertive so that she can state that she truly wants to become a professional (a Doctor to be precise), and just like her brother, it will take her a lot of studying and work which she would rather have her parents support as she does so. Gave her the same homework in self-hypnosis and breathing exercises as before.

Session IV – Follow up Session

Induction/ Deepener/Script(s)
Induction use (again) of the eye fixated on hand. Contraindications: contacts/eye injury. Chose because it can cause some hallucination Use of the special place of relaxation deepener. Script(s) included control rooms of the mind, pseud-orientation in time, anchoring.
Session IV was a follow-up meeting with the client scheduled much a measureable time after the last session. Empirical observation notes recorded the patient’s body language revealed an increased display of positive carriage and her general appearance exudes this as well. The client reported she has achieved a far more focused approach to her academic studies as well as toward her overall life environment as well. The client further reports how the hypnotherapy suggestions and self-hypnosis practice toward gaining sustainable control of herself proves successful in outcomes of her completing various exams and as projected toward her approach to her studies in general with doing so by taking steady strides an in a much more relaxed and focused manner. Engaged in the general discussion in this session the client exhibited a positive locus of control reporting how she continues shaping her own life and no longer succumbing to external factors formerly holding her down and holding her back in academic and life goals.
Jointly review of the goals set in the previous sessions showed the client on track. She reports practicing self-hypnosis occurs on an average of once a week, and with the beneficial implications of this showing in client demeanour and the successes she discusses in her personal and academic goals concurs this intervention methodology in CBA therefore, proves beneficial at the time of this session. We agreed this should be the final session, and I thought it wise to provide the Library of Life script to the client for her discretionary use for increasing her use of internal resources with further ego strengthening.
Further, with the client mentioning she still experiences lingering while tolerable but nonetheless problematic anxiety during certain exams at school, this evoked the decision to also employ the Control Room of the Mind (Hammond, 1990) allowing instructing her how to slightly control this lingering anxiety by turning it down as the exam(s) get closer. In this manner, this allows the patient the ability of transferring this lingering chronic excess of performance anxiety automatically to the suggestion of the positive panel of LED light mental imagery allowing the client away from the distress and focusing her brain activity on the test as a subjective comfortable rate.


During hypnotic trance, I installed a mental anchor (Bodenhamer and Hall, 2000; O’Conner and Seymour, 2003), which was where she would make a “thumbs-up” with her left hand, and bringing her out of the hypnotic-trance back to a wonderful feeling of confidence and control from a time she recalled doing well on an exam from when she was 13 years old.

Remarks on the Case Study

Anxiety disorders are among the most prevalent diagnoses within the United States and growing throughout advanced global economies (Martin, 2003), and they are the most common type of mental disorder found in adolescents (Bradley, 2001). As a consequence the increased prevalence of prescribing drugs for adolescent anxiety versus clinical treatment continues on the rise and remains a controversial debate among medical practitioners. Researchers such as Fisher Greenberg (1989, p. 327) have reported their finding "so much empirical support for the success of psychosocial approaches in dealing with such problems as depression (and) anxiety” They assert how psychotherapeutic treatments have (and continue) for the most part proven that adding drugs to psychotherapy treatment show no significant enhancement to the outcomes according to statistical meta-analysis demonstrating on the average how use of comparative control groups in clinical studies of psychotherapy groups versus medicated groups proved the superiority in potency of the psychotherapeutic approaches in treating anxiety. Consequently, while certain trends even in the 21st century prove argumentative when current practices attempt comparing psychotherapy treatment outcomes to medication results and doing so continues prodding a complicated and even dramatic in the medical and social science field of treating mental and emotional disorders (Bryant et al, 2005).
In the case study presented here, the familial underpinnings of the culture of home clearly shows the implications of how her anxiety disorder seeded and grew. The work of Whitefield’s healing the wounded child within addresses the very issues this client confronted in the sessions discussed. The cultural conditioning of generational aspects of the client home life and likely social conditioning as well (1967).


As outlined in the introduction the above scholastic dialogue intended and successfully provided a case study conducted with the client permission as presented in the collaborative work in this academic exercise in development of this case study in a report form and described the symptoms and comorbidity of the 18-year-old university student with a 4.0 GPA suffering performance anxiety and seeking CH as a treatment according to the precepts of locus of control and cognition therapy. Four sessions with the client apply hypnotherapy as part of the psychotherapeutic process using empirical precepts of observation, and outcomes of the sessions in discovery of the source of the anxiety experienced by the client in performing academic text exams, proved a successful process. The understanding of CBM as the underlying focus of both the application of CH subsequent with the psychotherapy applications in addressing, treating, and providing the client with instruction of self-hypnosis as a tool for creating a new and true identify of self and replacing the false identity mirroring the impressions of her family proved the formula of success.


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