TMS Therapy and PTSD – Treatment Without Medication

PTSD (Posttraumatic Stress Disorder): a mental health condition triggered by the experience of a traumatic event. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event.

TMS (Transcranial Magnetic Stimulation): a non-invasive brain therapy that administers magnetic pulses (as used in MRI technology) to brain regions thought to play a role in the symptoms of clinical depression.

This article was medically reviewed by Dr. Troy Noonan, MD Psychiatry. Dr. Noonan received his M.D. from Finch University at the Chicago Medical School, Psychiatry Residency and fellowship at the University of South Florida (USF) College of Medicine. He is Certified by the American Board of Psychiatry & Neurology.


TMS Therapy and PTSD

This article examines the relevance of TMS Therapy and PTSD. Since TSM is commonly confused with ECT (Electroconvulsive Therapy), we encourage you to read our TMS vs ECT article for a detailed comparison of these vastly different treatments. 

This article explores the most common types of PTSD, including general and specific symptoms. We’ll also explain how PTSD symptoms present across various demographics (adults, military veterans, police officers, teens, children, and sexual assault survivors). 

Finally, we’ll explore the DSM 5 diagnosis standards for PTSD, and common treatments, including recent and current research on the safety and efficacy of TMS Therapy and PTSD. By the time you’ve read this article, you’ll be thoroughly informed about taking the next step in living PTSD free. 

What is PTSD and How Does it Happen?

PTSD (Posttraumatic Stress Disorder) is an anxiety disorder that develops as a result of a traumatizing event, sometimes called a “stressor.” The American Psychiatric Association (APA) added PTSD to the DSM-III (the third edition of Diagnostic and Statistical Manual of Mental Disorders) in 1980.

While the addition was controversial at first, the PTSD diagnosis has filled an important gap in psychiatric theory and practice. In the first DSM-III formulation, the stressor was conceptualized as a traumatic event outside the range of usual human experience. 

TMS Therapy and PTSD

The original PTSD diagnosis focused on events such as war, torture, rape, genocide, and specific historical events like the Hiroshima and Nagasaki bombings, the WWII Holocaust, natural disasters (fires, hurricanes, earthquakes, and volcanic eruptions), as well as human-made disasters (plane crashes, explosions, and automobile accidents). 

The DSM-III categorized other stressful life events like severe illness divorce, job loss, financial failures, loss of loved one as “ordinary stressors.” According to the DSM-III, anxiety disorders resulting from these were diagnosed as adjustment disorders rather than PTSD. This distinction assumed that the average person has adequate coping skills for dealing with such events. 

Today, the conceptualization for Traumatic Stressor can include any event where the survivor is very afraid and doesn’t have adequate control over the event. These stressors can include physical abuse, sexual assault, severe illness, betrayal trauma, or moral injury. Anyone who has gone through such a trauma can develop PTSD.

This conceptual transition came as a result of defining the stressor as being outside of the control of the person who experienced it. This newer conceptualization can also include events witnessed by the subject, as well as experienced. We will explore the link between PTSD and witnessed trauma later in this article.

Common Confusions About Trauma and PTSD

It is important to understand the distinction between negative or stressful memories about an event, and full-blown PTSD. A trauma survivor may feel on edge after a traumatic event. They may have trouble sleeping and doing daily activities, like attending school, or work, or socializing. However, in normal cases the person will start feeling better within a few weeks or months. In some cases, this recovery will be temporary and PTSD symptoms may start later, usually because of a triggering stimulus (more on this later). 

In other cases, the symptoms will persist, or worsen over time, while in others, the symptoms will come and go. In all cases, if the symptoms (covered below) persist more than a few months and disrupt the person’s regular life and routines, it might be time to start a PTSD evaluation process.

Personal factors, including age, gender, and emotional or social development can affect whether the stressor gives way to PTSD. Another factor in the lasting effect of a traumatic event is the subject’s immediate response or experience following the event.

For example, a child sexual assault victim may experience a combination of sexual assault trauma and betrayal trauma if their attacker is an immediate family member and/or if the abuse persists in secret or because of the abuser not being able to report the abuse. 

This lack of social support can greatly increase the possibility of the child developing PTSD. We will explore this in more detail in section three of this article.

Symptoms of PTSD and Types of PTSD

PTSD symptoms fit into one of four categories. People with PTSD may experience symptoms from any or all these categories, but the experience will vary from person to person. 

  • Re-Experience: memories, nightmares, flashbacks (feeling like you’re experiencing the event again), sensory stimuli (sights, sounds, tastes, smells, physical sensations), that trigger a reliving of the event. 
  • Uncontrolled Thoughts: these negative thoughts may include the survivor’s thoughts about themselves (guilt, shame, etc.), or others (mistrust, paranoia, etc.). They may also include a loss of interest in, or lack of ability to experience or receive, love and other positive social emotions. 
  • Avoidance: avoiding people or situations that might trigger one of the re-experience symptoms mentioned above. This may include avoidance of social situations, movies, music, or activities (driving, flying, etc.).
  • Hypervigilance: a person with PTSD may be constantly looking for threats or danger. They might become suddenly angry, or paranoid. Hypervigilance will make it hard to relax, concentrate, or sleep.

Since hypervigilance can cause overstimulation of the sympathetic nervous system, a person with PTSD may self-medicate via drugs, drinking, or other addictive behaviors as an artificial means of inducing homeostasis

Types of PTSD

Understanding PTSD starts with understanding how it differs from our normal stress response. PTSD can start as a normal stress response and later develop into PTSD symptoms. Our normal response to stressful situations is called Acute Stress. Acute stress affects your sympathetic nervous system, which controls your fight, flight, or freeze response. It also affects the immune system, and endocrine system—which controls your metabolism. 

Acute stress can happen as a result of an accident, illness, injury, and abnormal stress at work, or relationship strife. In the case of Acute Stress, the hypothalamus (a region of the forebrain) responds by releasing Corticotropin-Releasing Hormone (CRH).

CRH is the central driver of the stress response, mainly in the operation of the Hypothalamic Pituitary Adrenal (HPA) axis. CRH causes the pituitary gland to release Adrenocorticotropic Hormone (ACTH) into the bloodstream. 

When ACTH reaches the adrenal glands, it causes the secretion of cortisol, which is a primary hormone for inducing Acute Stress. In normal stress response, the pituitary and hypothalamus detect the high concentrations of cortisol in the bloodstream and respond by turning off the stress response. This returns the body to normal pre-arousal state. 

Simply put, acute stress is temporary and does not disrupt daily life, or lead to lasting changes in how the brain responds to stimulus. Acute Stress response can therefore be managed by talk therapy or ordinary stress management strategies, including exercise, meditation, or group therapy. However, prolonged exposure to stressful circumstances can cause abnormally elevated cortisol levels. Over time, this can lead to long term changes in how the HPA axis responds to stress, or even normal stimuli. This is known as Chronic Stress, and can cause a multitude of anxiety disorders, including PTSD.

The Department of Veterans Affairs, tells us that between 6% and 33% of people can develop an acute stress (anxiety) disorder within just a month of a traumatic event. This rate, however, differs based on the type of trauma suffered. For example, the statistics tell us that about 13% to 21% of individuals are likely to develop acute stress disorder after a car accident, while twenty to fifty of rape, assault, or mass shooting victims are likely to develop anxiety disorders, including PTSD.

Uncomplex PTSD

Uncomplex PTSD is a commonly diagnosed type of PTSD that usually responds well to treatment. It presents with similar symptoms to other types of PTSD. However, uncomplex PTSD doesn’t coexist with other mental health problems, like depression.

Complex PTSD

Complex PTSD is the result of multiple traumas or ongoing trauma that persists or repeats over a period of months, or years. This contrasts with PTSD that occurs as a result of one traumatic experience. This chronic trauma that causes complex PTSD can cause behavior problems and relationship issues later in life. 

Complex PTSD can also manifest in the form of physical health problems including chronic pain and fatigue. Complex PTSD requires longer treatment cycles and slower recovery rates. It may also be accompanied by treatments for physical problems like chronic pain or fatigue.

Comorbid PTSD

Comorbid PTSD is when PTSD symptoms occur in conjunction with other mental health problems, such as panic disorders, anxiety disorders, major depressive disorder, or substance abuse. Treatment for Comorbid PTSD can involve PTSD treatment as well as interventions for other mental health conditions. 

Dissociative PTSD

This type of PTSD is characterized by dissociative symptoms, including emotional detachment, depersonalization-derealization. People with depersonalization-derealization symptoms frequently feel that they’re observing themselves from outside their body. They may also have a sense that things around them aren’t real. 

While it’s normal to have a passing feeling of depersonalization or derealization, the recurrence or persistence of these feelings is classified as a disorder. This is especially true when the depersonalization or derealization interferes with your ability to live a normal life.

Dissociative PTSD is typically accompanied by other mental health conditions, including flashbacks, amnesia, and the general PTSD symptoms listed above. It is also more common in those who have experienced early life trauma.

NOTE: If you’re experiencing one or more of the four categories of PTSD symptoms (reexperience, uncontrolled thoughts, avoidance, or hypervigilance) go to our assessments page to start a self-assessment. 

PTSD Across Various Demographics

Anyone can develop PTSD at any age and during any state of their life. While some factors can increase the likelihood of PTSD, most of them are out of the person’s control. PTSD is also more likely to occur as a result of certain types of traumas, the most common being sexual assault, and combat situations. 

PTSD in Adults

Statistics from the National Center for PTSD tell us that 60% of men and 50% of women experience at least one trauma in their life. However, the type of trauma differs for men and women, with women being more likely to experience sexual abuse or child abuse and men being more likely to experience physical assault, combat, or to witness death or severe injury. 

Other U.S. population statistics tell us that about 6% of people will develop PTSD at some time in their lives and that about 15 million adults experience symptoms at least once a year. This combination of statistics tell us that only 10% of the people who experience some type of trauma will develop PTSD as a result. The statistics also tell us that women are more likely to develop PTSD than men (8% of women compared to 4% of men).

PTSD in Women

As mentioned above, women experience different types of traumas than men. Some of the four symptom types (reexperience, uncontrolled thoughts, also occur more commonly for women than for men. Early research in PTSD focused primarily on combat veterans. Researchers soon started recognizing similarities in symptoms experienced by female sexual assault survivors. 

On average, one out of three women experience sexual assault at some point in their life. Women are also more likely to experience childhood abuse, neglect, or domestic violence (as children or adults). Since this abuse usually comes at the hands of a loved one or guardian, it is more commonly being categorized as betrayal trauma. Betrayal trauma is a specialized category of psychological trauma that focuses on the social impact of the trauma.

Betrayal trauma occurs when a trusted person or institution violates one’s well-being. This violation can include physical, emotional, or sexual abuse. 

“When psychological trauma involves betrayal, the victim may be less aware or less able to recall the traumatic experience because to do so will likely lead to confrontation or withdrawal by the betraying caregiver, threatening a necessary attachment relationship and thus the victim’s survival. Research findings indicate that adults are less likely to fully recall childhood abuse by caregivers or close others than by strangers.”

-Jennifer J. Freyd, PhD and Professor of Psychology at University of Oregon Tweet

While betrayal trauma doesn’t always lead to PTSD, it is characterized by additional symptoms including feelings of worthlessness, shame, or being unloved or unlovable. These symptoms can be present whether the betrayal trauma survivor experiences PTSD. This could explain why, as mentioned earlier, women are more than twice as likely as men to develop PTSD. 

PTSD in Military and Law Enforcement

Those working in the military and law enforcement are often in fast paced, high-pressure situations where they have to make life or death decisions. These decisions can have an immediate lethal consequence for them, or someone else. 

I have personally had about a half dozen military veteran friends tell me horrific stories about some of these decisions. One example, which I have heard from more than one veteran, is the experience of driving through the desert in a military convoy and seeing a figure walking along ahead. 

In some instances, these seemingly innocent people would be waiting to ambush U.S. military vehicles with RPGs hidden under their clothes. Those in the military convoy would have to decide, within a few seconds, whether to shoot the person or risk being abused or have their convoy attacked by suicide bombing. 

In some instances, these seemingly innocent people would be waiting to ambush U.S. military vehicles with RPGs hidden under their clothes. Those in the military convoy would have to decide, within a few seconds, whether to shoot the person or risk being abused or have their convoy attacked by suicide bombing. 

“Sometimes, you were right, and it turned out to be a man dressed in a burka with an RPG or a bomb under his clothes,” I remember one Dessert Storm veteran saying over beers one night. “Other times, it was just a civilian. But you never knew. It was either shoot them or risk your whole team.”

Other stories include watching comrades blown to pieces by bombs, or bleeding out on the battle field while under fire, dragging comrades back to safety after severe injuries, including loss of limbs. These are the combat experiences that veterans often re-experience during PTSD episodes. In preparation for this article, I found an UCLA study published in Neuroscience News explaining how even news reports were triggering PTSD symptoms in combat veterans. 

“A lot of our vets are extremely upset about the headlines in the news about Afghanistan,” says Dr. Kagan, who is also a staff psychiatrist with the Veterans Administration Greater Los Angeles Healthcare System and medical director of UCLA Operation Mend’s intensive treatment program for post-9/11 veterans. “It’s not just those who served in Afghanistan,” he said. “It’s those who served in Iraq. It’s those who served in Vietnam, as well.”

Statistics from the National Center for PTSD tell us that between 11% and 20% of Combat veterans involved in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) experience PTSD symptoms on a yearly basis. Combat veterans from the Gulf War (Desert Storm) experience PTSD at a rate of 12%. The PTSD diagnosis rate for soldiers from the Vietnam War was at 15% at the time of the most recent study (The National Vietnam Veterans Readjustment Study [NVVRS] in late 1980s). The estimated average was much higher than this, but not verified by data. 

Statistics from the National Center for PTSD also tell us that veterans in the veteran health care system are likely to report sexual assaults that happened while they were serving in the military. These rates of reported abuse were as high as 55% for women and 38% for men. 

However, an often-neglected demographic for PTSD is people serving in domestic law enforcement. Cognitive psychologists Drs. Janet and David Shucard have reported on electroencephalography (EEG) studies conducted while presenting police officers with various decision-making situations. The studies compared the decision-making abilities of officers with higher levels of PTSD to those with little or no PTSD symptoms. 

The results pointed to disruptions in the area of the brain involved in rapid decision making for officers with higher levels of PTSD. The researchers suspect (and with good reason in my opinion) this could lead to inability to screen out distractions or hold their attention during high-risk situations. 

PTSD in Children and Teens

Data from the National Center for PTSD tell us that 14% to 43% of boys and 15% to 43% of girls experience at least one traumatic event during childhood. Out of those, 1% to 6% of boys and 3% to 15% of girls will develop PTSD. 

Child protection services in the U.S. receive about three million reports of childhood abuse or neglect every year. These reports reveal the following statistics for various types of abuse:

These reports involve about 5.5 million children, with about 30% of cases yielding proof of child abuse. As with adults, children are more likely to develop PTSD in response to certain types of trauma. PTSD symptoms also present differently in children and teens than they do in adults. 

PTSD in school-aged children (ages 5-12) are likely to have flashbacks but may also have problems remembering details of the trauma. School age children might also remember the details of the trauma in the wrong order. They are also likely to believe there were signs that the trauma was going to happen, and to develop beliefs that they can avoid future trauma by looking for these warning signs.

School age children might also play out details of their trauma, sometimes acting in the place of the perpetrator (playing shooting games after witnessing a shooting etc.). I remember seeing an example of this in a murder documentary where the child who had witness the murder drew pictures of himself with over-sized eyes. This turned out to be the child’s way of telling the adults in his life that he had seen something important. 

PTSD in teens (ages 12-18) presents more like it does in adults. The difference being that teenagers are more prone to impulsive or aggressive responses to their PTSD symptoms. For example, a teenager who experiences a trauma in response to an environmental trigger may lash out at the source of the stimulus. 

Common Misconceptions About PTSD in Children and Teens

While we’re talking about PTSD in children and teens, it’s important to note that children and teens will experience other challenges which should not be confused with PTSD symptoms. For example, children who are sexually abused may have excessive anger, fear, worry, sadness, loneliness, or feelings of worthlessness. They may also show signs of self-harm or develop substance abuse problems, or forms of avoidance such as playing video games instead of socializing. These may be signs that the teen or child doesn’t yet have the coping mechanisms to deal with the trauma and needs the guidance of an adult to develop these skills. 

Remember that one criterion for defining a traumatic experience is the ability to respond to it, both during and after the experience. A well-adjusted adult is more likely to have a set of cognitive, social, and emotional tools for dealing with the immediate effects of trauma. Children and teens are less likely to have these coping skills, and therefore may have unpredictable or concerning responses to trauma. This would also make them more likely to develop PTSD after the experience. 

This is why it’s important for parents and guardians to understand the effects of PTSD, as well as the distinction between PTSD symptoms and other behaviors. Proactive treatments will also be important for children and teens who have recently experienced trauma. One example of proactive intervention is the Psychological First Aid (PFA) which is being used with school-aged children and teens who have survived trauma. 

NOTE: If your child or teen has recently experienced a trauma, or is experiencing one or more of the four categories of PTSD symptoms mentioned earlier (re-experience, uncontrolled thoughts, avoidance, or hypervigilance) go to our assessments page to learn more. 

PTSD Diagnosis and Risk Factors

We’ll start this section with an excerpt from the DSM-5 on the criteria for diagnosing PTSD:

—START OF DSM-5 EXCERPT—

Primary Care PTSD Checklist for DSM-5

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

  • a serious accident or fire
  • a physical or sexual assault or abuse
  • an earthquake or flood
  • a war
  • seeing someone be killed or seriously injured
  • having a loved one die through homicide or suicide

Have you ever experienced this kind of event? YES / NO
If no, screen total = 0. Please stop here.

If yes, please answer the questions below:

In the past month, have you…

  • Had nightmares about the event(s) or thought about the event(s) when you did not want to? YES / NO
  • Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? YES / NO
  • Been constantly on guard, watchful, or easily startled? YES / NO
  • Felt numb or detached from people, activities, or your surroundings? YES / NO
  • Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? YES / NO

If you answer “yes” to any 3 items (items 1 to 5 above), you should talk to a mental health care provider to learn more about PTSD and PTSD treatment.

Answering “yes” to 3 or more questions on the PC-PTSD-5 does not mean you have PTSD. Only a mental health care provider can tell you for sure. And, if you do not answer “yes” to 3 or more questions, you may still want to talk to a mental health care provider. If you have symptoms that last following a trauma, treatment can help—whether or not you have PTSD.

—END OF DSM-5 EXCERPT—

Factors That Increase Likelihood of Developing PTSD

Before we talk about PTSD and TMS Therapy, let’s summarize the factors that increase the likelihood of developing PTSD. Keep in mind that there are likely trillions (or more) ways a person can experience and respond to trauma, so this is simply a generalized list. 

The first factor is the severity of the trauma. While there is very little that can be done about this, it’s important to remember that certain types of traumas, such as sexual assault, rape, and betrayal trauma, carry a higher probability for converting to PTSD. 

The second factor is the survivor’s sense of safety or assumption that the trauma could not occur. For example, the emotional impact of the trauma will be more severe if the survivor experiences the TYPE of trauma in an environment that they assumed to be safe (their home, school, church, a friend’s house).  

 

The immediate response to the trauma. The survivor’s immediate action after the trauma plays a big role in whether they develop PTSD. This is why it’s important to be proactive about preventing PTSD. For example, those who seek social support or proactive treatments (like talk therapy) are more likely to work through the trauma in a way that reduces likelihood of developing PTSD symptoms. 

The level of familiarity with the victim of the trauma. This factor comes into play when the trauma is witnessed, but not directly experienced. For example, if you witness a violent crime committed against someone who you identify with (via gender, ethnic group, age, social status, geographic proximity, etc.), the witnessing of that experience is more likely to lead to PTSD. This is because we assess threats based on the likelihood of it happening to them. Hence, the more you identify with the victim, the more your brain will process the event as a potential personal threat.  

Now that you have a thorough grip on the basics of PTSD, let’s talk about TMS Therapy and PTSD. 

TMS Therapy and PTSD Treatment

"“Effects on PTSD are often sustained for up to 2-3 months, but more long-term studies are needed in order to understand and predict duration of response. In short, while TMS appears safe and effective for PTSD, important steps are needed to operationalize optimal approaches for patients suffering from this disorder.”

Transcranial Magnetic Stimulation (TMS) is one of the safest and most effective methods for treating various mental health conditions without medication. TMS uses magnetic fields (similar to those used in MRIs) to stimulate blood flow in the prefrontal cortex and promote neurotransmitters that play a role in depression, and in anxiety disorders like PTSD.

According to controlled clinical studies, 83% of Neurostar TMS patients see a positive response using TMS therapy. The clinical trials also showed TMS to have a 11% relapse rate across all patients, which is a lower rate than any other depression treatment. Only 37% of TMS patients needed additional TMS, and 85% of these patients re-achieved clinical benefits. 

Dopamine and Depression Treatment

TMS was FDA approved in 2008 treating clinical depression and in 2018 for treating OCD (Obsessive Compulsive Disorder). 

The Neurobiological Case for TMS and PTSD Treatment

While TMS has not (yet) been FDA approved for treating PTSD, it acts on the region of the brain that plays a key role in properly managing stress and overcoming mental health conditions, like clinical depression and OCD. For example, the amygdala (brain region that manages threat assessment, and fear response) and the mid-anterior cingulate cortex are over-stimulated by PTSD.

The anterior midcingulate cortex (ACC) is instrumental in negative affect, pain and cognitive control. It has previously been proposed that this region uses information about punishment to control aversively motivated actions.

SOURCE: National Library of Medicine Article on the causal role for the anterior midcingulate cortex in negative affect and cognitive control.

Meanwhile, PTSD causes the parts of the brain instrumental in memory and higher thinking to be less active. These brain regions include the orbitofrontal cortex, the hippocampus, the ventromedial PFC and dorsolateral PFC, and the right inferior frontal gyrus. The Prefrontal Cortex (PFC) brain is instrumental for emotional regulation, decision making, attention regulation, initiation of conscious voluntary behavior.

The ventromedial PFC plays a role in suppressing negative emotions, social decision-making, memory consolidation, as well as the dissipation of a conditioned response. Simply put, the “conditioned response” is instrumental for the “triggering” phenomenon that leads to PTSD episodes (reexperiencing, uncontrolled thought). 

The other brain regions that become less active because of PTSD are responsible for a combination of higher brain functions, many of which help a person to cope with fearful and stressful experiences instead of reacting to them. The research on the long-term impact of PTSD shows decreases in cortical thickness of the ACC in correlation with PTSD symptoms. This structural damage is especially prominent in the hippocampus, which helps regulate memory and is believed to play a role in creative imagination. The hippocampus also stores long-term memories.

In other words, it decides what short-term memories become long-term memories, and with what emotional context. This is called “memory consolidation.”

When your Anterior Midcingulate Cortex (ACC) and Prefrontal Cortex are properly engaged, the brain can calm the body down and properly manage responses to stimulus as well as making decisions and storing memories in a way that doesn’t divide the world into black and white categories of “threat/non-threat.” 

More Information TMS and PTSD Treatment

TMS treatment sessions are non-invasive, require no medications or sedatives, and convenient enough to be done during a patient’s lunch break, after which they can return to their normal workday. TMS treatment cycles typically last six to eight weeks, with five 20-minute treatments per week.

"“Transcranial magnetic stimulation has shown its potential to help patients suffering from depression and headaches. With today’s marketing authorization, patients with OCD who have not responded to traditional treatments now have another option.”

-Carlos Peña, Ph.D., M.S., director of the Division of Neurological and Physical Medicine Devices in the FDA’s Center for Devices and Radiological Health. Tweet

If you or someone you know would like a medication free way to treat PTSD, Mental Health Management Group would love to help you learn more. Mental Health Management Group offers treatment for mental wellness, emotional, behavioral conditions including major depressive disorder, PTSD, and much more. 

They do this through psychiatric medical evaluation, treatment plans, FDA-approved medication management, and therapies with successful outcomes for adults, adolescents, children, and families. They have worked with thousands of patients suffering from depression and other mental illnesses. 

To see if you or a family member qualify for TMS Therapy and PTSD treatment, fill out the patient referral form and one of our practitioners will call you. If you prefer to learn more before talking to someone, fill out one of our free mental health assessments to get started. If medication, talk therapy, and other interventions haven’t worked for you, let us help you find a better way. Contact us today and find out. 

This concludes our article on TMS Therapy and PTSD.

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